[HSF] On pump beating heart
Ben Bidstrup
benjamin.bidstrup at bigpond.com
Sun Feb 18 13:26:53 EST 2007
A well designed observational study can tell us a
lot. However, some of our colleagues can't tell
when an observational study is designed or is
merely a dredging exercise.
>>Don,
>>Can you give the reference for mating earth worms?
>Yes but you wouldn't give it credence because
>it is only an observational study.
>>
>>
>>>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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>>
>>--
>>Ben Bidstrup FRACS FRCSEd FEBCTS
>>Consultant Cardiothoracic Surgeon
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Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon
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