From donross at bigpond.com Wed Aug 1 11:37:28 2007 From: donross at bigpond.com (Donald Ross) Date: Tue Jul 31 20:37:59 2007 Subject: [HSF] Technique of the week In-Reply-To: <51677.35787.qm@web81608.mail.mud.yahoo.com> References: <51677.35787.qm@web81608.mail.mud.yahoo.com> Message-ID: <6821754C-2916-422A-9068-746C8CAFE2C0@bigpond.com> tea, Everything is cut off the catheter including all of the balloon just leaving the silasic tube. An equivalent solid silastic plunger would be better! Don On 01/08/2007, at 10:13 AM, Tea Acuff wrote: > So you drive the needle from the aortic advential side inward into > the silastic plunger and move the plunger up and down to remove the > needle? What role does the partially cut balloon play? > tea > > > > ----- Original Message ---- > From: Donald Ross > To: OpenHeart-L@lists.hsforum.com > Sent: Thursday, July 26, 2007 7:30:37 AM > Subject: Re: [HSF] Technique of the week > > > A few eccentric opcab surgeons use variations of Vettath's > technique for avoiding side clamping for proximals. > This uses a metal plug in a punched aortic hole to control bleeding > while the graft is sewn in the usual way. An adventitial purse string > stops the hole from enlarging and minimises bleeding when the needle > is passed against the metal plug "outside in" > I have used this in 85 cases and Murali Vettath has, by now, done > several hundred. > John Brereton, my "anaortic" opcab colleague found the metal plug > difficult to use and tried a 14F silastic Foley catheter instead, > driving the needle into the catheter and then withdrawing it together > with the needle. > This is a real breakthrough, making the technique really easy and > more reliable because it ensures the needle actually emerges through > the aortic hole, never catching any adventitia. > I used it today on a terrible unclampable aorta which only had a few > soft spots. > > Details: > The aorta is pulled out of the chest and steadied with heavy > pericardial stay sutures places close to the SVC. > A patch of adventitia is cleared and a 1.0 cm superficial purse > string of 5-0 proline is placed ( I go round twice ) > The 14F silastic catheter has the balloon cut off at an angle and a > silk marking suture is tied about 6cm from this end. All the bits on > the other end are cut off and it is clamped with a haemostat. > With the pressure <100 a stab in the centre of the purse string is > made and enlarged with a mosquito clamp to allow the anvil of a 3.5 > mm punch to be introduced. The hole is punched with care to make sure > it is in the centre, elevating it during the cut helps. > The catheter/obturator is introduces to the marker and the purse > string lightly tied. > ( I leave one end 1 cm long to facilitate cutting it out at the end) > You need a 5-0 suture with a HALF CIRCLE needle to make wide bites in > the aorta, driving the point of the needle into the catheter. > Withdrawing the catheter brings the needle with it which is then put > into the graft. > It is best to put the graft down after two passes, keeping the > working end of the suture short. > After suturing all the way round with one end, cut out the purse > string, pull out the catheter and tie down the graft with an > assistant's finger over it to stop the inevitable few leaks which I > secure with a 6-0 also on a half circle needle. > NB The half circle needle is really important. > > Don > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the > policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the > policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- From benjamin.bidstrup at bigpond.com Wed Aug 1 12:51:25 2007 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Tue Jul 31 21:52:21 2007 Subject: [HSF] Technique of the week In-Reply-To: <6821754C-2916-422A-9068-746C8CAFE2C0@bigpond.com> References: <51677.35787.qm@web81608.mail.mud.yahoo.com> <6821754C-2916-422A-9068-746C8CAFE2C0@bigpond.com> Message-ID: Don, You could superglue closed the end that sits inside the aorta. You had some shents made - can they not make a suitable aortic occluder. Call it say 'Easyprox' or Noclamp prox' >tea, >Everything is cut off the catheter including all of the balloon just >leaving the silasic tube. An equivalent solid silastic plunger would >be better! >Don >On 01/08/2007, at 10:13 AM, Tea Acuff wrote: > >>So you drive the needle from the aortic advential side inward into >>the silastic plunger and move the plunger up and down to remove the >>needle? What role does the partially cut balloon play? >>tea >> >> >> >>----- Original Message ---- >>From: Donald Ross >>To: OpenHeart-L@lists.hsforum.com >>Sent: Thursday, July 26, 2007 7:30:37 AM >>Subject: Re: [HSF] Technique of the week >> >> >>A few eccentric opcab surgeons use variations of Vettath's >>technique for avoiding side clamping for proximals. >>This uses a metal plug in a punched aortic hole to control bleeding >>while the graft is sewn in the usual way. An adventitial purse string >>stops the hole from enlarging and minimises bleeding when the needle >>is passed against the metal plug "outside in" >>I have used this in 85 cases and Murali Vettath has, by now, done >>several hundred. >>John Brereton, my "anaortic" opcab colleague found the metal plug >>difficult to use and tried a 14F silastic Foley catheter instead, >>driving the needle into the catheter and then withdrawing it together >>with the needle. >>This is a real breakthrough, making the technique really easy and >>more reliable because it ensures the needle actually emerges through >>the aortic hole, never catching any adventitia. >>I used it today on a terrible unclampable aorta which only had a few >>soft spots. >> >>Details: >>The aorta is pulled out of the chest and steadied with heavy >>pericardial stay sutures places close to the SVC. >>A patch of adventitia is cleared and a 1.0 cm superficial purse >>string of 5-0 proline is placed ( I go round twice ) >>The 14F silastic catheter has the balloon cut off at an angle and a >>silk marking suture is tied about 6cm from this end. All the bits on >>the other end are cut off and it is clamped with a haemostat. >>With the pressure <100 a stab in the centre of the purse string is >>made and enlarged with a mosquito clamp to allow the anvil of a 3.5 >>mm punch to be introduced. The hole is punched with care to make sure >>it is in the centre, elevating it during the cut helps. >>The catheter/obturator is introduces to the marker and the purse >>string lightly tied. >>( I leave one end 1 cm long to facilitate cutting it out at the end) >>You need a 5-0 suture with a HALF CIRCLE needle to make wide bites in >>the aorta, driving the point of the needle into the catheter. >>Withdrawing the catheter brings the needle with it which is then put >>into the graft. >>It is best to put the graft down after two passes, keeping the >>working end of the suture short. >>After suturing all the way round with one end, cut out the purse >>string, pull out the catheter and tie down the graft with an >>assistant's finger over it to stop the inevitable few leaks which I >>secure with a 6-0 also on a half circle needle. >>NB The half circle needle is really important. >> >>Don >>_______________________________________________ >>OpenHeart-L mailing list >> >>Send postings to: >>OpenHeart-L@lists.hsforum.com >> >>To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>http://mmp.cjp.com/mailman/listinfo/openheart-l >> >>All messages transmitted by the OpenHeart-L are subject to the policies and >>disclaimers posted at: >>http://www.hsforum.com/listdisclaim >>----------------------------------------- >>_______________________________________________ >>OpenHeart-L mailing list >> >>Send postings to: >> OpenHeart-L@lists.hsforum.com >> >>To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>http://mmp.cjp.com/mailman/listinfo/openheart-l >> >>All messages transmitted by the OpenHeart-L are subject to the policies and >>disclaimers posted at: >>http://www.hsforum.com/listdisclaim >>----------------------------------------- >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: >OpenHeart-L@lists.hsforum.com > >To UNSUBSCRIBE, to CHANGE email address, or to view archives: >http://mmp.cjp.com/mailman/listinfo/openheart-l > >All messages transmitted by the OpenHeart-L are subject to the >policies anddisclaimers posted at: >http://www.hsforum.com/listdisclaim >----------------------------------------- -- Two things are infinite; the universe and human stupidity; and I am not sure about the universe. Albert Einstein The greatest obstacle to discovery is not ignorance --- it is the illusion of knowledge. Daniel J Boorstin Ben Bidstrup FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon From benjamin.bidstrup at bigpond.com Wed Aug 1 12:54:22 2007 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Tue Jul 31 21:55:12 2007 Subject: [HSF] Inotropes, ventricular fibrillation and myocardial protection In-Reply-To: References: Message-ID: Why the amiodarone. Surely with some perfusion, the electrolyte imbalances within the myocardium would correct and SR ensue. If anything use lidocaine. Less toxic and cheaper, not a negative inotrope. It is what Yacoub taught me many years ago, and I have used it to good effect (infrequently I might add). >Tohru, > I did an AVR on an 87 yo man as a 2nd case just a couple of hours ago. >Again, no LV vent, only a sump. While closing the aortotomy, I began the >continuous warm retrograde blood. The heart began fibrillating >after a couple of >minutes. I gave amio and then cardioverted. The heart had a slow junctional >rhythm until the clamp was released. A sinus rhythm developed shortly >afterwards. He came off with no inotropes. It's much easier on >the heart and >your nerves to cardiovert a clamped, flaccid heart rather than >trying to do it >after the clamp has been released. > I look forward to your visit at the STS. As I said before, I'll try to >have a couple of interesting cases for you and other interested >members of HSF >to watch and criticize to your heart's content. > >Hal > > > >************************************** Get a sneak peek of the all-new AOL at >http://discover.aol.com/memed/aolcom30tour >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: > OpenHeart-L@lists.hsforum.com > >To UNSUBSCRIBE, to CHANGE email address, or to view archives: >http://mmp.cjp.com/mailman/listinfo/openheart-l > >All messages transmitted by the OpenHeart-L are subject to the policies and >disclaimers posted at: >http://www.hsforum.com/listdisclaim >----------------------------------------- -- Two things are infinite; the universe and human stupidity; and I am not sure about the universe. Albert Einstein The greatest obstacle to discovery is not ignorance --- it is the illusion of knowledge. Daniel J Boorstin Ben Bidstrup FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon From benjamin.bidstrup at bigpond.com Wed Aug 1 12:56:19 2007 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Tue Jul 31 21:57:09 2007 Subject: AW: [HSF] STS Meeting (OT) In-Reply-To: References: Message-ID: Hal, Far from it. You performed well in great adversity - the heckling from the far end or down under contingent. I even remember some of it. >Tea, > No, I think this should be the year for you or someone else to make a fool >of themselves doing a talk. I did an excellent job of doing that to myself >at the last STS. >Hal > > > >************************************** Get a sneak peek of the all-new AOL at >http://discover.aol.com/memed/aolcom30tour >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: > OpenHeart-L@lists.hsforum.com > >To UNSUBSCRIBE, to CHANGE email address, or to view archives: >http://mmp.cjp.com/mailman/listinfo/openheart-l > >All messages transmitted by the OpenHeart-L are subject to the policies and >disclaimers posted at: >http://www.hsforum.com/listdisclaim >----------------------------------------- -- Two things are infinite; the universe and human stupidity; and I am not sure about the universe. Albert Einstein The greatest obstacle to discovery is not ignorance --- it is the illusion of knowledge. Daniel J Boorstin Ben Bidstrup FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon From prasannasimha at gmail.com Wed Aug 1 08:32:39 2007 From: prasannasimha at gmail.com (psimha) Date: Tue Jul 31 22:10:05 2007 Subject: [HSF] Inotropes, ventricular fibrillation and myocardial protection In-Reply-To: References: Message-ID: <46AFE9BF.3050003@sify.com> Ben, I use Amiadorone in the pump for all emazes (and postop) and Amiadorone in the pump for all aortic valves. Since the St Thomas Cardioplegia (which we mix in blood) already has procaine adding Lignocaine would be redundant.