Windsurfing, surfing, Maui, The Gorge, and random rants.

Thursday, October 27, 2011

Looking at Lowers and AWT registration fun.

After spending one day hanging at Uppers, we decided to really shake things up, so we moved our butts down to Lowers for the next day's action. The weekend swell was still with us along with the Windsurfing Magazine test crew, giving the new crop of 2012 wave boards a good shake out (preview - almost all are very nice, and most are now officially tri or quad fin shapes).  Julia was out riding the 2012 Goya quad 78 which has been working very well for her.  It was my duty to take some pictures with my new super zoom and this is what I got...

Besides Julia we had some other friends getting in on the fun.  Such as Royn Bartholdi...

The next three shots are a guy we recently met at a party and I just can't remember his name, and I'm also not sure about the last two, but they're all getting some nice turns. Anybody got names for me, please speak up!

Besides all the on the water action, I could't help but turn my camera to the left and get a quick pic of Maddy, one of the very lovely gals with the windsurfing test crew. As you can see, this turned into a bit of a self portrait.  And speaking of lovely, I also caught Rebecca returning from her session on a new Simmer board and showing nothing but smiles.  Nice!  PS - Rebecca has not one but two blog's, here and here, that you should really check out.

Now as every windsurfing paying attention to current events is no doubt aware, the American Windsurfing Tour's premier event, The Makani Classic at Hookipa, is here, starting today Oct 27th.  Right now we're looking at light but sail-able wind for the next four or five days. Unfortunately the north shore is dead flat at the moment but a medium sized bump (3-6') feet is due for Friday, and a much larger swell (up to 15') is predicted for Monday.  Sam and the AWT crew have the interesting challenge of picking the best three of the next six days (from Oct 27 - Nov 2) to run the show.  Word is today (Thurs) is officially on hold.  No waves so no big surprise there.  I'm guessing they will get some action tomorrow with the medium swell that's forecast, and probably Saturday as well.  After that, hopefully we'll have better wind and wave info to make the call for Sun, Mon, Tues.  It would be sweet if heats could be run in the significant waves that are predicted for Monday.  Anyway, some action is guaranteed and we'll all see it soon enough.

Meanwhile, AWT has put together an amazing week of parties with something fun going on every night.  I feel it is my sacred duty to participate in these as much as possible (as I can't compete otherwise) and try to bring some of the fun to you.  Last night was the opening registration at the Kahalui Ale house.  Julia, Rebecca, and Debbie were handing out the swag to all the competitors.  I assisted them, mostly by taking pictures with a few select participants (Brawzinho, Boujmaa, me!, and a really large T-shirt with a three headed monster.  Also there was this scary dude at the front door to greet everyone.)

Tonight is the Goya/Quattro party, tomorrow 4th Friday in Paia, Saturday is the Maui Ultra Fin lounge party at Neil Pryde, and Monday night is Halloween.  Whoa! - going to be a challenge keeping up with all that but I think I can do it.  And hopefully get some competition action shots from Hookipa as well.

One last thing- just a medical update.  Most of you know I had a little procedure about six weeks ago that basically involved ripping my chest open and replacing a big chunk of my aorta along with some extensive repair work in the heart valve region.  Ouch!  Well I'm felling much better now and very recently I started riding my mountain bike for exercise, which included a  ride from Kanaha to Hookipa, something like a 15 mile round trip.  And let me tell you, it was crowded at Hookipa! Not much more to report other then the recovery seems to be going as well as possible and, unless I hear otherwise from medical professionals, I plan on adding easy hills to the biking, light jogging, and some mellow swimming/paddling over the next few weeks.  I've been asked when I might be able to windsurf again. My best guess is six months after the surgery, which would mean roughly mid March.  Maybe a touch sooner for good behavior. Sometime before that I'll talk with a cardiologist and I'm sure I'll get better advice.  Anyway, for now it's all good!

Monday, October 24, 2011

Uppers Zoomed In

As mentioned in my most recent post, I've been hanging at Kanaha while everyone else is playing on the water.  I'm trying to make myself a bit more useful to society so I brought my latest fairly cheap super zoom point & shoot camera to the beach.  In this case it's a Panasonic DMC-FZ40, available on Amazon for a mere $280.  The thing about this camera is it offers a really long zoom for an inexpensive price.  To get the equivalent on a DSLR would probably cost a few grand just for the lens.  Of course you are giving up some important features with the cheaper camera, especially lens speed and low light performance.  But if your main goal is to sit on the beach and take hand held pictures of your buddies way way out on the waves while sitting in your Tommy Bahama beach chair, it's not a bad trade off.

