[HSF] On pump beating heart
Donald Ross
donross at bigpond.com
Sun Feb 18 09:09:09 EST 2007
Ani
>
> Could you please expand on your technique of 'side to side' for an
> 'end to end' anastomosis.
You can extend the reach of either ima by adding artery or vein as a
"composite graft" For this I always do a "side to side" by clipping
the blind ends of the grafts, making a slit in them about twice the
diameter of the smallest then lay them side to side like mating earth
worms and whack them together leaving a wide clean opening. Often
the blind ends are re clipped close to the anastomosis to eliminate
any cul de sac. I use a side to side technique for coronaries as well.
Go to http://beating-heart.com/home.htm and click on "movies" to
see a lima to lad "side to side"
> Where the RIMA is used as inflow, how long a stump do you have to
> use? Do you also construct the T-graft as a side to side?
You can extend it from anywhere depending on its size and whether you
want to use the cut off piece for another graft.
The T graft is done "end to side" with the "end" spatulated to
achieve a long slit on the "side"
>
> Also could you broaden on why stability of angina and Left Main
> Disease should influence grafting configuration?
I choose to use both imas if I believe there may be a chance of hypo-
perfusion. ie tight L main, unstable angina on small imas.
My logic is that if grafts are not likely to have to supply critical
blood flow immediately the you can get away with one ima for inflow
( remember the ima doesn't reach its full potential for some time and
has reduced flow in the first 24 hours as well)
I have been burned in the early days of Tector inspired lima T rima
on pump from inadequate inflow.
Don
>
> Thanks
>
> Ani
>
>
> ----- Original Message -----
> From: Donald Ross<mailto:donross at bigpond.com>
> To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-
> L at lists.hsforum.com>
> Sent: Friday, February 16, 2007 6:56 PM
> Subject: Re: [HSF] On pump beating heart
>
>
> Giuseppi,
> Non-aortic inflow, is the key to brain safe opcab or oncab and I
> applaud your use of the rima for that purpose. One of my colleagues
> often attaches the radial to it proximally and uses the distal piece
> for the Cx as T graft from the lima.
>
> I have occasionally used the rima as the inflow for composite grafts
> ( via transverse sinus) and have also had an anastomotic stenosis
> using the and to end technique. I now, always do a side to side
> anastomosis in this situation which I believe is fool proof. ( Very
> necessary for me! )
> My preferred configuration, however, which covers most
> contingencies is to use the rima for the LAD and the lima for Cx as
> well as inflow for a T graft to the rest of the heart.
> If the angina is stable and there is no L main I just use a lima
> plus T graft.
> Don
>
>
> On 17/02/2007, at 12:49 AM, Giuseppe Rescigno wrote:
>
>> Don,
>> I know that is not so orthodox, but in these pts I use the proximal
>> part of the RIMA as inflow for the sequential vein graft (T-T). I
>> wrote a paper on a few cases that was published in the HSF. At that
>> time I had no flowmeter but I had good results from a clinical
>> standpoint. In a recent case the pt had ST depression in the ICU, I
>> asked to restudy the patient and there was a stenosis at the
>> anastomotic site. I reopened the chest and I redid the anastomosis
>> after a low dose heparin. Everything was OK. This technique is
>> useful because there is no risk to jeopardize the LIMA-LAD. I would
>> really appreciate the opinions from all of you.
>>
>> Giuseppe
>>
>>
>>
>> Giuseppe Rescigno M.D.
>> Cardiothoracic Surgeon
>>
>> Lancisi Hospital
>> Torrette - Ancona
>> Italy
>>
>>
>>
>> On Friday, February 16, 2007, at 12:32PM, "Donald Ross"
>> <donross at bigpond.com<mailto:donross at bigpond.com>> wrote:
>>> Hey, Ed you could go the whole hog (or roo) and hang everything to
>>> the imas.
>>> In some folks it is hard to fond a soft spot.
>>> Don
>>> On 16/02/2007, at 10:13 AM, Edward Bender wrote:
>>>
>>>> I echo Johns praise, Roberto. In some of my patients where the
>>>> aorta is heavily calcified, the is one spot somewhere on the aorta
>>>> that is soft. I use epi-aortic ultrasound, and, if no exophytic
>>>> plaque, will use the heartstring device to sew on the top end
>>>> (sorry for my acquired Aussie idiom).
