CVICU Visit and Post-Op summary

We have just returned home from the CVICU. We are going to eat and then return to see Wren. If he is stable I will return home to sleep tonight because it might be my last good sleep for a while.

Here is a picture of Wren in his CVICU bed. He has hedgehog with him. He still has a chest tube, catheter, central line, IV's and is intubated on the ventilator. While we were there they turned down the ventilator to 80.



How is he doing?
When we saw Wren he was still completely sedated from the OR. However, he started to rouse at one point and his blood pressure and BPM rose very rapidly. The nurse was still waiting for the orders to be delivered by pharmacy (he will be on fentanyl and morphine drips overnight) so they quickly gave him IV versed and morphine and he calmed down again to the same stable pattern.

Dr Hanley said he did very well in surgery and the anesthesia attending (Dr Boltz) said he was "like a rock". She was very pleased with him - no surprises.

What is the plan?
In the ICU, the team has a plan for every shift. The plan for this shift is to keep Wren sedated and stable. If he is stable on the vent they will start to turn down his medications and vent settings in the hope of extubating him tomorrow - not too late in the day. It just depends how he does.

He is being maintained on:
Fentanyl
Morphine
Milidrone (for heart function)
Versed (short term)
And something else to help perfusion.

They are monitoring chest tube output (it was about up to the 3 or 30cc when I looked) which is still slow but steady post-op but should stop over 2 or so days.

Was the surgery a success?
Yes, it was a success BUT it was not an unqualified repair. As we expected, this less invasive option did not make it possible to get all of the stenosis in the valve. Basically, the aortic valve IS too small and although Dr Hanley opened the leaflets a bit by cutting some attachment at the base of the leaflet AND shaved the leaflets where they had thickened a mild-moderate gradient remains.

In my previous post I said that Dr H would leave the repair if the gradient was <35. Well, it was 34. He says that it may come down a bit post-op but it will go up again over time as scarring develops. He hopes to make it till Wren is 7 or 8 when he should be able to fit a large enough valve to last till adulthood. His view is that you want a Kono to be the final valve replacement if at all possible - taking down konos is risky and complex.

So, we are relieved he has his valve and has a chance to do very well for years BUT of course we are anxious about the progression of gradient from mild-mod to MODERATE to SEVERE. Before surgery Wren's gradient was 75+ and classed as severe.

The other interesting comment was that while the patch above the valve was very straightforward, the sub-aortic tissue was very complex. It was dense, fibrous, scarred and extremely tight. It extended to the mitral valve and was attached to it.

Dr Hanley had to remove quite a lot of tissue in the resection to get at the obstruction.

However, he was pleased to see that both valves work well even though they are not normal anatomy. His mitral valve is only mildly parachute and his aortic valve is good for a bicuspid. He went so far as to say that IF the subaortic obstruction recurs in 2-3 years he would recommend a repeat opening of the valve and LVOT - perhaps being more aggressive in treatment of the AV.

This time, he achieved satisfactory improvement without regurg. He explained that when you work on a valve you have to balance leakage and constriction. If you do too much work to address constriction, you get leakage. If you have too much leakage you have to constrict the valve. In this case, there was no leakage immediately post-op.

Now, to dinner
Josh is serving spaghetti. Meanwhile, you can look at these two pictures of Wren dragging his animals around during the 5 hour wait AND the new LPCH train track.