Those of you who windsurf and do so at Kanaha and occasionally are in the upper / windward reef (cleverly known as "Uppers") know that the break up there is a long distance - maybe a mile or so - from the beach.  Unfortunately this distance rules out easy viewing or getting good photos of the action up there, unlike Hookipa where everything is right in front of the spectators looking down from a perfect viewing bluff.  Yes Hookipa is awesome for action photos - yet another reason for pros and photographers to be there (besides the awesome conditions of course). Uppers is the quiet place to do your own thing out of public sight.  Which can be a bummer on the bigger days when Uppers has very nice conditions along with some very skilled riders.  One such rider often up there ripping it up in all conditions is Nick Warmuth, who I've pointed out in some prior posts.  Anyhoo, this new camera does a very decent job of bringing the far away action in close.  It's not perfect, but for now it seems a whole lot better then anything I used before. So without further ado, below are today's shots from Uppers.

The first photo shows Nick cutting back and throwing some big spray off a wave.  Riley Coon is the second shot throwing a sweet goiter (if there can be such a thing).  The third is my buddy Sven Zedlick making a nice top turn.  Garth Pond is doing the same in photo five.  Larry (?) is in number nine. I'm looking for names on the others (so if anyone knows send me a comment),

Sunday, October 23, 2011

On Da Rock (It's a good thing)

I'm writing this from our little Ohana up country Maui. We've been on island about ten days. The sun is rising into a clear blue sky, the birds are doing their usual morning song and dance (and fortunately without any roosters involved in the process) and there is a new 15 ft swell arriving on our north shores today. The American Windsurfing Tour is also gearing up for an exciting week of windsurfing competition and parties. I can't do any competing but I can do parties, so I got that going for me (which is nice).

It's been 5 1/2 weeks since my little medical procedure. The whole experience already feels like a dream, or some story I read on someone else's blog. Did it really happen? I have to look down at my already fading scar to remind myself that yes, it really did. I've also seen some medical bills going back and forth to further remind me. Want to know what open heart surgery in the US might cost? Hint, around $150K. Nice to have health insurance even though we have a high deductible so we're not getting off entirely free. But what would have happened if we were without - like so many others? I find it hard to imagine (good bye life savings). I'm also guessing I might have entered that special place called "uninsurable", meaning past medical procedures or illnesses rule out future private health insurance, if I ever need any. The funny thing is I'm probably much less likely to have any medical issues now, but whatever. Such is life on the US health insurance wheel of fortune - I'll avoid further rants and just be happy that we are good for now.

Speaking of good, I really feel it. I'll admit the the packing and travel totally wore me out, and the first day or so here I mostly napped. But lately I've been hanging at Kanaha while Julia's board testing for Windsurfing Magazine's annual review, and I've been riding my beater Maui trail bike back and forth between Kanaha and Paia - about a ten mile round trip with some heavy head wind to make it interesting.  I'm not feeling any pain and all the bike riding so far has been problem free. My plan is to slowly step up the effort and soon add yoga, light jogging and light swimming to the mix.  The basic info I have on the recovery process is it takes 6-8 weeks for the sternum to heal sufficiently to allow more vigorous exercise - I'm counting on being good in 6 (just a few days away).  I've also been told to wait at least 6 months before any activities that could involve sudden impact - which is why I'm thinking no (except maybe extremely light) windsurfing until then.  But perhaps a little surfing before might be possible?  I'm in unknown waters here, but I'm pretty confident that I'm healing about as quickly as possible. If any of my readers are cardiologists or have medical expertise in this area, please feel free to leave me some comments about my expectations!

Quick rant. Why couldn't they extend the bike path from Kanaha by the private Maui golf course / country club (which resembles a retirement home in terms of the clientele) to the Baldwin beach trail which runs to Paia? Did the golf course and private McMansions along the side of it have to take up all the space between the ocean and the highway?  Really?  We need Bill Muarry to blow up some golfers, I mean gophers, and clear us some space for our bike path.  Who's with me!  One good thing about the country club though - it has one really huge kick ass Banyan tree (actually several trees all connected) right in the middle of their parking lot. Possible the biggest on the north shore. Standing under it, staring at the vines swaying down 100 ft from the canopy reminds me of a something out of Avatar. Check it out...

