[HSF] Re: [HSF ] OPCAB pitfall

[Salerno, Tomas]

no, this has not occurred yet. However. I might be criticized if flows were not measured and something bad occurred, although flow measurements is not stand of care in USA
 
Tomas

________________________________

From: openheart-l-bounces at lists.hsforum.com on behalf of prasannasimha
Sent: Wed 1/31/2007 8:26 PM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Re: [HSF ] OPCAB pitfall



I am not being cheeky but if the graft requires a redo if the flows are
inadequate  / blocked are you "reportable"
Prasanna
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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