[HSF] Dr Jean Bachet

Wed Oct 11 11:09:48 EDT 2006

Dear Dr. Bachet 
the drawing did not pass. it has to be .jpg format and less than 50kb to
pass the HSF server. Please feel free to send it to my personal email, I
would edit it and post it on your behalf. 
Thank you for your very courteous words. 
Kindest Regards  

NFA

> From: Jean BACHET
> Dear Prasanna,
> I use a regular aortic cannula (generally one with a strait tip, as it is
> easier to insert in this location that an angled one). Most frequently I
use
> Medtronic DLP cannula 18 French. I have attached  a drawing illustrating
> this type of cannulation (it is supposed to appear soon in a US text book,
> but I don't know when exactly).
> 
> Jean Bachet.
> 
> ----- Original Message -----
> From: "prasannasimha" <prasannasimha at gmail.com>
> To: <OpenHeart-L at lists.hsforum.com>
> Sent: Wednesday, October 11, 2006 12:38 PM
> Subject: Re: [HSF] Dr Jean Bachet
> 
> 
> Dear Dr Bachet ,
> I do recollect reading some posts of yours for eg leiomyoma and IVC
> thrombosis, wrt porcine valves and also and wrt my Image of the week wrt
> aortoarteritis.
> Thanks for the info on the Kazui technique. Can you please tell us also
> about what cannula you use for inomminate perfusion ? Is it directly
> cannulated or via a graft ?
> 
> Prasanna
> Jean BACHET wrote:
> > Dear Prasanna, Roberto and Nasser,
> >
> > the Kazui technique and the one we described with my mentor D. Guilmet
in
> > the late 80s and called "Cold Cerebroplegia" are based on exactly the
same
> > concept: Avoidance of aortic cross-clamping and  general deep
hypothermia
> on
> > the one hand  and selective antegrade cerebral perfusion on the other
> hand.
> > Therefore in both methods the core temperature of the patient
> > (naso-paryngeal temp.) is lowered to about 24°C. When this temperature
is
> > reached, the main CPB is discontinued and the cerebral perfusion started
> at
> > a flow rate of 10ml/kg. The arch repair is then carried out under distal
> > circulatory arrest. As soon as the distal repair is completed, the main
> CPB
> > is resumed and the proximal anastomosis (or repair in case of necessary
> AVR,
> > Bentall etc...) is carried out while the patient is rewarmed back to
36°C
> > (naso paryngeal and rectal temp.)
> > The diffrences betwen the two methods are the following:
> > 1/ The arterial cannulation:
> > We used to cannulate both innominate artery and left common carotid
artery
> 
> > through purse string sutures on the side of the vessels (like a femoral
> > artery). This had the advantage of having a continuous perfusion without
> any
> > interruption throughout the arch repair. In addition de-airing is easy.
> > Some drawbacks were observed, though. It is difficult in patients with
> acute
> > type A dissection encompassing the cerebral vessels or in patients with
> > severe atherosclerosis of those vessels (which fortunately enough is not
> > very frequent in France). It may also be harmful in presence of a very
> small
> > carotid artery (I had one case of hemplegia on POD 2 by occlusion of a
> left
> > carotid artery at the site of cannulation).
> > Kazui cannulates the innominate artery and the left carotid artery
through
> > their ostium after having opened the arch under circulatory arrest. It
> > requires only one or two minutes and is quite easy. He uses specially
> > designed balloon cannulas.
> > Concerning the main circuit, I presently almost never cannulate the
> femoral
> > artery anymore. In acute cases (Type A Diss.) I cannulate systematically
> the
> > right axillary artery under the clavicle. In chronic cases, I use very
> > liberally the innominate artery which, in most patients is large enough
to
> > accept a regular aortic cannula. Through this I do the whole CPB and
cool
> > down the patient. When I stop the main CPB, I crossclamp the innominate
> > artery at its origin and perfuse the brain through this cannula. Then I
> open
> > the arch and put a ballon cannula in the left carotid artery and start
> > perfusing both sides. I know that Kazui often uses a similar technique.
