[HSF] On pump beating heart
hgrmd at aol.com
hgrmd at aol.com
Wed Feb 28 14:57:04 EST 2007
Don,
Your jazzman is living testament to the efficacy of extensive endarterectomies, whether done on or off. The naysayers could possibly use some technical tips.
Hal
-----Original Message-----
From: donross at bigpond.com
To: OpenHeart-L at lists.hsforum.com
Sent: Wed, 28 Feb 2007 2:12 AM
Subject: Re: [HSF] On pump beating heart
> 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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