[HSF] Aortic dissection and CPR

Sat Sep 15 23:47:27 EDT 2007

I agree with you Ani, it is worthwhile cannulating the
dissection directly, as this is easier. The potential
true lumen should be visible on scan, but as you say,
it does not matter if false lumen is cannulated.
For more stable cases it is quite feasible to
cannulate the innominate artery with a normal aortic
cannula, and this takes less time than axillary.

For patients undergoing CPR, such as John`s case
described below, I think it would still be worthwhile
to expose the femorals, and if no more than another 5
mins have passed, then you can resuscitate them on the
pump and cool them down. If you can treat the
immediate cause of death (shock, tamponade, coronary
occlusion), then it is worth doing so. If the
dissection itself does not look like it is going to
rupture it would then be best to wean off the pump,
close up, and see if the patient wakes up. If he wakes
up then proceed with the final repair!

I have had many pleasant surprises when I have tried a
last ditch resuscitation attempt, always with severe
criticism from the anaesthesiologist.

By the way, that last dissection of mine we discussed,
came for his follow up in my rooms this week....fully
functional.

Dave Harris

--- Ani Anyanwu <anianyanwu at hotmail.com> wrote:

> 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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Dr. David G. Harris, FCS, MMED,
Cardiothoracic Surgeon        
Suite 207                                
Kuils River Private Hospital,        
PO Box 1200, Kuils River, 7579, Cape Town, South Africa.            
Tel +27-21-9006411             
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