[HSF] On pump beating heart

Mon Feb 26 20:36:19 EST 2007

Dave,
  Thanks for the clarification.  Just make sure that you aren't finessing too vessels just so you can do the case off pump.  Like Mark, I believe extensive endarterectomies should have a definite place in your quiver as we continue to get patients with more diffuse disease.  Anyway, good luck with your policy and let us know how it goes.
Hal 

-----Original Message-----
From: drdharris at yahoo.co.uk
To: OpenHeart-L at lists.hsforum.com
Sent: Mon, 26 Feb 2007 3:51 PM
Subject: Re: [HSF] On pump beating heart

HA HA, I knew I would get you guys going! What I meant
was I RECENTLY started to do 100% off pump! That was
the last 20 consecutive cases! Have not hit any rough
ones since then! I`ll keep you posted!

Seriously though, of course I agree there are
`IMPOSSIBLE` cases! And these are probably done best
beating on the pump. But I still am convinced the
results will be better if you do 90% off pump, which I
will generally aim for....however after recently see
patients trash their legs and their bowel after being
on the pump I vowed I`ll try to do 100% off!

--- hgrmd at aol.com wrote:

> 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 
> 
=== 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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