AW: AW: [HSF] aortic root reimplantation and Rv dysfx

Fri Sep 7 04:41:23 EDT 2007

Ani,
I saw beating hearts dilatation ending in catastrophes, also on pump.
Sometimes, not always  it is better to clamp and go on.

For breakdown of air conditioning I suggest Shumway´s myocardial protection
method.
Roberto

-----Ursprüngliche Nachricht-----
Von: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Ani Anyanwu
Gesendet: Mittwoch, 5. September 2007 19:27
An: openheart-l at lists.hsforum.com
Betreff: RE: AW: [HSF] aortic root reimplantation and Rv dysfx

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: İnappropriate RV preservation .Any additional measures could>
been taken ???> erdinc > _______________________________________________>
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