[HSF] aortic root reimplantation and Rv dysfx

Wed Sep 5 11:53:14 EDT 2007

Although I tend to agree with Ani - part of the question is do you think the
RV will recover?  If so, then trying a RVAD for a few days.  If the RV is
d-e-d dead then hope may be lost if the underlying problem is not corrected
especially in a pre-op train wreck like this patient.  Another technique
that I have used a few (very few, with debatable success) has been, with the
chest open, put 1 fem-v cannula in the RA and then feed thru the other Fem-V
another cannula in to the PA (I am not sure the best cannulas for this - by
Tandem has some stuff which is good).  Then when the RVAD is weaned, just
pull them out from the groins (which may need to be closed - but this can be
done at the bedside) - or at least it does not involve opening the chest
again.

-michael

On 9/5/07, Ani Anyanwu <anianyanwu at hotmail.com> wrote:
>
> I think at this stage no form of RVAD will be beneficial. Like in all
> other scenarios, if a VAD is placed too late the chances of success are very
> slim. The timing to place any post cardiotomy VAD (if available) would be in
> the initial OR setting as an alternative to sending the patient to ICU on
> high dose inotropes and open chest.
>
> Post-cardiotomy VADs, and in particular RVADs, are not good salvage tool.
> While they can prevent deterioration in end-organ function, and maintain
> organ perfusion while awaiting cardiac recovery, they will only rarely
> reverse progressive decline if placed hours or days after such dysfunction
> has already taken place.
>
> I would be keen to hear from others experience but I suspect those cases
> where it was successful was when it was placed during or shortly after the
> initial operation. With availability of simpler VADs (such as the tandem
> heart Dr Salerno suggested which is now available in many cath labs)
> temporary RV support can be easily instituted in most institutions.
>
> Ani
>
>
>
> > Date: Wed, 5 Sep 2007 07:11:19 +0530> From: prasannasimha at gmail.com> To:
> OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] aortic root
> reimplantation and Rv dysfx> CC: > > 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 21:56:4
> 4 +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, T
> rival 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,dire
> ct 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 > >
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