Those with aortic aneurysms - need info on the circulatory arrest procedure

[Chrisandgary]

Hi! More questions from me again!
Anyone have information on the Circulatory arrest procedure?
Thank you
Christine

 

[901]

Hi! More questions from me again!
Anyone have information on the Circulatory arrest procedure?
Thank you
Christine

I used to have an aortic aneurysm! They made an incision in my right shoulder, just below the collar bone, to hook me up to the heart-lung machine. The procedure was called the Bentall Procedure. I believe the "arrest" portion of the procedure was the same as for valve replacement (I got a couple of those at the same time, also). I understand that there was ice involved but I was asleep, so I didn't notice.

 

[CCRN]

Nothing like the voice of experience........

Nothing like the voice of experience........

Hi! More questions from me again!
Anyone have information on the Circulatory arrest procedure?
Thank you
Christine

Hi Christine,

Circulatory arrest is used most often with the Bentall procedure which replaces the aortic valve and the aorta up to and including the arch. I am one of the extremely "fortunate" people who not only assists during the procedure (I work in Cardiothoracic surgery), but also have been the patient on the table which made the process infinitely more fun. Basically what happens is, once your chest is open, the surgeon will locate your right atrial appendage, cannulate with the venous return cannula (takes blood to the perfusion machine to oxygenate), and cannulate your aorta passed the defective area (takes oxygen blood back to the body from the perfusion machine). After this is done he/she will instruct the perfusionist to go on bypass while simultanuously beginning to cool the patient down to 16-18 degrees C. The heart will go into standstill due to the cooling and help of a solution also given by the perfusionist. The Surgeon will crossclamp the aorta proximally to the aortic cannula, thus, placing the patient on heart circulatory bypass. The next step is to open the bypassed part of the aorta, cut out the aortic valve and dissect out the right and left coronary arteries located at the root of the aorta. Once this is done and the defective part of the aorta is disattached at the root, a dacron graft with a mechanical valve already attached or a tissue valve with a dacron graft is sewn in for replacement. The coronay arteries will also be reattached to the graft at the new root area. By the time the above mentioned steps are complete, the patient is removed from bypass, the clamp is removed, and the distal end of the graft is attached to the patient's aorta at the healthy portion. It took my surgeon about 25 minutes to do this part but it can safely be done within a 40 min. time period. The circulatory arrest with "profound" hypothermia preserves brain function. The great vessels off the arch have to be taken into consideration as well as all the blood loss that would take place while the largest vessel in the body is open with continued circulation. After the graft is connected the patient is returned to bypass while rewarming occurs. Interestingly enough, the actual "nuts and bolts" of the procedure is done in little over an hour. Most of the time is taken up with about an hour's worth of prep prior to cannulation, the cooling, and warming process. The rewarming process is slow in order to protect the sensitive brain and can take 1 1/2 to 2 hours. The heart usually starts beating spontaneously once adequately rewarmed and is gradually weaned off bypass. The cannulas are removed with sites closed, the pacing wires and chest tubes are placed, the chest is inspected for any bleeding areas, and closure begins. Before you know it the patient's carted off to the ICU for an "extended nap" and wakes up about 2 am the next morning wondering where everybody is. Is this what you wanted to know? Please let me know if some of the terms used are unfamiliar. I tried to make it as straight-forward without any fancy medical jargon as possible. Hope it helps.

RBG

 

[901]