It
> > is very simple. It avoids any kind of cannula switch when resuming CPB
and
> > allows a permanent antegrade aortic flow into the aorta during CPB (No
> > danger of retrograde debris embolism or false channel pressurisation and
> > malperfusion).
> > I think that it is important to perfuse both sides, as about 10 to 15%
of
> > human beings have an abnormal circle of Willis and unilateral perfusion,
> as
> > it is more and more frequently proposed in the literature, might prove
> > dangerous in those individuals. It is also important to cross clamp or,
> > better, to occlude the left subclavian artery with a small Foley
catheter
> in
> > order to avoid steal syndrome during perfusion and tedious blood back
flow
> > through this vessel during repair.
> > 2/ The perfusate temperature.
> > In our method we used to perfused the brain with blood cooled down to
> 12°C.
> > This had been decided rather empirically on the analogy of cold blood
> > cardioplegia. As it proved quite efficacious we did not change. But, as
> > already stated, it required a more sophisticated CPB circuit (Two heat
> > exchangers, one separate arterial line for the brain)
> > In Kazui's method the brain is perfused at the same temperature as the
> whole
> > body (24-25°C) The circuit is simpler. The patient's core temperature
> > remains steady. The pefusionists have less work and concerns and
everybody
> > is happier!. So I did change.
> > 3/ Another important difference is the mode of reimplantation of the
arch
> > vessels. The great majority of  patients in our experience (as in
general
> in
> > Europe and US) had an "en bloc" reimplantation of the epiaortic vessels,
> > whereas most patients of Kazui's experience have a separate
reimplantation
> > of those vessels. But this has nothing to do with the method of brain
> > protection. I think that it relates to the local surgical culture and
> > training in our different countries.
> > I hope that this answer would be somewhat useful.(and that my
explanations
> > are comprehensible and not too boaring!)
> > I do insist that both methods have proved in our experienc equally easy
to
> > use and surgeon and patient friendly .
> >
> > Here are some references about those various experiences:
> >
> > BachetJ., Guilmet.D., Goudot B., et al.
> > Cold cerebroplegia. A new technique of cerebral protection during
> operations
> > on the transverse aortic arch.
> > J Thorac Cardiovasc Surg. 1991 Jul;102(1):85-93; discussion 93-4.
> >
> > Bachet J., Guilmet D.
> > Brain protection during surgery of the aortic arch.
> > J Card Surg. 2002 Mar-Apr;17(2):115-24.
> >
> > BachetJ., Guilmet.D., Goudot B., et al.
> > Antegrade cerebral perfusion with cold blood: a 13-year experience.
> > Ann Thorac Surg. 1999 Jun;67(6):1874-8; discussion 1891-4.
> >
> > Bachet J., Goudot B., Dreyfus G. et al.
> > How do we protect the brain? Antegrade selective cerebral perfusion with
> > cold blood during aortic arch surgery.
> > J Card Surg. 1997 Mar-Apr;12(2 Suppl):193-200.
> >
> >
> > Kazui T., Bashar AH.
> > Total aortic arch replacement and limited circulatory arrest of the
brain.
> > J Thorac Cardiovasc Surg. 2005 May;129(5):1207-8.
> >
> > Di Eusanio M, Schepens MA, Morshuis M. et al.
> > Separate grafts or en bloc anastomosis for arch vessels reimplantation
to
> > the aortic arch.
> > Ann Thorac Surg. 2004 Jun;77(6):2021-8.
> >
> > Kazui T., Yamashita K., WashiyamaN. et al.
> > Usefulness of antegrade selective cerebral perfusion during aortic arch
> > operations.
> > Ann Thorac Surg. 2002 Nov;74(5):S1806-9; discussion S1825-32.
> >
> > Kazui T.
