[HSF] Ahh, the Holiday Transfer. Would anyone do anything different?

Fri Nov 30 13:16:18 EST 2007

Bill:

 But surely you would not assess the success of pediatric operations by their being extubated after surgery or indeed being alive a year later? That obviously is the difficulty with assessing utility of pediatric as opposed to adult operations as assessment of success is more complex. If I did a mitral repair in a 60 year old with ruptured papillary muscle and they were alive 10 years later that is a success but if I did a Norwood on a child and they died on the 10th year people would be divided as to whether it was a success. You guys really do great things in correcting and treating congenital heart disease and it amazes me how most centers can now do such complex procedures which such low mortality. However the problem is that our success in surgery brings new medical and ethical quandaries. Is it possible that keeping some of these babies alive (which we can) might not always be the 'best' thing to do? 

The question I asked was a real one (I have no idea of what this procedure is and the prognosis and aftercare required) - given that this child has survived surgery and is in this particular country what do you think his life expectancy would be? What would you regard also as a success for this kind of operation in terms of survival (beyond survival of surgery)? 

By the way what reasons precisely did the Chief give for not wanting this child operated and does he still stand by his opinion having seen the outcome of surgery? It is a feat how you do such complex surgery in foreign lands as dealing as with the local politics and obstacles is probably more formidable than the surgical challenges. 

