[HSF] aortic root reimplantation and Rv dysfx

[Tohru Asai]

erdinc
I came late to this topic. I am sorry to hear the sad outcome. It is easier
said than done always. But let me put my comment.

First of all, why you started to cool down during coronary anastomoses?
Althouth I usually do complex cases all clamped with cardioplegia, I would
have kept normothermic during coronary anastomoses in your strategy to avoid
ventricular fibrillation or any LV instability, especially with the impaired
LV function. Also from your description of proximal RCA being 1.5 cm (huge
ectatic!). It might have caused atheroembolisation to branches of RCA,during
distorting the heart for OM anastomosis ( just a possibility )

At the time of LV distension, what I think should have been done was LV vent
via apex or via RSPV immediately. Then switching from a single venous
cannula to bicaval cannulation with snears. I would have open RA to put
pursestring suture around CS and start "direct" coronary sinus cardioplegia.
( Sorry for anecdote, but this is my routine for all valves and believe
Septal and RV protection is much better. Anatomically the tip of retrograde
cannula with RA pursestring tends to go beyond orifices of middle cardiac
vein and small cardiac vein that are responsible for inferior, septal and RV
free wall perfusion. I have arrested more than 3 hours only with this
CS-pursestring retrograde intermittent cold blood cardioplegia  and weaned
CPB with mild dose of inotropic in a complex case.) Anyway, antegrade root
administration of cardioplegia was not good idea without vent and competent
aortic valve in this situation, even though with root suction and LV
compression. What happened was probably inadequate and mal-distribution of
cardioplegic solution. Ani's comment was generally right, but there should
be one condition. Good distribution and adequate amount of cardioplegia
delivery to myocardium should be guaranteed. Increased LV subendocardial
pressure without venting might have played a harmful role to diminish
collateral distribution to RV territory.

I cannot say anything about RCA revascularization without watching angiogram
as well. ( I might miss some info about exactly where is occlusion of RCA
and any tiny collaterals from LCA.) With understanding Hal's point and
erdinc's answer, there seemed not much to be done.

At the end, I personally don't think RCA endarterectomy was a good idea
especially in such a desparate situation. Even with 1 mm lumen found in
distal RCA, I would have tried direct anastomosis and stay away from
endarterectomy, which may potentially occlude valuable braches with remnant
plaque. But probably you did not have an option. I just recalled a long
heated discussion of LAD endarterectomy early in this year.

Anyway thank you for sharing your tough case. I learned a lot from many
experienced members.
-- 
Tohru Asai