(Incidentally Amiadorone is very cheap in India !!) Prasanna Ben Bidstrup wrote: > Why the amiodarone. Surely with some perfusion, the electrolyte > imbalances within the myocardium would correct and SR ensue. If > anything use lidocaine. Less toxic and cheaper, not a negative > inotrope. It is what Yacoub taught me many years ago, and I have used > it to good effect (infrequently I might add). > > >> Tohru, >> I did an AVR on an 87 yo man as a 2nd case just a couple of hours >> ago. Again, no LV vent, only a sump. While closing the aortotomy, I >> began the >> continuous warm retrograde blood. The heart began fibrillating after >> a couple of >> minutes. I gave amio and then cardioverted. The heart had a slow >> junctional >> rhythm until the clamp was released. A sinus rhythm developed shortly >> afterwards. He came off with no inotropes. It's much easier on the >> heart and >> your nerves to cardiovert a clamped, flaccid heart rather than >> trying to do it >> after the clamp has been released. >> I look forward to your visit at the STS. As I said before, I'll >> try to >> have a couple of interesting cases for you and other interested >> members of HSF >> to watch and criticize to your heart's content. >> >> Hal >> >> >> >> ************************************** Get a sneak peek of the >> all-new AOL at >> http://discover.aol.com/memed/aolcom30tour >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/listinfo/openheart-l >> >> All messages transmitted by the OpenHeart-L are subject to the >> policies and >> disclaimers posted at: >> http://www.hsforum.com/listdisclaim >> ----------------------------------------- > > From prasannasimha at gmail.com Wed Aug 1 08:56:53 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Tue Jul 31 22:27:27 2007 Subject: [HSF] Inotropes, ventricular fibrillation and myocardial protection In-Reply-To: References: Message-ID: <46AFEF6D.8080006@gmail.com> That is one of the major benefits of Amiadorone - good for both atrial and ventricular arrhythmia's as long as you do not have a long QT. Prasanna Hgrmd@aol.com wrote: > Ben, > I essentially replaced lido with amio about a year and half ago at the > behest of an excellent German anesthesiologist with whom I worked. So far, I've > had no regrets. Amio seems to be more effective in stopping ventricular > arrhythmias, plus it also takes care of the atrial ones. I've yet to identify > amio-associated pulmonary injury, though I'm well aware of this possibility. > Does lidocaine truly cause less LV despression than amiodorone? If so, > that's news to me. As for cost, I generally don't use much amio for very long. > My main concern is performance. > > Hal > > > > ************************************** Get a sneak peek of the all-new AOL at > http://discover.aol.com/memed/aolcom30tour > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > > > From donross at bigpond.com Wed Aug 1 13:27:13 2007 From: donross at bigpond.com (Donald Ross) Date: Tue Jul 31 22:27:46 2007 Subject: [HSF] Technique of the week In-Reply-To: References: <51677.35787.qm@web81608.mail.mud.yahoo.com> <6821754C-2916-422A-9068-746C8CAFE2C0@bigpond.com> Message-ID: Ben, If 1000 surgeons wanted to buy such stuff it may possibly cover the cost . The shents cost $18000 but it would cost $30000 to even get them approved in OZ so it was a bit of a bummer! Don On 01/08/2007, at 11:51 AM, Ben Bidstrup wrote: > Don, > You could superglue closed the end that sits inside the aorta. > You had some shents made - can they not make a suitable aortic > occluder. > Call it say 'Easyprox' or Noclamp prox' > > > > > >> tea, >> Everything is cut off the catheter including all of the balloon >> just leaving the silasic tube. An equivalent solid silastic >> plunger would be better! >> Don >> On 01/08/2007, at 10:13 AM, Tea Acuff wrote: >> >>> So you drive the needle from the aortic advential side inward >>> into the silastic plunger and move the plunger up and down to >>> remove the needle? What role does the partially cut balloon play? >>> tea >>> >>> >>> >>> ----- Original Message ---- >>> From: Donald Ross >>> To: OpenHeart-L@lists.hsforum.com >>> Sent: Thursday, July 26, 2007 7:30:37 AM >>> Subject: Re: [HSF] Technique of the week >>> >>> >>> A few eccentric opcab surgeons use variations of Vettath's >>> technique for avoiding side clamping for proximals. >>> This uses a metal plug in a punched aortic hole to control bleeding >>> while the graft is sewn in the usual way. An adventitial purse >>> string >>> stops the hole from enlarging and minimises bleeding when the needle >>> is passed against the metal plug "outside in" >>> I have used this in 85 cases and Murali Vettath has, by now, done >>> several hundred. >>> John Brereton, my "anaortic" opcab colleague found the metal plug >>> difficult to use and tried a 14F silastic Foley catheter instead, >>> driving the needle into the catheter and then withdrawing it >>> together >>> with the needle. >>> This is a real breakthrough, making the technique really easy and >>> more reliable because it ensures the needle actually emerges through >>> the aortic hole, never catching any adventitia. >>> I used it today on a terrible unclampable aorta which only had a few >>> soft spots. >>> >>> Details: >>> The aorta is pulled out of the chest and steadied with heavy >>> pericardial stay sutures places close to the SVC. >>> A patch of adventitia is cleared and a 1.0 cm superficial purse >>> string of 5-0 proline is placed ( I go round twice ) >>> The 14F silastic catheter has the balloon cut off at an angle >>> and a >>> silk marking suture is tied about 6cm from this end. All the bits on >>> the other end are cut off and it is clamped with a haemostat. >>> With the pressure <100 a stab in the centre of the purse string is >>> made and enlarged with a mosquito clamp to allow the anvil of a 3.5 >>> mm punch to be introduced. The hole is punched with care to make >>> sure >>> it is in the centre, elevating it during the cut helps. >>> The catheter/obturator is introduces to the marker and the purse >>> string lightly tied. >>> ( I leave one end 1 cm long to facilitate cutting it out at the end) >>> You need a 5-0 suture with a HALF CIRCLE needle to make wide >>> bites in >>> the aorta, driving the point of the needle into the catheter. >>> Withdrawing the catheter brings the needle with it which is then put >>> into the graft. >>> It is best to put the graft down after two passes, keeping the >>> working end of the suture short. >>> After suturing all the way round with one end, cut out the purse >>> string, pull out the catheter and tie down the graft with an >>> assistant's finger over it to stop the inevitable few leaks which I >>> secure with a 6-0 also on a half circle needle. >>> NB The half circle needle is really important. >>> >>> Don >>> _______________________________________________ >>> OpenHeart-L mailing list >>> >>> Send postings to: >>> OpenHeart-L@lists.hsforum.com >>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>> http://mmp.cjp.com/mailman/listinfo/openheart-l >>> >>> All messages transmitted by the OpenHeart-L are subject to the >>> policies and >>> disclaimers posted at: >>> http://www.hsforum.com/listdisclaim >>> ----------------------------------------- >>> _______________________________________________ >>> OpenHeart-L mailing list >>> >>> Send postings to: >>> OpenHeart-L@lists.hsforum.com >>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>> http://mmp.cjp.com/mailman/listinfo/openheart-l >>> >>> All messages transmitted by the OpenHeart-L are subject to the >>> policies and >>> disclaimers posted at: >>> http://www.hsforum.com/listdisclaim >>> ----------------------------------------- >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/listinfo/openheart-l >> >> All messages transmitted by the OpenHeart-L are subject to the >> policies anddisclaimers posted at: >> http://www.hsforum.com/listdisclaim >> ----------------------------------------- > > > -- > > > Two things are infinite; the universe and human stupidity; and I am > not sure about the universe. > Albert Einstein > > The greatest obstacle to discovery is not ignorance --- it is the > illusion of knowledge. > Daniel J Boorstin > > Ben Bidstrup FRACS FRCSEd FEBCTS > Consultant Cardiothoracic Surgeon > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the > policies and disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- From benjamin.bidstrup at bigpond.com Wed Aug 1 13:56:53 2007 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Tue Jul 31 22:57:35 2007 Subject: [HSF] Inotropes, ventricular fibrillation and myocardial protection In-Reply-To: <46AFE9BF.3050003@sify.com> References: <46AFE9BF.3050003@sify.com> Message-ID: I beg respectfully to differ. The lidocaine (a fast Na channel blocker) is all but gone after a short while in the cardioplegia scenario. Getting a suitable level back into the circulation and thus the heart at release of the clamp is what is needed. Perhaps a randomised study is in the offing. http://circ.ahajournals.org/cgi/content/abstract/79/5/1106 This reference relates to defib energy levels but i think you will see where I am coming from. At James Cook, I was involved in the development of a non depolarising cardioplegia solution, which is slowly working its way up the development path. The main components are lidocaine and adenosine. >Ben, >I use Amiadorone in the pump for all emazes (and postop) and >Amiadorone in the pump for all aortic valves. Since the St Thomas >Cardioplegia (which we mix in blood) already has procaine adding >Lignocaine would be redundant.(Incidentally Amiadorone is very cheap >in India !!) >Prasanna >Ben Bidstrup wrote: >>Why the amiodarone. Surely with some perfusion, the electrolyte >>imbalances within the myocardium would correct and SR ensue. If >>anything use lidocaine. Less toxic and cheaper, not a negative >>inotrope. It is what Yacoub taught me many years ago, and I have >>used it to good effect (infrequently I might add). >> >>>Tohru, >>> I did an AVR on an 87 yo man as a 2nd case just a couple of >>>hours ago. Again, no LV vent, only a sump. While closing the >>>aortotomy, I began the >>>continuous warm retrograde blood. The heart began fibrillating >>>after a couple of >>>minutes. I gave amio and then cardioverted. The heart had a >>>slow junctional >>>rhythm until the clamp was released. A sinus rhythm developed shortly >>>afterwards. He came off with no inotropes. It's much easier on >>>the heart and >>>your nerves to cardiovert a clamped, flaccid heart rather than >>>trying to do it >>>after the clamp has been released. >>> I look forward to your visit at the STS. As I said before, I'll try to >>>have a couple of interesting cases for you and other interested >>>members of HSF >>>to watch and criticize to your heart's content. >>> >>>Hal >>> >>> >>> >>>************************************** Get a sneak peek of the >>>all-new AOL at >>>http://discover.aol.com/memed/aolcom30tour >>>_______________________________________________ >>>OpenHeart-L mailing list >>> >>>Send postings to: >>> OpenHeart-L@lists.hsforum.com >>> >>>To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>http://mmp.cjp.com/mailman/listinfo/openheart-l >>> >>>All messages transmitted by the OpenHeart-L are subject to the policies and >>>disclaimers posted at: >>>http://www.hsforum.com/listdisclaim >>>----------------------------------------- >> >> > >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: >OpenHeart-L@lists.hsforum.com > >To UNSUBSCRIBE, to CHANGE email address, or to view archives: >http://mmp.cjp.com/mailman/listinfo/openheart-l > >All messages transmitted by the OpenHeart-L are subject to the >policies and disclaimers posted at: >http://www.hsforum.com/listdisclaim >----------------------------------------- -- Two things are infinite; the universe and human stupidity; and I am not sure about the universe. Albert Einstein The greatest obstacle to discovery is not ignorance --- it is the illusion of knowledge. Daniel J Boorstin Ben Bidstrup FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon From benjamin.bidstrup at bigpond.com Wed Aug 1 13:57:40 2007 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Tue Jul 31 22:58:33 2007 Subject: AW: [HSF] STS Meeting (OT) In-Reply-To: <774703.62712.qm@web81612.mail.mud.yahoo.com> References: <774703.62712.qm@web81612.mail.mud.yahoo.com> Message-ID: Fly Qantas - no crashes! >I prefer to make a fool of myself in writing like the HSF. It is >better documentation. Come to think of it you do an excellent job of >that also. You must be Rainman's brother, the one who always does an >"excellent job" (of driving). >tea > > >----- Original Message ---- >From: "Hgrmd@aol.com" >To: OpenHeart-L@lists.hsforum.com >Sent: Tuesday, July 31, 2007 8:22:22 PM >Subject: Re: AW: [HSF] STS Meeting (OT) > > >Tea, > No, I think this should be the year for you or someone else to make a fool >of themselves doing a talk. I did an excellent job of doing that to myself >at the last STS. >Hal > > > >************************************** Get a sneak peek of the all-new AOL at >http://discover.aol.com/memed/aolcom30tour >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: >OpenHeart-L@lists.hsforum.com > >To UNSUBSCRIBE, to CHANGE email address, or to view archives: >http://mmp.cjp.com/mailman/listinfo/openheart-l > >All messages transmitted by the OpenHeart-L are subject to the policies and >disclaimers posted at: >http://www.hsforum.com/listdisclaim >----------------------------------------- >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: > OpenHeart-L@lists.hsforum.com > >To UNSUBSCRIBE, to CHANGE email address, or to view archives: >http://mmp.cjp.com/mailman/listinfo/openheart-l > >All messages transmitted by the OpenHeart-L are subject to the policies and >disclaimers posted at: >http://www.hsforum.com/listdisclaim >----------------------------------------- -- Two things are infinite; the universe and human stupidity; and I am not sure about the universe. Albert Einstein The greatest obstacle to discovery is not ignorance --- it is the illusion of knowledge. Daniel J Boorstin Ben Bidstrup FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon From benjamin.bidstrup at bigpond.com Wed Aug 1 13:59:39 2007 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Tue Jul 31 23:00:21 2007 Subject: [HSF] Lidocaine Message-ID: I have added another reference just for Hal to look at. http://www.biophysj.org/cgi/content/abstract/46/1/15 -- Two things are infinite; the universe and human stupidity; and I am not sure about the universe. Albert Einstein The greatest obstacle to discovery is not ignorance --- it is the illusion of knowledge. Daniel J Boorstin Ben Bidstrup FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon From benjamin.bidstrup at bigpond.com Wed Aug 1 15:42:09 2007 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Wed Aug 1 00:43:00 2007 Subject: [HSF] Inotropes, ventricular fibrillation and myocardial protection In-Reply-To: References: Message-ID: Well argued. I cannot take issue with your strategy. If amio is used for a short while, I guess the depression is likely to be small. Needs an RCT! >Ben, > I essentially replaced lido with amio about a year and half ago at the >behest of an excellent German anesthesiologist with whom I worked. >So far, I've >had no regrets. Amio seems to be more effective in stopping ventricular >arrhythmias, plus it also takes care of the atrial ones. I've yet >to identify >amio-associated pulmonary injury, though I'm well aware of this possibility. >Does lidocaine truly cause less LV despression than amiodorone? If so, >that's news to me. As for cost, I generally don't use much amio >for very long. >My main concern is performance. > >Hal > > > >************************************** Get a sneak peek of the all-new AOL at >http://discover.aol.com/memed/aolcom30tour >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: > OpenHeart-L@lists.hsforum.com > >To UNSUBSCRIBE, to CHANGE email address, or to view archives: >http://mmp.cjp.com/mailman/listinfo/openheart-l > >All messages transmitted by the OpenHeart-L are subject to the policies and >disclaimers posted at: >http://www.hsforum.com/listdisclaim >----------------------------------------- -- Ben Bidstrup FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon Two things are infinite; the universe and human stupidity; and I am not sure about the universe. Albert Einstein The greatest obstacle to discovery is not ignorance --- it is the illusion of knowledge. Daniel J Boorstin From benjamin.bidstrup at bigpond.com Wed Aug 1 15:43:15 2007 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Wed Aug 1 00:44:13 2007 Subject: [HSF] Technique of the week In-Reply-To: References: <51677.35787.qm@web81608.mail.mud.yahoo.com> <6821754C-2916-422A-9068-746C8CAFE2C0@bigpond.com> Message-ID: Yes I forgot about the ridiculous approval processes. Back to the IDC. >Ben, >If 1000 surgeons wanted to buy such stuff it may possibly cover the cost . >The shents cost $18000 but it would cost $30000 to even get them >approved in OZ so it was a bit of a bummer! >Don >On 01/08/2007, at 11:51 AM, Ben Bidstrup wrote: > >>Don, >>You could superglue closed the end that sits inside the aorta. >>You had some shents made - can they not make a suitable aortic occluder. >>Call it say 'Easyprox' or Noclamp prox' >> >> >> >> >>>tea, >>>Everything is cut off the catheter including all of the balloon >>>just leaving the silasic tube. An equivalent solid silastic >>>plunger would be better! >>>Don >>>On 01/08/2007, at 10:13 AM, Tea Acuff wrote: >>> >>>>So you drive the needle from the aortic advential side inward >>>>into the silastic plunger and move the plunger up and down to >>>>remove the needle? What role does the partially cut balloon play? >>>>tea >>>> >>>> >>>> >>>>----- Original Message ---- >>>>From: Donald Ross >>>>To: OpenHeart-L@lists.hsforum.com >>>>Sent: Thursday, July 26, 2007 7:30:37 AM >>>>Subject: Re: [HSF] Technique of the week >>>> >>>> >>>>A few eccentric opcab surgeons use variations of Vettath's >>>>technique for avoiding side clamping for proximals. >>>>This uses a metal plug in a punched aortic hole to control bleeding >>>>while the graft is sewn in the usual way. An adventitial purse string >>>>stops the hole from enlarging and minimises bleeding when the needle >>>>is passed against the metal plug "outside in" >>>>I have used this in 85 cases and Murali Vettath has, by now, done >>>>several hundred. >>>>John Brereton, my "anaortic" opcab colleague found the metal plug >>>>difficult to use and tried a 14F silastic Foley catheter instead, >>>>driving the needle into the catheter and then withdrawing it together >>>>with the needle. >>>>This is a real breakthrough, making the technique really easy and >>>>more reliable because it ensures the needle actually emerges through >>>>the aortic hole, never catching any adventitia. >>>>I used it today on a terrible unclampable aorta which only had a few >>>>soft spots. >>>> >>>>Details: >>>>The aorta is pulled out of the chest and steadied with heavy >>>>pericardial stay sutures places close to the SVC. >>>>A patch of adventitia is cleared and a 1.0 cm superficial purse >>>>string of 5-0 proline is placed ( I go round twice ) >>>>The 14F silastic catheter has the balloon cut off at an angle and a >>>>silk marking suture is tied about 6cm from this end. All the bits on >>>>the other end are cut off and it is clamped with a haemostat. >>>>With the pressure <100 a stab in the centre of the purse string is >>>>made and enlarged with a mosquito clamp to allow the anvil of a 3.5 >>>>mm punch to be introduced. The hole is punched with care to make sure >>>>it is in the centre, elevating it during the cut helps. >>>>The catheter/obturator is introduces to the marker and the purse >>>>string lightly tied. >>>>( I leave one end 1 cm long to facilitate cutting it out at the end) >>>>You need a 5-0 suture with a HALF CIRCLE needle to make wide bites in >>>>the aorta, driving the point of the needle into the catheter. >>>>Withdrawing the catheter brings the needle with it which is then put >>>>into the graft. >>>>It is best to put the graft down after two passes, keeping the >>>>working end of the suture short. >>>>After suturing all the way round with one end, cut out the purse >>>>string, pull out the catheter and tie down the graft with an >>>>assistant's finger over it to stop the inevitable few leaks which I >>>>secure with a 6-0 also on a half circle needle. >>>>NB The half circle needle is really important. >>>> >>>>Don >>>>_______________________________________________ >>>>OpenHeart-L mailing list >>>> >>>>Send postings to: >>>>OpenHeart-L@lists.hsforum.com >>>> >>>>To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>http://mmp.cjp.com/mailman/listinfo/openheart-l >>>> >>>>All messages transmitted by the OpenHeart-L are subject to the policies and >>>>disclaimers posted at: >>>>http://www.hsforum.com/listdisclaim >>>>----------------------------------------- >>>>_______________________________________________ >>>>OpenHeart-L mailing list >>>> >>>>Send postings to: >>>> OpenHeart-L@lists.hsforum.com >>>> >>>>To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>http://mmp.cjp.com/mailman/listinfo/openheart-l >>>> >>>>All messages transmitted by the OpenHeart-L are subject to the policies and >>>>disclaimers posted at: >>>>http://www.hsforum.com/listdisclaim >>>>----------------------------------------- >>>_______________________________________________ >>>OpenHeart-L mailing list >>> >>>Send postings to: >>>OpenHeart-L@lists.hsforum.com >>> >>>To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>http://mmp.cjp.com/mailman/listinfo/openheart-l >>> >>>All messages transmitted by the OpenHeart-L are subject to the >>>policies anddisclaimers posted at: >>>http://www.hsforum.com/listdisclaim >>>----------------------------------------- >> >> >>-- >> >> >>Two things are infinite; the universe and human stupidity; and I am >>not sure about the universe. >>Albert Einstein >> >>The greatest obstacle to discovery is not ignorance --- it is the >>illusion of knowledge. >>Daniel J Boorstin >> >>Ben Bidstrup FRACS FRCSEd FEBCTS >>Consultant Cardiothoracic Surgeon >>_______________________________________________ >>OpenHeart-L mailing list >> >>Send postings to: >>OpenHeart-L@lists.hsforum.com >> >>To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>http://mmp.cjp.com/mailman/listinfo/openheart-l >> >>All messages transmitted by the OpenHeart-L are subject to the >>policies and disclaimers posted at: >>http://www.hsforum.com/listdisclaim >>----------------------------------------- >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: >OpenHeart-L@lists.hsforum.com > >To UNSUBSCRIBE, to CHANGE email address, or to view archives: >http://mmp.cjp.com/mailman/listinfo/openheart-l > >All messages transmitted by the OpenHeart-L are subject to the >policies anddisclaimers posted at: >http://www.hsforum.com/listdisclaim >----------------------------------------- -- Ben Bidstrup FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon Two things are infinite; the universe and human stupidity; and I am not sure about the universe. Albert Einstein The greatest obstacle to discovery is not ignorance --- it is the illusion of knowledge. Daniel J Boorstin From benjamin.bidstrup at bigpond.com Wed Aug 1 15:59:43 2007 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Wed Aug 1 01:00:26 2007 Subject: AW: [HSF] STS Meeting (OT) In-Reply-To: <559907.42507.qm@web81603.mail.mud.yahoo.com> References: <559907.42507.qm@web81603.mail.mud.yahoo.com> Message-ID: Really! >Like Einstein, I may be only half correct. >Cheers, >tea > > >----- Original Message ---- >From: "Hgrmd@aol.com" >To: OpenHeart-L@lists.hsforum.com >Sent: Tuesday, July 31, 2007 9:24:06 PM >Subject: Re: AW: [HSF] STS Meeting (OT) > > >Tea, > Rainman's brother? That's not the first time I've been termed an idiot >savant. > >Hal > > > >************************************** Get a sneak peek of the all-new AOL at >http://discover.aol.com/memed/aolcom30tour >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: >OpenHeart-L@lists.hsforum.com > >To UNSUBSCRIBE, to CHANGE email address, or to view archives: >http://mmp.cjp.com/mailman/listinfo/openheart-l > >All messages transmitted by the OpenHeart-L are subject to the policies and >disclaimers posted at: >http://www.hsforum.com/listdisclaim >----------------------------------------- >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: > OpenHeart-L@lists.hsforum.com > >To UNSUBSCRIBE, to CHANGE email address, or to view archives: >http://mmp.cjp.com/mailman/listinfo/openheart-l > >All messages transmitted by the OpenHeart-L are subject to the policies and >disclaimers posted at: >http://www.hsforum.com/listdisclaim >----------------------------------------- -- Ben Bidstrup FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon Two things are infinite; the universe and human stupidity; and I am not sure about the universe. Albert Einstein The greatest obstacle to discovery is not ignorance --- it is the illusion of knowledge. Daniel J Boorstin From prasannasimha at gmail.com Wed Aug 1 12:51:47 2007 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Wed Aug 1 02:29:32 2007 Subject: [HSF] Inotropes, ventricular fibrillation and myocardial protection In-Reply-To: References: <46AFE9BF.3050003@sify.com> Message-ID: <89c4ed2d0707312321q548f4ac4p24cc9f8451cffcdc@mail.gmail.com> I am not saying that the procaine or lignocaine is still acting. What I meant is that since the fibrillation is occurring with the hotshot delivery with high local lignocaine changing the drug class may be beneficial. Prasanna On 8/1/07, Ben Bidstrup wrote: > > I beg respectfully to differ. The lidocaine (a fast Na channel > blocker) is all but gone after a short while in the cardioplegia > scenario. Getting a suitable level back into the circulation and thus > the heart at release of the clamp is what is needed. > > Perhaps a randomised study is in the offing. > > http://circ.ahajournals.org/cgi/content/abstract/79/5/1106 > > This reference relates to defib energy levels but i think you will > see where I am coming from. > > At James Cook, I was involved in the development of a non > depolarising cardioplegia solution, which is slowly working its way > up the development path. The main components are lidocaine and > adenosine. > > > > > >Ben, > >I use Amiadorone in the pump for all emazes (and postop) and > >Amiadorone in the pump for all aortic valves. Since the St Thomas > >Cardioplegia (which we mix in blood) already has procaine adding > >Lignocaine would be redundant.(Incidentally Amiadorone is very cheap > >in India !!) > >Prasanna > >Ben Bidstrup wrote: > >>Why the amiodarone. Surely with some perfusion, the electrolyte > >>imbalances within the myocardium would correct and SR ensue. If > >>anything use lidocaine. Less toxic and cheaper, not a negative > >>inotrope. It is what Yacoub taught me many years ago, and I have > >>used it to good effect (infrequently I might add). > >> > >>>Tohru, > >>> I did an AVR on an 87 yo man as a 2nd case just a couple of > >>>hours ago. Again, no LV vent, only a sump. While closing the > >>>aortotomy, I began the > >>>continuous warm retrograde blood. The heart began fibrillating > >>>after a couple of > >>>minutes. I gave amio and then cardioverted. The heart had a > >>>slow junctional > >>>rhythm until the clamp was released. A sinus rhythm developed shortly > >>>afterwards. He came off with no inotropes. It's much easier on > >>>the heart and > >>>your nerves to cardiovert a clamped, flaccid heart rather than > >>>trying to do it > >>>after the clamp has been released. > >>> I look forward to your visit at the STS. As I said before, I'll > try to > >>>have a couple of interesting cases for you and other interested > >>>members of HSF > >>>to watch and criticize to your heart's content. > >>> > >>>Hal > >>> > >>> > >>> > >>>************************************** Get a sneak peek of the > >>>all-new AOL at > >>>http://discover.aol.com/memed/aolcom30tour > >>>_______________________________________________ > >>>OpenHeart-L mailing list > >>> > >>>Send postings to: > >>> OpenHeart-L@lists.hsforum.com > >>> > >>>To UNSUBSCRIBE, to CHANGE email address, or to view archives: > >>>http://mmp.cjp.com/mailman/listinfo/openheart-l > >>> > >>>All messages transmitted by the OpenHeart-L are subject to the policies > and > >>>disclaimers posted at: > >>>http://www.hsforum.com/listdisclaim > >>>----------------------------------------- > >> > >> > > > >_______________________________________________ > >OpenHeart-L mailing list > > > >Send postings to: > >OpenHeart-L@lists.hsforum.com > > > >To UNSUBSCRIBE, to CHANGE email address, or to view archives: > >http://mmp.cjp.com/mailman/listinfo/openheart-l > > > >All messages transmitted by the OpenHeart-L are subject to the > >policies and disclaimers posted at: > >http://www.hsforum.com/listdisclaim > >----------------------------------------- > > > -- > > > Two things are infinite; the universe and human stupidity; and I am > not sure about the universe. > Albert Einstein > > The greatest obstacle to discovery is not ignorance --- it is the > illusion of knowledge. > Daniel J Boorstin > > Ben Bidstrup FRACS FRCSEd FEBCTS > Consultant Cardiothoracic Surgeon > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies > and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > -- Prasanna Simha M From anianyanwu at hotmail.com Wed Aug 1 15:30:50 2007 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Wed Aug 1 10:31:41 2007 Subject: [HSF] Inotropes, ventricular fibrillation and myocardial protection Message-ID: I still do not understand why we are alarmed about transient ventricular fibrillation on reperfusion and why using drugs to suppress it will have any impact on outcome. Ani > Date: Wed, 1 Aug 2007 11:51:47 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] Inotropes, ventricular fibrillation and myocardial protection> CC: > > I am not saying that the procaine or lignocaine is still acting. What I> meant is that since the fibrillation is occurring with the hotshot delivery> with high local lignocaine changing the drug class may be beneficial.