[HSF] aortic root reimplantation and Rv dysfx

[psimha]

Glenn will not help if the PA pressures are high (Not CVP). You have to 
consider either septostomy or RVAD (roller at least as Ed has suggested 
- we have also used it variably)and lots of prayers. If you do not have 
Milrinone try a theophylline infusion. It works at times. I would 
consider keeping the chest open . It will be a tough call.You can also 
consider inhaled SNP since you do not have NO. Lots of prayers required. 
I haven't been able to do PA counterpulsation (basically because we 
don't get offhand zero porosity grafts.
Prasanna
erdinç naseri wrote:
> Prasanna,
> 1.CVP is 25 mmHg 2.PO2 is  already 65 mmHg (FIO2 70%) .He is very  close to end-stage lung disease with severe bilateral hyperinflated black lungs. 3.No   milrinone  is not available.
> erdinc  > Date: Tue, 4 Sep 2007 21:56:44 +0530> From: prasannasimha at gmail.com> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] aortic root reimplantation and Rv dysfx> CC: > > In a desperate circumstance you can try to do a BD Glenn if the PA > pressure is OK.Another option is to perforate the IAS so that you get an > adequate LV preload at the cost of desaturation. These are the some of > the things that may work in the presence of RV dysfunction when we do > not have a mechanical support for the RV. Incidentally what is the CVP > and PA pressures and do you have access to Milrinone and NO ?> Prasanna> 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 smal
>  l 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> > -----------------------------------------> >> >> > > > > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBS
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