Back to the AWT and parties.  Last night was the kick off at Kanaha Kai (Hot Sails).  Jeff Henderson and co had a nice little throw down and it was great seeing the windsurfing tribe mostly gathered in one space.  If conditions can rally later this week it's going to be an epic competition and I promise to be there with camera in hand for all the action.  I might not be able to sail at the moment, but I sure can click, click, click!

One last thing....  when this whole heart surgery - I might die or be hugely damaged - thing was going down, I couldn't help but think about our upcoming trip to Maui and our plan to pick up some shiny new windsurfing gear to play in the waves.  At that time the whole trip - if not my life - seemed potentially on the rocks.  So I am very pleased to report that not only are we here, but we got all our new gear!  Below is the new 2012 Goya 78 quad that we picked up along with a quiver of 2012 Guru sails. Suffice to say this is the most awesome-ness windsurfing kit on the planet.  For now Julia gets to play on it, but I'm pretty sure my time will come soon enough...

Sunday, October 9, 2011

Living With Less (and Loving It!)

[ Edit - embedded a video at the end about living with less. ]
This is a bit of a philosophical post that's been swirling around my head for awhile and which recent events have brought to the surface.  Forgive me for this little detour and I swear I will return to bikinis real soon!

I just finished reading Unbroken: A World War II Story of Survival, Resilience, and Redemption .  It's an  amazing story about a man whose dreams of winning an Olympic medal where crushed by WWII and years of living in the hellish conditions of a concentration camp.  Returning home he fought depression and... OK I'm not going to spoil the book, just read it.  But here's the thing, all this happened about 70 years ago - very little time in the scale of human history.  Imagine being transplanted back to that time - no TV, no modern music, no rock, no rap, no hip hop, no electric guitars, no DJ's, no dance music, no raves, no jets flying across country and the world in a matter of hours, no iPhones or iPads, no computers or internet, no video games, no nationally televised sporting events, no super bowl (or ads), no burning man or anything close. Surfing and skiing barely existed with extremely difficult and limited gear, no windsufing or kiting or mtn. biking - and so on and so on.  Antibiotics were just being discovered and people still routinely died from tuberculous and ordinary infections.  Polio raged.  There were few diseases that medicine could cure - anything serious was a death sentence.  Child birth was extremely dangerous. Infant and mother mortality was much higher. Wars were terrible, being drafted was routine and expected, and depending on your deployment you could face a 70% or greater chance of dying or losing major body parts.

Now return yourself to the present.  Things seem pretty good in comparison. And yet many people are so very unhappy.  Sure, there are serious inequities and jobs are scarce and so on.  Would you prefer to be taken back to the good times of say 1941?  Maybe jump on a military transport ship about to invade Iwo Jima?  How willing are you to die extremely horribly right now to defend your lifestyle?  Personally I think we are living in the good days.  My recent life saving surgery was not possible just twenty years ago and repairing a heart valve only become reality in the past few.  I'm happy to be alive today!

It's been said that happiness is relative and people judge themselves on the scale of their neighbor's and friend's happiness and accomplishments.  We live in a culture where everyone wants more, despite having so much.  Bigger houses, bigger stock portfolios, bigger and newer cars.  This is what motivates many, and the perception of having less or not having one's fair share makes people very unhappy.  There are stories of people buying $360K homes on a $30K income.  Or owing $80K on a used pick up truck after years of trading up and rolling over the debt.  Did they really need that?  Is it worth owing so much of your life to the man?  I know it's easy to say this in retrospect and for sure there was predatory lending and so on going on.  But the fundamental principal of greed by everyone from the top to the bottom seems to have brought us to this precipice.  I understand what the Wall Street protesters are feeling, but where were they five years ago when all this was really going down?  I believe everyone was too caught up in the frenzy to take notice of the sins of the moment. Yet if people were happy living simply and within their means, would there ever have been a real estate bubble in the first place?

Personally, I try to find happiness in the little things. Such as surfing a beautiful wave, especially with friends (who don't snake it!).  Windsurfing is a joy that's hard to describe unless you experience it.  Jumping over a wave and landing a clean forward loop - amazing!  Or powder skiing in arm pit high dry snow, making fresh tracks top to bottom on an untouched slope under bluebird skis.  I've seen grins on people's faces from end to end that last all day.  Just waking up in the morning to a beautiful sunrise, knowing that the day has so many potential joys and adventures.  There are other joys for sure. Some folks would dance all night, others live to perform making great music and/or art.  These are the things we should prioritize. Everything else is noise.

