AW: [HSF] aortic root reimplantation and Rv dysfx

[erdinç naseri]

DEar Dr.Harris,
I reviewed the patient's chart.He was given 6600 cc of blood cardioplegia and 90 mEq K through the procedure.I doubt that we would be able to give more than that.
erdinc> Date: Wed, 5 Sep 2007 22:40:02 +0100> From: drdharris at yahoo.co.uk> Subject: RE: AW: [HSF] aortic root reimplantation and Rv dysfx> To: OpenHeart-L at lists.hsforum.com> CC: > > 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> > -----------------------------------------> > > > > _______________________________________________> 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> -----------------------------------------