>>>>
>>>> Ed Bender, MD
>>>>
>>>>
>>>> On Feb 15, 2007, at 4:43 PM,
>>>> rowlesjohn at aol.com<mailto:rowlesjohn at aol.com> wrote:
>>>>
>>>>> Roberto
>>>>>
>>>>> Your operation for this elderly, high risk gentleman is a classic
>>>>> example of the less is more philosophy to facilitate an excellent
>>>>> outcome. Did the heart distend during the fibrillation and if so,
>>>>> how was it managed?
>>>>>
>>>>> Thanks,
>>>>>
>>>>> John Rowles
>>>>>
>>>>>
>>>>> -----Original Message-----
>>>>> From: battr at medizin.uni-leipzig.de<mailto:battr at medizin.uni-
>>>>> leipzig.de>
>>>>> To: OpenHeart-L at hsforum.com<mailto:OpenHeart-L at hsforum.com>
>>>>> Sent: Thu, 15 Feb 2007 9:36 AM
>>>>> Subject: AW: [HSF] On pump beating heart
>>>>>
>>>>>
>>>>> Today I have done our N° 50 case of sever atherosclerotic aorta +
>>>>> 2-3 vessel
>>>>> disease. The patient , 83 years old, was unstable, and with 3
>>>>> vessel disease
>>>>> + left main, MI I grade. In TEE we recognized MI II grade. I
>>>>> canulated the
>>>>> axyllary artery, as the whole aorta was calcified. Went on pump,
>>>>> did
>>>>> LIMA-LAD and veins to obtuse marginal and RCA. The heart
>>>>> fibrillated by
>>>>> doing the obtuse marginal, after which could be easily
>>>>> defibrillated. I
>>>>> anastomosed the veins to the innominate artery (truncus) at 34
>>>>> degrees.
>>>>> Sorry, Hal, I did not touch the Mitral.
>>>>>
>>>>> He came out of pump without drugs, he is now awake at ICU waiting
>>>>> to be
>>>>> extubated.
>>>>>
>>>>>
>>>>>
>>>>> I remembered that email from Tea, and want to know what is he
>>>>> doing in these
>>>>> cases. Hal, would you have done aortic replacement on DHCA to just
>>>>> access to
>>>>> the mitral?
>>>>>
>>>>>
>>>>>
>>>>> We presented our experience last week with 49 cases in Hamburg.
>>>>>
>>>>> Roberto
>>>>>
>>>>>
>>>>>
>>>>> _____
>>>>>
>>>>> Von: OpenHeart-L at hsforum.com<mailto:OpenHeart-L at hsforum.com>
>>>>> [mailto:OpenHeart-L at hsforum.com] Im
>>>>> Auftrag von
>>>>> Tea Acuff
>>>>> Gesendet: Montag, 22. Juli 2002 15:23
>>>>> An: OpenHeart-L
>>>>> Betreff: Re: [HSF] On pump beating heart
>>>>>
>>>>>
>>>>>
>>>>> Just a few clarifications. I have experienced acute ischemia (or
>>>>> at least
>>>>> what we attribute to be acute ischemia). My point is not that
>>>>> never occurs,
>>>>> but it is that I am very poor at predicting when it will occur and
>>>>> have been
>>>>> amazed at the cases it did not (since I violate most of the
>>>>> "rules"). If I
>>>>> am suspicious, I will precondition as a test (which frequently
>>>>> passes), I
>>>>> don't like to shunt. I pace the RCA if necessary. If I can't
>>>>> position an
>>>>> important vessel, I will add RV support or CPB. I think that a
>>>>> beating
>>>>> heart techique "de-embolizes" the vessel much better than
>>>>> retrograde
>>>>> cardioplegia for redo's and avoids a sometimes difficult cross
>>>>> clamp. We
>>>>> should think first beating heart and secondarily off pump unless
>>>>> there is a
>>>>> specific reason to avoid the pump eg bad aorta, bad lungs,
>>>>> emergency on
>>>>> anticoagulants,etc.
>>>>> Tea Acuff
>>>>>
>>>>>
>>>>>
>>>>> In a message dated 7/21/02 6:02:17 PM Central Daylight Time,
>>>>> mkcd at comcast.net<mailto:mkcd at comcast.net> writes:
>>>>>
>>>>>
>>>>>
>>>>>
>>>>>
>>>>>
>>>>> On pump and full Myocardial arrest although there are several
>>>>> surgeons who
>>>>> advocate going on pump for hemodynamic support then doing beating
>>>>> heart
>>>>> assisted. Anyone with this approach care to share your experience
>>>>> with us ?
>>>>>
>>>>> Mercedes
>>>>>
>>>>>
>>>>>
>>>>>
>>>>>
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