[HSF] aortic root reimplantation and Rv dysfx

[erdinç naseri]

Dear Tohru,
> 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. 
1.I usually do the distal coronary anstomosis while cooling the patient in order to decrease the X-clamp and CPB time.Distorting the heart lead to increased AR and in turn LV distention( for several seconds) not cooling.Have used this strategy in tens or may be hundred and so of long cases with no problem.
 
 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 )
2.RCA was externally huge but on CAG is was a several cm dilated stump of the RCA so there was no possibility of embolization ( no distal run off)> > At the time of LV distension, what I think should have been done was LV vent> via apex or via RSPV immediately.
3.In these cases if the  temperature isn't still very low the cardiac activity will revert to normal as soon as you put back the heart in the pericardial sac.IMHO there is no need to hastilly put a L heart sump but if the cardiac activity is not good enough and LV distention continues your statements are quiet right.
 
 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.)
 
4. You are right direct CS insertion gives much more control of the retrograde than through Ra purse suture.
 
 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.4.LV distention was a matter of seconds not even one minute, so it is not a factor in the quality of myocardial protection in that case.
> 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.
 
5. Sometimes coronary endarterectomy is the only option because you can't surure  a graft to a rocky tissue.This was the case and open endarterctomy  and patch angioplasty ended far more distal than the beginning of PDA.
thanks for your valuable comments
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