1. Straight forward Case got Complicated –
Managed quickly with Available Resources
- A Case Report
By
M.V.Krishna Mohan
Sr. Clinical Perfusionist
RHRC, Indore
Mobile: +91 8959907711
Email:- krismo2006@gmail.com

2. About the Case
 It was a case of CABG + Aortic Valve
Replacement
 A 70 year Male Patient
 Single Graft + Valve Replacement
 Height – 165cm
 Weight – 50kg
 BSA – 1.51m2
 BFR – 3.63 LPM

3. PUMP Set up
 Oxygenator – Affinity NT
 Custom Tubing Pack – Medtronic
 BCD – Myotherm XP
 Cardioplegia – Cold Blood Cardioplegia
 Arterial Cannula – Select Series Straight
Plastic Tip (72220Fr)
 Venous Cannula – DSSVC (32 x 40Fr)
 Cardioplegia Antegrade : Direct Ostial Coronary
Cardioplegia (Dlp 30010,
30012,30014)

4. CPB Circuit
 Routine pump was set up.
 AV Loop : Arterial 3/8 x 3/32
Venous ½ x 3/32
 Cardioplegia : ¼ x 1/16 line.

5. Cardioplegia Line Set up
 Eventhough we use Myotherm we don’t use High Potassium
and Low Potassium separately
 In routine, we give blood through BCD (only for cooling) and
Cardioplegia Solution by syringe pump which is connected to
the CP line at the tip with the help of Straight Adapter (DLP -
10001)
 Method : To Make an universal pump pack for all cases we
adopted this modifications
 In other cases where the Isothermic cardioplegia the same
pump head is used.
 At any time We can incorporate BCD - to plan Cold Blood
cardioplegia.

6. About the Case
 Patient was put on CPB as routine and cooled to
28oC.
 Aortic Cross clamp applied.
 Aortomy done
 Direct Coronary Cardioplegia delivered
 Heart Arrested
 After some time, Suddenly the Surgical Field
was full of blood………..

7. Incident – So called Accident
WITH CROSS CLAMP
DISPLACED CROSS CLAMP
FLOODED WITH BLOOD
Note: These images or not real images of the patient

8. Incident – So called Accident
 First Surgeon Shouted, What’s wrong, field is
full of blood, be on low flows and gradually
stop the pump..
 Meanwhile cardiotomy and venting was
increased to maximum
 Checked for the cause
 It was the Cross Clamp displaced, by the
time it was checked, as per the Instructions
of the surgeon I had stopped the Pump.
Here started the Main Problem …………

9. Incident – So called Accident
 As soon as pump was stopped there was a column of air
in Arterial cannula.
 If there is column of air in arterial line after reposition x
clamp while the pump in standby position there has to be
air in aorta, aortic arch and its branches.
 At Table everyone is panic.
 At my side I have no assistance.
 Then I asked what was the problem… why
 Enquired from Anaesthetist what was the cause.
 I Told Anaesthetist to place Patient in Steep
Trendelenberg Position.

10. CPB Management
 First I started Rapid Cooling to initiate
surface cooling.
 Secondly, Asked surgeon to Put CP needle
in SVC and connect one limb of Y-adapter of
cp line to cannula and applied clamp distally
towards RA. Initiated Retrograde Cerebral
Perfusion.
 Luckily, We planned for Cold Blood CP in this
patient, so the Myotherm is readily cool (8oC)

11. CPB Management
 Slow Retrograde perfusion started at 150ml/min to
200ml/min.
 Meanwhile necessary medications were given
 Head is packed with ice packs
 As the flow was given for some time, the deairing
achieved with proper venting of aortic root, again
cross clamp re applied, arterial cannula was
disconnected, deaired and connected. Now the
system is now deaired completely and it is ready
to go on pump.

12. CPB Management
 Slowly Arterial pump was started, patient
was completely put on pump the SVC
clamp was removed and the Retrograde
Cerebral perfusion was stopped.
 Now, Surgeon proceeded with the actual
surgery and Valve Replacement done with
21mm St. Jude Biocor Tissue valve and
One Saphenous Vein Graft to LAD.

13. CPB Management
 Aorta closed with layers.
 Slowly patient was rewarmed to 32oC.
 Regained the Electrical acitivity
 Cross Clamp Removed
 Heart Came back with VT/VF, reverted
with Cardioversion and Cordarone
 Slowly rewarmed fully and Weaned off the
CPB.

14. Post Operative Scenario
 Patient was shifted to Surgical ICU.
 Patient was put on Prolonged Ventilation
 After 24Hrs slowly weaning of ventilation
was started.
 Patient was Awake with all limb movements
 Responding to verbal commands
 Respiration regained
 Neurologically fine.

15. Patient as on Today
 Today, we are glad and very happy to
have this patient 4 ½ year followup.
Patient is doing well with no complications.

16. Take Home Message
 At the time of Crisis, one should not be
panic, As a team we should consider ones
suggestions and follow.
 Despite of least assistance, the resources
present at the instance should be utilized
for the benefit of patient.

17. I Welcome
 Any Questions?
 Any Suggestions?