Ani

> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Ahh, the Holiday Transfer. Would anyone do anything different?> Date: Fri, 30 Nov 2007 02:47:02 -0500> From: ichfno at aol.com> CC: > > > Ani;> > See note to Tea. By the way, the Stage 2 Norwoods that I did?last year both look great! The girl from the Chernobyl Heart movie is engaged to be married, last week I recieved an letter with pictures from a Shone's Syndrome I did in Memphis in 1994, she was Ukrainian, still is actually, at any rate she sent pictures of her wedding (12 months ago) and her new baby girl! Shone's that was done in 1994 and now having babies, wonder how she is, I think that answers it. Also on the web page you can see the pictures of the wedding and the letter her grandmother wrote to me. > > > > Look I am not saying that we are succesful everywhere we go, we have our share of case failures and program failures, but I will say this, our successes are spectacular, and that is what drives us.> > > > Bill> > > > > > > > > > > > Yes. That Dr Novick was right doesn't mean the Chief was wrong. > > Maybe the Chief knows something we don't (e.g. about the healthcare provision or > natural history after heart surgery in his country) and what might seem the best > and successful therapy in one country might not necessarily be the same in > another. What I would want to know is what is the likelihood that this > particular 7 month old in his country would remain alive to see his 5th 10th > 15th and 20th birthday after this life saving operation?> > > Ani> > > > > Date: Thu, 29 Nov 2007 18:24:15 -0800> From: tacuff at swbell.net> Subject: Re: > [HSF] Ahh, the Holiday Transfer. Would anyone do anything different?> To: > OpenHeart-L at lists.hsforum.com> CC: > > How about the possibility in this case > that both the Chief and you were right with different recommendations!> > tea> > > > ----- Original Message ----> From: "ichfno at aol.com" <ichfno at aol.com>> To: > OpenHeart-L at lists.hsforum.com> Sent: Thursday, November 29, 2007 10:41:50 AM> > Subject: Re: [HSF] Ahh, the Holiday Transfer. Would anyone do anything > different?> > Okay, here is my do nothing story for the day. In a former Soviet > Union Country at present, presented a child who is 7 months old, 5 KGS, had > coarctation repair as newborn, at which time they did not address his MS, but > did send to cath lab to balloon his stenotic aortic valve. No gradient after > coarc, 60 gradient by echo after balloon, down from 90 gradient measured in lab, > left him with 1-2 plus AI. So, now seven months later, has 22 mmHg peak mitral > gradient and 1 plus MR, with single pap muscle by echo, 2-3 plus AI and 60 mmHG > LVOTO gradient with subvalve 7mm. Massively dialated LA, LV dialated as well, > cachectic, can see every rib, breathing 45 times/minute. Chief at the > Institution returns from Moscow, tells mother child should go home to die, > operation is not possible, even though we have scheduled child for an operation. > Mother says, I cannot do nothing, I must do everything possible for my only > child. Mother refuses advice of Chief, child goes> to operating room, Chie> f > makes entire surgical team sign note stating that we know he has advised against > surgery that is doomed to failure. We all sign!> > Child is in ICU, 0.08 epi, > 0.75 milrinone, sternum closed, cvp 12, BP 95/68. Did Ross-Konno, spilt single > pap muscle and opened both commissures, no LVOTO gradient, Mitral down to 4 > mmHg, mild MR, no AI, no residual VSD, sometimes you just can't do nothing!> > > > WNovick MD> > > > > If you reflect on your story, sometimes nothing is the > hardest thing to do. > It does have the advantage, however, that one is able to > reverse the choice with > better information or a change in the situation to > change your odds...possibly > including the arrival of a "better" surgeon or > better plan. > tea > > > > ----- Original Message ----> From: Michael > Firstenberg <msfirst at gmail.com>> To: OpenHeart-L at lists.hsforum.com> Sent: > Wednesday, November 28, 2007 9:18:51 PM> Subject: RE: [HSF] Ahh, the Holiday > Transfer. Would anyone do anything > different?> > So - just dont do something, > stand there....> > Michael Firstenberg <msfirst at gmail.com>> > -----Original > Message-----> From: "Tea Acuff" <tacuff at swbell.net>> To: OpenHeart-L at lists.hsforum.com> > Sent: 11/28/2007 9:55 PM> Subject: Re: [HSF] Ahh, the Holiday Transfer. Would > anyone do anything > different?> > As per some of the other comments, he had a > better chance with nothing. Your > findings would point to that although it is a > calculated quess preop.> > tea> > > ----- Original Message ----> From: Michael > Firstenberg <msfirst at gmail.com>> To: OpenHeart-L at lists.hsforum.com> Sent: > Sunday, November 25, 2007 7:52:57 PM> Subject: Re: [HSF] Ahh, the Holiday > Transfer. Would anyone do anything > different?> > The tear was at the SVG->PDA > site going into the arch (as per CT) and > down a little, but did not appear to > involve the native ostium nor > the valve - the AI appeared to be from being > bicuspid/fused.> > > -michael> > > On Nov 25, 2007, at 8:44 PM, Tea Acuff > wrote:> > > What did you find on opening the aorta? Did the dissection go > > > proximal to the grafts? Was the dissection the cause of the AI or > > was that > just the biscupid valve?> >> > tea> >> >> > ----- Original Message ----> > From: > Michael Firstenberg <msfirst at gmail.com>> > To: OpenHeart-L at lists.hsforum.com> > > Sent: Sunday, November 25, 2007 6:58:39 PM> > Subject: Re: [HSF] Ahh, the > Holiday Transfer. Would anyone do > > anything different?> >> > he was a little > wet - but not bleeding to death.> >> >> >> > -michael> >> >> >> >> > On Nov 25, > 2007, at 7:48 PM, zzhoumd at pol.net wrote:> >> >>> >> Just wonder if Factor 7 may > help.> >>> >> Sent via BlackBerry by AT&T> >>> >> -----Original Message-----> >> > From: Michael Firstenberg <msfirst at gmail.com>> >>> >> Date: Sun, 25 Nov 2007 > 18:47:53> >> To:OpenHeart-L at lists.hsforum.com> >> Subject: [HSF] Ahh,> >> the > Holiday Transfer. Would anyone do anything different?> >>> >>> >> The wonders of > holiday in the U.S. is that we (academic medical> >> centers) seem to get all of > transfers.> >> This was my case from yesterday and would be very interested in> > >> comments (besides shipping to a better surgeon......).> >>> >> 61 year/old, > hypertensive, diabetic, severe abdominal obesity (BMI> >> 48, 300 lbs, around 5' > 4')> >> presents to outside hospital with refractory chest/back pain,> >> > radiating to legs.> >> CT Angio - aortic dissection, just about the valve to the > iliacs.> >> head/visceral/renal/femorals off true lumen (but very small)> >> > Surgery resident from outside hospital calls me for transfer (on> >> cardizem > drip for BP control, no beta-blockers, not working, should> >> we > heparinize...... discussion for another time!!!)