A few years ago Julia and I decided to live with much less and enjoy life more.  Around 2006 I had the sure feeling that real estate was going to tank and the economy would soon follow.  How did an ordinary dude realize this when so many experts claimed it was unpredictable, a black swan? (I say these experts buried their heads in the sand)  Actually it's a mystery, but I did understand that bubbles can burst and real estate can fall, having painfully experienced both first hand in Boston in the late 80's and the tech bust of the 00's.  We decided to sell our modest ranch house in Portland and move into a much smaller cottage in Hood River (which we bought very cheap very long ago).  Our ranch had almost doubled in price in less then ten years and I remember telling our realtor that surely this craze could not continue.  We had put a lot of blood, sweat and tears into our little home, but it took less then one weekend to sell it (and it happened while we were skiing).

We settled into our 700 sq ft 1/1 cottage in Hood River.  Hood River is a town where people live to have fun - it's the main reason to be here.  So if you ask someone in town what they do, you're most likely going  to hear something like windsurfing, kiting, biking, skiing, kayaking and so forth. Work and career becomes secondary to the life style.  We love it here.  All our cars are old (97 Honda CRV, 2001 Ford Van) and long ago paid off and since we walk or bike as much as possible we hardly put any miles on them (the van only has 44K).  We have not had a car payment this millennium and I'm not tempted to acquire one anytime soon.

We built a garage with a tiny apartment where we did as much of the finish work as possible (tiling, painting, and so on).  We ended up with a very comfy 700sq ft efficiency (in essence one big room with a separate bath) and an amazing view of the river and Mt Adams. We rented the cottage to a friend which covers a big chunk of our tiny mortgage.  Meaning that we now basically live for free - and that has some advantages!

One huge advantage is we could afford to travel to Maui and continue to pursue our passions.  It's only been in the last three years that we've learned to surf  - and I still have a long ways to go.  But I already find it difficult to believe there could be life without surfing.  How is that possible?  We rent a small ohana - basically an in-law cottage on the same property as the main house.  It's about 650sq ft with 1 bed 1 bath, very modestly furnished with a shared yard and driveway. The two cats are super friendly. We own no furniture, no TV, no stereo (except my old laptop).  We bought an old Dodge Caravan on the cheap as a surf mobile.  I have about ten t-shirts, eight board shorts, and a few sandals for clothes.  Our biggest extravaganza is our surf and windsurf gear. But for the most part, it occurs to me that we live with less than the average college freshman.  And I love this life!  What more do you need?

I guess my point is this - look around and decide what makes you happy.  Do you need a new car or a bigger house. Really?  Does it make sense to blame others for past decisions right or wrong, or would it be best to forget the past, take some responsibility, and move on with the future.  I've had some bad luck myself, which includes an early divorce (too young!), being laid off (several times), just missing once in a life time chances to get rich (twice company stock tanked just before my options matured and then I was laid off), family and future dreams dashed by harsh reality, and just recently life threatening totally unexpected open heart surgery.  But I've always believed in trying to turn lemons into lemonade.  Life is what you make of it.  Look for happiness in the little things.  Try not to blame others - it will only make you less happy.  Find peace.  Enjoy!

Wednesday, October 5, 2011


Exactly three weeks ago from today, as I'm writing this, I was just coming out of exceptionally complex heart surgery that essentially saved my life.  (The full story starts here, in case you haven't seen it) Right now my recovery is still going great. Hopefully in the not too distant future (months anyway) I'll be able to jump on a surf board and/or windsurf again. That's the possibility that I really wanted.  We also got the green light to return to Maui in about a week.  I'm thinking warm water and tropical skies should really help the rehab progress.  Yes!

For now I'm concentrating on gradually getting my strength back and following the rehab schedule.  One thing I was warned about on my discharge was a potential lack of appetite.  Which seems funny because I've had the exact opposite situation - I'm hungry all the time!  Which makes sense as I'm told the body can consume up to 3000 extra calories daily while repairing itself from such major surgery.  I've been eating the equivalent of five meals a day (I've been drinking high protein Ensure, but not as a meal replacement, as an addition).  The strategy seems to be working as my weight loss stopped around week two (low point 166.6) and has steadily inched up since (morning weight now 171.5).  Another thing that really helped is cutting way back on pain meds around week two. I had been taking Percocet, but no more.  I'm all ibuprofen now, about 4-6 (200mg each) a day.

