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Another Open Heart Surgery… This time we didn’t know quite what to expect. The surgeon told us that he would go in and see what he could do but that he wouldn’t really know the plan until he got in there and saw what was going on. Performing surgery while on ECMO is risky because due to the large amount of plastic tubing on the ECMO circuit, the patient has to be on heavy blood thinners to prevent clotting.
A healthy person relies on their blood to clot when they have a wound as this stops the bleeding; when a foreign substance is introduced into the body, however, the platelets in the blood get confused and start clotting too quickly. This can allow a blood clot to get into the blood stream affecting the heart, lungs or brain. To prevent this, patients on ECMO are put on large amounts of blood thinners (this time around she was on Heparin) – this stops the clotting but also puts them at a severe risk of bleeding and stroke.
Performing surgery while on blood thinners means that bleeding will be an issue – they have ways of dealing with it but it is certainly not ideal.
After a few hours of waiting, the surgeon came out to tell us that he had come up with a solution that he was hoping would help; he removed the coronary button (the piece of tissue that was used to move the left Coronary Arteries- see foot note for further information on how this surgery was performed) and re-positioned it to take the kink out of the anastomosed (narrowed) artery. It sounds an awful lot simpler than it is but he was cautiously optimistic that he had corrected the issue. Laura would remain on ECMO while we waited for her heart to recover.
An hour or so later we were able to greet Laura in the hallway as they brought her back to the PCICU – we would greet her many times in this same spot.
It took a whole crew of people to move her with all that she was hooked up to. They needed to get her bleeding under control before we would be able to go in to see her. The surgery was a relative success but due to the vast ischemia (cell death caused by lack of blood flow to an organ) to her heart, it still could not support her without the help of ECMO.
Once we were able to go in there wasn’t much shock value left – we had pretty much seen it all at this point. We settled in and watched as she was infused with plasma and platelets to get her bleeding under control. There was the usual post-op routine of getting medication levels sorted out, getting the bleeding to slow down and making sure she remained warm and comfortable. She remained in a paralyzed state as she was still relying on ECMO to support her vital organs. At this point, her heart was still not doing much on it’s own.
A couple hours after surgery the unit was closed down for a chest closure on another child in the unit. We went to the waiting room to wait and after an hour or so, we received a call from the unit.
They had to do another emergent surgical procedure on Laura.
She had developed a number of large blood clots around her heart – they would have to open her up and remove them before they got into her blood stream. This hit us hard. Not because it was a major surgery but because we had now gone about 36 hours with no sleep and Laura had been through so much already. Due to this procedure, the unit would remained closed for another hour or two – Laura shut down the unit many times during her stay… It became awkward hearing other families gripe about how they couldn’t see their kids…our bad – sorry.
Later that evening we were finally able to go see Laura again and nothing much had changed – other than her growing number of surgeries and procedures. At this point we were at 2 Open heart surgeries and 3 surgical procedures (chest closure after surgery #1, sternal re-opening (sternotomy) and ECMO cannulation (getting put on the machine), and now, this sternal clean-out- removing the blood clots). There was a lot of bleeding to deal with again but gradually, this started to slow down. By this point, Laura was incredibly swollen and had her entire blood volume replaced many times over the last 24 hours.
At this point in our adventure, Laura was still not entirely stable on ECMO – she had many fluctuations in blood pressure and they were having to consistently make changes to her ECMO flows and settings to keep her blood pressure where it needed to be.
Late that evening it was time to head back to the apartment to try to get a good night’s sleep before we tackled another day…
Laura’s first surgery – Arterial Switch – explained:
In patients with Transposition of the Great Arteries, there is one main issue – the pulmonary artery is connected to the Left Ventricle and the aorta is connected to the Right Ventricle. In a normally functioning heart, the opposite is true – the pulmonary artery arises from the Right Ventricle and the aorta is connected to the left ventricle. This allows a normally functioning heart to send blood to the lungs to pick up oxygen, and then pump it back into the left ventricle (through the coronary arteries) to be brought through the aorta to the rest of the body.
To perform the arterial switch procedure, the surgeon detaches the pulmonary artery and the aorta at the bases and re-attaches the pulmonary artery to the right ventricle and the aorta to the left ventricle.
During this process, the coronary arteries must be moved from their current location on the pulmonary artery to their new, correct position on the aorta (called the neo-aorta because it has been reinvented). To move the less than 1mm coronary arteries, the surgeon can not simply grab them, he must cut out a piece of tissue, called the button, around the coronary arteries and use this to move and re-attach them. This way none of the sutures end up on the coronary arteries themselves.
In Laura’s case – rather than created a separate coronary button for each artery, the surgeon opted to create one button that housed both coronaries as they were so close together. The reason she arrested the first time was that one of the coronary arteries became kinked – this is a large risk when moving two arteries from the same source – to get one of them to straighten out, you run the risk of kinking the other.
After this second surgery – we were hoping that with the slight tweak to the angle of the button, that both arteries would remain straight and unobstructed.
- the more you know 🙂