AW: [HSF] aortic root reimplantation and Rv dysfx

Wed Sep 5 23:40:02 EDT 2007

I am not too sure that speed does not make a
difference. If Erdink had done the procedure in an
hour, maybe the story would have been different. No
matter how superior our cardioplegic cocktails are, we
cannot always presume that the stuff is getting there
and washing out the H+ ions. Shukri Kouri has shown
this with his myocardial pH studies.

It looks like a case of inadequate cardioplegia
delivery to the RV. Retrograde does not get to the RV
too well, and I presume he had a case of an AV groove
area which was almost standing still - I am surprised
he got the patient off the pump....well done. I think
these cases do better with larger volumes of
cardioplegia (initially), given only antegrade, so the
RV can get plegia via the left sided collaterals.

I would have re-implanted the RCA osteum if the pre-op
angio had showed some flow still to the prox 1/3 of
the RCA...it is easy for me to comment now, but maybe
this blood flow was interrupted by the surgery.

Dave Harris 
--- Ani Anyanwu <anianyanwu at hotmail.com> wrote:

> 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 veno
>  us> 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 t
>  he 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: Ýnappropriate 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 poli
>  cies and > disclaimers posted at:>
> http://www.hsforum.com/listdisclaim>
> -----------------------------------------
>
_________________________________________________________________
> The next generation of MSN Hotmail has arrived -
> Windows Live Hotmail
> http://www.newhotmail.co.uk
> _______________________________________________
> 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
> -----------------------------------------
> 