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Last Post:
Apr 1, 2009 4:40 PM
by: George Tolis
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Posts:
49
Registered:
9/23/08
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Cardiothoracic Safety Reporting System - New Vignette January 2009
Posted:
Jan 6, 2009 7:37 PM
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Reported by: Surgeon
Primary Problem: practice norm need to be changed
Operative Category: Valvular Heart Disease
Procedure: Others (Specify)
Thousands of patients have undergone tricuspid valve (TV) surgery, either isolated or combined with mitral repair/replacement. This is usually performed without the aortic cross clamp. As I was repairing and testing the TV in such a case ST segment changes occurred acutely. I suspected compromise (perhaps tenting) of the right coronary artery (RCA) by sutures in the repair Band in the TV annulus. These were removed immediately but the ST changes persisted. Upon inspecting the RCA and its branches, I noticed tiny air bubbles. Immediately a cross clamp was applied and warm/cold cardioplegia given in both the aortic root, and via the coronary sinus with a vent in the root. This resulted in the aspiration of a significant volume of air bubbles. Inspection of the septum was consistent with preop ECHO findings, revealing no VSD and perhaps a pinhole patent foramen ovale (we could not pass a small probe through it into the left atrium). This was sutured. The post op ECHO also showed tiny bubbles of the type routinely seen post mitral and aortic surgery. The patient woke up with no deficit. Using CO2 to flood the pericardium may have changed the composition of these air emboli sufficiently to prevent a major complication. I believe after this experience it may be a mistake to open the Right side of the heart and assume that positive pressure in the aortic root or the LV/LA will prevent aspirating small (or large) volumes of air into these chambers. I also believe that vigorous testing of the TV with the right side open has the potential to force air through the lungs into the LA, LV, aortic root, RCA and carotid arteries.
Human Factors Analysis: CTSNet would like to hear your thoughts on how you would have handled a similar situation.
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Posts:
30
Registered:
9/23/08
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Re: Cardiothoracic Safety Reporting System - New Vignette January 2009
Posted:
Jan 22, 2009 6:37 AM
in response to: Thomas Ferguson
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Excellent point, haven't noticed it ever, but your observations are legitimate. I would consider having the clamp on for right sided repairs as well from now.
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Re: Cardiothoracic Safety Reporting System - New Vignette January 2009
Posted:
Mar 29, 2009 8:32 AM
in response to: Thomas Ferguson
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As common practice, we always look for communications between L&R sides of circulation before proceed to the planned procedure. A small PFO or a residual VSD dected from TEE is closed by fibrillation or even crossclamping/ cardiac arrest. A tiny atrial septal deffect can easily introduce air to the left side. That was excellent pick up which resulted in a good outcome.
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Posts:
28
Registered:
9/23/08
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Re: Cardiothoracic Safety Reporting System - New Vignette January 2009
Posted:
Apr 1, 2009 4:40 PM
in response to: Thomas Ferguson
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I agree with your actions after recognizing what the problem is. The only thing I would point out is the approach to the tricuspid valve. Even in the most time consuming operation involving a tricuspid annuloplasty (such as multi CABG/MVR/TVR), I never take off the clamp for the tricuspid repair. Opening the right atrium, getting the stitches and the ring in and closing the atrium can be achieved in 20 minutes easily. The field is clean, the stitches are accurately placed and the aorta is not in your way between the 8 and 11 o'clock position, reducing the chance of your annuloplasty stitches injuring the aortic leaflets. It is well worth the extra twenty minutes of ischemia.
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