AW: [HSF] aortic root reimplantation and Rv dysfx

Wed Sep 5 19:26:56 EDT 2007

Dear Roberto

I agree with what you say. In the present day of modern myocardial protection, there is generally no longer a need for speed or systemic hypothermia as a method of myocardial preservation. Obviously erdinc's situation is different as unpredictability of myocardial protection, logistic problems such as with breakdown in airconditioning and maybe varied ability to ensure good quality cardioplegia may mean speed and hypothermia continue to be important (such as in his recently reported AVR case). 

I discussed the issue of hybrid approaches recently with a colleague and would be interested to know other's opinions on it. I know for example Dr Salerno would likely advocate doing all the CABG without CPB then going on pump to do the rest beating. However, what does one gain with such hybrid approaches? In erdinc's case, the attempt to do the grafts beating heart, albeit on pump, probably worsened rather than helped the situation (for example, even perfused myocardium could become ischemic during LV distension). What specifically is the advantage of not clamping the heart and doing the CABG as the heart will be clamped anyway? With modern myocardial preservation, are the risks of the ischemia still time dependent? I can understand the logic of avoiding ischemia entirely as Salerno and some others would do, but if one is going to render the heart ischemic anyway, what is the down-fall of an extra 15 to 30 minutes of ischemia to additionally perform two grafts?

Ani

> From: battr at medizin.uni-leipzig.de> To: OpenHeart-L at lists.hsforum.com> Subject: AW: [HSF] aortic root reimplantation and Rv dysfx> Date: Wed, 5 Sep 2007 17:31:53 +0200> CC: > > Erdinc,> It seems a little confuse and complicate OP.> If you have 3 vessel disease with impossibility of revascularization of the> RCA, you must do LIMA-LAD and radial to OM in a 62 years old patient.> Retrograde cardioplegia, with the balloon in the ostium of the CS plus> ostial cardioplegia are excellent protection. A very little RCA doesn't need> to be revascularized but the RV needs to be protected.> Was the aortic valve insufficient? Then the best protection is to begin with> retrograde and when you have given 1000 ml of blood cardioplegia, add 500 ml> through the RCA ostium. And repeat blood retrograde each 20 minutes.> If you do it complicate you win 15 minutes clamping time doing beating heart> and you may loose 30 minutes of pump run...> Why did you cooled so much? It was not a circulatory arrest??> > I would have not done the endarterectomy if the artery was a little one. And> the tricuspid annuloplasty, was it "intuitive" or after TEE? > Do it simple is the first law.> Roberto> > -----Ursprüngliche Nachricht-----> Von: openheart-l-bounces at lists.hsforum.com> [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von erdinç naseri> Gesendet: Dienstag, 4. September 2007 17:12> An: openheart-l at lists.hsforum.com> Betreff: [HSF] aortic root reimplantation and Rv dysfx> > > 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> -----------------------------------------> > _______________________________________________> 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> -----------------------------------------
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