> Prasanna> > On 8/1/07, Ben Bidstrup wrote:> >> > I beg respectfully to differ. The lidocaine (a fast Na channel> > blocker) is all but gone after a short while in the cardioplegia> > scenario. Getting a suitable level back into the circulation and thus> > the heart at release of the clamp is what is needed.> >> > Perhaps a randomised study is in the offing.> >> > http://circ.ahajournals.org/cgi/content/abstract/79/5/1106> >> > This reference relates to defib energy levels but i think you will> > see where I am coming from.> >> > At James Cook, I was involved in the development of a non> > depolarising cardioplegia solution, which is slowly working its way> > up the development path. The main components are lidocaine and> > adenosine.> >> >> >> >> > >Ben,> > >I use Amiadorone in the pump for all emazes (and postop) and> > >Amiadorone in the pump for all aortic valves. Since the St Thomas> > >Cardioplegia (which we mix in blood) already has procaine adding> > >Lignocaine would be redundant.(Incidentally Amiadorone is very cheap> > >in India !!)> > >Prasanna> > >Ben Bidstrup wrote:> > >>Why the amiodarone. Surely with some perfusion, the electrolyte> > >>imbalances within the myocardium would correct and SR ensue. If> > >>anything use lidocaine. Less toxic and cheaper, not a negative> > >>inotrope. It is what Yacoub taught me many years ago, and I have> > >>used it to good effect (infrequently I might add).> > >>> > >>>Tohru,> > >>> I did an AVR on an 87 yo man as a 2nd case just a couple of> > >>>hours ago. Again, no LV vent, only a sump. While closing the> > >>>aortotomy, I began the> > >>>continuous warm retrograde blood. The heart began fibrillating> > >>>after a couple of> > >>>minutes. I gave amio and then cardioverted. The heart had a> > >>>slow junctional> > >>>rhythm until the clamp was released. A sinus rhythm developed shortly> > >>>afterwards. He came off with no inotropes. It's much easier on> > >>>the heart and> > >>>your nerves to cardiovert a clamped, flaccid heart rather than> > >>>trying to do it> > >>>after the clamp has been released.> > >>> I look forward to your visit at the STS. As I said before, I'll> > try to> > >>>have a couple of interesting cases for you and other interested> > >>>members of HSF> > >>>to watch and criticize to your heart's content.> > >>>> > >>>Hal> > >>>> > >>>> > >>>> > >>>************************************** Get a sneak peek of the> > >>>all-new AOL at> > >>>http://discover.aol.com/memed/aolcom30tour> > >>>_______________________________________________> > >>>OpenHeart-L mailing list> > >>>> > >>>Send postings to:> > >>> OpenHeart-L@lists.hsforum.com> > >>>> > >>>To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > >>>http://mmp.cjp.com/mailman/listinfo/openheart-l> > >>>> > >>>All messages transmitted by the OpenHeart-L are subject to the policies> > and> > >>>disclaimers posted at:> > >>>http://www.hsforum.com/listdisclaim> > >>>-----------------------------------------> > >>> > >>> > >> > >_______________________________________________> > >OpenHeart-L mailing list> > >> > >Send postings to:> > >OpenHeart-L@lists.hsforum.com> > >> > >To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > >http://mmp.cjp.com/mailman/listinfo/openheart-l> > >> > >All messages transmitted by the OpenHeart-L are subject to the> > >policies and disclaimers posted at:> > >http://www.hsforum.com/listdisclaim> > >-----------------------------------------> >> >> > --> >> >> > Two things are infinite; the universe and human stupidity; and I am> > not sure about the universe.> > Albert Einstein> >> > The greatest obstacle to discovery is not ignorance --- it is the> > illusion of knowledge.> > Daniel J Boorstin> >> > Ben Bidstrup FRACS FRCSEd FEBCTS> > Consultant Cardiothoracic Surgeon> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies> > and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> > > > -- > Prasanna Simha M> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> ----------------------------------------- _________________________________________________________________ 100?s of Music vouchers to be won with MSN Music https://www.musicmashup.co.uk/index.html From prasannasimha at gmail.com Wed Aug 1 21:15:53 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Wed Aug 1 10:46:29 2007 Subject: [HSF] Inotropes, ventricular fibrillation and myocardial protection In-Reply-To: References: Message-ID: <46B09CA1.1070007@gmail.com> Ani, Having graduated from voodoo homemade cocktails to blood and its variants, you would easily be able to see that the bad cardioplegia's did have a higher (more accurately uniform) incidence of fibrillation which came down with better modifications of cardioplegia's. That does make us wary and anyway fibrillation is not something by any stretch normal.Transient defibrillation may appear innocuous but then it has been shown that such hearts have indeed been improperly preserved (from works of Buckberg and Kirklin).Remember that sometimes speed etc etc may compensate but this may become an issue in longer case. Prasanna Ani Anyanwu wrote: > I still do not understand why we are alarmed about transient ventricular fibrillation on reperfusion and why using drugs to suppress it will have any impact on outcome. > > Ani > > > > >> Date: Wed, 1 Aug 2007 11:51:47 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] Inotropes, ventricular fibrillation and myocardial protection> CC: > > I am not saying that the procaine or lignocaine is still acting. What I> meant is that since the fibrillation is occurring with the hotshot delivery> with high local lignocaine changing the drug class may be beneficial.> Prasanna> > On 8/1/07, Ben Bidstrup wrote:> >> > I beg respectfully to differ. The lidocaine (a fast Na channel> > blocker) is all but gone after a short while in the cardioplegia> > scenario. Getting a suitable level back into the circulation and thus> > the heart at release of the clamp is what is needed.> >> > Perhaps a randomised study is in the offing.> >> > http://circ.ahajournals.org/cgi/content/abstract/79/5/1106> >> > This reference relates to defib energy levels but i think you will> > see where I am coming from.> >> > At James Cook, I was involved in the development of a non> > depolarising cardioplegia solution, which is slowly working its way> > up the development path. The main components are lidocaine and> > adenosine.> >> >> >> >> > >Ben,> > >I use Amiadorone in the pump for all emazes (and postop) and> > >Amiadorone in the pump for all aortic valves. Since the St Thomas> > >Cardioplegia (which we mix in blood) already has procaine adding> > >Lignocaine would be redundant.(Incidentally Amiadorone is very cheap> > >in India !!)> > >Prasanna> > >Ben Bidstrup wrote:> > >>Why the amiodarone. Surely with some perfusion, the electrolyte> > >>imbalances within the myocardium would correct and SR ensue. If> > >>anything use lidocaine. Less toxic and cheaper, not a negative> > >>inotrope. It is what Yacoub taught me many years ago, and I have> > >>used it to good effect (infrequently I might add).> > >>> > >>>Tohru,> > >>> I did an AVR on an 87 yo man as a 2nd case just a couple of> > >>>hours ago. Again, no LV vent, only a sump. While closing the> > >>>aortotomy, I began the> > >>>continuous warm retrograde blood. The heart began fibrillating> > >>>after a couple of> > >>>minutes. I gave amio and then cardioverted. The heart had a> > >>>slow junctional> > >>>rhythm until the clamp was released. A sinus rhythm developed shortly> > >>>afterwards. He came off with no inotropes. It's much easier on> > >>>the heart and> > >>>your nerves to cardiovert a clamped, flaccid heart rather than> > >>>trying to do it> > >>>after the clamp has been released.> > >>> I look forward to your visit at the STS. As I said before, I'll> > try to> > >>>have a couple of interesting cases for you and other interested> > >>>members of HSF> > >>>to watch and criticize to your heart's content.> > >>>> > >>>Hal> > >>>> > >>>> > >>>> > >>>************************************** Get a sneak peek of the> > >>>all-new AOL at> > >>>http://discover.aol.com/memed/aolcom30tour> > >>>_______________________________________________> > >>>OpenHeart-L mailing list> > >>>> > >>>Send postings to:> > >>> OpenHeart-L@lists.hsforum.com> > >>>> > >>>To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > >>>http://mmp.cjp.com/mailman/listinfo/openheart-l> > >>>> > >>>All messages transmitted by the OpenHeart-L are subject to the policies> > and> > >>>disclaimers posted at:> > >>>http://www.hsforum.com/listdisclaim> > >>>-----------------------------------------> > >>> > >>> > >> > >_______________________________________________> > >OpenHeart-L mailing list> > >> > >Send postings to:> > >OpenHeart-L@lists.hsforum.com> > >> > >To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > >http://mmp.cjp.com/mailman/listinfo/openheart-l> > >> > >All messages transmitted by the OpenHeart-L are subject to the> > >policies and disclaimers posted at:> > >http://www.hsforum.com/listdisclaim> > >-----------------------------------------> >> >> > --> >> >> > Two things are infinite; the universe and human stupidity; and I am> > not sure about the universe.> > Albert Einstein> >> > The greatest obstacle to discovery is not ignorance --- it is the> > illusion of knowledge.> > Daniel J Boorstin> >> > Ben Bidstrup FRACS FRCSEd FEBCTS> > Consultant Cardiothoracic Surgeon> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies> > and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> > > > -- > Prasanna Simha M> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> ----------------------------------------- >> > _________________________________________________________________ > 100?s of Music vouchers to be won with MSN Music > https://www.musicmashup.co.uk/index.html_______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > > > From jrodriguezcampos at yahoo.com Wed Aug 1 08:57:21 2007 From: jrodriguezcampos at yahoo.com (Jorge Rodriguez Campos) Date: Wed Aug 1 10:57:50 2007 Subject: Rv: [HSF] ima dilatation Message-ID: <564589.64303.qm@web51405.mail.re2.yahoo.com> ----- Mensaje reenviado ---- De: Jorge Rodriguez Campos Para: OpenHeart-L@lists.hsforum.com Enviado: lunes, 30 de julio, 2007 12:01:21 Asunto: Re: [HSF] ima dilatation Dear Mark, Don an other. Skeletonizaci?n IMA, after heparinized, to cut distal, to see the flow and clipped, an then can inmerse in papaverine diluted.-( see the image) 20 minutes after the graft has better flow and diameter.