[HSF] On pump beating heart

Salerno, Tomas TSalerno at med.miami.edu
Tue Feb 27 16:34:27 EST 2007 

I have had the attitude that all coronary patients will be done off
pump; similarly, I only repair valves (if I can).  Dr. Juan Parodi,
father of vascular surgery, also told me that all vascular procedures
are booked as closed procedures, and only if that fails, open procedure
is one. In that manner, he does over 97% of patients closed.

Having been a surgeon who enjoyed cardioplegia arrest, warm heart
surgery, and others, the day I decided to eliminate the heart lung
machine for coronary artery surgery, I booked all cases as off pump. And
with success.

Tomas

-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of David Harris
Sent: Tuesday, February 27, 2007 4:25 PM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] On pump beating heart

Thanks Hal.

Yes, I do endarterectomy, and I will not do this off
pump. We only get the occasional patient who needs it.
I have thought of taking out stents but have not been
brave enough! We sometimes get those calcific horrors
where there is no place to open the vessel. The last
one needed 2 `traditional` long incision
endarterectomies, with long patch anastomoses.

Us `opcabbers` get enthusiastic when we can safely do
a full revascularisation the same way we would do it
on pump, we enjoy the operation more so approaching
100% makes us feel better! We still know it is better
for the patient, even if marginally. But would not
hesitate to go on, and not hesitate to decide go on
pump pre-op if we think it safer. Just like you, I am
sure, would like to repair 100% of the valves you
tackle, but also would not spend too much time mucking
about when it becomes clear that the valve should
rather be cut out and replaced.
Dave
--- hgrmd at aol.com wrote:

> 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
> 
=== 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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