Hi Christine,

Circulatory arrest is used most often with the Bentall procedure which replaces the aortic valve and the aorta up to and including the arch. I am one of the extremely "fortunate" people who not only assists during the procedure (I work in Cardiothoracic surgery), but also have been the patient on the table which made the process infinitely more fun. Basically what happens is, once your chest is open, the surgeon will locate your right atrial appendage, cannulate with the venous return cannula (takes blood to the perfusion machine to oxygenate), and cannulate your aorta passed the defective area (takes oxygen blood back to the body from the perfusion machine). After this is done he/she will instruct the perfusionist to go on bypass while simultanuously beginning to cool the patient down to 16-18 degrees C. The heart will go into standstill due to the cooling and help of a solution also given by the perfusionist. The Surgeon will crossclamp the aorta proximally to the aortic cannula, thus, placing the patient on heart circulatory bypass. The next step is to open the bypassed part of the aorta, cut out the aortic valve and dissect out the right and left coronary arteries located at the root of the aorta. Once this is done and the defective part of the aorta is disattached at the root, a dacron graft with a mechanical valve already attached or a tissue valve with a dacron graft is sewn in for replacement. The coronay arteries will also be reattached to the graft at the new root area. By the time the above mentioned steps are complete, the patient is removed from bypass, the clamp is removed, and the distal end of the graft is attached to the patient's aorta at the healthy portion. It took my surgeon about 25 minutes to do this part but it can safely be done within a 40 min. time period. The circulatory arrest with "profound" hypothermia preserves brain function. The great vessels off the arch have to be taken into consideration as well as all the blood loss that would take place while the largest vessel in the body is open with continued circulation. After the graft is connected the patient is returned to bypass while rewarming occurs. Interestingly enough, the actual "nuts and bolts" of the procedure is done in little over an hour. Most of the time is taken up with about an hour's worth of prep prior to cannulation, the cooling, and warming process. The rewarming process is slow in order to protect the sensitive brain and can take 1 1/2 to 2 hours. The heart usually starts beating spontaneously once adequately rewarmed and is gradually weaned off bypass. The cannulas are removed with sites closed, the pacing wires and chest tubes are placed, the chest is inspected for any bleeding areas, and closure begins. Before you know it the patient's carted off to the ICU for an "extended nap" and wakes up about 2 am the next morning wondering where everybody is. Is this what you wanted to know? Please let me know if some of the terms used are unfamiliar. I tried to make it as straight-forward without any fancy medical jargon as possible. Hope it helps.

RBG

WOW! I think this is exactly part of what I had performed. I like the description, except what is cannulate?
I don't know the times that it took but I know that they had problems when they got to the "inspect for bleeding" before closure step. I was told later that I was on the table for more than 12 hours due to bleeding issues. I also had a MVR and MAZE Procedure performed.

 

[Chrisandgary]

Very nice explanation! Is the Circulatory arrest procedure necessary for the replacement of the aortic tissue?
Three surgeons told us that is how it would be done, while 1 surgeon (the one we set up the surgery with) said he wouldnt know until he got in there.He stated if he got a good clamp on the aorta he would not need to do the C.A procedure.
I called today to ask him if he clamped the aorta - would that be a set up for another aneurysm down the road?

He told his secretary to tell me "No, it would not lead to another aneursym"
What are your feelings on this?
We are going to Cornell to have this done (NYC) they are extremely skilled and have the lowest mortality rate in the nation. This surgeon does 250 of these per year with many on ross reops (which is my husband)- My hubby has all the faith the doc will do the right thing when he gets in there - I just want to be sure all our bases are covered so we dont ever need a 4th OHS!
Thank you!
Christne
Christine

 

[CCRN]

WOW! I think this is exactly part of what I had performed. I like the description, except what is cannulate?
I don't know the times that it took but I know that they had problems when they got to the "inspect for bleeding" before closure step. I was told later that I was on the table for more than 12 hours due to bleeding issues. I also had a MVR and MAZE Procedure performed.

Cannulate means to put a cannula or tube into something in order to be able to transfer fluid from one source to another. (Best I can put it for the use without a dictionary) There are aortic and venous cannulas and look like thick clear tubes about the size of a regular garden hose. The ones used in the chest are different from the ones used in the groin. The surgeons I work with rarely cannulate via the upper chest like in your procedure but I know it's done because my surgeon told me he might use that option. I'm not sure but the method might give better field visualization. Usually the upper and lower vena cava is cannulated separately so the surgeon can get to the mitral valve through the right side of the heart. He probably did the mitral replacement and the MAZE while the atrium was open and before the Bentall. You had a regular overhaul of you cardiovascular system! Your procedures should have been scheduled for at least 8 if not 10 hours. Cooling the body down to 16 C plays havoc with clotting factors and the bypass machine will chew up platelets like there's no tomorrow (other little goodies God gave us to help the coagulation process). That's why you had the "bleeding issues". It's kind of a run of the mill thing. They probably spent about six hours on prep/procedure and the rest of the time waiting for you to literally jell. (or is it gell?) Does all this make some sense?

