Thursday, May 20, 2010
Plan For Surgery
Two weeks ago, the day before Kimble's Cleft Lip surgery, Kimble underwent some CathLab procedures. This was in anticipation of his next heart surgery in June. The doctors told us a bit about what happened during that time, and what the results told them at the time, and all of this questioned whether he would actually have the surgery in June as planned. So we have waited...anxiously, to find out what their "roundtable discussion" decided for Kimble.
During the CathLab, Dr. Fagen took some measurements of bloodflow through all of Kimble's faulty valves and tiny ventricles, as well as through the normal ones. He temporarily plugged up the hole between the two atriums (ASD, or Atrial Septal Defect) and measured how increased the pressure became in his right heart, which actually was quite minimal based on what they were anticipating. They considered plugging up the shunt as well, to see if enough bloodflow went through his right chamber to sustain his life, but it was too risky to do in the CathLab, so they didn't do that. However, with all of their measurements, they found that Kimble's right ventricle had indeed grown some, since he was born, and that there was a fair amount of capillaries extending their way through the ventricle and that the ventricle muscle had relaxed somewhat and was actually pumping blood, albeit a very small amount.
So, as I mentioned before, the results made them question not whether he will have another surgery, but if waiting maybe six months, will be advantageous to let his right ventricle grow more. In delaying the surgery, will it give things a chance to grow and function better, and thus possibly changing what type of surgery he will have? As I've mentioned before, and as I'm reminded in every conversation we have with Kimble's doctors, this is not a simple case. Kimble is complicated in his structure, his defects, and not a textbook case. In my understanding, it's not that he's complicated so much, but that there are so many things going on with him, that it ends up being more of a "weighing the odds and risks" and what they hope will give him a better life with as much heart function as possible.
That being said, yesterday was the day I finally received the phone call that would tell us whether surgery was still planned for June. The answer? YES. My heart sunk at the news. Although I know he needs more surgery, there is a huge risk that he won't survive it, and as a mother, I tend to dwell on that aspect of it.
Originally, Kimble was scheduled to have the Glenn procedure at this next surgery. This is where they reroute the bloodflow coming from the upper part of his body via the Superior Venacava, and instead of it going to the right side of his heart, it will go directly to his lungs to get oxygenated, which is normally what the right heart would be doing (pumping that blood to the lungs to get oxygenated).
However, Kimble's doctors have some other plans for that surgery. Before they do the Glenn (which most likely, they will end up doing), they want to try out a few things. First, they want to close the ASD. Currently, this hole between the two atriums, is where most of Kimble's bloodflow goes, instead of going down to the right ventricle via the tricuspid valve, which as we have talked about, is about as faulty as they come. The tricuspid simply isn't allowing enough blood into the right ventricle, so the blood chooses to go the easier route, and it slips across the hole and over to the left side of the heart. This means that the left ventricle is now pumping blood that is NOT oxygenated, to the body. Not the best scenario.
Now, the left ventricle, when it pumps blood to the body, begins it's journey via the aortic artery. Along the aorta, Kimble has a BT shunt. This shunt forms a Y, allowing that blood to either go to the body and begin it's circulation, or it can go to the pulmonary artery (coming from the right ventricle) where it travels to the lungs to get oxygenated. Kimble's body has learned to regulate that in a happy balance, so that some blood can get oxygenated, and some goes to the body. Thus, Kimble constantly gets mixed blood, meaning both red (oxygenated) blood and blue (non-oxygenated) blood circulating through his body, and therefore normally has oxygen saturation in the low 80s.
Ok, so now we come to the surgical plans. Under the watchful eye of the surgeon, in the O.R., they will close the ASD, as well as block off the BT shunt. Then they will watch and see what happens. There are two probable scenarios. First, with all this blood being forced to go where it should go in a normal heart, this could open up the tricuspid enough, allowing blood to fill up the right ventricle, and then it would go through the pulmonary valve and begin it's journey to the lungs to get oxygenated, as it should. If this happens and all is good, this could possibly mean that Kimble's heart could essentially be fully functioning. Would enough blood be getting pumped through that right ventricle to sustain his life? That is the question.
The other alternative, would be that after closing off the ASD and the BT shunt, there would be a huge increase in pressure in the right heart because it is not able to meet the demands of the body. Thus, he would go into heart failure immediately...or possibly, all could be fine, or within minutes, or days, the heart would fail. They should be able to see whether or not this is life sustaining.
If this fails, under these controlled circumstances, which it probably will, they are already in the O.R. (nice and safe) and they would then begin rerouting the bloodflow, and doing the Glenn procedure, as originally planned.
This surgery is scheduled for June 21st. One month away.