[HSF] On pump beating heart

Wed Feb 28 19:17:51 EST 2007

  Glad it wasn't Billy T


>>Though Don Ross does them by using his long shunts, he is in a tiny 
>>minority.  Perhaps the naysayers of endarterectomy who are 100% 
>>OPCAB'ers would rethink their position if they tried it on pump. 
>>Believe me, it works well.
>They sure do.
>  When I was a young fella I did three long endos on an "inoperable" 
>Jazz guitarist. 25 years on he is still playing and angina free 
>despite his vile vein grafts.
>Don
>>
>>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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-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon