[HSF] tricuspid noncoaptation

[erdinç naseri]

Dear forum members,
Before reading all your kind responses to my posting I would like to inform you about the patient.
Yesterday I operated her.Since preop CT showed near total close contact between the cardiac structures and sternum I decided to go thru R chest .Preoperatively  we put a pigtail in the aorta at the level of celiac trunk( which incidentally was a very small artery).L femoral arterial cannulation and R anterior thoracotomy.( continous NTG thru pigtail). Dense adhesion of the cardiac structures .Unable to isolate aorta .Selective SVC and IVC cannulation with balloon tiped cannulaes.On CPB and opened RA.RA and RV act as a single chamber.Leaflets wrer merely adhesed to the RV wall.Tricuspid valve annulus was very far from the atriotomy incision( because of the apical adhesions)Though from the beginning it was almost obvious that annuloplasty won't work I decided to give a chance.Put semirigid ring (30 mm).Result was a wide open tricuspid annulus.Explanted it and put a 29 mm Sorin MORE bioprostesis .There was no problem in the appearance of the the valve. Closed RA and asked  for an epicardial echo. +++ central TR .Opened RA  and examined the valve. Couldn't figure out the problem.( sutures had been passed while the valve was out of the annulus(single pledgetted sutures).While explanting the valve the  cardiac activity seemed to be depressed( temp 37,MAP 55, good urination ).VF  and several bouts of defibrillation gave nothing.Put  a LA sump( thru atrial septum) and cooled to 20 C. TCA with RCP thru SVC and effluent coming out of femoral artery with SO2>60% and PO2 >30.Arrest time 28 minutes.Retrograde blood cardioplegia for induction ,maintenance and hot shot. Put  31 MORE bioprosthesis.Annulus somehow traumatized by previous sutures but no major problem happened.Deairing from LA thru atrial septum.Warming with spontaneous cardiac activity.Weaning with inotropics .Epicardial echo showed a normal prosthesis with no regurg.Now at postop 14.th hour   she is not awakened .She started having diaphragmatic and later on bilateral lower extremity muscular jerks.Diagnosed as seizures and started Epdantoin and diazepam with no response.Pentobarbital was started and the seizure activity ceased.Venous bloog gas thru reverse L IJV showed PO2 34 and SO2 61%.Now the problem is much bigger and again any advice will be welcomed.
erdinc