The other warning concerned depression that supposedly hits around the first or second week after leaving the hospital.  I believe the cause is due to hormonal imbalances from the intensive repair process, plus perhaps being suddenly very physically limited.  And maybe the ongoing pain and lack of sleep.  Anyway, I seem to have side stepped much of that so far.  Actually sleep isn't perfect yet - I can't rest on my stomach which has always been my preferred snoozing position. But anyways, I feel nothing but encouragement to be recovering so quickly - and nada depression!

I hit a major rehab milestone by walking downtown to attend the Hood River Hop Fest last weekend.  There were over fifty taps on hand, many were unique fresh hop versions of old staples, such as Mirror Pond Pale Ale.  I sampled about seven or eight beers, consumed two Solstice pizza slices and a pulled BBQ chicken, told my story about twenty times to various friends over the course of a few hours, then did the long uphill walk home. And felt pretty good (especially after the beers). It was almost worth staying in HR a few extra weeks just to attend this.

We've also been taking progressively harder hikes, such as last weekend to Catherine Creek Arch. This is a pretty awesome hike just a few miles east of us on the Washington side, near Lyle.  Here the heavily wooded western gorge gives way to the very dry and desert like eastern gorge.  So it's got both trees and tumble weeds.  Also the occasional rattler though we didn't see any.  The coolest part of this hike is the famous arch, which you can hike right through if you're so inclined.  We hiked to the top of it and dangled our feet down toward the opening.  There are many other spectacular hikes around the Gorge, and if you need a guide book I highly recommend our friend Scott Cook's Curious Gorge (and Pokin Round the Gorge) offerings.  Great photos, historically educational, and highly entertaining!

One interesting tidbit I learned about my esteemed surgeon Dr Eric Kirker is that he is one of only five in North America capable of repairing a heart valve as he did for me.  And I'm not sure how many in the entire planet could do this as the technique is so new and very advanced. Again it seems amazing that I was in just the right place and time to have this done.  Fate?

I already mentioned that the company I work for, Kryptiq Corp, provides an application that allows doctors to send lab and medical information directly to patients via secure email.  In fact I'm one of the engineers developing this app. The really cool part is that I've been able to use this to get otherwise difficult to obtain information regarding my surgery.  Such as the complete operation report.  Now I might have said earlier that I didn't want to know the dirty details, but honestly it's pretty amazing to see what was actually done.  So in the spirit of sharing all this (some folks really wanted to see this) I'm including all below.  Skip this if you don't want the details.  Otherwise enjoy....

DATE OF ADMISSION: 09/12/2011.

CHIEF COMPLAINT: This is a 53-year-old white male seen at the request of Dr. Ali Rahimtoola for evaluation and treatment of aortic aneurysm with potential dissection.

HISTORY OF PRESENT ILLNESS: This is a 53-year-old physically active white male who presents with an essentially asymptomatic type 1 aortic dissection. The patient begins history by noting a typhus infection in Maui in 12/2010. From that time, the patient had intermittent episodes of palpitations and he noted increased pulsations of the abdominal area since that time. The patient denies inanition, abdominal pain, chest pain, shortness of breath at any time. He has not had syncope, headache or any physical disruption from his very active physical activities including ultimate frisbee, surface boarding, windsurfing and vigorous mountain biking. The patient biked to the emergency room for a followup echocardiogram on 09/12/2011 at which time the patient's aortic insufficiency and aortic aneurysm were noted. The patient on exam denies any neurologic symptoms, chest pain or shortness of breath. He has been very active up to the present time. He notes no previous episodes of chest pain. The patient has had no previous cardiac history. PAST

MEDICAL HISTORY: Significant for the absence of diabetes, stroke or hypertension. He has had previous ACL surgery and has had a duodenal hematoma from active trauma from an injury at ultimate Frisbee. He did not require operation.

