The Florida Society of Thoracic & Cardiovascular Surgeons 2012 - - PowerPoint PPT Presentation

The Florida Society of Thoracic & Cardiovascular Surgeons

Ocean Reef Club Key Largo, Florida

2012 Annual Meeting

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 EndoVent Pulmonary Vent EndoPlege Coronary Sinus Catheter QuickDraw Venous Cannula

TM TM

EndoVent Pulmonary Vent

• Thin wall, 8.3 Fr

design provides high flow rates to ensure adequate venting in all sizes

• f patients.
• Non-heparin coated

EndoVent

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
• f venous blood
• Median sternotomy performed, with manual

control of bleeding, canulation and institution

• f 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