> > Simple and safe cannulation technique for antegrade selective cerebral
> > perfusion.
> > Ann Thorac Cardiovasc Surg. 2001 Jun;7(3):186-8.
> >
> > Kazui T., Yamashita K., , Muhammad BA. et al.
> > Total arch replacement using aortic arch branched grafts with the aid of
> > antegrade selective cerebral perfusion.
> > Ann Thorac Surg. 2000 Jul;70(1):3-8; discussion 8-9.
> >
> > Kazui T., Inoue T., Yamada O. et al.
> > Selective cerebral perfusion during operation for aneurysms of the
aortic
> > arch: a reassessment.
> > Ann Thorac Surg. 1992 Jan;53(1):109-14.
> >
> > Etc...
> >
> > Jean BACHET
> >
> > p.s. thank you very much for welcoming me in the Forum. I  have already
> sent
> > a few messages, from time to time, but obviously they were not broadcast
> as
> > I never got any feedback.
> >
> >
> >
> > ----- Original Message -----
> > From: "prasannasimha" <prasannasimha at gmail.com>
> > To: <OpenHeart-L at lists.hsforum.com>
> > Sent: Tuesday, October 10, 2006 3:25 PM
> > Subject: Re: [HSF] Dr Jean Bachet
> >
> >
> > Dr Bachet,
> > Thanks for the info. I was really hesitant to use GRF but in the
> > presence of life threatening bleeding it looked "Oh so attractive" as it
> > was the only thing at hand !!
> > Can you please elaborate on the Kazui technique ?
> > Prasanna
> >
> > Jean BACHET wrote:
> >
> >> Dear Dr. Battellini,
> >>
> >> just a few words to let you know that I have received your message.
> >> Concerning your question and to make it short, I have stopped perfusing
> >>
> > the
> >
> >> brain at 12 °C while the rest of the body is maintained at 25-26°C
about
> 4
> >> years ago. I presently use the perfusion mode described by Kazui. The
> >>
> > change
> >
> >> was not due to unsatisfactory results but only to the fact that, after
> >> seeing me once using  Kazui's technique, my perfusionnists insisted
that
> >> this  method was simpler and musch less expensive. I was rapidly
> conviced.
> >>
> > I
> >
> >> must insist that both methods are equally safe and that the important
> >> features are selective antegrade perfusion of the brain and avoidance
of
> >> deep core hypothermia.
> >>
> >> Cordiali saluti.
> >>
> >> Jean BACHET.
> >> ----- Original Message -----
> >> From: "Dr. Roberto Battellini" <battr at medizin.uni-leipzig.de>
> >> To: <OpenHeart-L at lists.hsforum.com>
> >> Sent: Tuesday, October 10, 2006 1:08 PM
> >> Subject: [HSF] Dr Jean Bachet
> >>
> >>
> >> Dear Dr Bachet,
> >> It´s a pleasure to have you in the forum.
> >> I want to ask you if in complete aortic arch cases you still use 2
> >> oxigenators so to keep the brain cold and the rest of the body warmer.
> >> Please describe how are  you performing this technique actually.
> >> Thanks,
> >> Roberto Battellini, Leipzig
> >>
> >> -----Ursprüngliche Nachricht-----
> >> Von: openheart-l-bounces at lists.hsforum.com
> >> [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Jean
BACHET
> >> Gesendet: Dienstag, 10. Oktober 2006 10:09
> >> An: OpenHeart-L at lists.hsforum.com
> >> Betreff: Re: [HSF] Posterior aortic bleed and Coronarybutton tears.
> >>
> >> Dear Prasanna,
> >>
> >> apparently you did well as the patient is now in good condition,
without
> >> bleeding, and extubated.