RBG

 

[901]

Cannulate means to put a cannula or tube into something in order to be able to transfer fluid from one source to another. (Best I can put it for the use without a dictionary) There are aortic and venous cannulas and look like thick clear tubes about the size of a regular garden hose. The ones used in the chest are different from the ones used in the groin. The surgeons I work with rarely cannulate via the upper chest like in your procedure but I know it's done because my surgeon told me he might use that option. I'm not sure but the method might give better field visualization. Usually the upper and lower vena cava is cannulated separately so the surgeon can get to the mitral valve through the right side of the heart. He probably did the mitral replacement and the MAZE while the atrium was open and before the Bentall. You had a regular overhaul of you cardiovascular system! Your procedures should have been scheduled for at least 8 if not 10 hours. Cooling the body down to 16 C plays havoc with clotting factors and the bypass machine will chew up platelets like there's no tomorrow (other little goodies God gave us to help the coagulation process). That's why you had the "bleeding issues". It's kind of a run of the mill thing. They probably spent about six hours on prep/procedure and the rest of the time waiting for you to literally jell. (or is it gell?) Does all this make some sense?

RBG

I thought it was odd when the surgeon scheduled my surgery that he didn't want anything else on the schedule that day. While I was still in the hospital he was doing a surgery in the morning and another one in the afternoon. When I had questions, his nurse had to catch him between surgeries and then call back. I can't remember how many units of blood they told me they used but I do remember that they said they used 20 packets of platelets (I don't know if that is a large amount or not).
Thanks for the explanation of "cannulate". Does that mean they were cannulating the chest cavity with the tubes that were draining from just below the sternum?
Do you know anything about frequency of heart block on double valve replacement patients?

 

[CCRN]

On heart block and chest tubes

On heart block and chest tubes

I thought it was odd when the surgeon scheduled my surgery that he didn't want anything else on the schedule that day. While I was still in the hospital he was doing a surgery in the morning and another one in the afternoon. When I had questions, his nurse had to catch him between surgeries and then call back. I can't remember how many units of blood they told me they used but I do remember that they said they used 20 packets of platelets (I don't know if that is a large amount or not).
Thanks for the explanation of "cannulate". Does that mean they were cannulating the chest cavity with the tubes that were draining from just below the sternum?
Do you know anything about frequency of heart block on double valve replacement patients?

Okay.....Platelets are usually given in packs of 5, so you got about 4 sets which, by my experience with double valve procedures, is about average. I guess you could call the chest tube insertion a cannulation process, but it's just a general term we use to describe putting the tubes in so we can connect to the perfusion (bypass) machine so the procedure can be accomplished. The chest tubes are really drainage tubes. The aortic and venous cannulas or tubes are to maintain your body's circulation while working on your heart. Heart block with any valve procedure is not uncommon. The electrical system of the heart is generally known BUT the good Lord made us all different. That's why some people get blocks and others don't...at least that's how it was explained to me by a physician once. My pathway maybe further away from the working area than somebody else's. Meaning I might not get heart block from the same procedure and another person might. Some people get heart block without surgery at all. It's a mystery but a known risk. I hope you're just a curious person and I'm not flippin you out with these explanations. You are okay with this, right?

RBG

 

[CCRN]

Great balls of fire.....

Great balls of fire.....

Very nice explanation! Is the Circulatory arrest procedure necessary for the replacement of the aortic tissue?
Three surgeons told us that is how it would be done, while 1 surgeon (the one we set up the surgery with) said he wouldnt know until he got in there.He stated if he got a good clamp on the aorta he would not need to do the C.A procedure.
I called today to ask him if he clamped the aorta - would that be a set up for another aneurysm down the road?

He told his secretary to tell me "No, it would not lead to another aneursym"
What are your feelings on this?
We are going to Cornell to have this done (NYC) they are extremely skilled and have the lowest mortality rate in the nation. This surgeon does 250 of these per year with many on ross reops (which is my husband)- My hubby has all the faith the doc will do the right thing when he gets in there - I just want to be sure all our bases are covered so we dont ever need a 4th OHS!
Thank you!
Christne
Christine

