[HSF] On pump beating heart

Ben Bidstrup benjamin.bidstrup at bigpond.com
Thu Feb 22 19:39:09 EST 2007 

The trick is one you gain with a lot of experience or listening to 
this group. Realise when it ain't right and get the pump setup before 
you get into trouble. This will mostly be evident when the heart does 
not like the position you put it in. If you have any doubt, don't 
think you can get away with doing the anastomosis quickly. Sure a 
s..t, this will be the one that is tough to do, keeps slipping or 
bleeding etc etc.

This should be very infrequent. Having it happen once a year is not 
an excuse for setting a pump up esp if it means throwing the setup 
out as I used to see one very out of touch perfusionist do.

>I agree fully with Tea: there is no need to have the
>pump primed for an OPCAB, unless it is a potential
>problem. Similarly, with increased experience, the
>cardiologists never ask for standby for PTCA. Those
>nasty earlier conversions were during the learning
>curve, when we did not know the limits. We know where
>the limits are now, and it will be safe: limited
>traction for first graft (LAD), with a few sutures
>just above phrenic nerve, use of shunts always, not
>accepting any extrasystole, (and sorting out what is
>causing them immediately), careful manipulation for
>last grafts by verticalisation only, and not accepting
>ANY hypotension before carrying on.
>I have recently changed to 100% OPCAB, and you can
>immediately see the difference, and the major
>difference is seen not only in hospital, but during
>the first 3 months.
>
>
>--- hgrmd at aol.com wrote:
>
>>  Tea,
>>    Knowing you as I do, I've no doubt that you speak
>>  the truth about your OPCAB experience (For once, I'm
>>  not kidding with you.).  I like the analogy of
>>  conversing with the heart and waiting for a
>>  response.  You have to be sure that the heart will
>>  tolerate that particularly position for the few
>>  minutes it takes to construct the anastomosis.
>>  However, I still maintain that a lot of OPCAB
>>  surgeons and their publications tend to ignore the
>>  emergent conversions with their inherent high M and
>>  M. 
>>    If you don't want to have a pump in the room while
>>  you do OPCAB, that's your business.  I don't think
>>  it would be a particularly strong selling point to
>>  your patients and referrals.  I would also
>>  conveniently not let your carrier know of your
>>  plans.
>>  Hal
>> 
>> 
>>  -----Original Message-----
>>  From: tacuff at swbell.net
>>  To: OpenHeart-L at lists.hsforum.com
>>  Sent: Wed, 21 Feb 2007 10:49 AM
>>  Subject: Re: AW: AW: [HSF] On pump beating heart
>>
>>
>>  It could happen, and does it if one does not develop
>>  an understanding of what is
>>  acceptable in positioning or not. It is like a
>>  conversation with the heart. You
>>  have to wait a minute or two for the response, but
>>  it can save you much misery.
>>  It is like rushing into a small bleed on the aorta
>>  or ventricle with big sutures
>>  and clamps. Or paying no attention to your wife. I
>>  haven't converted emergently
>>  in several years. I can actually only remember one
>>  case of converting during the
>>  anastomosis over the past decade. I have massaged
>>  the heart occasionally, but so
>>  have all of you other reasons. Temporary bumps are
>>  temporary bumps and is a
>>  characteristic of working on the heart not the
>>  technique per se.  The conversion
>>  was a long endarterectomy and the patient kept
>>  having VT, but could wait for the
>>  pump. I am thinking of not even having the pump set
>>  up any more, since we don't
>>  use it without telling before hand that the heart is
>>  talking trash to me.
>>  Honestly, I get in more trouble
>>   with emergent need for CPB after I have weaned off
>>  the stupid thing. That is
>>  not nearly as common as the (good?) old days, but I
>>  am willing to bet it is much
>>  more common (even relatively) than is the need for
>>  an experienced off pump
>>  surgeon to crash on. Do I lie? I doubt it. I see
>>  what goes for normal in other
>>  ORs.
>>  tea
>>
>>
>>  ----- Original Message ----
>>  From: "Hgrmd at aol.com" <Hgrmd at aol.com>
>>  To: OpenHeart-L at lists.hsforum.com
>  > Sent: Monday, February 19, 2007 6:25:08 AM
>>  Subject: Re: AW: AW: [HSF] On pump beating heart
>>
>>
>>  Roberto,
>>    I've done OPCAB on unstable patients.  It's scary
>>  as heck until  you get
>>  the LIMA plugged in.  In a patient who had already
>>  fibrillated, I  wouldn't
>>  consider using it, nor would I want any surgeon
>>  doing as such on one of  my
>>  family
>>  members.  Can you get away with it?  Probably.  But
>>  I  think it's foolhardy. 
>>  As I said previously, a lot of papers on OPCAB don't
>>   take into consideration
>>  the emergent conversions when they compare the 2
>>  modalities.  The few papers
>>  I've seen on emergent conversion to on pump  show
>>  extremely high death and
>>  morbidity.
>>  Hal
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>
>Dr. David G. Harris, FCS, MMED,
>Cardiothoracic Surgeon       
>Suite A2                               
>Tygerberg Hospital, 7505      
>Cape Town, South Africa.           
>Tel +27-21-9762347            
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-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon

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