[SEOBowhntr]

MZ,
Sorry to hear that the TEE went so rough, we usually use Versed, and don't often have too many issues with patients waking up, nor remembering much if they do. Because you are a Dialysis RF patient, they may have gone light on anesthesia as most of the sedatives are renally excreted. The Heart Catheterization is usually pretty easy, they should numb up the chosen access site, usually the Rt. Femoral Artery, and then proceed to introduce a 6 French, most common catheter and perform the procedure through that. The worst part often times is being on bedrest after the procedure. I would agree with your Cardiologist, though I didn't know that calcification was more common with renal patients. I've just seen less complications with mechanical vs. tissue (bovine or porcine) valves, and would personally take a mechanical for myself if needed. I too am scared to death of surgery after damned near dying from a Tonsillectomy and Pharyngealpalatoplasty. (Had a little bleeding into the lungs problem) Good Luck, and keep us updated as you are able!!

Doug

[MedicalZebra]

Well, I had the cardiac cath on Friday-- and needed SIX doses of Versed plus a Valium-- and I still was screaming! I thoroughly scared the hell out of everyone in the cath room! I don't think there's any doubt that I need more anesthesia than what they are currently giving!

I got the collagen plug on the femoral artery, which is really sore now, but at least it's not infected. (It feels really gross, especially when I stand up.)

I am going for a consult with the cardiac surgeon on Wednesday the 18th, with a tentative surgery date of Jan. 25. The cardiac cath also showed a foramen ovale, which the surgeon didn't know whether it had been there since birth, or was caused by one of the tips of the IJ catheters I had for hemodialysis. So that will be repaired when they do the mitral valve replacement.

The surgeon said because of the extensive calcification, the surgery is going to be a lot tougher than they originally thought-- he mentioned the possibility that the heart could split during surgery. I am getting my Healthcare Proxy filled out tomorrow at dialysis-- just want to be ready in case the unthinkable happens.

[heartnurseinva]

Originally Posted by MedicalZebra

The cardiac cath also showed a foramen ovale, which the surgeon didn't know whether it had been there since birth, or was caused by one of the tips of the IJ catheters I had for hemodialysis. So that will be repaired when they do the mitral valve replacement.

The surgeon said because of the extensive calcification, the surgery is going to be a lot tougher than they originally thought-- he mentioned the possibility that the heart could split during surgery.

It is not too uncommon for someone like yourself to have a patent formen ovale--a PFO closure is minor compared to your valve surgery. I find it hard to believe your PFO was caused by a IJ catheter--but I guess anything is possible.

Did the cardiologist or the surgeon say the word, "split"? If you are seeing the surgeon on the 18th for the consult, have him clarify what he will do during the surgery. If the doc was explaining the valve surgery, he does have to open/cut into the heart to perform the valve replacement. I have never heard of a case in which the heart split as a result of a valve replacement. Again...anything is possible. Please don't worry about that though!!! Usually valves that are grossly overcalcified can be literally scooped out--this sometimes means a lengthy perioperative course.

As far as the pain control issue that you were orginally concerned about (and still are, I'm sure)..speak to the anesthesiologist while you are in the preop area. He will be the one to make you comfortable with Versed/Morphine. Stress to him that you require more--you will be surprised that cardiology will not pass that info onto the CT surgery. My girlfriend is the same way (the one I mentioned in this post previously)--she told the anesthesiologist to give her 10 of Versed--he did 5mg at a time 5 mins apart. That is a crapload for the normal person. Anyways...long story, short...She told me that Ativan was her best friend postop. She said the Percocet and the Morphine was nice..but the Ativan made it even better. Usually all 3 are standard postop orders..ask for them!!! They may be a little cautious given your renal status..explain this concern to your nephrologist though..if he is ok to max you all on all the pain meds...make sure he addresses it to CT surgery.
Good luck to you and let us know how the surgery goes!!!

[MedicalZebra]

This is MedicalZebra's Fiance' Rick,

I have some questions I need you all to shed light on:

1) Her Mitral Valve Surgery with initially a success. But, her BP was never really that high and eventually got to Hypotension levels. One of you mentioned this problem.

2) In a four day span (including during the operation) she had 3 dialysis sessions. One of mentioned continuous Dialysis. I think the dialysis was a contributing factor in her death.

3) Preliminary results (unofficial of course) have ruled out infection or embolism as a cause...