- Jorge Rodriguez Campos ----- Mensaje original ---- De: Donald Ross Para: OpenHeart-L@lists.hsforum.com Enviado: lunes, 30 de julio, 2007 4:19:19 Asunto: Re: [HSF] ima dilatation Mark, I think my unfortunate dissections with retrograde ima injection may have been related to the fine olive tipped needle from DLP which I used . I think it was "too sharp" and hopefully the 22G angiocath will be safer. It must have been at least 10 years since I abandoned intra-luminal injection, so really the advantages can't be all that great. Cheers, Don On 29/07/2007, at 2:13 PM, Mark Levinson wrote: > > On Jul 22, 2007, at 1:05 AM, Donald Ross wrote: > >> Tohru, >> I appreciate the details of how you sex up the internal mammary. >> I hope, somewhat different from the technique you use for the >> external variety. >> >> I like your technique for intra-luminal injection and will start >> doing it again to avoid the advential band which was not >> detected because the ima was not fully dilated. >> >> BTW I use verapamil undiluted >> >>> > > Don: > > Skeletonization and then intraluminal injection allows you to > identify these bands (if any are left after skeletonized harvest) > and they are snipped with > the fine coronary scissors before grafting. I use the same > intraluminal injection as Tohru Asai (only with VG + Regitine) and > this confirms that the > graft has high flow, no dissections and no strictures before I > gamble the fate of the patient on it. > > I think distal injection can be done safely, and the response is > immediate so you can then plan the case knowing the graft is OK or > not. > > If the IMA dissects with retrograde injection, it is most likely > that a flap already exists and you just made it more obvious. > Better to know before > grafting than to find out in the ICU. I find that local > dissections can be hidden under the pedicle in non-skeletonized > conduits. > > However, I have watched video of your dissection technique, and I > know that you take the vein, and not much is left... > > > Mark > > Mark M. Levinson, MD > Founder, Editor-in-Chief, > The Heart Surgery Forum > WWW: > Email: > > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the > policies anddisclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- __________________________________________________ Correo Yahoo! Espacio para todos tus mensajes, antivirus y antispam ?gratis! Reg?strate ya - http://correo.espanol.yahoo.com/ __________________________________________________ Correo Yahoo! Espacio para todos tus mensajes, antivirus y antispam ?gratis! Reg?strate ya - http://correo.espanol.yahoo.com/ From TSalerno at med.miami.edu Wed Aug 1 12:19:38 2007 From: TSalerno at med.miami.edu (Salerno, Tomas) Date: Wed Aug 1 11:20:29 2007 Subject: [HSF] Inotropes, ventricular fibrillation and myocardial protection Message-ID: A fibrillating heart is. "Dying" heart. The brain does not have seizure during CPB; neither should the heart fibrillate. Tomas ----- Original Message ----- From: openheart-l-bounces@lists.hsforum.com To: OpenHeart-L@lists.hsforum.com Sent: Wed Aug 01 10:45:53 2007 Subject: Re: [HSF] Inotropes,ventricular fibrillation and myocardial protection Ani, Having graduated from voodoo homemade cocktails to blood and its variants, you would easily be able to see that the bad cardioplegia's did have a higher (more accurately uniform) incidence of fibrillation which came down with better modifications of cardioplegia's. That does make us wary and anyway fibrillation is not something by any stretch normal.Transient defibrillation may appear innocuous but then it has been shown that such hearts have indeed been improperly preserved (from works of Buckberg and Kirklin).Remember that sometimes speed etc etc may compensate but this may become an issue in longer case. Prasanna Ani Anyanwu wrote: > I still do not understand why we are alarmed about transient ventricular fibrillation on reperfusion and why using drugs to suppress it will have any impact on outcome. > > Ani > > > > >> Date: Wed, 1 Aug 2007 11:51:47 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] Inotropes, ventricular fibrillation and myocardial protection> CC: > > I am not saying that the procaine or lignocaine is still acting. What I> meant is that since the fibrillation is occurring with the hotshot delivery> with high local lignocaine changing the drug class may be beneficial.> Prasanna> > On 8/1/07, Ben Bidstrup wrote:> >> > I beg respectfully to differ. The lidocaine (a fast Na channel> > blocker) is all but gone after a short while in the cardioplegia> > scenario. Getting a suitable level back into the circulation and thus> > the heart at release of the clamp is what is needed.> >> > Perhaps a randomised study is in the offing.> >> > http://circ.ahajournals.org/cgi/content/abstract/79/5/1106> >> > This reference relates to defib energy levels but i think you will> > see where I am coming from.> >> > At James Cook, I was involved in the development of a non> > depolarising cardioplegia solution, which is slowly working its way> > up the development path. The main components are lidocaine and> > adenosine.> >> >> >> >> > >Ben,> > >I use Amiadorone in the pump for all emazes (and postop) and> > >Amiadorone in the pump for all aortic valves. Since the St Thomas> > >Cardioplegia (which we mix in blood) already has procaine adding> > >Lignocaine would be redundant.(Incidentally Amiadorone is very cheap> > >in India !!)> > >Prasanna> > >Ben Bidstrup wrote:> > >>Why the amiodarone. Surely with some perfusion, the electrolyte> > >>imbalances within the myocardium would correct and SR ensue. If> > >>anything use lidocaine. Less toxic and cheaper, not a negative> > >>inotrope. It is what Yacoub taught me many years ago, and I have> > >>used it to good effect (infrequently I might add).> > >>> > >>>Tohru,> > >>> I did an AVR on an 87 yo man as a 2nd case just a couple of> > >>>hours ago. Again, no LV vent, only a sump. While closing the> > >>>aortotomy, I began the> > >>>continuous warm retrograde blood. The heart began fibrillating> > >>>after a couple of> > >>>minutes. I gave amio and then cardioverted. The heart had a> > >>>slow junctional> > >>>rhythm until the clamp was released. A sinus rhythm developed shortly> > >>>afterwards. He came off with no inotropes. It's much easier on> > >>>the heart and> > >>>your nerves to cardiovert a clamped, flaccid heart rather than> > >>>trying to do it> > >>>after the clamp has been released.> > >>> I look forward to your visit at the STS. As I said before, I'll> > try to> > >>>have a couple of interesting cases for you and other interested> > >>>members of HSF> > >>>to watch and criticize to your heart's content.> > >>>> > >>>Hal> > >>>> > >>>> > >>>> > >>>************************************** Get a sneak peek of the> > >>>all-new AOL at> > >>>http://discover.aol.com/memed/aolcom30tour> > >>>_______________________________________________> > >>>OpenHeart-L mailing list> > >>>> > >>>Send postings to:> > >>> OpenHeart-L@lists.hsforum.com> > >>>> > >>>To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > >>>http://mmp.cjp.com/mailman/listinfo/openheart-l> > >>>> > >>>All messages transmitted by the OpenHeart-L are subject to the policies> > and> > >>>disclaimers posted at:> > >>>http://www.hsforum.com/listdisclaim> > >>>-----------------------------------------> > >>> > >>> > >> > >_______________________________________________> > >OpenHeart-L mailing list> > >> > >Send postings to:> > >OpenHeart-L@lists.hsforum.com> > >> > >To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > >http://mmp.cjp.com/mailman/listinfo/openheart-l> > >> > >All messages transmitted by the OpenHeart-L are subject to the> > >policies and disclaimers posted at:> > >http://www.hsforum.com/listdisclaim> > >-----------------------------------------> >> >> > --> >> >> > Two things are infinite; the universe and human stupidity; and I am> > not sure about the universe.> > Albert Einstein> >> > The greatest obstacle to discovery is not ignorance --- it is the> > illusion of knowledge.> > Daniel J Boorstin> >> > Ben Bidstrup FRACS FRCSEd FEBCTS> > Consultant Cardiothoracic Surgeon> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies> > and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> > > > -- > Prasanna Simha M> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> ----------------------------------------- >> > _________________________________________________________________ > 100?s of Music vouchers to be won with MSN Music > https://www.musicmashup.co.uk/index.html_______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > > > _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From TSalerno at med.miami.edu Wed Aug 1 12:25:07 2007 From: TSalerno at med.miami.edu (Salerno, Tomas) Date: Wed Aug 1 11:25:32 2007 Subject: Rv: [HSF] ima dilatation Message-ID: I injet papaverine into the endothoracic fascia near the LIMA prior to dissection. I also injet papaverine into the fascia near mammary once dissection completed. I have regretted injecting the LIMA directly (damage) Tomas ----- Original Message ----- From: openheart-l-bounces@lists.hsforum.com To: Forum Heart Surgery Forum Sent: Wed Aug 01 10:57:21 2007 Subject: Rv: [HSF] ima dilatation ----- Mensaje reenviado ---- De: Jorge Rodriguez Campos Para: OpenHeart-L@lists.hsforum.com Enviado: lunes, 30 de julio, 2007 12:01:21 Asunto: Re: [HSF] ima dilatation Dear Mark, Don an other. Skeletonizaci?n IMA, after heparinized, to cut distal, to see the flow and clipped, an then can inmerse in papaverine diluted.-( see the image) 20 minutes after the graft has better flow and diameter.- Jorge Rodriguez Campos ----- Mensaje original ---- De: Donald Ross Para: OpenHeart-L@lists.hsforum.com Enviado: lunes, 30 de julio, 2007 4:19:19 Asunto: Re: [HSF] ima dilatation Mark, I think my unfortunate dissections with retrograde ima injection may have been related to the fine olive tipped needle from DLP which I used . I think it was "too sharp" and hopefully the 22G angiocath will be safer. It must have been at least 10 years since I abandoned intra-luminal injection, so really the advantages can't be all that great. Cheers, Don On 29/07/2007, at 2:13 PM, Mark Levinson wrote: > > On Jul 22, 2007, at 1:05 AM, Donald Ross wrote: > >> Tohru, >> I appreciate the details of how you sex up the internal mammary. >> I hope, somewhat different from the technique you use for the >> external variety. >> >> I like your technique for intra-luminal injection and will start >> doing it again to avoid the advential band which was not >> detected because the ima was not fully dilated. >> >> BTW I use verapamil undiluted >> >>> > > Don: > > Skeletonization and then intraluminal injection allows you to > identify these bands (if any are left after skeletonized harvest) > and they are snipped with > the fine coronary scissors before grafting. I use the same > intraluminal injection as Tohru Asai (only with VG + Regitine) and > this confirms that the > graft has high flow, no dissections and no strictures before I > gamble the fate of the patient on it. > > I think distal injection can be done safely, and the response is > immediate so you can then plan the case knowing the graft is OK or > not. > > If the IMA dissects with retrograde injection, it is most likely > that a flap already exists and you just made it more obvious. > Better to know before > grafting than to find out in the ICU. I find that local > dissections can be hidden under the pedicle in non-skeletonized > conduits. > > However, I have watched video of your dissection technique, and I > know that you take the vein, and not much is left... > > > Mark > > Mark M. Levinson, MD > Founder, Editor-in-Chief, > The Heart Surgery Forum > WWW: > Email: > > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the > policies anddisclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- __________________________________________________ Correo Yahoo! Espacio para todos tus mensajes, antivirus y antispam ?gratis! Reg?strate ya - http://correo.espanol.yahoo.com/ __________________________________________________ Correo Yahoo! Espacio para todos tus mensajes, antivirus y antispam ?gratis! Reg?strate ya - http://correo.espanol.yahoo.com/ From anianyanwu at hotmail.com Wed Aug 1 16:26:41 2007 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Wed Aug 1 11:27:14 2007 Subject: [HSF] Inotropes, ventricular fibrillation and myocardial protection Message-ID: Well then there are millions of people walking the street today with dead hearts. All Tohru's patients for a start. Ani > Subject: Re: [HSF] Inotropes, ventricular fibrillation and myocardial protection> Date: Wed, 1 Aug 2007 11:19:38 -0400> From: TSalerno@med.miami.edu> To: OpenHeart-L@lists.hsforum.com> CC: > > A fibrillating heart is. "Dying" heart.> > The brain does not have seizure during CPB; neither should the heart fibrillate.> > Tomas> > > > ----- Original Message -----> From: openheart-l-bounces@lists.hsforum.com > To: OpenHeart-L@lists.hsforum.com > Sent: Wed Aug 01 10:45:53 2007> Subject: Re: [HSF] Inotropes,ventricular fibrillation and myocardial protection> > Ani,> Having graduated from voodoo homemade cocktails to blood and its > variants, you would easily be able to see that the bad cardioplegia's > did have a higher (more accurately uniform) incidence of fibrillation > which came down with better modifications of cardioplegia's. That does > make us wary and anyway fibrillation is not something by any stretch > normal.Transient defibrillation may appear innocuous but then it has > been shown that such hearts have indeed been improperly preserved (from > works of Buckberg and Kirklin).Remember that sometimes speed etc etc may > compensate but this may become an issue in longer case.> Prasanna> Ani Anyanwu wrote:> > I still do not understand why we are alarmed about transient ventricular fibrillation on reperfusion and why using drugs to suppress it will have any impact on outcome.> > > > Ani> >> >> >> > > >> Date: Wed, 1 Aug 2007 11:51:47 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] Inotropes, ventricular fibrillation and myocardial protection> CC: > > I am not saying that the procaine or lignocaine is still acting. What I> meant is that since the fibrillation is occurring with the hotshot delivery> with high local lignocaine changing the drug class may be beneficial.> Prasanna> > On 8/1/07, Ben Bidstrup wrote:> >> > I beg respectfully to differ. The lidocaine (a fast Na channel> > blocker) is all but gone after a short while in the cardioplegia> > scenario. Getting a suitable level back into the circulation and thus> > the heart at release of the clamp is what is needed.> >> > Perhaps a randomised study is in the offing.> >> > http://circ.ahajournals.org/cgi/content/abstract/79/5/1106> >> > This reference relates to defib energy levels but i think you will> > see where I am coming from.> >> > At James Cook, I was involved in the development of a non> > depolarising cardioplegia solution, which is slowly working its way> > up the development path. The main components are lidocaine and> > adenosine.> >> >> >> >> > >Ben,> > >I use Amiadorone in the pump for all emazes (and postop) and> > >Amiadorone in the pump for all aortic valves. Since the St Thomas> > >Cardioplegia (which we mix in blood) already has procaine adding> > >Lignocaine would be redundant.(Incidentally Amiadorone is very cheap> > >in India !!)