[HSF] Inotropes, ventricular fibrillation and myocardialprotection

Salerno, Tomas TSalerno at med.miami.edu
Wed Aug 1 16:45:27 EDT 2007 

Well put. The heart has so much reserve that it is true that most surgeons seem to be satisfied with their method of myocardial protection.

Most rely on hypothermia for protection; yet, few measure septal temperature.

Others use retrograde alone for valves; it is known that flow distribution across the myocardial regions are uneven, and both retrograde/antegrade (alternating or simultaneous ) are needed to perfuse all areas of the myopcardium under conditions of CPB.

Ventricular fibrillation has been abandoned as a method of myocardial protection, especially in hypertrophied hearts. 
When allowed to persist, especially with LV distention and low perfusion pressure, myocardial damage occurs.



Tomas

----- Original Message -----
From: openheart-l-bounces at lists.hsforum.com <openheart-l-bounces at lists.hsforum.com>
To: OpenHeart-L at lists.hsforum.com <OpenHeart-L at lists.hsforum.com>
Sent: Wed Aug 01 14:52:48 2007
Subject: Re: [HSF] Inotropes, 	ventricular fibrillation and myocardialprotection

What this does is once again ask the question, how do we measure 
myocardial preservation?

We can look at the highly sensitive markers such as Troponin which 
indicate some element of damage to components of the myofibrils. and 
so on. Echo - RWMA ECG and the list goes on.
We need to look at use of inotropes, IABP, survival. Khuri published 
on his intramyocardiall pH device stating that poor preservation as 
reflected by pH changes resulted in altered long term survival.

Much of the cocktails' components have been determined by isolated 
rat heart experiments. They have translated well to the human, but it 
is very hard to measure total water content of an intact heart or 
regional blood flow distribution in a human model.

Why is it that there is no universal cocktail. Put 100 cardiac teams 
in a room and you will have 120 different ways of preserving the 
myocardium.
I review papers that look at different methods of preservation and 
they use markers such as inotrope use to determine improvement. How 
variable that is is a whole new debate.




>Tomas,
>
>   A fibrillating heart is a dying heart?  Is this an edict of some 
>sort?  I've seen plenty of hearts that fibrillated during some part 
>of their open heart operation only to have a completely, and I mean 
>completely, normal EF on remote echo.  Speaking in absolutes serves 
>no purpose.
>
>
>
>Hal
>
>
>-----Original Message-----
>From: Salerno, Tomas <TSalerno at med.miami.edu>
>To: OpenHeart-L at lists.hsforum.com
>Sent: Wed, 1 Aug 2007 11:19 am
>Subject: Re: [HSF] Inotropes, ventricular fibrillation and 
>myocardial protection
>
>
>
>
>A fibrillating heart is. "Dying" heart.
>The brain does not have seizure during CPB; neither should the heart 
>fibrillate.
>Tomas
>
>----- Original Message -----
>rom: openheart-l-bounces at lists.hsforum.com 
><openheart-l-bounces at lists.hsforum.com>
>o: OpenHeart-L at lists.hsforum.com <OpenHeart-L at lists.hsforum.com>
>ent: Wed Aug 01 10:45:53 2007
>ubject: Re: [HSF] Inotropes,ventricular fibrillation and myocardial   
>rotection
>Ani,
>aving graduated from voodoo homemade cocktails to blood and its
>ariants, you would easily be able to see that the bad cardioplegia's
>id have a higher (more accurately uniform) incidence of fibrillation
>hich came down with better modifications of  cardioplegia's. That does
>ake us wary and anyway fibrillation is not something by any stretch
>ormal.Transient defibrillation may appear innocuous but then it has
>een shown that such hearts have indeed been improperly preserved (from
>orks of Buckberg and Kirklin).Remember that sometimes speed etc etc may
>ompensate but this may become an issue in  longer case.
>rasanna
>ni Anyanwu wrote:
>  I still do not understand why we are alarmed about transient ventricular
>ibrillation on reperfusion and why using drugs to suppress it will have any
>mpact on outcome.
>
>  Ani
>
>
>
>   
>>  Date: Wed, 1 Aug 2007 11:51:47 +0530> From: prasannasimha at gmail.com> To:
>penHeart-L at lists.hsforum.com> Subject: Re: [HSF] Inotropes, ventricular
>ibrillation and myocardial protection> CC: > > I am not saying that the
>rocaine or lignocaine is still acting. What I> meant is that since the
>ibrillation is occurring with the hotshot delivery> with high local lignocaine
>hanging the drug class may be beneficial.> Prasanna> > On 8/1/07, Ben Bidstrup
>benjamin.bidstrup at bigpond.com> wrote:> >> > I beg respectfully to differ. The
>idocaine (a fast Na channel> > blocker) is all but gone after a short while in
>he cardioplegia> > scenario. Getting a suitable level back into the 
>circulation
>nd thus> > the heart at release of the clamp is what is 
>needed.> >> > Perhaps a
>andomised 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
>here I am coming from.> >> > At James Cook, I was involved in the development
>f 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)
>nd> > >Amiadorone in the pump for all aortic valves. Since the St Thomas> >
>Cardioplegia (which we mix in blood) already has procaine 
>adding> > >Lignocaine
>ould be redundant.(Incidentally Amiadorone is very cheap> > >in India !!)> >
>Prasanna> > >Ben Bidstrup wrote:> > >>Why the amiodarone. Surely with some
>erfusion, the electrolyte> > >>imbalances within the myocardium would correct
>nd SR ensue. If> > >>anything use lidocaine. Less toxic and cheaper, not a
>egative> > >>inotrope. It is what Yacoub taught me many years ago, and I have>
>  >>used it to good effect (infrequently I might 
>add).> > >>> > >>>Tohru,> > >>>
>  did an AVR on an 87 yo man as a 2nd case just a couple of> > >>>hours ago.
>gain, no LV vent, only a sump. While closing the> > >>>aortotomy, I began the>
>  >>>continuous warm retrograde blood. The heart began fibrillating> > >>>after
>  couple of> > >>>minutes. I gave amio and then cardioverted. The 
>heart had a> >
>>>slow junctional> > >>>rhythm until the clamp was released. A sinus rhythm
>eveloped shortly> > >>>afterwards. He came off with no inotropes. It's much
>asier on> > >>>the heart and> > >>>your nerves to cardiovert a 
>clamped, flaccid
>eart rather than> > >>>trying to do it> > >>>after the clamp has been
>eleased.> > >>> I look forward to your visit at the STS. As I said before,
>'ll> > try to> > >>>have a couple of interesting cases for you and other
>nterested> > >>>members of HSF> > >>>to watch and criticize to your heart's
>ontent.> > >>>> > >>>Hal> > >>>> > >>>> > >>>> > >>>**************************************
>et a sneak peek of the> > >>>all-new AOL 
>at> > >>>http://discover.aol.com/memed/aolcom30tour>
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>  Daniel J Boorstin> >> > Ben Bidstrup FRACS FRCSEd FEBCTS> > Consultant
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-- 
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


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