Her BP just could not get high enough for the team to do anything (a cruel paradox if you ask me). She was CLEARLY not getting enough circulation to all parts of her body (her right hand was even turning blue). The cardiac surgeon was very perplexed and I just want to know what happened. I don't want to blame anyone but, I just feel that the dialysis played some part in this outcome!

So,... what should I be asking and what should I be looking for when I get the official autopsy?

[SEOBowhntr]

Rick,
I am very sorry to hear this. Any surgery this major is high risk, esp. for a patient dependent on hemo-dialysis. There are a multitude of things that could have caused her death, excluding embolism and infection. Unfortunately, many are hard to detect until an autopsy is performed. The dialysis likely was not a contributing factor, esp. the continuous type, because it normally has a lesser effect on the blood pressure than standard treatments do. Of the many things that may have contributed, heart rhythm abnormalities are common in this type of surgery, and can be very difficult to control. Electrolyte imbalances are also common and difficult to control, esp. in renal failure patients. Other contributing factors would include uncontrollable bleeding, pulmonary edema as a result of needing fluid to adjunct her BP, and those fluids not being excreted, etc. It would be difficult to pinpoint one specific thing with my limited knowledge of her situation. I wish I could offer more, but that is all I know. Sorry for your loss.

Doug

[SFCardiacRN]

I'm sorry for your loss. Patients with renal insufficiancy are at higher risk in cardiac surgery. It becomes very tricky to control pulmonary edema and BP when the kidneys don't work. I'm betting the nursing notes will give you more information than the autopsy. Look at the course of vital signs and drugs/drips used. Was an Intra-Aortic Balloon used to aid circulation?

[MedicalZebra]

She DID often have trouble with DANGEROUSLY low BP after dialysis sessions. Her sessions usually lasted 4 Hours, 3 Times a week. Her solution to it was unusual but IT WORKED every time: A container of Kool Aid Juice and a candy bar. No one could explain why that worked. It also seemed allot of things that would bring normal patients BP up would bring HERS DOWN. Is this yet another anomally to postomously add to her Medical Zebra resume!
Has anyone ever encountered this and could it have been something ICU didn't consider (or Telemetry for that matter)?

[MedicalZebra]

I thought I would bring you all up to date on the "prelimary" findings from the Pathologists. The Cardiac Surgeon has been great answering all of my questions and concerns about Darlene's death (MedicalZebra to all of you).
He has PERSONALLY contacted me via phone and usually right away, which I must say I appreciate considering I'm sure he has a hefty surgery schedule. In fact, it was this Cardiac Surgeon who took the initiative to speak with the Pathologist.

The findings seem to indicate SEVERE scarring on the heart and the muscle itself was very thick. Something I'm told would not have been picked unless there was a biopsy done. The Pathologists had wondered how she could've made it this far with the degree of damage she had to her heart. I must confess we all knew of her enlarged heart but, attributed to almost 18 years of Dialysis. The Cardiac Surgeon had given us ample information about her chances getting the Mitral Valve Replacement to which Darlene replied,

"Well, if I don't get this I'll die of Congestive Heart Failure".

She was an amazing woman who had a firm grasp of her situation and if she had any question I know she would often seek this forum out. She was always beating the odds and perplexing doctors and it seems she did that right to the end. She shouldn't have been able to do the things she didon a daily basis from what the Pathologist discovered, I'm just glad I got to have her in my life as long as I did. If anything can be passed on from this I think you should NEVER underestimate the sheer strength of Love and will power.
I'd like to think that's what kept her with me these last four years.

I can't thank you all enough for helping her AND me. And I will always remember how much her Cardiac Surgeon went out of his way to make sense of all this and settle any fears, regrets and questions I had and be forever grateful.

Take Care Everyone,

Rick
MedicalZebra's Fiance'

[dianah]

God bless you, Rick. -- D

[SEOBowhntr]

Rick,
Sorry for your loss. Sounds like in essence, she did it her way, without regrets, and who could ask for anything more. A very good Oncologist I worked with several years ago said to his patients when he'd counsel them on a treatment plan the following:

With the news I've brought you today, you have to make a decision of one of two things. But those two things are not Chemo vs. Radiation, or Treatment vs. Non-Treatment. The decision you have to make now is whether you will go on living or go on dying. Each and every day of our lives, we are living and dying, but we can choose which we are doing.

I would guess that Darlene chose to go on living in each day, and for that her life must've been full of many good memories.

God Bless, and Take Care.