Heart-lung transplantation: Technical aspects
Wickii T. Vigneswaran, Edward R. Garrity, John A. Odell in LUNG Transplantation, 2016
The trachea is anastomosed with 3-0 polydioxanone suture (PDS). The membranous part is connected with a running suture and the cartilaginous part with interrupted sutures (Figure 17.4). Surrounding fat tissue may be fixed to the trachea with single stiches. Next, the right atrium is connected to the residual right recipient atrium by using 3-0 Prolene extra-long (Figure 17.5). Alternatively, a bicaval anastomosis can be created with 4-0 Prolene, which is our preferred approach today. Finally, the aorta is anastomosed with 4-0 Prolene running suture (Figure 17.6). The lung is suctioned out, steroids are administered, the tape is removed, and the heart is carefully drained of any residual air. The aortic cross-clamp is removed. At this point a vent drain can be inserted into the pulmonary artery at the cannulation site.
Critical Care and Anaesthesia
Tjun Tang, Elizabeth O'Riordan, Stewart Walsh in Cracking the Intercollegiate General Surgery FRCS Viva, 2020
What are the cardiovascular effects of releasing the aortic cross-clamp?The removal of the aortic cross-clamp is associated with a significant reduction in systemic vascular resistance and a consequent decrease in the mean arterial pressure. The blood vessels in the previously ischaemic areas are severely dilated because of the accumulation of metabolites such as adenosine, lactate, and CO2 during the time of ischaemia. This promotes shift in blood flow and volume into those previously under-perfused areas causing central hypovolaemia. There is subsequently washing off the said metabolites, exacerbating hypotension.Reactive hyperaemia also ensues following unclamping due to smooth muscle relaxation, thus facilitating higher flows in areas after removal of the aortic clamp.Left ventricular end-diastolic pressure decreases significantly and myocardial perfusion increases. However, decreased myocardial contractility may be an issue due to acidosis after prolonged clamping time (increased lactate and PaCO2).The blood flow to area proximal to the clamp site reduces to levels of pre-clamping relatively quickly.
Methods and Procedures
Richard A. Jonas, Jane W. Newburger, Joseph J. Volpe, John W. Kirklin in Brain Injury and Pediatric Cardiac Surgery, 2019
During the first 24 hours after surgery, hemodynamic status was determined at specified intervals following removal of the aortic cross-clamp. Measurements include cardiac index, systemic and pulmonary resistance, and calculated oxygen consumption. Myocardial and brain isoenzymes of creatine kinase (CK-MB and CK-BB) were measured upon induction of anesthesia; upon reaching 32°C (rectal) during the rewarming phase; and then 1.5, 3, and 6 hours following resumption of bypass. Measurements of CK-BB (in IU/L) were performed by International Immunoassay Laboratories Inc., Santa Clara, California. The study nurse recorded daily medications, respiratory status, laboratory studies, fluid balance, blood and blood product requirements, and significant medical events until hospital discharge.
A comparison of early clinical outcomes of off-pump and on-pump coronary artery bypass grafting surgery in elderly patients
Published in Acta Chirurgica Belgica, 2018
Ahmet Yuksel, Atif Yolgosteren, Iris Irem Kan, Mustafa Cagdas Cayir, Yusuf Velioglu, Mustafa Yalcin, Mustafa Tok, Murat Bicer, Isik Senkaya Signak
Median sternotomy was performed to all patients that were implemented CABG with CPB. Heparin was given at the dose of 350 IU/kg and as ACT >450 s. LITA and other grafts were prepared by standard technique. After purse strings that were put into ascending aorta and right atrial appendage for standard CPB, arterial cannula and two-stage venous cannula was used. With the roller pump, approximately 60–80 mmHg tension arterial was tried to provide with the flow of 1.8–2.2 L/mn/m2. While we supplant cardiopulmonary bypass, aortic cross clamp was put and diastolic arrest was provided by cristalloid cardioplegia. Firstly, distal anastomoses in company with CPB and with aortic cross clamp in the situation that heart is in diastolic arrest was carried out, and then, proximal anastomoses were performed with side clamp that was put into ascending aorta. After CPB was ended and canullaes were removed, heparin was neutralized with protamine.
Acute type A aortic dissection – a review
Published in Scandinavian Cardiovascular Journal, 2020
Tomas Gudbjartsson, Anders Ahlsson, Arnar Geirsson, Jarmo Gunn, Vibeke Hjortdal, Anders Jeppsson, Ari Mennander, Igor Zindovic, Christian Olsson
Surgical treatment of ATAAD cannot be truly evidence-based. The advantages and disadvantages of each permutation of cannulation, perfusion, and surgical repair remain. Often, a conservative approach, using femoral artery cannulation, HCA with any form of cerebral perfusion, and a supracoronary graft replacing the dissected ascending aorta will suffice and provide the safest alternative. Even repair under aortic cross-clamp cannot be rejected outright, based on the data available. Still, unique patient and dissection characteristics must be recognized and, if necessary, influence strategy. If a risk of malperfusion through the femoral artery is envisioned or detected, an alternative arterial cannulation site should be chosen. Younger patients, or patients with connective tissue disease, may benefit most from valve-sparing aortic root repair (which, notably, can be undertaken during rewarming and may not necessarily prolong CPB time or procedural time). Arch inspection during HCA may reveal a longitudinal tear motivating arch replacement, in turn an impetus for meticulous cerebral perfusion and protection, allowing ample time for repair. Thus, optimal management of a wide spectrum of ATAAD patients requires surgical adaptation and versatility, which is provided more and more often in dedicated aortic centres and is often associated with documented improvement in outcomes [86].
Early, Single Center Experience with Ozaki Technique for Aortic Valve Reconstruction
Published in Structural Heart, 2020
Alberto Albertini, Eliana Raviola, Simone Calvi, Alberto Tripodi, Paola Quagliara, Fabio Zucchetta, Elisa Mikus
Results: The mean age was 52.95 ± 14.72 years old (21–74 years, 76.2% male). The predominant pathology was aortic valve stenosis (61.9%) followed by aortic regurgitation (33.3%) and one patient was treated for endocarditis (4.7%). Nine patients (42.8%) presented with a bicuspid aortic valve and in one patient a monocuspid valve was found. Concomitant procedures included: coronary arteries by-pass grafts (5 patients, 23.8%), ascending aorta replacement (1 patient, 4.7%), mitral valve valvuloplasty (5 patients, 23.8%), interventricular septal myectomy (1 patient, 4.7%). The mean aortic cross-clamp time and cardiopulmonary bypass time were respectively 131.95 and 119.57 minutes. All patients have been extubated (mean intubation time 9.76 ± 4.99 hours) and intensive care unit and hospital stay was respectively 2.5 ± 1.25 and 6.10 ± 4.68 days. There was no in-hospital mortality. Transthoracic echocardiography showed a peak aortic pressure gradient of 14.09 ± 7.62 mmHg and a mean aortic pressure gradient of 7.91 ± 3.33 mmHg. Aortic valve regurgitation was trivial in 8 patients (38%) and no valve stenosis was detected.
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