[HSF] Re: [HSF ] OPCAB pitfall
rsboova at comcast.net
rsboova at comcast.net
Fri Feb 2 03:19:10 EST 2007
Michael - I do > 95 % OPCAB ( declining CABG volume , clearly the minority of OHS cases currently ) Literature indicates outcomes are equivalent to on pump with a few excepted parameters i.e. bleeding , delirium, ventilator time .This has worked well in my hands as > 25% of my patients are octagenarians and avoiding CPB conceptually appeals to me . Excellent results with either technique especially comparing IMA to LAD vs PCI so no criticism of either approach .
I routinely perform medistim graft flow measurement ( graft flow, diastolic filling , and pulsatility index with print out ) and majority add fluorescein angiogram with pictures for chart . The documentation is accepted by the cardiologists and preferred by me for future reference . Graft revision rare but occaisionally occur , usually in patients with poor conduits or targets .
RSB
-------------- Original message --------------
From: "Michael Firstenberg" <msfirst at gmail.com>
> For those of you who perform these tests - how often do you have to revise
> your grafts?
> I believe the data from the people that sell these devices suggests as high
> as 15%?
>
> -michael
>
>
> On 1/31/07, 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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