[HSF] Postop cardiac syncope
Ani Anyanwu
anianyanwu at hotmail.com
Tue Apr 17 22:09:11 EDT 2007
Prasanna
Do you generally place a femoral line for most cases? In practice how easy is it to place a percutaneous cannula over a wire when patient is in extremis? Is it straightforward repairing the resultant defect (I presume you repair the artery open)?
By the way, you never responded to Dr Salerno's comments on cold blood perfusion - what are your thoughts?
Thanks
Ani
----- Original Message -----
From: prasannasimha<mailto:prasannasimha at gmail.com>
To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
Sent: Monday, April 16, 2007 11:58 AM
Subject: Re: [HSF] Postop cardiac syncope
Always have the femorals painted in every case and usually I have a
femoral line that can be quickly converted to a percut cannula for
emergency perfusion.
If things are going from bad to worse - elective TCA freshen edges and
patch the hole
(not had to use it)
Is that OK ?
Prasanna
Michael Firstenberg wrote:
> Ahhhh - a perfect example!
> While I do not start protamine until "I have complete control of the
> aorta"
> for that very reason. How many surgeons insist of giving protamine
> with the
> cannula still in - just in case of a protamine reaction. Of those,
> how many
> wait until the protamine is 1/4? 1/2? completely in? I agree though -
> either way - I think the key is to have a plan, a back-up plan, and a
> back-up back-up plan and keeping in the back of your mind what can
> happen if
> the plans dont go as planned. This is why cardiac surgery will never be
> just a technical exercise.
>
>
> -michael
>
>
> On 4/16/07, Ben Bidstrup <benjamin.bidstrup at bigpond.com<mailto:benjamin.bidstrup at bigpond.com>> wrote:
>>
>> One should be able to justify doing almost every move in cardiac
>> surgery. E.g. I do not give protamine until the aortic cannula is
>> removed. Reason: If there is bleeding from cannulation site,
>> cardiotomy can be use to return blood to oxygenator and aortic line
>> can be placed in RA to re-infuse lost volume, whilst finger controls
>> bleeding aorta. It has saved several patients' bacon over the years.
>> One could conversely argue that protamine should be given before
>> removal as hypotension can be dealt with by transfusion, and if
>> needed a return to CPB can be achieved rapidly.
>> But I agree with Prasanna, every move needs to be thought about and
>> if needed an alternate strategy available. Cardiac surgery lends
>> itself to practicing these manoeuvres in the simulation lab. May have
>> to in the future.
>>
>>
>> >I do not call it "Ugly American" but one of perception and
>> >preconceiving things. When a particular group had come to our
>> >hospital years ago, I used to quiz them with a contrarian viewpoint
>> >and this was actually to try to pick their mind as to why a
>> >particular thing was being done (or not done) .It was not accepted
>> >well Sometimes I got the answer - that is the way we do it back
>> >home. (But, I am an obstinate fellow) .Unfortunately they did not
>> >realize that today they are there but when they have gone back home
>> >we are again stranded if only a protocol is given and not the
>> >rationale (and typically an Indian has to see a Protocol and try to
>> >find a way to alter it !!). This can be easily misinterpreted.
>> >After this experience when I went to Croatia, I was hoping that I
>> >did not repeat the same thing as explaining the rationale seems to
>> >be more lasting than telling "this is the way we do it back home".
>> >Prasanna
>> >
>> >hgrmd at aol.com wrote:
>> >>Ani,
>> >> Americans using arcane abbreviations is just another example of
>> >>the "Ugly American". We are way too narcisstic. One of the
>> >>beautiful benefits from HSF for me is that it has further opened my
>> >>eyes to the fact that there are plenty of great surgeons worldwide.
>> >>Hal -----Original Message-----
>> >>From: anianyanwu at hotmail.com<mailto:anianyanwu at hotmail.com>
>> >>To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
>> >>Sent: Sun, 15 Apr 2007 9:33 AM
>> >>Subject: Re: [HSF] Postop cardiac syncope
>> >>
>> >>
>> >>Well for once I thought I could understand an email from Tea till I
>> >>got to the penultimate paragraph which I read 3 times and still
>> >>couldn't figure out what it was on about. Oh well at least I
>> >>understood the first half. Although not said, I presume that Tea
>> >>does not use the heart-lung machine and cardioplegic arrest for
>> >>CABG as that may reduce the likelihood of unexpected conduction
>> >>problems so prophylactic pacing wires will be of different utility
>> >>compared to surgeons who use cardioplegic arrest. Similarly, many
>> >>surgeons who use non-cardioplegic CPB methods for CABG do not apply
>> >>pacing wires and conduction problems are also rare (unpublished
>> >>observations).
>> >>So really I am not sure there is an indication to place wires
>> >>routinely in these scenarios (OPCAB or intermittent fibrillatory
>> >>arrest or beating heart CABG). Should we do things just because we
>> >>can? We could also leave patients connected to an external
>> >>defibrillator for 5 days given the low likelihood of spontaneous
>> >>life threatening arrhythmia (which may be of same magnitude of
>> >>frequency with unexpected heart block). Where patients have a
>> >>perceived risk factor for developing heart block (actually Tea, I
>> >>suspect some would consider an endarterectomy to the PDA such a
>> >>factor) then selective use of wires may be judged necessary.
>> >>
>> >>And by the way for the non US surgeons who may be wondering, levo =
>> >>noradrenaline or norepinephrine; JAHCO=some regulatory body
>> >>governing I think quality of care in hospitals. One of the
>> >>curiosities of American medicine is why doctors chose to refer to
>> >>things other than by their real name. Everything has an
>> >>abbreviation, pseudonym, eponym or code - and it is interesting how
>> >>in medical meetings and discussions they expect everyone else in
>> >>the world to know what these non-universal codes mean!
>> >>
>> >>Ani
>> >> ----- Original Message ----- From: Tea
>> >>Acuff<mailto:tacuff at swbell.net<mailto:tacuff at swbell.net>> To:
>> >>OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>>
>> >>Sent: Saturday, April 14, 2007 11:32 PM
>> >> Subject: Re: [HSF] Postop cardiac syncope
>> >>
>> >>
>> >> 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<mailto:msfirst at gmail.com<mailto:msfirst at gmail.com<mailto:msfirst at gmail.com>
>> >>
>> >> To: OpenHeart-L at lists.hsforum.com<mailto<mailto:OpenHeart-L at lists.hsforum.com<mailto>:
>> OpenHeart-L at lists.hsforum.com<mailto: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<mailto:TSalerno at med.miami.edu<mailto:TSalerno at med.miami.edu<mailto: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<mailto: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<mailto<mailto:OpenHeart-L at lists.hsforum.com<mailto>:
>> OpenHeart-L at lists.hsforum.com<mailto: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<mailto:tacuff at swbell.net<mailto:tacuff at swbell.net<mailto:tacuff at swbell.net>>>
>> >> > To:
>> >>OpenHeart-L<mailto:OpenHeart-L at lists.hsforum.com<mailto<mailto:OpenHeart-L at lists.hsforum.com<mailto>:
>> OpenHeart-L at listshsforum.com<mailto:OpenHeart-L at listshsforum.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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