GENERAL: This is a tanned and healthy-appearing 53-year-old gentleman in no distress at rest.
VITAL SIGNS: BP 120/80, heart rate 64, respirations 14, O2 saturation 100 percent on room air.
CHEST: Well-developed.
HEART: Regular rate and rhythm. A brisk systolic and soft diastolic murmur heard in the aortic position. He has no heaves or lifts.
ABDOMEN: Soft and nontender. Soft palpation is noted at midpoint. He is definitely without surgical findings of the abdomen.
SKIN: Warm and dry, no lesions seen.
EXTREMITIES: No cyanosis or clubbing. He has equal pulses at the radial and posterior tibial bilaterally with the Corrigan's pulse.
NEUROLOGIC: Cranial nerves 2-12 grossly intact.
LABORATORY DATA: Echocardiogram from Hood River indicates preserved left ventricular function, dilated aortic root consistent with aneurysm and significant aortic insufficiency. A suggestion of dissection is also present. CT scan carried out at Providence Portland reveals type 1 aortic dissection with greater than 6.5 cm dilatation of the aortic root. The tear extends all the way down the descending aorta. Both kidneys have inflow with contrast filling the parenchyma of each kidney.

IMPRESSION AND PLAN: A 53-year-old gentleman with likely chronic aortic dissection. The extent of the dissection with aneurysmal dilatation mandates urgent reparative surgery. The patient is a candidate for aortic replacement with or without aortic root sparing. In addition, the patient may require a period of circulatory arrest for arch replacement, stent placement or elephant trunk type repair. The risks of surgery are high and include paraplegia, stroke, infection, MI, recurrent dissection and death. This has been discussed with the patient and his family. They are agreeable to proceed. PARQ was carried out by myself and also Dr. Eric Kirker who will attend his surgery. The patient is at extraordinary risk for both medical and surgical management. It is unusual in that he is largely asymptomatic from this extensive aortic pathology. Plans for the patient were discussed with Dr. Cynthia Ferrier who is covering for Dr. Malcolm Mcaninch today.

POSTOPERATIVE DIAGNOSIS: Severe aortic insufficiency, type A dissection, type 1, aortic root arch aneurysm, bicuspid aortic valve.

PROCEDURE: Intravascular ultrasound, thoracic endovascular stent with a Gore Tag 31 x 15 cm graft for frozen elephant trunk valve-sparing aortic root replacement (TD5), ascending arch and proximal descending replacement, also right axillary cannulation and transesophageal echocardiogram.

ANESTHESIA: General endotracheal anesthesia plus deep hypothermic circulatory arrest 27 minutes and cardiopulmonary bypass.

SURGEON: Eric Kirker, MD.

ASSISTANT: Kristy Khoury, PA.

INTRAVENOUS FLUID: Not applicable.


SPECIMENS: Ascending and root of aorta were sent.

DRAINS: Blake drain times 2.



DESCRIPTION OF PROCEDURE: The patient taken the operating room and placed on the table in the supine position. Placed under general endotracheal anesthesia, at which time a right internal jugular Swan-Ganz catheter and a left radial arterial line were placed. Transesophageal echocardiography was performed, revealing severe AI, moderate mitral regurgitation and severe dilatation of the aortic root with dissection flaps.

At this time, the patient was prepped and draped in the usual sterile fashion. A needlestick was performed in the right common femoral artery followed by a guidewire placed up this and, via Seldinger technique, changed out to an 8-French sheath. A Bentson wire was placed up through the aorta under fluoroscopy and intravascular ultrasound was used to visualize the wire. Clearly, the wire was in the false lumen. After some manipulation, we were unable to go into the true lumen and we did at that time turn our attention to the left leg. A needlestick was performed and this was switched over with Seldinger to an 8-French sheath followed by a Bentson wire and again intravascular ultrasound was performed, revealing we were, indeed, in the true lumen.

At this time, that being in place, we did secure the extra stiff Amplatzer wire in the true lumen and turned our attention back to the patient's chest. An incision was made in the infraclavicular fossa on the right-hand side. Dissection made with electrocautery down through layers of the chest, splitting the pectoralis major muscles and, indeed, opening the infraclavicular fossa and exposing the axillary artery. The axillary artery was looped proximal and distally with Vesseloops.

