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

Sun Dec 23 14:27:35 EST 2007

Ed,

Interesting that we have the same answers - yes, it is a comfort zone.  My
Boss (who also trained me) does all of his CABGs off pump and his beliefs
are all consistent with what has been discussed in this posting.  However, I
am concern about all of the hemodynamic pertubations which occur with
off-pump surgery - everytime you mobilize the heart, pressure up, pressure
down, output up down, levo here, neo there, etc etc....even with experiences
hands on both sizes of the blood brain barrier this happens.  I go on pump,
tell my Pump driver what pressure and flows I want (Svensson's Rule,
MAP=Age when over 65, thank you Lars) and I go to work in not only a
bloodless field, but it is quiet with only a little background music
(classic rock.......although I have a partner who loves Brittney and
50cent.....) and get the work done and then slowly come off pump.  I think,
with nothing to prove my hypothesis, that the end organs like this
better..... and with the comorbidities that we seem to deal with these days,
I think this is safer.  I seem to have a run on cirrhotics lately (3 in the
past 2 weeks alone) not to mention, no one has normal kidneys anymore......

The bottom line is while the "pump" may not be good for the brain (emboli
etc), hard to argue what we do during off-pump surgery is any better - in
fact, it may be worse..

-michael

On 12/22/07, Edward Bender <ebender001 at charter.net> wrote:
>
> Mike:
> I find it interesting that you do your CABG's on pump because of your
> youth.  I do them on pump due to my old age and my unwillingness to
> exit my comfort zone.  I also worry that as my tremor increases, my
> ability to do small off-pump vessels will diminish.
> Ed Bender, MD
>
> On Dec 22, 2007, at 5:28 PM, Michael Firstenberg wrote:
>
> > 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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> >>
> >>
> >>
> >> --
> >> Prasanna Simha M
> >> _______________________________________________
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