69 years female with severe aortic stenosis , mitral regurgitation .anomalous circumflex arising from the right coronary artery . Intraoperatively , uneventful aortic valve replacement using mechanical ATS size 23 and mitral repair using commissural annuloplasty and posterior band enforcement resulted in compitant valve . 30 minutes post weaning , ECG changes and low cardiac output requiring high inotropes with no much benefit . My question what happened ,and what to do
#Bradycadia with 3rd Degree #AVBLOCK following #Balooning of the Aortic Root.
Marked Bradycardia 2°[ 3°AVB] AS A RESULT OF ballooning effect at Aortic Root
- Intra-aortic balloon pump for mechanical circulatory support is necessary
- Possible reasons of low cardiac output syndrome: -poor myocardial function requiring longer reperfusion time; - preoperative depressed left ventricular function; -presence of pulmonary hypertension including pulmonary vascular resistance and left ventricular diastolic dysfunction; -iatrogenic damage to the coronary arteries
The cause for the post -op deterioration with failure of inotropic support may point to high LVEDP. The long standing LV outflow tract obstruction with MR makes the LV systolic function appear better than it actually is. Once the two lesions are addressed the true LV dysfunction is unmasked. High LVEDP leads to poor coronary perfusion and further deterioration of LV function. Afterload reduction, inotrope support and aggressive diuretic therapy combined with interim mechanical circulatory support may work.
I agree with all the authors suggestions. Another possibility may be development of dynamic LV OT obstruction. It is rare complication following AVR but it can occur when there is severe hypertrophy of LV specially of IVS and hypotension does not respond to inotrops. Volume expansion or intravenous alpha agonist may be helpful.
Echo showed hypokineasia of lateral wall , the patient was unstable to go to the cathlab , so the OM was grafted . Dramatic changes to ECG . THE patient improved and weaned off pump on minimal support . I think thev circumflex artery , being anomalous originating from the RCA ,making it more vulnerable to injury
That is definitely a possibility. Now you can do a CT coronary angiography, that can show the status of native LCX artery wheather there is any injury present or not.
Ok Doc,
Likely reason was damage or kinking of Circumflex artery. Needs urgent Angio and possible grafting to OM territory. many surgeons would release the annuloplasty band.
One of the known complication of mitral valve annular repair.