> > >Prasanna> > >Ben Bidstrup wrote:> > >>Why the amiodarone. Surely with some perfusion, the electrolyte> > >>imbalances within the myocardium would correct and SR ensue. If> > >>anything use lidocaine. Less toxic and cheaper, not a negative> > >>inotrope. It is what Yacoub taught me many years ago, and I have> > >>used it to good effect (infrequently I might add).> > >>> > >>>Tohru,> > >>> I did an AVR on an 87 yo man as a 2nd case just a couple of> > >>>hours ago. Again, no LV vent, only a sump. While closing the> > >>>aortotomy, I began the> > >>>continuous warm retrograde blood. The heart began fibrillating> > >>>after a couple of> > >>>minutes. I gave amio and then cardioverted. The heart had a> > >>>slow junctional> > >>>rhythm until the clamp was released. A sinus rhythm developed shortly> > >>>afterwards. He came off with no inotropes. It's much easier on> > >>>the heart and> > >>>your nerves to cardiovert a clamped, flaccid heart rather than> > >>>trying to do it> > >>>after the clamp has been released.> > >>> I look forward to your visit at the STS. As I said before, I'll> > try to> > >>>have a couple of interesting cases for you and other interested> > >>>members of HSF> > >>>to watch and criticize to your heart's content.> > >>>> > >>>Hal> > >>>> > >>>> > >>>> > >>>************************************** Get a sneak peek of the> > >>>all-new AOL at> > >>>http://discover.aol.com/memed/aolcom30tour> > >>>_______________________________________________> > >>>OpenHeart-L mailing list> > >>>> > >>>Send postings to:> > >>> OpenHeart-L@lists.hsforum.com> > >>>> > >>>To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > >>>http://mmp.cjp.com/mailman/listinfo/openheart-l> > >>>> > >>>All messages transmitted by the OpenHeart-L are subject to the policies> > and> > >>>disclaimers posted at:> > >>>http://www.hsforum.com/listdisclaim> > >>>-----------------------------------------> > >>> > >>> > >> > >_______________________________________________> > >OpenHeart-L mailing list> > >> > >Send postings to:> > >OpenHeart-L@lists.hsforum.com> > >> > >To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > >http://mmp.cjp.com/mailman/listinfo/openheart-l> > >> > >All messages transmitted by the OpenHeart-L are subject to the> > >policies and disclaimers posted at:> > >http://www.hsforum.com/listdisclaim> > >-----------------------------------------> >> >> > --> >> >> > Two things are infinite; the universe and human stupidity; and I am> > not sure about the universe.> > Albert Einstein> >> > The greatest obstacle to discovery is not ignorance --- it is the> > illusion of knowledge.> > Daniel J Boorstin> >> > Ben Bidstrup FRACS FRCSEd FEBCTS> > Consultant Cardiothoracic Surgeon> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies> > and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> > > > -- > Prasanna Simha M> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------> >> > > _________________________________________________________________> > 100?s of Music vouchers to be won with MSN Music> > https://www.musicmashup.co.uk/index.html_______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies and > > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> >> > > > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> ----------------------------------------- _________________________________________________________________ Feel like a local wherever you go with BackOfMyHand.com http://www.backofmyhand.com From prasannasimha at gmail.com Wed Aug 1 22:02:42 2007 From: prasannasimha at gmail.com (psimha) Date: Wed Aug 1 11:33:38 2007 Subject: [HSF] Inotropes, ventricular fibrillation and myocardial protection In-Reply-To: References: Message-ID: <46B0A79A.4080200@sify.com> ??? Prasanna Ani Anyanwu wrote: > Well then there are millions of people walking the street today with dead hearts. All Tohru's patients for a start. > > Ani > > > > >> Subject: Re: [HSF] Inotropes, ventricular fibrillation and myocardial protection> Date: Wed, 1 Aug 2007 11:19:38 -0400> From: TSalerno@med.miami.edu> To: OpenHeart-L@lists.hsforum.com> CC: > > A fibrillating heart is. "Dying" heart.> > The brain does not have seizure during CPB; neither should the heart fibrillate.> > Tomas> > > > ----- Original Message -----> From: openheart-l-bounces@lists.hsforum.com > To: OpenHeart-L@lists.hsforum.com > Sent: Wed Aug 01 10:45:53 2007> Subject: Re: [HSF] Inotropes,ventricular fibrillation and myocardial protection> > Ani,> Having graduated from voodoo homemade cocktails to blood and its > variants, you would easily be able to see that the bad cardioplegia's > did have a higher (more accurately uniform) incidence of fibrillation > which came down with better modifications of cardioplegia's. That does > make us wary and anyway fibrillation is not something by any stretch > normal.Transient defibrillation may appear innocuous but then it has > been shown that such hearts have indeed been improperly preserved (from > works of Buckberg and Kirklin).Remember that sometimes speed etc etc may > compensate but this may become an issue in longer case.> Prasanna> Ani Anyanwu wrote:> > I still do not understand why we are alarmed about transient ventricular fibrillation on reperfusion and why using drugs to suppress it will have any impact on outcome.> > > > Ani> >> >> >> > > >> Date: Wed, 1 Aug 2007 11:51:47 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] Inotropes, ventricular fibrillation and myocardial protection> CC: > > I am not saying that the procaine or lignocaine is still acting. What I> meant is that since the fibrillation is occurring with the hotshot delivery> with high local lignocaine changing the drug class may be beneficial.> Prasanna> > On 8/1/07, Ben Bidstrup wrote:> >> > I beg respectfully to differ. The lidocaine (a fast Na channel> > blocker) is all but gone after a short while in the cardioplegia> > scenario. Getting a suitable level back into the circulation and thus> > the heart at release of the clamp is what is needed.> >> > Perhaps a randomised study is in the offing.> >> > http://circ.ahajournals.org/cgi/content/abstract/79/5/1106> >> > This reference relates to defib energy levels but i think you will> > see where I am coming from.> >> > At James Cook, I was involved in the development of a non> > depolarising cardioplegia solution, which is slowly working its way> > up the development path. The main components are lidocaine and> > adenosine.> >> >> >> >> > >Ben,> > >I use Amiadorone in the pump for all emazes (and postop) and> > >Amiadorone in the pump for all aortic valves. Since the St Thomas> > >Cardioplegia (which we mix in blood) already has procaine adding> > >Lignocaine would be redundant.(Incidentally Amiadorone is very cheap> > >in India !!)> > >Prasanna> > >Ben Bidstrup wrote:> > >>Why the amiodarone. Surely with some perfusion, the electrolyte> > >>imbalances within the myocardium would correct and SR ensue. If> > >>anything use lidocaine. Less toxic and cheaper, not a negative> > >>inotrope. It is what Yacoub taught me many years ago, and I have> > >>used it to good effect (infrequently I might add).> > >>> > >>>Tohru,> > >>> I did an AVR on an 87 yo man as a 2nd case just a couple of> > >>>hours ago. Again, no LV vent, only a sump. While closing the> > >>>aortotomy, I began the> > >>>continuous warm retrograde blood. The heart began fibrillating> > >>>after a couple of> > >>>minutes. I gave amio and then cardioverted. The heart had a> > >>>slow junctional> > >>>rhythm until the clamp was released. A sinus rhythm developed shortly> > >>>afterwards. He came off with no inotropes. It's much easier on> > >>>the heart and> > >>>your nerves to cardiovert a clamped, flaccid heart rather than> > >>>trying to do it> > >>>after the clamp has been released.> > >>> I look forward to your visit at the STS. As I said before, I'll> > try to> > >>>have a couple of interesting cases for you and other interested> > >>>members of HSF> > >>>to watch and criticize to your heart's content.> > >>>> > >>>Hal> > >>>> > >>>> > >>>> > >>>************************************** Get a sneak peek of the> > >>>all-new AOL at> > >>>http://discover.aol.com/memed/aolcom30tour> > >>>_______________________________________________> > >>>OpenHeart-L mailing list> > >>>> > >>>Send postings to:> > >>> OpenHeart-L@lists.hsforum.com> > >>>> > >>>To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > >>>http://mmp.cjp.com/mailman/listinfo/openheart-l> > >>>> > >>>All messages transmitted by the OpenHeart-L are subject to the policies> > and> > >>>disclaimers posted at:> > >>>http://www.hsforum.com/listdisclaim> > >>>-----------------------------------------> > >>> > >>> > >> > >_______________________________________________> > >OpenHeart-L mailing list> > >> > >Send postings to:> > >OpenHeart-L@lists.hsforum.com> > >> > >To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > >http://mmp.cjp.com/mailman/listinfo/openheart-l> > >> > >All messages transmitted by the OpenHeart-L are subject to the> > >policies and disclaimers posted at:> > >http://www.hsforum.com/listdisclaim> > >-----------------------------------------> >> >> > --> >> >> > Two things are infinite; the universe and human stupidity; and I am> > not sure about the universe.> > Albert Einstein> >> > The greatest obstacle to discovery is not ignorance --- it is the> > illusion of knowledge.> > Daniel J Boorstin> >> > Ben Bidstrup FRACS FRCSEd FEBCTS> > Consultant Cardiothoracic Surgeon> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies> > and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> > > > -- > Prasanna Simha M> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------> >> > > _________________________________________________________________> > 100?s of Music vouchers to be won with MSN Music> > https://www.musicmashup.co.uk/index.html_______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies and > > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> >> > > > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> ----------------------------------------- >> > _________________________________________________________________ > Feel like a local wherever you go with BackOfMyHand.com > http://www.backofmyhand.com_______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > > > From anianyanwu at hotmail.com Wed Aug 1 16:42:58 2007 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Wed Aug 1 11:43:49 2007 Subject: [HSF] Inotropes, ventricular fibrillation and myocardial protection Message-ID: Prasanna What you do now is no less voodoo that what you graduated from; indeed your current cardioplegia recipe is very much a 'homemade cocktail'. We have to be careful in ascribing benefits to things we do without being able to demonstrate such benefits scientifically.Many never add drugs like adenosine and esmolol, as you might do, to cardioplegia and have good results. I recall recently, one of our senior members (maybe Dr Tom Martin?) said he still uses crystalloid cardioplegia and yet has fantastic results in very complex cases several of which he has shared on this forum. Indeed the more I quiz people about this 'fibrillation is bad' theory the less I am convinced about it. A day or two ago I learnt from Hal that he sometimes defibrillates with the clamp on and then that later will count as the heart being in SR when you declamp? Tohru induces fibrillation in all patients and has good results. We also learnt that many of us actually don't even know what is in the cardioplegia or hot-shot we use. Cardioplegia is indeed still voodoo. There are basic principles which have to be adhered to depending on whether you are cold or warm, arrested or beating; aside from this, most of the rest is voodoo, including, I suspect, the suggestion that transient fibrillation indicates poor protection. Ani > Date: Wed, 1 Aug 2007 20:15:53 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] Inotropes, ventricular fibrillation and myocardial protection> CC: > > Ani,> Having graduated from voodoo homemade cocktails to blood and its > variants, you would easily be able to see that the bad cardioplegia's > did have a higher (more accurately uniform) incidence of fibrillation > which came down with better modifications of cardioplegia's. That does > make us wary and anyway fibrillation is not something by any stretch > normal.Transient defibrillation may appear innocuous but then it has > been shown that such hearts have indeed been improperly preserved (from > works of Buckberg and Kirklin).Remember that sometimes speed etc etc may > compensate but this may become an issue in longer case.> Prasanna> Ani Anyanwu wrote:> > I still do not understand why we are alarmed about transient ventricular fibrillation on reperfusion and why using drugs to suppress it will have any impact on outcome.> > > > Ani> >> >> >> > > >> Date: Wed, 1 Aug 2007 11:51:47 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] Inotropes, ventricular fibrillation and myocardial protection> CC: > > I am not saying that the procaine or lignocaine is still acting. What I> meant is that since the fibrillation is occurring with the hotshot delivery> with high local lignocaine changing the drug class may be beneficial.> Prasanna> > On 8/1/07, Ben Bidstrup wrote:> >> > I beg respectfully to differ. The lidocaine (a fast Na channel> > blocker) is all but gone after a short while in the cardioplegia> > scenario. Getting a suitable level back into the circulation and thus> > the heart at release of the clamp is what is needed.> >> > Perhaps a randomised study is in the offing.> >> > http://circ.ahajournals.org/cgi/content/abstract/79/5/1106> >> > This reference relates to defib energy levels but i think you will> > see where I am coming from.> >> > At James Cook, I was involved in the development of a non> > depolarising cardioplegia solution, which is slowly working its way> > up the development path. The main components are lidocaine and> > adenosine.