[HSF] "Patients don't want cardiopulmonary bypass" - the great con
hgrmd at aol.com
hgrmd at aol.com
Sun Dec 23 12:45:05 EST 2007
This posting illustrates what I was talking about.
Hal
-----Original Message-----
From: Vipin Zamvar <zamvarv at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Sun, 23 Dec 2007 12:49 am
Subject: RE: [HSF] "Patients don't want cardiopulmonary bypass" - the great con
Michael,
Let me correct a few misconceptions that many surgeons have about off-pump
surgery. The following comments (which are randomly arranged) are based
entirely on my own personal experience (248 of the last 250 CABG operations
performed off-pump; of the 248 off-pump operations, one needed a conversion
intraoperatively.)
1) The first one is that small vessels cannot be safely grafted: To perform a
safe and secure anastomosis, the diameter is a critical issue only during the
learning curve. I do not feel performing an anastomosis on a 1.25 mm vessel is
any more difficult than on a 2 mm vessel. There are a few tricks that can be
used while grafting a small vessel. (It is absolutely essential that the
stabilization is secure, so there is no or minimal motion). A shunt is an
absolute must. This prevents the inadvertent taking of the posterior wall of the
coronary artery. In a small vessel the shunt also helps while turning corners at
the heel or toe. You can gently puncture the shunt at the heel when the needle
passes through the coronary wall, and then pull the shunt away. The needle is
pulled along with the shunt; then the needle can be disengaged from the shunt,
and pulled away.
2) The second is that you cannot completely revascularise the patient: I
routinely do 4 or 5 grafts for patients with 3 vessel disease, and occasionally
also 6 grafts. The position of the coronary artery is absolutely not a problem.
Again this is due to the use of many techniques, which combine to ensure that
access for any part of the heart is no problem at all. These techniques include
the single deep posterior pericardial stitch, opening of the right pleura, use
of the trendelenburg position, and judicious use of intraoperative fluids.
3) I have often felt that if I were doing on-pump surgery, then doing 5 or 6
grafts would be fraught with the dangers of a long pump time. I also find that
small vessels can sometimes be difficult to graft on-pump (For example, when I
am doing AVR + CABG).
4) I often find myself comfortable in being able to offer coronary surgery to
patients with diffusely diseased arteries and extensive comorbidities only
because I am confident to be able to complete the operation off-pump. I often
take on patients when others are more conservative or reluctant.
5) I feel that surgeons who wish to start/increase performing off-pump surgery
should not select their patients on the basis of size of the coronary artery.
Sometimes a 2.5 mm artery which can bleed a lot when an arteriotomy is made, can
be more difficult to deal than a 1.5 mm artery which does not bleed as much.
In fact if anybody is serious about persuing off-pump surgery, he must not
select patients at all. He must start off-pump in all patients.
6) The one drawback I feel about off-pump surgery is that I find it difficult to
give away cases to my trainees; unless they are relatively senior. I would have
been able to give away a higher proportion of cases if I had been doing on-pump
surgery.
7) Off-pump surgery is associated with a significant decrease in perioperative
morbidity; and because of this it is of great benefit especially in high risk
patients. But to be able to get excellent results in high risk patients, the
surgeon has to be doing this procedure all the time.
Can I add that the pump is always available to me. I will use the pump without
hesitation anytime I feel that the pump would be safer.
Visiting cenres or surgeons that routinely perform a high proportion of cases
off-pump can be a big advantage.
Vipin Zamvar
> From: msfirst at gmail.com> Subject: Re: [HSF] "Patients don't want
cardiopulmonary bypass" - the great con> Date: Sat, 22 Dec 2007 18:28:33 -0500>
To: OpenHeart-L at lists.hsforum.com> CC: > > I dont like hitting my thumb with a
hammer when I hang a picture in > my home, but sometimes I need to use the tool.
CPB is one of the > greatest inventions to modern medicine and when I need my
CPB I want > it done with bypass (and I want my heart arrested with antegrade
and > retrograde when I get my AVR). There have been countless papers > talking
about the harmful neuro effects of CPB - and while I do not > have the
reference, I recall the NEJM article (ok, stop laughing) > that said there was
no different in CBP pts vs age matched controls > vs matched patients getting
hip replacements. As people have > mentioned, there are good surgeon and bad
surgeons who give good and > bad operations, but I think at the end of the day
not using bypass > when it should have been used has probably hurt more people
than > using bypass. Yes, there are micro embolic, air, alterations in > flow,
etc - but in the long run are there longterm problems - I guess > if is knocks
out the random part of your brain where your anniversary > date, children's
names and birthdates, or wife's name are stored. > Like any useful tool -
misapplication can result in a catastrophe. I > do most of my CABGs on-pump for
a variety of reasons, many of which > are related to my youth, but I do off-pump
when the targets are big > (which in our practice is rare) or when patients need
a LIMA to LAD > only. Contrary to much of the "literature" by those to make
their > careers writing about off-pump, I still find it hard to believe that >
the anastamosis is as good or that the patients get as complete a > revasc. I
have seen and grafted many small OMs, diags, even LADs > that would have been a
pain in ass to graft off-pump - I guess one > could argue that those didnt need
grafting at all. Furthermore, as I > am sure Ani can attest to, many patients
have significant neuro- > cognitive improvements when they get more blood flow
to their brains > - whether this is accomplished with a VAD or CABG or valvular
surgery > - separating this out from the obvious potential harmful effects of >
CPB on the brain is impossible......besides heart surgery is not > cosmetic
surgery or botox injections, we are dealing with major > problems and sometimes
a few small battles are lost to win a war.> > -michael> > > > > > On Dec 22,
2007, at 5:24 AM, Prasanna Simha M wrote:> > > I would like to know one thing
that is physiological wrt to > > cardiopulmonay> > bypass ?> > Prasanna> >> > On
Dec 22, 2007 3:14 PM, <NielsB at aol.com> wrote:> >> >>> >> This discussion is
always interesting. I must again one of the many> >> excellent quotes of my
great friend and previous partner in > >> Buffalo:> >>> >> "Why do people feel
so safe when they enter an airplane? Because > >> the pilot> >> goes with you,
and he would probably not go if the plane was unsafe.> >> But when the cardiac
surgeons say: we are going on pump it is not > >> exactly> >> true, because the
surgeons does not go on pump himself, only the > >> patient"> >>> >> Of course
it does not mean that the pump is a priori bad, > >> sometimes we> >> need> >>
it sometimes not, it is a tool and an important one some times.> >>> >> We
should not be so fixed on this issue any more, but also not > >> ignore the> >>
issues. As the previous writer said, maybe a couple of hours on > >> the pump>
>> will> >> rejuvinate the brain. Of course that is a joke as far as we know,>
>> because I> >> really dont find much evidence that the brain is better with
than > >> without> >> pump.> >> Most sudies show that cognitive functions etc
are worse or equal > >> with> >> pump> >> not better.> >>> >> So maybe most
patients do not understand all this things, but as> >> surgeons> >> maybe it is
our responsibility to use the tool when it is > >> indicated and> >> necessary,
and in my opinion in CABG it is not usually required.> >>> >> Jacob Bergsland>
>>> >>> >> **************************************> >> See AOL's top rated> >>
recipes (http://food.aol.com/top-rated-recipes? > >> NCID=aoltop00030000000004)>
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