A midline sternotomy was then performed. Dissection made with electrocautery down through the layers of the chest, exposing the sternum, which was divided with a sternal saw, treated with Gelfoam, and the pericardium was cleaned off of its fat. The patient was fully heparinized. After the heparin had a chance to circulate, the axillary artery was clamped proximal and distally, opened with an 11 blade, extended with scissors, and matched to the proximal end of a 10 Hemashield graft, which was sewn with 5-0 Prolene. After this was accomplished, Bioglue was placed on it. It was cannulated with a 7 Sarns Soft-Flow cannula, hooked up to the cardiopulmonary bypass circuit without air. It is important to mention that even though we were heparinized now, prior to heparinization, 2 whole units of the patient's blood were drawn off to be given back to the patient at the end of the case.

The pericardium was opened and there was an inflammatory aneurysm in the ascending aorta, at least 8 cm in diameter, going down into the root. Extensive dissection was performed around the aorta. A pursestring was placed into the right atrium. This was cannulated with a 3-stage venous cannula, hooked up to the cardiopulmonary bypass circuit without air. Another pursestring was placed in the right atrium, which was cannulated with a retrograde cardioplegia circuit. Another pursestring was placed in the right superior pulmonary vein, which was cannulated with an LV vent.

At this time, we did proceed with cardiopulmonary bypass and began cooling the patient intensely. The patient was cooled all the way down to 18 degrees centigrade as a goal. At this time, we did turn our attention to the ascending aorta. With the great size of the ascending aorta, a large cross-clamp was placed around the aorta as well as the pulmonary artery and clamped and we did arrest with retrograde cold blood cardioplegia. The ascending aorta was opened widely and we could clearly visualize very large destroyed dissection flaps. Hand-held cardioplegia was used to give antegrade cold blood cardioplegia down the right coronary ostia. However, a total of 1200 was given at the beginning. For the remainder of the case, an additional 300 mL was given retrograde every 20-25 minutes. This was done with the patient having clear blood coming back from the right and left coronary ostia. Extensive dissection was performed, dissecting out the entire root and the ascending aorta below the clamp. The root was dissected down to the annulus exteriorly.

The valve appeared to have good valvular tissue, but be a bicuspid valve. Therefore, I chose to spare it at this time. Fourteen interrupted subvalvular sutures were placed with pledgets. After this was accomplished, a 34 graft was brought onto the field. The outflow tract was sized to a 25. Therefore, a 34 graft was chosen. The 14 sutures were brought up through the bottom of the graft, the graft was dropped into position. The Hagar dilator was placed down the left outflow tract again and all the sutures were tied, starting with the commissures and then running around.

At this time, the patient reached 18 degrees centigrade. We did tip in steep Trendelenburg position and proceeded with deep hypothermic circulatory arrest. It is important to mention the patient had already received a gram of Solu-Medrol and high dose of propofol to provide burst suppression. Once on deep hypothermic circulatory arrest, the ascending aorta was completely resected as well as the lesser curvature of the arch and the ascending aorta was resected all the way up to the innominate artery. The proximal transverse arch was also removed completely. The true lumen clearly had the guidewire in, which I had left. The true and false lumen were reapproximated with Teflon felt provided as a neomedia. Running Vicryl was used to reapproximate those 2 layers. Bioglue was placed on the 2 layers. After that was accomplished, the guidewire was pulled forth. A 15 cm x 31 mm Gore Tag graft was placed over the guidewire and put down the descending aorta in an antegrade fashion. After this was accomplished, it was found to be past the subclavian. It was deployed. After it was deployed, multiple tacking sutures were used to secure it to the aorta so that it would not slide or "bird's beak." After this was accomplished, the 28 sidearm Hemashield graft was cut to size, brought onto the field and sewn to the arch. After that was accomplished, the graft on the axillary artery was clamped and the cannula was removed, cannulated into the side arm and secured of the ascending graft. We had to de-air the patient at that time, replace the crossclamp and proceed with cardiopulmonary bypass and rewarming. The total deep hypothermic circulatory arrest time from 18 degrees centigrade was 27 minutes and the patient's cranial saturations never dropped below 57 percent.

That being the case, I did turn my attention back to the root. The commissures were secured to the graft with pledgeted RB Prolenes. The valve was truly bicuspidized. Trussler stitches were placed in the edges of the fused right and left cusps to shorten it and make it the same length as the noncoronary cusp. There was good approximation at this time and the valve was tested for competency with cold saline and was found to be competent. At this time, I did proceed to take a stitch and run it along the inside of the graft, securing the edges of the aorta with the valve back to the Hemashield graft. After this was accomplished, 2 coronary ostia holes were cut in the Hemashield graft and the coronary buttons were cut out circumferentially and sewn to the graft with 5-0 Prolene. This was all reinforced with Bioglue. After that was accomplished, the 34 graft was cut off at the level of the sinotubular junction, just above the commissures, the distal graft was cut to length and the distal and proximal grafts were anastomosed with running 4-0 Prolene. After this was accomplished, ophthalmic cautery was used to make a small hole in the ascending graft and an ascending vent was placed.

