The Florida Society of Thoracic & Cardiovascular Surgeons

Transcription

1 The Florida Society of Thoracic & Cardiovascular Surgeons 2012 Annual Meeting Ocean Reef Club Key Largo, Florida

2 CASE PRESENTATION Alfredo Rego MD, PhD South Florida Heart and Lung Institute

3 INTRA-OPERATIVE NIGHTMARES

4 Minimally invasive Mitral Valve Replacement New approach; New technology New problems

5 COMPLICATIONS OF INTRA- AORTIC BALLOON CLAMPING DURING MICS

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7 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

8 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

9 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

10 Soft Tissue Retractor Placement Used For All Platforms

11 Port Access Cannulation Strategy Heart Lung Machine Functions Performed From The Jugular and Femoral Areas

12 EndoPlege Coronary Sinus Catheter PA Vent CS Catheter

13 ENDOCLAMP* System EndoClamp Occlusion Balloon EndoPlege Coronary Sinus Catheter TM EndoVent Pulmonary Vent QuickDraw Venous Cannula TM

14 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

15 Novare Minimal Invasive Cross Clamp

16 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.

17 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

18 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

19 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

20 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

21 Laser Assisted Cardiac Lead Removal How to manage Intra-operative complications

22 CENTRAL VENOUS AVULSION DURING LASER LEAD EXTRACTION

23 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 Patient presents with a fractured Fidelis Lead with inappropriate discharge, electrical storm and a persistent buzzing sound.

24 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

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27 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

28 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

29 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

30 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

31 Procedure 14 Fr SLS 2 min and 23 sec, 5792 pulses 16 Fr SLS 5 min and 23 sec, 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

32 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.

33 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

34 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

35 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

36 Name the tumor

37 Bad day at the Dentist

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40 Young patient with Intractable Hiccups

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