[HSF] Dr Jean Bachet
Tea Acuff
tacuff at swbell.net
Wed Oct 11 17:45:08 EDT 2006
What about using the new internet service Pando? It can handle large DVD files and is free at least at the moment? Mark? I would like to post cardiac MR cines for discussion and "teaching" (learning?) purposes.
Tea
----- Original Message ----
From: prasannasimha <prasannasimha at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Wednesday, October 11, 2006 9:14:09 AM
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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