I didn't realize this would be his 3rd surgery. Okay, I am just a lowly nurse. However, since your guy and I are now surgical relatives , I think you are covering your bases and appear to be doing what I, my own neurotic self, would. There's another guy that's pretty smart (as we all are on this site) who had pretty much the same surgery as mine (Bentall) and had his surgery by a Doc is NYC who almost exclusively did only Bentalls with an M&M rate of 0.7 which is really good. Of course, this % rate was reported by the surgeon and must be taken into judgement. You want someone who does 200 to 300 of the procedures a year. It is true he really won't be totally sure until he gets a good direct look. He's a good surgeon......he's being honest with you. I kind of like the guy and don't even know him. Clamping the aorta does not cause an aneurysm. We even put little things on the clamp that cushions the compression. As for the circulatory arrest, many aortic repairs/replacements have been done without it. If the defect is just at the root the process can be little more than replacing the valve and a bit of graft. As I understand it, the closer you get to the arch, the more necessary the CA. My aorta had to be replaced up to the arch but my surgeon told me it could be beyond and he wouldn't know till he "got in there". I'm zippin around and using having been on CA as an excuse for any lapses in expected social inequities shown. I'll keep you and yours in my prayers......that's the best treatment I know.

RBG

 

[Chrisandgary]

[Thank you for all of the great info! M husbands aunt is a ct OR nurse at Columbia and she told me the same thing - the clamp will not cause a future aneurysm and it is used in every OHS. Also that it is soft, rubberized etc.
Now, if they only do the root - not the arch - is there a good possibility he'll have a future aneurysm in the arch?
Maybe this was my question afterall - it just took me awhile to arrive at it!
It is my understanding they will only do the root if that is where the problem is - and only the arch too if the problem is also there? It is not in some surgical views to just do the arch too even if it is okay?
I just dont want him to have a 4th surgery down the road. I have great faith in this surgeon - just trying to cover all my bases!
This may just be a crystal ball question and know one knows the answer.
Thank you all for your great info - and no you are not freaking me out! I was most freaked out when I got the note in the mail from the cardiologist that said"Aorta appears to be dilating we need a catscan" Now that I am on a mission - gaining info - consulting surgeons - and have the date set - I feel in control!
Thany you again!
Christine

 

[901]

Okay.....Platelets are usually given in packs of 5, so you got about 4 sets which, by my experience with double valve procedures, is about average. I guess you could call the chest tube insertion a cannulation process, but it's just a general term we use to describe putting the tubes in so we can connect to the perfusion (bypass) machine so the procedure can be accomplished. The chest tubes are really drainage tubes. The aortic and venous cannulas or tubes are to maintain your body's circulation while working on your heart. Heart block with any valve procedure is not uncommon. The electrical system of the heart is generally known BUT the good Lord made us all different. That's why some people get blocks and others don't...at least that's how it was explained to me by a physician once. My pathway maybe further away from the working area than somebody else's. Meaning I might not get heart block from the same procedure and another person might. Some people get heart block without surgery at all. It's a mystery but a known risk. I hope you're just a curious person and I'm not flippin you out with these explanations. You are okay with this, right?

RBG

The explanations are great! I wanted to thank you for taking the time to make them. Many times, when I'm in to see the Dr. and he tells me something I don't understand, I don't think of questions until much later after I've tried to "digest" what he said. That's usually when the "flippin out" happens and I have fifty why/why not questions all at the same time.
I'm praying that my block is temporary or at least can be managed with drugs. I feel like getting a pacer will be a "black eye" to an otherwise outstanding operation.
The surgeon told me, at some point, that there was a greater risk of heart block with me because the two valves replaced are close together and the area where the block is occurring is between them. I thought that when they took the pacer off in the hospital, I was past that!

 

[CCRN]

Of roots and arches

Of roots and arches

[Thank you for all of the great info! M husbands aunt is a ct OR nurse at Columbia and she told me the same thing - the clamp will not cause a future aneurysm and it is used in every OHS. Also that it is soft, rubberized etc.
Now, if they only do the root - not the arch - is there a good possibility he'll have a future aneurysm in the arch?
Maybe this was my question afterall - it just took me awhile to arrive at it!
It is my understanding they will only do the root if that is where the problem is - and only the arch too if the problem is also there? It is not in some surgical views to just do the arch too even if it is okay?
I just dont want him to have a 4th surgery down the road. I have great faith in this surgeon - just trying to cover all my bases!
This may just be a crystal ball question and know one knows the answer.
Thank you all for your great info - and no you are not freaking me out! I was most freaked out when I got the note in the mail from the cardiologist that said"Aorta appears to be dilating we need a catscan" Now that I am on a mission - gaining info - consulting surgeons - and have the date set - I feel in control!
Thany you again!
Christine