> >> I just would like to comment about the use of GRF glue in such cases. I
> >> certainly won't recommend it . GRF glue has been proposed by our group
> >> almost 30 years ago in surgery of acute dissection to stick together
the
> >>
> > two
> >
> >> dissected layers of the aortic wall. For this purpose it has proved to
be
> >> quite efficacious. But it is a poor haemostatic agent and is not very
> >>
> > useful
> >
> >> in that indication. In addition, as you know, it is polymerized with
> >> formaline and glutaraldehyde which are rather toxic if not used very
> >> carefully. Putting such products very near the main left coronary might
> be
> >> harmful (I remember seeing a sphenous bypass on a right coronary
bypasss
> >> shrinking in a few minutes when one of the members of the operating
team
> >> accidentaly poured on it a few cc of those aldehydes during repair of
an
> >> acute type A dissection). For me the best haemostatic glue, so far,
> >>
> > remains
> >
> >> the fibrin glue and I use it quite liberally (not to say
systematically)
> >>
> > in
> >
> >> all my aortic root replacements (Bentall, Valve-sparing procedures,
> Ross).
> >> It is certainly not a panacea but it surely helps.
> >>
> >> Jean BACHET.
> >> ----- Original Message -----
> >> From: "prasannasimha" <prasannasimha at gmail.com>
> >> To: <OpenHeart-L at lists.hsforum.com>
> >> Sent: Monday, October 09, 2006 8:54 PM
> >> Subject: [HSF] Posterior aortic bleed and Coronarybutton tears.
> >>
> >>
> >>
> >>
> >>> Today I did a Ross and had a peculiar set of problems. I would like to
> >>> know how the forum members would approach this.
> >>> Basically the case was a lady with a bicuspid aortic valve with
> >>> endocarditis with large vegetations. The line of cusp closure was
> >>> anteroposterior and the pulmonary valve was tricuspid so I managed to
> >>> get a homograft and did a Ross . When I opened the aorta I found the
> >>> Left ostium could be dissected with a good margin of tissue but the
> >>> right was very much adjacent to the annulus. Like in an arterial
switch
> >>> I took the RCA button taking a part of the annulus with it and I
thought
> >>> I had a decent margin. I did not make a separate button for the Left
> >>> main ostium but left it as a tongue of the distal aorta as originally
> >>> described by Dr Sampath Kumar of AIIMS Delhi.
> >>> I went ahead with the autograft implantation and when the time came
for
> >>> implantation of the RCA button when I lifted the button the annular
> >>> strip just sheared off partially and I was not even pulling !! I was
> >>> left with an unpleasant task of reattaching that piece with fine
sutures
> >>> and then implanted the button but even then my bites were terrifyingly
> >>> close to the RCA ostium.
> >>> I would like to know how members would handle this situation
especially
> >>> if the button was torn at the ostium or extended into it . One obvious
> >>> answer would be to oversew and do a CABG if the patient was old
enough.
> >>> Any other methods ?
> >>> Patient has been weaned easily and in fact on vasodilators despite a
> >>> ridiculously long cross clamp time.
> >>> She was pretty dry on closing  but started to bleed later on and I
> >>> re-explored her. She was bleeding from the posterior root anastomosis
> >>> only if her pressures went above 110 mmHg systolic. It would stop with
> >>> decreased pressure. I presume some conformational change was occurring
> >>> of the root at higher pressures leading to the bleeding. Any way I
> >>> avoided going back on CPB and could suture the area of the leak with
> >>> induced hypotension to 50 mm Hg transiently. I packed that area with
> >>> some Surgicel (I was toying of placing some fat and covering the whole
> >>> area with pericardium but was worried if the let main may get
> >>> compressed.and came out and am keeping my fingers crossed. So far
> >>> bleeding has not occurred and I am using sedation and controlling the
> >>> pressure pretty aggressively. Has any one used GRF glue in that area
and
> 
> >>> if so is it safe near the left main ?
> >>> Any other tips / tricks to manage posterior aortic bleeds ? I have
once
> >>> managed this by obliterating the transverse sinus with a series of
purse
> >>> string sutures.
> >>> Prasanna
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