After this was accomplished, we did give the patient warm blood cardioplegia. During 2 minutes of warm blood cardioplegia, 2 right ventricular and 2 right atrial pacing wires were placed. The patient began beating. Once the patient began beating, the patient was put into steep Trendelenburg position again. The vents were turned on high, the cross-clamp was removed in a low flow state and the flow state was brought back up. After this was accomplished, we began ventilating. After ventilating some time, we did load the patient's ventricle and check the function of the aortic valve. The aortic valve was completely competent with no evidence of regurgitation or stenosis. At this time, also the mitral valve improved greatly with its very trivial mitral regurgitation. At this time, we did remove the LV vent, tie down its pursestring, and again view the valves, finding them in good condition, just as described earlier. With the patient completely de-aired, we removed the ascending vent, tied down its hole with a pursestring and another pledgeted Prolene. With the vent out, the patient ventilating, warm and in normal sinus rhythm, we were able to wean from cardiopulmonary bypass.

At this time, we weaned from cardiopulmonary bypass, removed the retrograde cardioplegic cannula, tied down its pursestring, removed the venous cannula, tied down its pursestring. The patient still hemodynamically stable, we reversed the patient's heparinization with protamine. At this time, we gave the patient back all his blood from the pump. The patient still hemodynamically stable, we did tie off the sidearm grafts and then cut them off. After this was accomplished, with the patient hemodynamically stable, we did use multiple topical hemostatic agents, including Gelfoam thrombin and Arista. With good surgical hemostasis and the patient hemodynamically stable, we also gave DDAVP. That being completed, with a good thromboelastogram, we gave the patient back his own blood. The patient was hemostatic and hemodynamically stable.

We did proceed with closure. Two Blake drains were placed, one behind the heart and one in front of the heart. The pericardium was closed with running Vicryl. Four interrupted figure-of-eight Pioneer cables were placed across the sternum. The underside of the sternum was reinspected and found to be hemostatic. The sternum was treated with vancomycin, Gelfoam, and thrombin paste. The sternum was reapproximated. The cables were tightened, clipped, and cut. The patient was washed out with antibiotic saline. We did at that time close the fascia with running Vicryl. We washed him out again. The subcutaneous tissue was closed with running Vicryl. Skin was closed with running Vicryl subcuticular stitch followed by LiquiBand. Attention turned to the axilla. The graft was tied off and cut low. With good surgical hemostasis, the pectoralis was reapproximated with running Vicryl. Subcutaneous tissue was reapproximated with running Vicryl. Skin was closed with running Vicryl subcuticular stitch followed by LiquiBand. The right groin line was removed. Pressure was held for 15 minutes and the groin was stable with good pulses in the feet. At this time, we did have instrument, sponge, and needle counts correct, did return the patient to the CCU, intubated, in stable condition, on no drips and having received no blood products.

HOSPITAL COURSE: Mr. Jones is a 53-year-old gentleman with likely chronic aortic dissection. The extent of the dissection with aneurysmal dilatation was determined to mandate urgent reparative surgery. The patient underwent the aforementioned procedure without complication on 09/13/2011.

By postoperative day #1, the patient was doing very well. Tubes and wires were discontinued, and he is looking great and transferred to 2G.

By postoperative day #2, he had no major issues. Pain was controlled. Insulin drip was discontinued. He was started on sliding scale insulin, and clonidine as needed was added for elevated blood pressures.

By postoperative day #3, the patient had no complaints. JP and pacing wires were discontinued. Lasix was initiated for weight being up and for volume overload.

By postoperative day 4, the patient did have an episode of atrial fibrillation the prior day and was started on the amiodarone protocol and quickly converted back into normal sinus rhythm. The patient was asymptomatic throughout the episode. He will be discharged on prophylactic amiodarone and metoprolol.

The patient feels very well. He has no major complaints.

Copyright © 2011 Jamin Jones, All rights reserved.