> >> >> >> >> > >Ben,> > >I use Amiadorone in the pump for all emazes (and postop) and> > >Amiadorone in the pump for all aortic valves. Since the St Thomas> > >Cardioplegia (which we mix in blood) already has procaine adding> > >Lignocaine would be redundant.(Incidentally Amiadorone is very cheap> > >in India !!)> > >Prasanna> > >Ben Bidstrup wrote:> > >>Why the amiodarone. Surely with some perfusion, the electrolyte> > >>imbalances within the myocardium would correct and SR ensue. If> > >>anything use lidocaine. Less toxic and cheaper, not a negative> > >>inotrope. It is what Yacoub taught me many years ago, and I have> > >>used it to good effect (infrequently I might add).> > >>> > >>>Tohru,> > >>> I did an AVR on an 87 yo man as a 2nd case just a couple of> > >>>hours ago. Again, no LV vent, only a sump. While closing the> > >>>aortotomy, I began the> > >>>continuous warm retrograde blood. The heart began fibrillating> > >>>after a couple of> > >>>minutes. I gave amio and then cardioverted. The heart had a> > >>>slow junctional> > >>>rhythm until the clamp was released. A sinus rhythm developed shortly> > >>>afterwards. He came off with no inotropes. It's much easier on> > >>>the heart and> > >>>your nerves to cardiovert a clamped, flaccid heart rather than> > >>>trying to do it> > >>>after the clamp has been released.> > >>> I look forward to your visit at the STS. As I said before, I'll> > try to> > >>>have a couple of interesting cases for you and other interested> > >>>members of HSF> > >>>to watch and criticize to your heart's content.> > >>>> > >>>Hal> > >>>> > >>>> > >>>> > >>>************************************** Get a sneak peek of the> > >>>all-new AOL at> > >>>http://discover.aol.com/memed/aolcom30tour> > >>>_______________________________________________> > >>>OpenHeart-L mailing list> > >>>> > >>>Send postings to:> > >>> OpenHeart-L@lists.hsforum.com> > >>>> > >>>To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > >>>http://mmp.cjp.com/mailman/listinfo/openheart-l> > >>>> > >>>All messages transmitted by the OpenHeart-L are subject to the policies> > and> > >>>disclaimers posted at:> > >>>http://www.hsforum.com/listdisclaim> > >>>-----------------------------------------> > >>> > >>> > >> > >_______________________________________________> > >OpenHeart-L mailing list> > >> > >Send postings to:> > >OpenHeart-L@lists.hsforum.com> > >> > >To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > >http://mmp.cjp.com/mailman/listinfo/openheart-l> > >> > >All messages transmitted by the OpenHeart-L are subject to the> > >policies and disclaimers posted at:> > >http://www.hsforum.com/listdisclaim> > >-----------------------------------------> >> >> > --> >> >> > Two things are infinite; the universe and human stupidity; and I am> > not sure about the universe.> > Albert Einstein> >> > The greatest obstacle to discovery is not ignorance --- it is the> > illusion of knowledge.> > Daniel J Boorstin> >> > Ben Bidstrup FRACS FRCSEd FEBCTS> > Consultant Cardiothoracic Surgeon> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies> > and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> > > > -- > Prasanna Simha M> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------> >> > > _________________________________________________________________> > 100?s of Music vouchers to be won with MSN Music> > https://www.musicmashup.co.uk/index.html_______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies and > > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> >> > > > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> ----------------------------------------- _________________________________________________________________ Celeb spotting ? Play CelebMashup and win cool prizes https://www.celebmashup.com/index2.html From anianyanwu at hotmail.com Wed Aug 1 16:46:14 2007 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Wed Aug 1 11:47:03 2007 Subject: [HSF] Inotropes, ventricular fibrillation and myocardial protection Message-ID: If Dr Salerno contends that a fibrillating heart is a dying heart, tens of millions of patients have been fibrillated worldwide during surgery over the last 3 decades - many intentionally as in Tohru's practice - and many as a passing event in the surgery. These patients are very much alive so the 'fibrillating dying heart' obviously had little bearing on later survival. Ani > Date: Wed, 1 Aug 2007 21:02:42 +0530> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] Inotropes, ventricular fibrillation and myocardial protection> From: prasannasimha@gmail.com> CC: > > ???> Prasanna> Ani Anyanwu wrote:> > Well then there are millions of people walking the street today with dead hearts. All Tohru's patients for a start.> > > > Ani> >> >> >> > > >> Subject: Re: [HSF] Inotropes, ventricular fibrillation and myocardial protection> Date: Wed, 1 Aug 2007 11:19:38 -0400> From: TSalerno@med.miami.edu> To: OpenHeart-L@lists.hsforum.com> CC: > > A fibrillating heart is. "Dying" heart.> > The brain does not have seizure during CPB; neither should the heart fibrillate.> > Tomas> > > > ----- Original Message -----> From: openheart-l-bounces@lists.hsforum.com > To: OpenHeart-L@lists.hsforum.com > Sent: Wed Aug 01 10:45:53 2007> Subject: Re: [HSF] Inotropes,ventricular fibrillation and myocardial protection> > Ani,> Having graduated from voodoo homemade cocktails to blood and its > variants, you would easily be able to see that the bad cardioplegia's > did have a higher (more accurately uniform) incidence of fibrillation > which came down with better modifications of cardioplegia's. That does > make us wary and anyway fibrillation is not something by any stretch > normal.Transient defibrillation may appear innocuous but then it has > been shown that such hearts have indeed been improperly preserved (from > works of Buckberg and Kirklin).Remember that sometimes speed etc etc may > compensate but this may become an issue in longer case.> Prasanna> Ani Anyanwu wrote:> > I still do not understand why we are alarmed about transient ventricular fibrillation on reperfusion and why using drugs to suppress it will have any impact on outcome.> > > > Ani> >> >> >> > > >> Date: Wed, 1 Aug 2007 11:51:47 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] Inotropes, ventricular fibrillation and myocardial protection> CC: > > I am not saying that the procaine or lignocaine is still acting. What I> meant is that since the fibrillation is occurring with the hotshot delivery> with high local lignocaine changing the drug class may be beneficial.> Prasanna> > On 8/1/07, Ben Bidstrup wrote:> >> > I beg respectfully to differ. The lidocaine (a fast Na channel> > blocker) is all but gone after a short while in the cardioplegia> > scenario. Getting a suitable level back into the circulation and thus> > the heart at release of the clamp is what is needed.> >> > Perhaps a randomised study is in the offing.> >> > http://circ.ahajournals.org/cgi/content/abstract/79/5/1106> >> > This reference relates to defib energy levels but i think you will> > see where I am coming from.> >> > At James Cook, I was involved in the development of a non> > depolarising cardioplegia solution, which is slowly working its way> > up the development path. The main components are lidocaine and> > adenosine.> >> >> >> >> > >Ben,> > >I use Amiadorone in the pump for all emazes (and postop) and> > >Amiadorone in the pump for all aortic valves. Since the St Thomas> > >Cardioplegia (which we mix in blood) already has procaine adding> > >Lignocaine would be redundant.(Incidentally Amiadorone is very cheap> > >in India !!)> > >Prasanna> > >Ben Bidstrup wrote:> > >>Why the amiodarone. Surely with some perfusion, the electrolyte> > >>imbalances within the myocardium would correct and SR ensue. If> > >>anything use lidocaine. Less toxic and cheaper, not a negative> > >>inotrope. It is what Yacoub taught me many years ago, and I have> > >>used it to good effect (infrequently I might add).> > >>> > >>>Tohru,> > >>> I did an AVR on an 87 yo man as a 2nd case just a couple of> > >>>hours ago. Again, no LV vent, only a sump. While closing the> > >>>aortotomy, I began the> > >>>continuous warm retrograde blood. The heart began fibrillating> > >>>after a couple of> > >>>minutes. I gave amio and then cardioverted. The heart had a> > >>>slow junctional> > >>>rhythm until the clamp was released. A sinus rhythm developed shortly> > >>>afterwards. He came off with no inotropes. It's much easier on> > >>>the heart and> > >>>your nerves to cardiovert a clamped, flaccid heart rather than> > >>>trying to do it> > >>>after the clamp has been released.> > >>> I look forward to your visit at the STS. As I said before, I'll> > try to> > >>>have a couple of interesting cases for you and other interested> > >>>members of HSF> > >>>to watch and criticize to your heart's content.> > >>>> > >>>Hal> > >>>> > >>>> > >>>> > >>>************************************** Get a sneak peek of the> > >>>all-new AOL at> > >>>http://discover.aol.com/memed/aolcom30tour> > >>>_______________________________________________> > >>>OpenHeart-L mailing list> > >>>> > >>>Send postings to:> > >>> OpenHeart-L@lists.hsforum.com> > >>>> > >>>To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > >>>http://mmp.cjp.com/mailman/listinfo/openheart-l> > >>>> > >>>All messages transmitted by the OpenHeart-L are subject to the policies> > and> > >>>disclaimers posted at:> > >>>http://www.hsforum.com/listdisclaim> > >>>-----------------------------------------> > >>> > >>> > >> > >_______________________________________________> > >OpenHeart-L mailing list> > >> > >Send postings to:> > >OpenHeart-L@lists.hsforum.com> > >> > >To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > >http://mmp.cjp.com/mailman/listinfo/openheart-l> > >> > >All messages transmitted by the OpenHeart-L are subject to the> > >policies and disclaimers posted at:> > >http://www.hsforum.com/listdisclaim> > >-----------------------------------------> >> >> > --> >> >> > Two things are infinite; the universe and human stupidity; and I am> > not sure about the universe.> > Albert Einstein> >> > The greatest obstacle to discovery is not ignorance --- it is the> > illusion of knowledge.> > Daniel J Boorstin> >> > Ben Bidstrup FRACS FRCSEd FEBCTS> > Consultant Cardiothoracic Surgeon> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies> > and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> > > > -- > Prasanna Simha M> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------> >> > > _________________________________________________________________> > 100?s of Music vouchers to be won with MSN Music> > https://www.musicmashup.co.uk/index.html_______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies and > > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> >> > > > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------> >> > > _________________________________________________________________> > Feel like a local wherever you go with BackOfMyHand.com> > http://www.backofmyhand.com_______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies and > > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> >> > > > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> ----------------------------------------- _________________________________________________________________ Feel like a local wherever you go with BackOfMyHand.com http://www.backofmyhand.com From rwmfglycar at aol.com Wed Aug 1 12:59:40 2007 From: rwmfglycar at aol.com (rwmfglycar@aol.com) Date: Wed Aug 1 12:04:06 2007 Subject: [HSF] Inotropes, ventricular fibrillation and myocardial protection In-Reply-To: References: Message-ID: <8C9A26C1A19EF5F-538-8C19@webmail-dd03.sysops.aol.com> -----Original Message----- From: Ani Anyanwu To: openheart-l@lists.hsforum.com Sent: Tue, 31 Jul 2007 2:24 pm Subject: RE: [HSF] Inotropes, ventricular fibrillation and myocardial protection Thank you for your wise words as always, Dr Frater. If you don't mind I would like to know more about details of your technique 1) How did you place your retrograde catheter? If you were going through the septum I presume you were feeding it directly into the sinus - is that the case? If not did you have any specific routine for ensuring you were in the proximal sinus and maximally perfusing the heart? The answers must be brief I am on a family get together at the foot of the Beartooth mountains in Montana. Yes. Having tried everything a vertical transeptal became my standard approach to the Mitral. The coronary sinus balloon was selfinflating and placed just inside the orifice and secured by a stitch. Sometimes doing a simple aortic I might not open the RA (laziness). Then it would be positioned at the posterior descending cor art and if prone to move anchored form outside with a stitch. The perfusionist kept a constant eye on the pressure and would tell us immediately if too low or too high. With the aorta open the retrograde flow from the R cor orifice was a clue. 2) How did you monitor the effectiveness and completeness of distribution of the cardioplegia or perfusate? What would be your indication that there might be a problem necessitating conversion to antegrade or cold technique (if ever). This is the weakest part of continuous warm. With cold cardioplegia itis easy and I would add essential, especially with cor disease, to know that the heart is uniformly cold When using warm perfusion there are possible ways of monitoring the effectiveness of the myocardial perfusion. None of these seemed to work very well in my hands and some were cumbersome and inconvenient. Certainly if retrograde was mechanically giving problems then supplementing with antegrade would be