[HSF] Aortic dissection and CPR

Ben Bidstrup benjamin.bidstrup at bigpond.com
Fri Sep 14 09:49:20 EDT 2007 

I have seen and heard of similar events when femoral cannulation is 
used. Take the clamp off the distal anastomosis and the false lumen 
blows up. No head circulation and off to the basement.

I have used direct cannulation when axillary has not been successful.

Has any one any tricks re axillary cannulation esp determining 
whether it is involved. I had one that I am sure dissected (more ?) 
when the pump was turned on and the perfusion pressure went to 300 mm 
Hg.



>Nand
>
>Are you sure transapical is quickest? I would like to hear from 
>surgeons who actually use this approach in practice, but I doubt 
>that it would truly be the quickest for surgeons not experienced in 
>its use. For what is already a desperate tense situation, making an 
>LV incision and guiding a cannula into the aorta may not be as 
>simple as it sounds.
>
>IMHO the quickest way if patient is in extemis or malperfusing is to 
>cannulate the dissection directly and as all surgeons are used to 
>the manouver of aortic cannulation they should be able to effect it 
>even in emergency. Several groups use direct cannulation for all 
>dissections and from what I understand it does not matter whether 
>the cannula ends up in true or false lumen provided the patient foes 
>not malperfuse (had one last year where on opening the cannula tip 
>was clearly in false lumen but the patient perfused okay).
>
>Ani
>
>
>
>
>
>>  Date: Thu, 13 Sep 2007 21:43:45 +1200> From: nkkejriwal at gmail.com> 
>>To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Aortic 
>>dissection and CPR> CC: > > We had two patients in the unit who 
>>arrested before reaching the OR. None of> them survived the repair. 
>>Recently, I had another case who arrested while> being transferred 
>>to theatre. He was intubated and CPR continued. My initial> plan 
>>was to establish bypass through femoral vessels while someone else 
>>was> massaging. However even external massage was not producing 
>>enough pressure> and this had been going on for over 10 minutes. 
>>TEE revealed pericardium> full of blood with empty heart. I did not 
>>proceed.> > John> > I agree that the quickest way to institute 
>>bypass would be transapical. What> cannula do you use?> Nand> > On 
>>9/11/07, jbflegejr at aol.com <jbflegejr at aol.com> wrote:> >> > I have 
>>had salvage of two patients who ruptured while on the operating> > 
>>table as they were prepared for anesthesia. They had not been 
>>induced> > completely but we opened there sternum anyway. One had 
>>femoral artery> > cannulation by a colleague, the other I 
>>cannulated through the> > ascending aorta as recently described by 
>>Curt Tribble. Both had no> > neurologic sequale. In one during the 
>>excitement I made the disal> > anastamosis a bit tight in effect 
>>causing an ascending aortic> > coarctation and he got hemoytic 
>>anemia from intraluminal felt and a> > year or so later I resected 
>>the area. If I encounter another case> > needing immediate 
>>cannulation, I will cannulate the ascending aorta> > through the LV 
>>apex which is quick and works well. I had another> > patient who 
>>presented in the ER in shock and with hyperacute ischemic> > ECG 
>>changes across the anterior leads. He had been worked up and a> > 
>>diagnosis of ascending aortic aneurysm and aortic insufficiency 
>>and> > normal coronary arteries established and operation scheduled 
>>for the> > day after Christmas but he came back the day before 
>>Christmas and went> > straight to the OR. He had a Type A 
>>dissection extending into and> > obstructing the Left coronary. I 
>>replaced the ascending aorta which> > relieved the coronary 
>>obstruction and replaced the valve with a> > Starr-Edwards valve. 
>>This was 35 years ago. About 25 years post op he> > had a CT scan 
>>for some reason and the radiologist saw that he had an> > aortic 
>>dissection down to the femorals and got rather excited about it> > 
>>and sent me the films. I did not recommend treatment. In modern 
>>times> > this kind of patient would have an aortic root 
>>replacement. John Flege> >> >> > -----Original Message-----> > 
>>From: tdmartin2000 at aol.com> > To: OpenHeart-L at lists.hsforum.com> > 
>>Sent: Mon, 10 Sep 2007 9:06 pm> > Subject: Re: [HSF] Aortic 
>>dissection and CPR> >> >> >> >> >> >> > Most of these pts with 
>>sudden deterioration have rupture into their> > pericardium> > and 
>>are not salvageable. I have attempted on multiple occasions and> > 
>>have had 2> > that we got out of the OR only to have anoxic 
>>cerebral deaths. If they> > have> > tamponade, CPR does no good, as 
>>you cannot fill. One of the ones we got> > out of> > the OR 
>>actually had arrest right after induction of anesthesia and we> > 
>>were on> > pump in under 10 min.> >> >> >> > Tom Martin> >> > U of 
>>Florida> >> > Gainesville> >> >> > -----Original Message-----> > 
>>From: james le <jamesle2007 at yahoo.com>> > To: 
>>OpenHeart-L at lists.hsforum.com> > Sent: Mon, 10 Sep 2007 6:35 am> > 
>>Subject: [HSF] Aortic dissection and CPR> >> >> >> >> > We recently 
>>had a case of Aortic dissection transferred from some> > other> > 
>>hospital for surgery. He had dissection aorta involving the 
>>entire> > aorta along> >> > with severe AR.> > On arrival BP was 90 
>>systolic, all pulses palpable and there> > was no> > neurological 
>>deficit> > At ER he suddenly developed severe Bradycardia and 
>>arrested and> > resuscitation was unsuccessful. TEE done after 
>>death showed only> > small amount> > of pericardial 
>>collection.> >> > During CPR we had a concern that vigorous massage 
>>could rupture> > aorta.> > How can we salvage such patients?> >> > 
>>Percutaneous bypass before we take to OR will help?> >> >> >> > 
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-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon

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