[HSF] Postop cardiac syncope

Sat Apr 14 21:32:23 EDT 2007

I think that Michael is completely correct. Nothing added or removed is without a possible perturbation of the original system, just as no patient exactly fits any system. Why then is one set of tasks, other than obligatory ones, always a correct one?

As it turned out I did measure flows, albeit by the asculatory Doppler flow measurement. The diastolic augmentation to the sequential graft ultimately ending with the PDA was impressive. The RSV to the diagonal was noticeable. The the flow in the Lima to the tiny LAD was difficult to hear either systolic or diastolic. Since I did not think that I could likely improve a bad plan I did not redo the LIMA. Measuring flow is not a fail safe maneuver either, but does give one extra piece of data to consider when the need for problem solving arises. I do not measure flow between sequential grafts.

After changing the patients support around (stopping the levo and adding fluid) and assessing the EKG and perfusion of the patient I decided that he was not having a significant ischemic event (pump dysfunction) masked by the levo. My working hypothesis, if any as i did not think it worth intervention emergently, was possible closure of the recent DES to the main RCA with flow to the distal RCA maintained by the sequential graft to the PL and PDA. I am surprised that no one suggested this even though I am not arguing strongly for this mechanism. I am thinking of a follow up CTA in a few months to see what if anything happened and to get a baseline if (or when) he has other events in the future. I suspect I will be finding more and more justifiable reasons to do this. 

I have not used pacing wires routinely for CABG patients. If I do not stir up unexpected rhythm problems by jacking the heart around and occluding major vessels, or if I do but l when I unocclude the RCA, for example, and it immediately goes away, I do not and have not seen post op problems. This case was remarkable in that respect. In the elderly or with patients with very slow heart rates, I sometimes (but not always) add atrial or v wires depending on my suspicion of rate or conduction problems. I routinely use wires for valves and struggling hearts. Even here, however, I find the desire to turn the heart into a EP prep of more theoretical than actual interest. I was raised on the value of pacing wires for both therapy and diagnosis but tended to find diminishing returns the more I needed to withdraw from that bank. This does not keep me from trying anyway when I desperately need to, but it does damper my enthusiasm when I don't. (Maybe I have this backwards?.) I have
 seen my share of tamponade from wires. Unlike Hal some were my patients , but like John some one else pulled on them.

As per comments on this thread, even something seen as straight forwardly simplistic and deemed as virtually harmless as pacing wires have a lot of nuance to different observers. As we continue the application the concept of results I would argue that since there is almost no maneuver or technique that is both universal and identical at the same time, only the equally peculiar evidence of direct observation and local accounting is suitable in the final analysis to serve as best practice. Not the poppy cock that is delivered almost daily to our institutions by consultants, JAHCO, and even our societies. Only if we test the results of the "guidelines" not test the presence of the guidelines themselves can they be found best or not. Our present infatiation with measuring whether we meet the guide as opposed to whether the guide delivers a result is either fantasy and hubris depending on whether it is believed. 

But back to my original query, or at least the one that led to my initiation of this thread: Is my perception (if true) that since I have had no complications by rarely placing pacing wires, my "best practice"? Even if the patient had pacing wires, unless all patients also have a temp pacer and then the block would likely be missed, he would have had the syncopal episode. Or did I just trade a pacemaker for hundreds of wires? Or to paraphrase Clint Eastwood, "Do you feel lucky today, punk?

tea

----- Original Message ----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Saturday, April 14, 2007 9:56:30 AM
Subject: Re: [HSF] Postop cardiac syncope

What I am learning is that there is a baseline rate of defined (and
undefined) complications for everything we do - and will never be zero (we
are fooling ourselves if we think we can reach zero).  Put wires on - see
problems pulling them off, dont put wires - regret it every once in a
while.  But, I think the key is to learn from each of these events so that
we can minimize the complications - either in quantity, magnitude, quality.

-michael

On 4/14/07, Salerno, Tomas <TSalerno at med.miami.edu> wrote:
>
> Dear Ani:
>
> You are correct, as I would have asked die you measure flows?  The one
> factor that has prevented problems perioperatively in my experience, has
> been documentation that the grafts are patent at time of closure. This
> has eliminated returns to the operating room emergentl.
>
> In the past I did not use to place ventricular wires, until one event
> such as yours occurred during the night, for whatever reason, and
> emergency pacing was necessary.  I now use at least one ventricular
> wire, although it is seldom that I need it during the postoperative
> period.
>
> Another explanation for your case is that the right graft went down,
> leading to heart block.
>
>
> Tomas
>
> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com
> [mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Ani Anyanwu
> Sent: Saturday, April 14, 2007 7:17 AM
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] Postop cardiac syncope
>
> Tea,
>
> With an unexplained cardiac event post-CABG would you consider
> angiography - either conventional or by CT? I know Dr Salerno might also
> add - did you use a flow-meter but as I have never used one I do not
> know if there is a correlation between observed flow and probability of
> later graft closure.
>
> Thanks
>
> Ani
> ----- Original Message -----
> From: Tea Acuff<mailto:tacuff at swbell.net>
> To: OpenHeart-L<mailto:OpenHeart-L at lists.hsforum.com>
> Sent: Thursday, April 12, 2007 10:51 PM
> Subject: [HSF] Postop cardiac syncope
>
>
> I would be interested in suggestions for a recent case, both to see
> how people think and perhaps to find a novel answer(s).
>
> The case.
>
> A seventy four year old male presented about 2-3 week ago with ST
> elevation inferior MI, which was aborted with a DES to the main RCA.
> This helped significantly since he had only a diagonal and high OM
> patent on the left with poor filling of occluded LAD and PL with
> moderate left main. He also had a 95% mid PDA and probably 70% proximal
> PDA. LVgram not done then. Very dominate RCA. He was sent home.
>
> Patient readmitted at two weeks after stopping Plavix for 4 days. TEE
> periop minimal inf LV dysfunction and mild MR. Had uneventful OPCAB with
> Lima to LAD, but even proximal LAD was 1mm or less as was PL of circ.
> RSV to Diag and RSV to OM, large PL of RCA and to endartectomized mid
> PDA. Extubed at or shortly after arrival to ICU. Bleeding 200-300 ccs
> first shift; no Swan Ganz. Was up in chair at 6-8 hours post op at shift
> change on moderate levo for BP (presumed vasoplagia by good ICU nurse)
> when his monitor went off and he was slumped over in chair. No meds and
> pushed on chest with resumed BP and NSR. CRX, Hct, K, ABG okay. I came
> in (about 40 minutes later), he had had 3rd degree HB with out
> ventricular response and had had another episode without syncope. I
> weaned levo and gave some colloid which stabilized. Since he had no
> pacer wires I got the cardiologist (probably could have found a pacing
> SG and done it myself) and put in a VVI pacer the next morning despite
> NSR. No
>   evidence of periop MI.
>
> How should I think about preventing any of this in the future or
> should I just say that everything worked properly? (Patient is afterall
> okay.)
> Does this happen at home when we think that they acutely occluded
> their grafts?
> Has anyone seen sudden and brief 3rd degree HB with otherwise NSR
> without clear ischemia? I don't remember ever seeing it exactly like
> this.
> What really happened? Or better yet what would you do to prove what
> you thought happened?
> Would anyone do anything different after his first syncope/arrest?
>
> tea
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