[HSF] Re: [HSF ] OPCAB pitfall

[Donald Ross]

Dear Thomas,
As you know we don't own a flow probe so can not answer that question.
Do you routinely measure flows in all grafts before and after heparin?
It would, indeed, be interesting to know exactly when the graft goes  
down and I think you have previously indicated that it can occur   
soon after the heparin is given?
If that is the case then my anti-thrombosis protocol may have some  
merit.
Don
On 01/02/2007, at 4:23 AM, Salerno, Tomas wrote:

> would like to know if flows were measured prior to closure of this  
> patient. It is possible that all grafts were already occluded at  
> the end of the operation...
>
> Tomas
>
> ________________________________
>
> From: openheart-l-bounces at lists.hsforum.com on behalf of Donald Ross
> Sent: Wed 1/31/2007 4:52 AM
> To: OpenHeart-L at lists.hsforum.com
> Subject: [HSF] Re: [HSF ] OPCAB pitfall
>
>
>
> This is a cautionary tale about a case done for a colleague  who is a
> dedicated opcaber but  has not yet developed a respect for the
> dangers of hypercoagulation.
> A routine off pump cabg X3 was done on his service with lima to Lad
> and SVG to Cx,Pda ( T-graft from lima, vein used because radial
> unavailable)
> Pre-op TEG was slightly hypercoagulable but this result was ignored
> and all the heparin was reversed and early post-op aspirin given.
> Next day the patient looked okay but there was a small troponin leak
> which triggered a re-cath.
> This showed complete thrombosis of the SVG which obviously required
> re-op.
>
> Because I have been similarly burnt I use a different protocol which
> so far has been effective.
> 1. Only reverse half heparin in all cases
> 2. Give clopidogrel as well as aspirin within 30 min of returning to
> recovery . ( clopidogrel ceased at 6 weeks)
> 3. If TEG is suspicious don't reverse heparin and give intra-op
> aspirin and clopidogrel
>
> A final observation  is that the SVG is more prone to this annoying
> complication than the IMA. Hopefully the radial is also protected.
> Don
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