Please forgive me for not knowing but why did your husband have the Ross procedure in the first place? If he had a bicuspid valve......did we talk about this before? Remember, I suffer the effects of CA. Anyway, my only other suggestion is, if he did have the bicuspid valve, considering the connective tissue disorder commonly seen with it, my surgeons have been sending a sample of the aorta during the procedure to see if the disorder is affecting the aorta as well. They then apparently choose to replace more of it if there is a positive showing there. Seems reasonable to ask your Doc if this is possible. I haven't been at work to ask this but one of my techs who has been very interested told me the Doc she worked with last week did just that. There are a few members here who did indeed have to have yet another surgery for aneurysm repair. I would make an appointment to sit down face to face even if it is just before the surgery and tell your surgeon ALL of your concerns. You guys are intitled. Let him know in complete detail your very good knowledge base about risk concerning repeated opening of the chest. Every time that occurs it significantly increases the risk of EVERYTHING. From what you've told me, the guy seems to be on the up an up and I believe he will listen to you and answer all your concerns. I wish there was a crystal ball all us bicuspids could look into and tell which of the many aspects of the defect affect us individually but, so far, I don't think ones been developed. You are not alone. For some strange reason, just realizing that made a big difference to me.

RBG

 

[Chrisandgary]

Please forgive me for not knowing but why did your husband have the Ross procedure in the first place? If he had a bicuspid valve......did we talk about this before? Remember, I suffer the effects of CA. Anyway, my only other suggestion is, if he did have the bicuspid valve, considering the connective tissue disorder commonly seen with it, my surgeons have been sending a sample of the aorta during the procedure to see if the disorder is affecting the aorta as well. They then apparently choose to replace more of it if there is a positive showing there. Seems reasonable to ask your Doc if this is possible. I haven't been at work to ask this but one of my techs who has been very interested told me the Doc she worked with last week did just that. There are a few members here who did indeed have to have yet another surgery for aneurysm repair. I would make an appointment to sit down face to face even if it is just before the surgery and tell your surgeon ALL of your concerns. You guys are intitled. Let him know in complete detail your very good knowledge base about risk concerning repeated opening of the chest. Every time that occurs it significantly increases the risk of EVERYTHING. From what you've told me, the guy seems to be on the up an up and I believe he will listen to you and answer all your concerns. I wish there was a crystal ball all us bicuspids could look into and tell which of the many aspects of the defect affect us individually but, so far, I don't think ones been developed. You are not alone. For some strange reason, just realizing that made a big difference to me.

RBG

Yes Gary has BAVD - it was only just confirmed last week from this surgeon we really like and have scheduled the surgery with.
He had Ross in 97 - was diagnosed with a heart murmer in 92 , the year after we got married - I decided we needed physicals as neither of us had had one in quite some time. The pcp picked it up and off we went to cardiology where it was diagnosed as AVR. He was medicated until 97 when it was suggested we do the Ross now as he had severe AVR at this point and was symptomatic. Three years later he went into severe regurg again - pulmonary was failing in the aortic spot. Surgery in 00 gave him a St. Judes mechanical and has been fine since - still is except for the aneurysm - which by the way has been enlarged since the Ross procedure and no one wanted to do anything with it. I believe all doctors involved believed it would not progress due to lack of info and because my hubby is very big and strong. As we surgeon hopped prior to these 2 ops, I kept asking about the genetic/heredity factor, etc. and was told not to worry. Now that the info has amassed in the past few years, I pulled out all of Garys records and only found "probable bicuspid aortic valve" I went further and requested the path report from the hospital and sure enough it states "2 calcified leaflets" The first 3 surgeons we went to in the past 2 weeks really could care less if it was BAVD. This one we chose - it was the first question out of his mouth -I showed him the path report and he confirmed (even though I already knew thanks to all the great info on this site! I really know my medical terminology).
So that is where we are at! I will look further into sampling the aortic tissue. That really seems like the answer!
Thank you again!
Christine