[HSF] aortic root reimplantation and Rv dysfx

[Edward Bender]

Leave the sternum open (usually you can close the skin over the open  
wound).  This alleviates mediastinal compression somewhat.  In cases  
of severe RV failure, obviously volume loading is required, but I  
have squeaked by with a mechanical assist for 6 - 12 hours (I have  
used the A-Med pump which Tea has blessed in the past or, in the  
absence of that, use smal cannulae in the RA and PA, and flow with a  
biomedicus or roller pump 2 - 3 liters per minute to help unload the  
RV.  I have been surprised at how effective this can be.  Good luck.  
Let us know how things turn out.

Ed Bender, MD


On Sep 4, 2007, at 11:11 AM, erdinç naseri wrote:

>
> 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 i
>  notopics 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
> _______________________________________________
> 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
> -----------------------------------------