[HSF] Re: [HSF ] OPCAB pitfall

[Salerno, Tomas]

hi Fon,
 
yes. flows measurements before and after protomine.
 
Tomas

________________________________

From: openheart-l-bounces at lists.hsforum.com on behalf of Donald Ross
Sent: Thu 2/1/2007 12:25 AM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Re: [HSF ] OPCAB pitfall



Thomas,
I expect that is so but you didn't say whether you tested flow before 
and after protamine. I am interested as such a protocol would give 
some insight to  graft closure which could be prevented by 
anticoagulant measures
Don
On 01/02/2007, at 9:24 AM, Salerno, Tomas wrote:

> in my experience unless one confirms graft patency via flowmetry or 
> spy, one runs the risk of closing the patient with grafts (vein or 
> artery) already occluded, regardless of how easy the anastomoses 
> were, and whether the patient was done on or off pump. Therefore, 
> any study that assesses graft patency postoperatively must have 
> documentation of flow patency at time of closure.
>
> Tomas
>
> ________________________________
>
> From: openheart-l-bounces at lists.hsforum.com on behalf of Donald Ross
> Sent: Wed 1/31/2007 4:04 PM
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] Re: [HSF ] OPCAB pitfall
>
>
>
> 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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