[HSF] off-pump CABG and mesenteric ischemia

[erdinç naseri]

Dear Dr. Harris,
There was fresh thrombus retrieved from R iliac artery.
errdinc> Date: Sun, 25 May 2008 10:10:16 +0000> From: drdharris at yahoo.co.uk> Subject: Re: [HSF] off-pump CABG and mesenteric ischemia> To: OpenHeart-L at lists.hsforum.com> CC: > > It sounds like you are describing progressive dissection of the aorta??> > ....progressive bowel ischaemia, then progressing to the iliac...??> > > > 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 > Fax +27-21-9006412 Mobile +27-83-3309587> > > --- On Sat, 24/5/08, erdinç naseri <enaseri at hotmail.com.tr> wrote:> > > From: erdinç naseri <enaseri at hotmail.com.tr>> > Subject: [HSF] off-pump CABG and mesenteric ischemia> > To: openheart-l at lists.hsforum.com> > Date: Saturday, 24 May, 2008, 7:00 PM> > I would like to share the following case and have the> > members' thoughts:> > 76 Y/O female,had acute inferior MI 5 days ago with post MI> > chest pain on full medication( including aggrastat) and> > sedation in ICU> > CAG:3 vessel disease with diffuse LAD and CRX lesions ,RCA> > completely occluded with TIMI I flow.Not suitable for PTCA> > and reffered for urgent CABG.> > taken to operation 6 days after AMI.> > Uneventful off-pump CABG( LAD,D1,OM2;OM3,PDA).Lima> > harvested but not used because of the dissection in the> > mid-segment.Fresh thombus in the RCA and arteriotomy> > site.After closing the sternum the anesthesiolgist noticed> > that temp was 33C.Started having multifocal VPC.s.Put> > NGtube and started warming by warm saline through NG and> > foley cath and externaly by blanket.One bout of VF which> > was successfully defibrilated.Took 90 minutes to bring the> > temp to 36.5. Taken to ICU stable with no inotropes and in> > sinus rhythm.Anticoagulated after few hours and ceasation> > of drainage with 4X 1 cc heparin.( routine off-pump> > protocol)Extubate on 12.th hour.Lab completely normal.ABG> > normal.Now after 10 hours she developed severe abdominal> > pain.Consulted with general surgeon .We pushed him to do an> > exploratory lap .on lap everything was normal except> > dilataion of colon ( no sign of necrosis,msenteric vessels> > pulsatile end bleeding, colon shiny but somehow dilated )> > small bowel + for peristalsi> > s but colon was silent. She had adhesions around the R> > upper quadrant due to previous cholecystectomy.Put rectal> > tube and and drains in Douglass and paracolic gutters and> > closed abdomen.TEE+TTE showed good cardiac action and no> > tamponade She was in good condition and with no pain on> > CPAP 10 hours after lap.In a matter of 30 minutes she> > developed R foot drop and no pulse there.R femoral arterial> > cath was withdrawn with no improvement .Started having> > metabolic acidosis. Bedsite femoral embolectomy revealed> > acute occlusion of the R ilia c artery with good antedgrade> > and retrogrde flow.Arteriotomy closed primarily but the limb> > didn't improved .opened the arteriotomy .good forward> > bleeding but no back bleeding .did embolectomy. nothing> > retrieved . washed with heparinized serum and local> > anesthetic.no back bleeding .Closed areteriotomy with patch> > and put a line inside the artery and started giving> > NTG.Opened femoral vein .let it bleed 1-2 minutes and then> > closed the vein. Limb im> > proved but metab acidosis progressing very severely.> > called general surgeon and opened the abdomen. To the> > suprise of the general surgeon ( he was against reopening)> > colon was dead from ceacum to the junction of sigmoid.Total> > colectomy and ... .Unfortunate end.> > What would be members' strategy in this patient.(> > PS:hemodynamics very stable untill late in the process with> > good urinationand CBc and ABG.On sinus rhythm untill the> > last hours .> > > > _______________________________________________> > 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> > -----------------------------------------> _______________________________________________> 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> -----------------------------------------