[HSF] aortic root reimplantation and Rv dysfx

[erdinç naseri]

Would like to have the forum members opinion regarding the following case:
62 Y/O male with history of HT,CAD and COPD.( heavy smoker)
CXR:Bilateral multiple bullae in the upper lobes, 
EKG:previous inferior MI and LVH.
CAG:LAD90%,OM2 80%,RCA totaly occluded no ante or retrograde filling,no LV graphy
TTE:AR 2-3 +,Aortic annulus 3.5 cm,Valsalva 4.3 cm,LVEDD 6.3 cm, Trival MR,TR 1 +,EF ( Simpson 's method) 25%,LV inferolateral akinesia
Operation( hours ago): aortic and single stage venous  cannulation,preparation of root during cooling showed dilataton of valsalva sinuses.Prox. RCA was at least 1.5 cm in diameter.on-pump  beating heart LAD anastomosis while cooling. Trial of OM2  anastomosis lead to severe LV dilation .Anastomosis aborted and cross clamp with antegrade aortic root cardioplegia with periods of aortic root suction and LV compression. when the heart showed electromechanical arrest ante through LAD graft and retro through CS.Cooled to 24 degrees( operation room temp 28 ,air condition out of work!) and finished OM anastomosis and started giving cardioplegia through it .Exploration  and arteriotomy of RCA showed  a totally occluded vessel with very small (<1 mm )PDA.Opened the aorta : oozing of desaturated blood from LC but nil from RC ostium.Aortic annular ,valsalva and STJ dilated  but leaflets of good quality and coaptation.Decided to do root reimplantation .I was trying to be fast because of the inability to give cardioplegia to RV .Still further cooled to 24.Aortic root reimplantation  and OM CABG in 121 minutes : gave hot shot and declamped .Heart started beating spontaneously at 28 degrees and after 10 minutes"of declamping.Continued with the proximals( LAD  and Cabrol graft )to graft and OM to proximal arch).Everyting looked OK with Lv contracting good with no dilation( no TEE available)Tried to wean and BP dropped with RV-RA dilation .CPB again and RCA endatrterectomy and by-pass to it with poor backflow distaly.30 more minutes on CPB and tried to wean but the same story.Changed the venous drainage to selective caval and did  a warm beating tricuspid ring annuloplasty.Actually the leaflets were in good shape and coaptation before annuloplasty but I remebered Hal's advices regarding TR.CPB > 300 minutes and tried weaning with the following findings: LV small and contracting well,direct LA pressure 8 mmHg , RV stand still ,RA dilated;CVP 20 mmHg.Had started inotopics already ,increased the doses to suprapharmacologic levels ,put IABP ( it increased the MAP) and closed the  sternum.ICU findings: MAP 65-70,ABG reasoable,good urination .
My comment: İnappropriate RV preservation .Any additional measures could been taken ???
erdinc