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Red Sea Rising: Strategies to Improve Surgical Visualization

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Editor’s Note:

This is a discussion on a very difficult case where anomalous venous return was overwhelming during a multi-valve repair / replacement- Making surgical correction nearly impossible.

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Well, it was one of those days…

Unspoken Silence: When everyone worries…  We Look to get past this morning’s -double-or-triple-valve-something, one step at a time.

And they were hard steps.

The double-valve-something reemerged as it had been canceled a couple of days prior.

The unspoken,  shared concern- was that this was a case that had the irretrievable potential outcome- that we are unwilling to accept- period.

It was finally time to make it so.  And that happened, but it was no cakewalk.  Super tuff exposure for the surgeon, and a lot of ambient noise in terms of EKG artifact that was distracting and yet concerning at the same time.

Nevertheless- The EKG looked like serious VT prior to engaging bypass- and that wave form just didn’t want to go away.

So naturally, I was concerned about myocardial protection, which is the essential premise for ALL heart surgeries- and IS the component and effect we all worry about- basically it is a simple proposition:  Don’t kill what you are in the process of fixing.

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We look for flat lines.

And that wasn’t happening.  Retrograde cardioplegia for AI (severe) and an additional MVR in the mix- with a question regarding the tricuspid.

Makes you wonder why you gave up beach volleyball, brew, and a carefree life to engage in this sort of occupation induced stress and intensity- but it also makes you question if indeed the heart was arrested (confirmed when shutting down the sucker pump for a second- to reveal that indeed the heart was flat lined- and the source of the noise on the EKG was simply a result of some sort of whimsical electrical expression- for god knows what kind of grounding issue).

So yeah the heart was indeed flat lined- but exposure sucked.

But that being said- you can check the “yes” box on the question of whether or not the myocardium was protected.

The MVR portion seemed to go without issue- but the AVR tested all of our nerves.  Make-it-break-it time, as the field was flooded with blood, the surgeon doing his best not to place blame on what was clearly becoming a tougher situation.

So, not ignoring the fact that the crux of the issue was to help effect the final placement of sutures to ensure the integrity of the aortic valve prosthesis we were implanting-  this pump run becomes a little cat and mouse game- of retarding forward flow to the patient- and timing it perfectly with each effort to place a suture- and then returning flow as his hand follows through and he prepares for the next suture placement.

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You can’t call it a roller coaster-

It more resembled paddling out on a surf board, and waiting for the next wave to start to break- speeding up to catch the curl- and running back to the break to catch the next one- so to speak.

Except it’s on a fast paced- time-lapse photography thing- and unforgiving…

In the mix are low pressures per Q reduction- mitigated by NEO prn, and watching venous sats (%) drop to mid 50’s, and then coming up for air and back up to a MAP of 70- and a venous % crawling with a little lag time back to midrange 60’s plus- to 70% if the breath of air (increased Q) is long enough to head into the next troughs (15 or so repetitions) of oncoming waves.

Gotta anticipate some sort of acidotic issues-

+ 50 MEQ NaHCO3 x a few

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The relationship with myself and this surgeon is built on total trust

In each other- so the question he forwarded was absolutely reasonable and part of the process of what we do so well- “Dude- are we ok?  Because I can finally see…?).

I think he wanted to make sure we were still on bypass. 🙂

The intermittant pulsatile approach was working- but was there going to be a cost?  It isn’t something I recommend or want to suggest as an option for perfusion practice- but it is a question that all of us may have to deal with at one point or another.

Do I really know the answer to that question?  Well, there is no certainty- but if I put myself in that position as the patient- I would think that pursuing any approach that eliminates the necessity of replacing an implanted valve that was just aborted due to poor visibility- Pretty much so- I would hold my breath long enough to not have to have that procedure reengaged on now potentially weakening wall structures.

23 years in the field adds up to that conclusion.  20 years ago I would have said sure- and it would have been a fair answer- albeit based on unfounded confidence.  (Yeah I can spike that ball kinduv thing).

But today …. I was resounding in my response- and told him that I wasn’t going to kill his patient.  This was based on experience- no bravado, and no absolute certainty– but just a gut check that what I was doing was going to help suppress a bad situation (the possibility of having to excise and then reimplant a new aortic valve- something the surgeon expressed during the course of the last 10 minutes of trying to seat the valve).

I won’t and can’t second guess that.  There comes a moment- when you just stand up for what you believe to be the truth- based on what you have seen before and what you formulate to be a rational set of predictable outcomes.

You have to hang your hat, and reputation somewhere.

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Floating right over the Water…

So the proposition in front of you is as follows:

  • You have a really tiny woman on bypass for a double valve replacement- with concomitant tricuspid insufficiency.
  • It’s a one shot kind of deal.
  • Exposure sucks.
  • Tons of air coming from one of the caval cannulaes,
  • A need to fluctuate forward Q to facilitate visual exposure.
  • The air in the venous line exacerbates due to low Q- and creates a venous lock that can only be overcome by increasing arterial Q-

So back in the day- it might have been a terrifying encounter that I would have bumped my Q up- and let them deal with it at the field, but on this day- she wasn’t going to survive a redo on the AVR- and it would have gotten nasty.

TODAY- that wasn’t going to happen.

So it became a consolidated effort in timing, anticipation, and pharmacological adjustments to the intermittent low Q situation we were pretty much committed to- in order to finish the replacement and offer a suggestion of survival to a very sick patient.

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Postop gas was exquisite.

Lactic acid bumped up a bit, but was clearly reflective of the steps we needed to take to manage a successful pump run.


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