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Re: Сага о мотоциклисте
послал Ken Mattox 15 Июнь 2003, 00:47
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18 hours post accident, the patient went to the OR where he underwent a median sternotomy. On opening the pericardium, he was noted to have a bluish discoloration at the very root of the aorta, which did not extend very far up the
ascending aorta. Cannulation was with a cannula in each of the vena cava, and very high on the ascending aorta. The aorta was opened and the following findings were seen:
Complete separation of the "post" of the commissure of the aortic valve between the left and non-coronary cusps, and tear of the left and non coronary cusps and complete flail of these leaflets into the left ventricle.
Tear in the root and ascending aorta at this location of the commisure post
Second tear in the root of the aorta just above the junction of the left and the right coronary cusps.
These two tears were full thickness. In very very careful review of the TEE, the transthoracic echo, the spiral enhanced CT, and the aortogram (yes, the catheter was appropriately placed very low in the aortic root, just above the aortic valve) NO aortic injury was seen on these studies.
A valve graft composite was inserted (St Jude Mechanical valve was part of this composite) and the distal end of the graft sutured to the higher ascending aorta. The coronary ostia were sewn to the graft. His ischemic pump time
was 42 minutes. Of course he was totally heparinized during the pump run.
We do not have homografts in this institution and I am not sure that I would have used one in this case.
He went to the ICU and was found to have NO increased hematoma in his left wrist or right elbow fractures. His hematocrit remained stable and no increase any hematoma around the pubic diastasis was noted. He was extubated in
about 8 hours, and his chest tubes were removed 24 hours post op.
The orthopods are going to do an ORIF on his elbow, but state that his pubic fracture and diastasis need NO therapy.
One big question now is when do we start coumadin. If we don't start coumadin, what do we do??
Thanks to the many persons who have commented both to the whole web list and to me personally on this interesting case which involves judgement in all of our areas of interest.
k
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