[HSF] Any One Had This Complication?

[Ani Anyanwu]

Before the bandwagon leaves, can I just ask we step back and look at alternate possibilities here. 
 
I know the IMA theory seems attractive but why then should a ligated IMA select out a colon for ischemia? There are numerous cases of GI ischemia in cardiac surgical patients who do not have IMA take down. Hal's patient was a vasculopath, elderly and had a long complex operation so has plenty reasons to have gut ischemia. While nowehere near as sexy or exotic, I would postulate that this complication was more likely due to the usual suspects - thrombosis, embolization or hypoperfusion - than to a ligated IMA. Even the axillobifemoral graft may be more likely to blame as any kinking, pressure, altered flow, or thrombosis in this graft intraoperatively could lead to gut hypoperfusion and there is also a possibility of steal phenomena during CPB with the limbs taking preference over the viscera which now become the most distal branches. I would not be surprised if even this complication has been seen spontaneously in patients with axillobifemoral graft who have not had any cardiac surgery. Actually a while ago one of my colleagues had a patient who had an aortic diversion operation for an inoperable thoraco-abdominal and developed gut ischemia some weeks after surgery. 
 
While the IMA hypothesis is very interesting I suspect there may be too much superthink here and we are ignoring more likely simpler explanations.
 
Ani
 
 > From: smschwartz at mac.com> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Any One Had This Complication?> Date: Sun, 27 Apr 2008 16:11:51 -0700> CC: > > Hal,> Very interesting timing. I did an aortic root replacement (27mm SJM > with valsalva graft), coronary reimplantation and RIMA-RCA for 80% > proximal RCA stenosis in a 65 yo man WITHOUT history of significant > vascular disease (and good distal pulses on exam). He had two bloody > stools the evening after surgery, but only a mild metabolic acidosis. > The following morning, hemodynamics were stable, but CK was about > 5000, with very little MB fraction. GI medicine has seen him, his > abdomen in non-tender, and he seems to be resolving what we think was > a transient bowel ischemia. Pump flows were >5 l/m, he had no acidosis > during the pump run, but was significantly vasodilated during and > after bypass (requiring vasopressin infusion to keep his BP > 50 > mmHg). He was on 320mg of Diovan in addition to beta blockers preop.> Any thoughts?> Steven Schwartz> > On Apr 27, 2008, at 5:49 AM, Hgrmd at aol.com wrote:> > > Dear Members,> > Last Friday was a tough day at the office. First I did a mitral,> > tricuspid, Cox-maze, CABG x1 on a 72 yo lady. I then did an AVR, > > MVR (heavily> > calcified posterior annulus), tricuspid, CABG x 4, Cox-maze on a 78 > > yo man. His> > past history was notable for the fact that he had an aorto-enteric > > fistula> > (previous AAA repair) requiring excision of the graft and a right> > axillary-bifemoral bypass. Intraop, I noticed that the LIMA had > > unusually brisk flow.> > About 4 hours postop, he had a bright red stool. NG aspirate > > nonbloody. By> > yesterday afternoon, he had begun to develop abdominal tenderness. > > He had a lap> > in the early evening. There was a dead colon requiring resection. > > The small> > bowel reportedly looked ischemic, but viable. He's much better this> > morning, though he's now developed ATN. His heart is working > > great. It'll be a> > struggle, but I'm cautiously optimistic he'll make it. Anybody > > seen this> > scenario?> >> > Hal> >> >> >> > **************Need a new ride? Check out the largest site for U.S. > > used car> > listings at AOL Autos.> > (http://autos.aol.com/used?NCID=aolcmp00300000002851)> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the > > policies and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> > Steven M. Schwartz, MD> smschwartz at mac.com> > > > > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
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