[HSF] Inotropes,
ventricular fibrillation and myocardial protection
rwmfglycar at aol.com
rwmfglycar at aol.com
Wed Aug 1 12:59:40 EDT 2007
-----Original Message-----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at 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 at lists.hsforum.com> Subject: Re: [HSF] Inotropes,
ventricular
fibrillation and myocardial protection> Date: Tue, 31 Jul 2007 15:52:22
-0400>
From: rwmfglycar at 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 <anianyanwu at hotmail.com>> To:
openheart-l at 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 at aol.com> Date: Mon, 30 Jul 2007 21:29:54
-0400>
Subject: > Re: [HSF]> Inotropes, ventricular fibrillation and
myocardial
protection> To:> OpenHeart-L at 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> > > > >>
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