[HSF] "Patients don't want cardiopulmonary bypass" - the great con

Sun Dec 23 17:55:28 EST 2007

> From: zamvarv at hotmail.com>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.)

What did you do before the last 250?

Ani

> To: openheart-l at lists.hsforum.com> Subject: RE: [HSF] "Patients don't want cardiopulmonary bypass" - the great con> Date: Sun, 23 Dec 2007 05:49:48 +0000> > > Michael,> > > > 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)> >> _______________________________________________> >> OpenHeart-L mailing list> >>> >> Send postings to:> >> OpenHeart-L at 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 at 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 at 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 at 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> -----------------------------------------
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