[HSF] Dr Jean Bachet

Wed Oct 11 11:38:46 EDT 2006

Thank you Prasanna ... an important bit of information ... and a good size
indeed . what program do you use ? 

NFA

> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
> bounces at lists.hsforum.com] On Behalf Of prasannasimha
> Sent: Wednesday, October 11, 2006 10:14 AM
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] Dr Jean Bachet
> 
> 
> Nasser not 50 Kb but 512 Kb. I will reduce it and send it if required. I
> think around 60-100 Kb is sufficient for on screen viewing without
> burdening the server and emails
> 
> Prasanna
> Nasser F. Abou'Seada wrote:
> > 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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