[HSF] On pump beating heart

David Harris drdharris at yahoo.co.uk
Sun Feb 25 23:08:30 EST 2007 

I can`t remember when I last saw a patient in
cardiogenic shock referred for surgery....we have
excellent cardiologists who intervene percutaneously,
and they do`nt turf the patient to us if half the
ventricle has been wiped out already.

--- hgrmd at aol.com wrote:

> When my group does OPCAB, they don't prime the pump,
> either.  However, they do have a perfusionist and a
> pump in the room ready to go if the need arises. 
> One hundred per cent OPCAB?  You apparently don't
> offer surgery to patients in cardiogenic shock and
> froth coming out the ET tube.  I have and do. 
> However, no way would I consider doing that type of
> patient off pump.  
>  
> Hal
>  
>  
> -----Original Message-----
> From: drdharris at yahoo.co.uk
> To: OpenHeart-L at lists.hsforum.com
> Sent: Wed, 21 Feb 2007 4:48 PM
> Subject: Re: [HSF] On pump beating heart
> 
> 
> 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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=== message truncated ===


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

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