Bleeding in a Jehovah's Witness patient undergoing a redo aortic valve replacement controlled with cryoprecipitate and a prothrombin complex concentrate.

PURPOSE: This is a case report involving a middle-aged Jehovah's Witness patient who underwent a redo aortic valve replacement, coronary artery bypass graft, and Maze procedure facilitated by cardiopulmonary bypass. The consent process included a discussion of the management of bleeding and hemostasis in the perioperative period in the context of the patients' religious choice and the possible consequences of avoiding transfusion in massive bleeding. The medical team agreed to abide by the patient's wishes with respect to the blood and blood products deemed unacceptable by the patient irrespective of the consequences. The consent included a discussion of manufactured hemostatic agents that are designated by the Hospital Liaison Committee Network for Jehovah's Witnesses as subject to personal decision. There was also a discussion of recombinant agents available, all of which are acceptable to Jehovah's Witness patients. The patient accepted the use of cryoprecipitate, prothrombin complex concentrate, and recombinant factor VIIa. CLINICAL FEATURES: After separation from cardiopulmonary bypass and protamine administration, blood loss was 350 mL over a ten-minute period. The international normalized ratio (INR) was 3.5 at that time. Cryoprecipitate 15 U, 1-deamino-8-D-arginine vasopressin 16 U, and a prothrombin complex concentrate, Octaplex®, 60 mL were administered. Blood loss improved significantly. The INR in the cardiac surgical intensive care unit was 1.3. The sample was taken approximately one hour following the administration of the hemostatic agents. The patient's chest was closed, and chest tube drainage was 310 mL over the next 12 hr. CONCLUSION: This is a novel case involving the use of prothrombin complex concentrate in the setting of a Jehovah's Witness patient undergoing a complex operative procedure.

Left ventricular outflow tract-right atrial fistula following aortic valve replacement.

A 59-year-old male, undergoing outpatient treatment of a sternal wound infection following elective aortic valve replacement surgery, presented with decompensated heart failure. The patient required emergency redo surgery after investigations revealed a left ventricular outflow tract to right atrial fistula due to endocarditis with right ventricular dysfunction. Echocardiography, in particular transesophageal echocardiography, was essential for the diagnosis of this rare event.

Acute Management of Infected Chronic Thromboembolic Disease.

A 29-year-old man with chronic pulmonary emboli presented to the hospital with progressive pleuritic chest pain. He was in acute right ventricular failure and received intrapulmonary arterial tissue plasminogen activator. Massive hemoptysis developed, requiring emergent thromboendarterectomy. A clot was visualized in the main left pulmonary artery that had formed a bronchovascular fistula into the left upper lobe bronchus. Pathology of the clot revealed fibrinopurulent exudate and Gram-positive cocci. The left pulmonary artery was repaired with a pericardial patch, and the left upper lobe was oversewn with subsequent left upper lobectomy. The patient was discharged home on postoperative day 23.

Subannular prosthetic valve embolization complicating transapical transcatheter aortic valve implantation: management without sternotomy.

Transapical transcatheter aortic valve implantation can be complicated by subannular device embolization. We describe 2 cases of transapical extraction without conversion to sternotomy, with a discussion of contributing factors and our strategy for salvage.

Interventional valve surgery: building a team and working together.

Transcatheter aortic valve implantation (TAVI) is a new modality that may change the therapeutic landscape in the management of aortic valve stenosis. Despite the excellent results of surgical aortic valve replacement, TAVI has the potential to revolutionize the treatment of elderly and high-risk patients with aortic stenosis. It therefore constitutes a new reality that cardiac surgeons have to acknowledge. As TAVI indications and techniques become better defined, the importance of a team approach to the implementation and performance of TAVI is becoming increasingly evident. The surgeon has a crucial role to play in the introduction, development, and sustainability of TAVI at any institution. In this article, we discuss the procedural technique involved in TAVI, as well as the cardiologist and heart surgeon individualities and team dynamics. We make a case for judicious team-based adoption of TAVI technologies, considering that evidence-based and health economics data are not yet available. We also illustrate how a team approach may lead to improved outcomes, better patient and institutional acceptance, and a better definition of the therapeutic niche of TAVI modalities, amid the excellent results of conventional aortic valve replacement surgery.