[HSF] On pump beating heart
erdinç naseri
enaseri at hotmail.com.tr
Thu Feb 22 11:21:31 EST 2007
There are 2 mechanisms for hemodynamic deterioration in OPCAB surgery:
1.Regional ischemia if you don't use an intracoronary shunt:
I.LAD:here if the stenosis is a mild one(50-70%) severe depression of
L V function and life threatening arrythmia occur.
II.RCA:AV conductance disturbances may lead to emergent conversion to
CPB if you don't use a shunt
2.Mecanical problems in the inflow and outflow of the ventricles ( mostly
RVOT as is obvious by external inspection and occurance of new AI or
increase in the degree of a previously present mild AI.This later one is
obvious in TEE):
I.CRX : prevented by herniation of the heart to the R hemithorax.
II.PDA:prevented by using cardiac suction devices as described
elsewhere.
TEE is a very valuable modality to predict these events and make
corrections or comnvert to CPB.
Personally I have been doing OPCABG for the last 8 years and the number is
more than 1500 .Very frequently I do very long andarterectomies and patch
angioplasties for all of the coronaries but even in the last year the
percentage of my OPCABG is around 50-60%.After all, graft patency must be
the most important goal of CABG operations and we should not sacrifice this
for other purposes.
erdinc
>From: Ben Bidstrup <benjamin.bidstrup at bigpond.com>
>Reply-To: OpenHeart-L at lists.hsforum.com
>To: OpenHeart-L at lists.hsforum.com
>Subject: Re: [HSF] On pump beating heart
>Date: Thu, 22 Feb 2007 19:39:09 +1100
>
>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 Fax +27-21-9761157 Mobile +27-83-3309587
>>_______________________________________________
>>OpenHeart-L mailing list
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>
>
>--
>Ben Bidstrup FRACS FRCSEd FEBCTS
>Consultant Cardiothoracic Surgeon
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