The Florida Society of Thoracic & Cardiovascular Surgeons 2012 Annual Meeting Ocean Reef Club Key Largo, Florida
CASE PRESENTATION Alfredo Rego MD, PhD South Florida Heart and Lung Institute
INTRA-OPERATIVE NIGHTMARES
Minimally invasive Mitral Valve Replacement New approach; New technology New problems
COMPLICATIONS OF INTRA- AORTIC BALLOON CLAMPING DURING MICS
Case Study 71 yr old white female non smoker with a history of Severe insufficiency of the mitral valve with prolapse Of both the anterior & posterior leaflets. Progressive symptoms of dyspnea on exertion, palpitations, and near syncope episodes over the last several months. Medical Hx: cardiac Arrhythmias, Gerd Family Hx: Non contributory Allergies: Codeine & Iodine
Pre-op Studies and Tests • TTE & TEE: Moderate to severe Mitral Regurgitation, No wall motion abnormality. Mild pulmonary HTN • Cardiac Catheterization: 50% Stenosis of the Mid LAD • EF 50% • Abnormal Platelet study PFA (EPI & ADP) > 300 Hematology consult obtained • PFT within normal limits • Patient Prepped for surgery per protocol • MICS approached planned
Surgical Procedure • Minimally invasive Mitral valve repair or replacement with left lateral thoracotomy • Successful Femoral Cannulation • TEE guided Endo-balloon delployment • CPB via groin cannuation • Excellent arrest with cardiolplegia (antegrade & retograde). • Procedure initiated without problems
Soft Tissue Retractor Placement Used For All Platforms
Port Access Cannulation Strategy • Heart Lung Machine Functions Performed From The Jugular and Femoral Areas
EndoPlege Coronary Sinus Catheter PA Vent CS Catheter
ENDOCLAMP* System EndoClamp Occlusion Balloon EndoPlege Coronary Sinus Catheter EndoVent TM Pulmonary Vent QuickDraw Venous Cannula TM
EndoVent Pulmonary Vent • Thin wall, 8.3 Fr design provides high flow rates to ensure adequate venting in all sizes of patients. EndoVent • Non-heparin coated
Novare Minimal Invasive Cross Clamp
Surgical Procedure • Shortly after initiating case low systemic pressure was noted • High Aortic line pressures noted by the perfusionist • Equal pressure both arms • TEE confirmed a flap at the level of the Ascending Thoracic Aorta • The balloon was deflated, development of proximal dissection noted • Minimally invasive approach aborted Median Sternotomy was initiated at this time.
Surgical procedure • The patient was cooled to 15 degrees • Opened the ascending Aorta and RCA tied off. • Ascending aorta repaired • Re-suspended the Aortic Valve at the level of the Right & Left Coronary Cusps • Circulatory arrest • Distal repair done to reconstitute forward flow
Surgical procedure • Proceeded with mitral valve procedure • Left atrium closed. Interposition graft compleated • RCA bypass done • Post-op by EF 45% , with no mitral or Aortic insufficiencies • Right Heart Failure noted 20 mins after the procedure • Placed back on Cardiopulmonary bypass • Coronary flows checked by flow probe analysis; which revealed excellent flows • Pacer wires placed, Sternotomy closed, Transported to CVICU
Post Operative course • Post op bleeding secondary to coagulopathy requiring multiple rounds of PRBC and Products • Patient maintained on high doses of pressors • Glycemeic control by Glucommander • Developed Renal Failure, Resp. Failure, Shock • Expired on the third post op day
Comments on MICS • Adoption of MICS technology • Percentage of Surgeons performing MICS • Learning experience • Push by Cardiologists and Patients • Team approach to developing a program • Patient selection • Pearls from the experts
Laser Assisted Cardiac Lead Removal How to manage Intra-operative complications
CENTRAL VENOUS AVULSION DURING LASER LEAD EXTRACTION
Clinical History 55 year-old male with history of non-ischemic dilated cardiomyopathy and non-sustained ventricular tachycardia. Single chamber ICD implanted in 2005 and upgraded with ventricular pacing lead in 2006. Patient presents with a fractured Fidelis Lead with inappropriate discharge, electrical storm and a persistent buzzing sound.
Past Medical History • Myocarditis of unknown etiology • CHF with multiple hospital admissions • Non-sustained VT • T-cell Lymphoma • Remote atrial lead replacement • Cardiomyopathy since 2005 (EF 20%) • Ex- drinker and ex-smoker • Appendectomy and vasectomy
Indications for Lead Removal • Fractured malfunctioning RV defibrillator lead with inappropriate firing of ICD, in conjunction with a CRT-D device upgrade • HRS/NASPE Class II indication
Procedure • Performed under GET • Intra-op TEE • CPB primed and in the room • Femoral arterial and venous access • Radial arterial access and neck CVL • Open-heart team • Surgeon and Cardiologist in the room
Procedure • Pocket incised and generator explanted • Dense adhesions noted throughout • Leads dissected free • The screw-in defibrillator lead was unscrewed then cut and prepared for removal with the Spectranetics Laser Sheath (SLS II) • A lead locking devise (LLD) was inserted, advanced to the tip and locked
Procedure • Extraction was initiated with a 14 Fr SLS II lase sheath in conjunction with an outer sheath • Resistance was found at the costo-clavicular angle and through the first part of the endovenous portion • A 16 Fr Sheath was the used and advanced to the distal innominate vein but found resistance at the subclavian junction
Procedure • 14 Fr SLS 2 min and 23 sec, 5792 pulses • 16 Fr SLS 5 min and 23 sec, 13060 pulses • Sheath advanced through the binding site at the SVC. • First sign of hypotension noted • No pericardial effusion by TEE • Right lung border sharp by Fluoroscopy • Hypotension persisted
Procedure • Resuscitation initiated via femoral line • Right thoracostomy performed with returned of venous blood • Median sternotomy performed, with manual control of bleeding, canulation and institution of CPB • Exploration under hypothermic arrest • Evulsion at the level of distal innominate, subclavian and SVC.
Procedure • Retained lead extracted open • Injury repaired with pericardial patch for the SVC – Subclavian and hemashield tube from innominate to RA • CPB 167 mins • Severe bi ventricular failure with sustained VT • Severe coagulopathy • Intra op death
Comments on Lead Extraction • Adoption of this technology • Percentage of Surgeons performing LE • Learning curve and experience • Not for everybody • Team approach to developing a program • Patient selection • Pearls from the experts
Comments on Lead Extraction • Indications for lead extraction • Surgical options • Surgical Complications • Management of intraoperative complications • Discussion of Clinical Case • Patient outcomes • Conclusions and Recommendations
Name the tumor
“Bad day at the Dentist”
Young patient with Intractable Hiccups
Recommend
More recommend
