[HSF] On pump beating heart
hgrmd at aol.com
hgrmd at aol.com
Mon Feb 26 01:07:10 EST 2007
Tea,
Coming from a guy who does a very high percentage of cases off pump, your comment about 100% OPCAB'ers is well taken. Having been an avid follower of HSF for a few years, I've definitely seen my share of breathless hyperbole (and no, I don't believe I've been a part of it).
Hal
-----Original Message-----
From: tacuff at swbell.net
To: OpenHeart-L at lists.hsforum.com
Sent: Sun, 25 Feb 2007 10:33 PM
Subject: Re: [HSF] On pump beating heart
I would put froth coming out of the ET under the category of "potential
problem". In reference to Chand's earlier patient with portal venous air, froth
in the ET would also qualify as "unstable" even if the BP was 100 on pressors.
One might not have to go on CPB, but it should be a consideration and available.
It would be hard to object in retrospect to CPB even if you go below 100% on
this one.
I actually looked up my rate for 2004 and 2005 for "CABG with no CPB" at my
primary hospital. The trend of cases is down and the trend of "CAB and valve or
other" is up. In two years I did 3 cases of CAB alone with CPB (including
redo's) in 150 cases. This is a 98% rate, I think. Next year could be 90% or
100%, but it won't be 10% or 50%.
Here is what I hear when surgeons tell me their rate of off pump surgery.
Although the most common thing they now say is that they stopped or it is
rountine. It is just a guess, as always I could be wrong, but when I check a
reference that visits the surgeon or see what they do year after year I think I
may be more right than not:
I tried a few but wasn't comfortable.=we had some bad results in the first ten
(I mean another surgeon obviously) so I stopped.
I do 10-20%=I tried it once or twice but didn't like it. I might try it again if
I have too.
I do 30-40%. =I do half of my single and double bypasses.
I do 50%.= I almost always do single and double bypasses and some easy PL or
PDAs.
I do all of mine OPCAB.= I try do do most of mine off pump (work in progress) or
perhaps it is actually my rountine.
I do 100% off pump.= Either I am FOS or I forgot about the couple of problem
patients last year. If he writes a lot of papers it is even money the former.
I have no one in mind when I wrote this. Promise. Almost.
tea
----- Original Message ----
From: David Harris <drdharris at yahoo.co.uk>
To: OpenHeart-L at lists.hsforum.com
Sent: Sunday, February 25, 2007 5:08:30 PM
Subject: Re: [HSF] On pump beating heart
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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