indicated. If the heart was beating then an arrythmia or arrest would be a most undesirable clue that the retrograde perfusion was inadequate. This of course signals a failure , demanding more retrograde flow, additional antegrade flow or conversion to cold depending on the circumstances of the case. 3) When you say you learnt from following your own patients what exactly did you learn about this technique (e.g. what modifications you made, caveats, pitfalls, benefits etc). This is a very large subject. Be gentle, careful. Inevitably there had to be a leap of faith in the beginning. Having started with beating heart open surgery and going through normothermic or tepid continuous antegrade coronary perfusion, hypothermia (as heat exchangers were developed), cold body/cold heart, clear cardiopegia, blood cardioplegia, warm body/cold heart, cold heart wth terminal warm heart (what Hal is using) it was not too difficult to take the ultiate step to relying on an empty continuously perfused warm heart as the optimal form of myocardial protection. Having made that decision you start with the simplest cases (Tough thing to do because the cost of failure is higher). When I started I was following Tom Salerno but you will see that I had a very broad experience to relate to. 4) Do you think your observations apply in the technique Hal describes i.e a heart arrested by cold antegrade/retrograde for a period and then converted to continuous warm retrograde or are there specific caveats with such an approach. I see this as a natural evolution. If you do the perfusion properly, do the cold right, and do the surgery properly, the terminal hot shot is extremely beneficial and in the course of daily practice very hard to to differentiate in results from cntinuous warm in terms of mortality. For me the spontaneous resumption of a beating heart with no need to defibrillate , the absence of need for inotropy in patients who came into the OR without inotropes and the absence of ventricles with worse LV function after surgery told me were on the right track. Now I have to be sociable. Talk to you later Bob Thank you in advance for your insightful reply. Ani > To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] Inotropes, ventricular fibrillation and myocardial protection> Date: Tue, 31 Jul 2007 15:52:22 -0400> From: rwmfglycar@aol.com> CC: > > Ani,> For about 12 years I did all valve cases with continuous warm > retrograde. i.e. NO cold perfusion at all. Interruptions were up to 5 > minutes. Taking the K out would allow the heart to start beating. > Dysrhthymia in te form of junctional rhythm would be the consequence of > the transseptal incision routinely used for mitral exposure. Myocardial > function with this method was> consistently well preserved and if the right valve operation was done > invariably improved.> Note the excellence of a result is invariably and obviously dependent > on the excellence of every detail; air removal is a very obvious > factor.> The stage of development you are all discussing was started about 20+ > years ago by Gerry Buckberg; he called it the "hot shot".> The single biggest objection to continuous warm is the perception or > real experience of some surgeons that the accuracy of performance is > impaired.> I do not attempt to dissuade people from this belief or perception. I > just know what suited me and what I learned from following my own > patients. The reason I suggested to Brent New that he get a follow up > echo at one year was for him to learn how his method of perfusion and > myocardial protection affected the myocardium of his patient.> Bob> > > -----Original Message-----> From: Ani Anyanwu > To: openheart-l@lists.hsforum.com> Sent: Tue, 31 Jul 2007 6:21 am> Subject: RE: [HSF] Inotropes, ventricular fibrillation and myocardial > protection> > > > > > > Hal> > My question was specifically regarding those patients for whom > retrograde is the> only source of perfusion (i.e. no CABG). In these patients, how long > are you> happy to leave the heart warm and clamped perfused solely with > retrograde?> > Thanks> > ANi> > > > > From: Hgrmd@aol.com> Date: Mon, 30 Jul 2007 21:29:54 -0400> Subject: > Re: [HSF]> Inotropes, ventricular fibrillation and myocardial protection> To:> OpenHeart-L@lists.hsforum.com> CC: > > Ani,> I prefer having a right > graft to> perfuse along with retrograde when I'm > giving warm continuous blood. > I do> believe that retrograde often doesn't > protect the right heart are > well as the> left. Generally, the time doesn't exceed > 20-30 minutes. The thing I > really> like about it is that it gives a rhythm > and tone to the LV prior to > clamp> removal. That way, after clamp removal, the > LV never just sits there > like a> log and distends. However, because of > concerns of inadequate RV > protection, I> wouldn't be comfortable relying on it for an > hour or two.> > Hal> > > > >> ************************************** Get a sneak peek of the all-new > AOL at >> http://discover.aol.com/memed/aolcom30tour> > _______________________________________________>> OpenHeart-L mailing list> > Send postings to:> > OpenHeart-L@lists.hsforum.com> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives:>> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages > transmitted by> the OpenHeart-L are subject to the policies and > disclaimers posted > at:>> http://www.hsforum.com/listdisclaim> > -----------------------------------------> _________________________________________________________________> 100?s of Music vouchers to be won with MSN Music> https://www.musicmashup.co.uk/index.html_______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies > and> disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------> > > > > ________________________________________________________________________> AOL now offers free email to everyone. 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Find out more about what's free from AOL at AOL.com. =0 From prasannasimha at gmail.com Wed Aug 1 22:34:43 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Wed Aug 1 12:05:22 2007 Subject: [HSF] Inotropes, ventricular fibrillation and myocardial protection In-Reply-To: References: Message-ID: <46B0AF1B.9060201@gmail.com> The choice of adding a particular drug has been based on experimental work and not just picked out of the blue. Yes people do cases with crystalloid and others with blood and so on and so forth but with each method there is some modifications which may give the good result in that particular persons hands if he recognizes the limiting factor in his /her technique.The sequential changes and their relative merits and demerits have originally been referred to by Mark Baimbridge's team and Buckberg and these have not been just pulled out of the hat. Adding adenosine, Esmolol and NTG, Insulin etc were all done to address a specific problem in the cardioplegic method that was used by me. Resolution of that problem was noted with some objective evidence of preservation be it myocardial function, CS Lactates and 5 min CS oxygen levels ,Inotropic usage and negation of a risk factor. I would not consider that voodoo !! I still strongly believe that clamp release with fibrillation indicates that there has been some deficiency in protection. Whether this leads to a poor outcome would be based on the hearts compensatory mechanisms. Any method that makes the heart compensate less is better. If we say one shock is inconsequential then what would you say if we then need multiple shocks to defibrillate the heart ? Prasanna Ani Anyanwu wrote: > Prasanna > > What you do now is no less voodoo that what you graduated from; indeed your current cardioplegia recipe is very much a 'homemade cocktail'. We have to be careful in ascribing benefits to things we do without being able to demonstrate such benefits scientifically.Many never add drugs like adenosine and esmolol, as you might do, to cardioplegia and have good results. I recall recently, one of our senior members (maybe Dr Tom Martin?) said he still uses crystalloid cardioplegia and yet has fantastic results in very complex cases several of which he has shared on this forum. Indeed the more I quiz people about this 'fibrillation is bad' theory the less I am convinced about it. A day or two ago I learnt from Hal that he sometimes defibrillates with the clamp on and then that later will count as the heart being in SR when you declamp? Tohru induces fibrillation in all patients and has good results. We also learnt that many of us actually don't even know what is in the cardioplegia or hot-shot we use. > > Cardioplegia is indeed still voodoo. There are basic principles which have to be adhered to depending on whether you are cold or warm, arrested or beating; aside from this, most of the rest is voodoo, including, I suspect, the suggestion that transient fibrillation indicates poor protection. > > Ani > > > > >> Date: Wed, 1 Aug 2007 20:15:53 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] Inotropes, ventricular fibrillation and myocardial protection> CC: > > Ani,> Having graduated from voodoo homemade cocktails to blood and its > variants, you would easily be able to see that the bad cardioplegia's > did have a higher (more accurately uniform) incidence of fibrillation > which came down with better modifications of cardioplegia's. That does > make us wary and anyway fibrillation is not something by any stretch > normal.Transient defibrillation may appear innocuous but then it has > been shown that such hearts have indeed been improperly preserved (from > works of Buckberg and Kirklin).Remember that sometimes speed etc etc may > compensate but this may become an issue in longer case.> Prasanna> Ani Anyanwu wrote:> > I still do not understand why we are alarmed about transient ventricular fibrillation on reperfusion and why using drugs to suppress it will have any impact on outcome.> > > > Ani> >> >> >> > > >> Date: Wed, 1 Aug 2007 11:51:47 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] Inotropes, ventricular fibrillation and myocardial protection> CC: > > I am not saying that the procaine or lignocaine is still acting. What I> meant is that since the fibrillation is occurring with the hotshot delivery> with high local lignocaine changing the drug class may be beneficial.> Prasanna> > On 8/1/07, Ben Bidstrup wrote:> >> > I beg respectfully to differ. The lidocaine (a fast Na channel> > blocker) is all but gone after a short while in the cardioplegia> > scenario. Getting a suitable level back into the circulation and thus> > the heart at release of the clamp is what is needed.> >> > Perhaps a randomised study is in the offing.> >> > http://circ.ahajournals.org/cgi/content/abstract/79/5/1106> >> > This reference relates to defib energy levels but i think you will> > see where I am coming from.> >> > At James Cook, I was involved in the development of a non> > depolarising cardioplegia solution, which is slowly working its way> > up the development path. The main components are lidocaine and> > adenosine.> >> >> >> >> > >Ben,> > >I use Amiadorone in the pump for all emazes (and postop) and> > >Amiadorone in the pump for all aortic valves. Since the St Thomas> > >Cardioplegia (which we mix in blood) already has procaine adding> > >Lignocaine would be redundant.(Incidentally Amiadorone is very cheap> > >in India !!)> > >Prasanna> > >Ben Bidstrup wrote:> > >>Why the amiodarone. Surely with some perfusion, the electrolyte> > >>imbalances within the myocardium would correct and SR ensue. If> > >>anything use lidocaine. Less toxic and cheaper, not a negative> > >>inotrope. It is what Yacoub taught me many years ago, and I have> > >>used it to good effect (infrequently I might add).> > >>> > >>>Tohru,> > >>> I did an AVR on an 87 yo man as a 2nd case just a couple of> > >>>hours ago. Again, no LV vent, only a sump. While closing the> > >>>aortotomy, I began the> > >>>continuous warm retrograde blood. The heart began fibrillating> > >>>after a couple of> > >>>minutes. I gave amio and then cardioverted. The heart had a> > >>>slow junctional> > >>>rhythm until the clamp was released. A sinus rhythm developed shortly> > >>>afterwards. He came off with no inotropes. It's much easier on> > >>>the heart and> > >>>your nerves to cardiovert a clamped, flaccid heart rather than> > >>>trying to do it> > >>>after the clamp has been released.> > >>> I look forward to your visit at the STS. As I said before, I'll> > try to> > >>>have a couple of interesting cases for you and other interested> > >>>members of HSF> > >>>to watch and criticize to your heart's content.> > >>>> > >>>Hal> > >>>> > >>>> > >>>> > >>>************************************** Get a sneak peek of the> > >>>all-new AOL at> > >>>http://discover.aol.com/memed/aolcom30tour> > >>>_______________________________________________> > >>>OpenHeart-L mailing list> > >>>> > >>>Send postings to:> > >>> OpenHeart-L@lists.hsforum.com> > >>>> > >>>To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > >>>http://mmp.cjp.com/mailman/listinfo/openheart-l> > >>>> > >>>All messages transmitted by the OpenHeart-L are subject to the policies> > and> > >>>disclaimers posted at:> > >>>http://www.hsforum.com/listdisclaim> > >>>-----------------------------------------> > >>> > >>> > >> > >_______________________________________________> > >OpenHeart-L mailing list> > >> > >Send postings to:> > >OpenHeart-L@lists.hsforum.com> > >> > >To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > >http://mmp.cjp.com/mailman/listinfo/openheart-l> > >> > >All messages transmitted by the OpenHeart-L are subject to the> > >policies and disclaimers posted at:> > >http://www.hsforum.com/listdisclaim> > >-----------------------------------------> >> >> > --> >> >> > Two things are infinite; the universe and hum