> >> "oh, I forgot to mention, > he had a CABGx4 in June of this year)> >>> >> My response - esmolol and ship > quickly> >> Upon arrival, still having pain, BP OK, neuro intact, faint femoral> > >> pulses, strong radials (no A-line)> >> Reviewed still with our local > Cardiology CT expert (lucky he was in> >> house)> >> - confirm dx> >> - all > grafts patent, LIMA-LAD, SVG->PDA, SVG->Dx, SVG->Om> >> - 3 proximals coming off > the ascending aorta> >> - LIMA lateral to sternum> >>> >> Taken emergently to > OR> >> Axillary cannulation (nice artery)> >> Wire in right femoral vein (ugly > groin, lots of fat, yeastly)> >> Intra-op TEE shows bicuspid aortic valve with > mild/mod AI.> >> Open the chest (they missed midline on the CABG and went > through a> >> bunch of ribs on the right- close to the RIMA)> >> Got in OK> >> > tons of mediastinal fat plastered to pericardium, plastered to> >> epicardial > fat.> >> NO, and I mean NO identifiable planes!> >> Finally found aorta after > about an hr of digging - found old> >> cannulation site> >> aorta looks ugly as > I exposed.> >> Finally found SVG to PDA graft - completely plastered to small > right> >> atrium> >> cannulated right vein - went on, cooled> >> could not find > "the heart/apex/etc) to vent - fortunately arrested> >> without fibbing (LV > didnt look too bad on TEE while cooling)> >> Cooled to 18C (didnt even look for > the LIMA - way laterally and> >> everything was a mess) -> kept feeding heart > with cold blood> >> Finally got around aorta - circ arrest, opened up, trimmed > to hemi-> >> arch - contained rupture, tear at right vein graft site> >> found > "something to sew to" distally in arch (30 min of circ arrest> >> time)> >> went > back on, started warming - blood coming from grafts, left main> >> and right > (all good, I assumed)> >> aortic valve - bicuspid ->fused, but leaflets normal > -> separated> >> left and non-cor leaflets and appeared to co-apt ok and hold > water> >> went closed> >> (mobilzing for AVR would have been very difficult - at > least for> >> me!)> >> On/off circ arrest, low flow, etc to fix leaks, mobilize, > visualize,> >> etc....> >> Bioglue to proximal aorta layers and dissection > plane.> >> Sewed proximal> >> root vent - cardiopledgia> >> Sewed on very > scarred, friable SVG buttons (got the right mobilzed> >> off the RA once empty > and repaired/resected tear)> >>> >> Took of x-clamp - slowly developed junction > rhythm as warming more> >> came off pump eventually with lots of drugs, inhaled > nitric> >> over an hour de-airing> >> TEE - still mild AI> >> - felt addressing > would be futile> >> - 6 hours on pump.....30 min DHCA, 4 hr cross clamp (on and > off)> >> Anesthesia up and down with tons of drugs/fluids/products/bicarb> >> > big chest - wet lungs, hard to ventilate, very unstable, up/down> >> > acidosis......(thought making urine???)> >> Very coagulopathic (would have liked > to have had Aprotinin) but used> >> TA.....> >> Tons of products (INR>6, PTT > unmeasurable, ACT after protamine>999,> >> platelts=18), but not bleeding too > bad> >> re-enforced graft site and potential space to co-seal, flow-seal,> >> > fibrilar, NuKnit, anything that I was allowed to leave in the chest> >> > (although no potential space - other than right pleural space - to> >> bleed > into)> >> Closed chest (modified weave and lots of wires through ribs)> >> > meta-stable> >>> >> went out to talk to family.......called back in....became > brady> >> cardiac as getting ready to move to bed....pulseless.....> >> chest > open - heart dead.....open CPR....intra-cardiac epi/vaso...> >> TEE showed LV > empty......(rupture into left chest? abd? something> >> else?)> >>> >> "the > end"> >>> >> Please comment as I know many of you have been there (either > on-line> >> or in private)..........> >>> >>> >> (fyi, this is the second > post-CABG dissection we got this week - the> >> first one was only a month out > and the redo was much easier)> >>> >> -michael> >>> >>> >>> >>> >>> >>> >>> >>> > >>> >> _______________________________________________> >> OpenHeart-L mailing > list> >>> >> Send postings to:> >> OpenHeart-L at lists.hsforum.com> >>> >> To > UNSUBSCRIBE, to CHANGE email address, or to view archives:> >> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >>> >> All messages transmitted > by the OpenHeart-L are subject to the> >> policies and> >> disclaimers posted > at:> >> http://www.hsforum.com/listdisclaim> >> -----------------------------------------> > >> _______________________________________________> >> OpenHeart-L mailing list> > >>> >> Send postings to:> >> OpenHeart-L at lists.hsforum.com> >>> >> To > UNSUBSCRIBE, to CHANGE email address, or to view archives:> >> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >>> >> All messages transmitted > by the OpenHeart-L are subject to the> >> policies and> >> disclaimers posted > at:> >> http://www.hsforum.com/listdisclaim> >> -----------------------------------------> > >> > _______________________________________________> > OpenHeart-L mailing > list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To > UNSUBSCRIBE, to CHANGE email address, or to view archives:> > > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted > by the OpenHeart-L are subject to the > > policies and> > disclaimers posted > at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> > > _______________________________________________> > OpenHeart-L mailing list> > >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to > CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> > >> > All messages transmitted by the OpenHeart-L are subject to the > > policies > and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > > -----------------------------------------> > _______________________________________________> > OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by > the OpenHeart-L are subject to the policies and > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> -----------------------------------------> > _______________________________________________> OpenHeart-L mailing list> > > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE > email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > > All messages transmitted by the OpenHeart-L are subject to the policies and > > disclaimers posted at:> http://www.hsforum.com/listdisclaim> > -----------------------------------------> > _______________________________________________> > OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by > the OpenHeart-L are subject to the policies and> disclaimers posted at:> > http://www.hsforum.com/listdisclaim> -----------------------------------------> > _______________________________________________> OpenHeart-L mailing list> > > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE > email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > > All messages transmitted by the OpenHeart-L are subject to the policies and > > disclaimers posted at:> http://www.hsforum.com/listdisclaim> > -----------------------------------------> > > ________________________________________________________________________> > More new features than ever. 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