[HSF] Provocative

Fri Jun 1 14:08:38 EDT 2007

Aren't there some juicy bits on coronary flows you could share with us?
Don
On 31/05/2007, at 11:09 PM, Salerno, Tomas wrote:

> This is not a paper. It is a book. Unfortunately I cannot PDF it.
>
> Sorry.
>
> Tomas
>
> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com
> [mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Michael
> Firstenberg
> Sent: Thursday, May 31, 2007 7:41 AM
> To: OpenHeart-L at lists.hsforum.com
> Subject: RE: [HSF] Provocative
>
> Ding ding ding foul.
> Dr Salerno you forgot a key rule of the forum of if you quote your own
> paper (particularly something hard to find) you must supply the pdf  
> - or
> at least part of it in pdf.
>
>
>
> Michael Firstenberg <msfirst at gmail.com>
>
> -----Original Message-----
> From: "Salerno, Tomas" <TSalerno at med.miami.edu>
> To: OpenHeart-L at lists.hsforum.com
> Sent: 5/31/2007 6:24 AM
> Subject: RE: [HSF] Provocative
>
> Recommended reading:
>
> Intraoperative Graft Patency Verification in Cardiac and Vascular
> Surgery
> Editors D'Ancona, Karamanoukian, Ricci, Salerno, Bergsland.
> Futura Publishing 2001
>
>
> Tomas
>
> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com
> [mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Mark
> Levinson
> Sent: Wednesday, May 30, 2007 11:36 PM
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] Provocative
>
>
> On May 25, 2007, at 12:34 AM, Ajit Damle wrote:
>
>>
>> 1.  How many of you record the flow in the OR note? Is it the
>> standard of
>> care in US?
>
> For many years, I measured flows, but I noticed that sometimes the
> data was
> either unhelpful, or confusing.     One thing I did for years was
> measure flow
> in the LIMA before removal of the cross clamp, and then after weaning
> from the pump.
> Invariably, the flows were much higher when the cross clamp was still
> on.    It was not
> unusual to see a LIMA go from 120 cc/min to 30 cc/min after release
> of the clamp.
> To me, this always implied 1) a correct anastomosis, and 2)
> competitive flow.
>
> However, when trying to use this experience for OPCAB, it is more
> confusing.
> I do not snare the proximal in OPCAB, so I don't have a baseline
> without competitive
> flow.  So, is 30 cc/min a great graft with competitive flow, or a
> poor graft in the setting
> of minimal competitive flow?
>
> I have tried to use the pulsatility index, but I find if I measue the
> same vessel over and over,
> I get different P.I. values, so this is not absolutely helpful.     I
> look at the diastolic waveforms now,
> but I can't re-explore the graft just based on my limited
> interpretation of these waves.
>
> In the few cases where I could tell a graft was bad, the audible
> waveform sounded like
> a hammer strike rather than a swishing flow signal.    This was
> helpful in 3 cases (all 3
> were kinks after resuming ventilation and resolving with tacking).
>
>>
>> 2.  Do you stipulate the perfusion pressure at the time of your
>> record?
>
> No, I don't     But I try not to make conclusion when the presssure
> is lower than
> what the patient will experience awake (120/80).     If the patient
> is hypotensive,
> the flows are taken during a non-physiologic period, and I remeasure
> when the
> pressure is normal.
>
>> 3  Is it mandatory, or do you do anyway,  include these in the OR
>> note?
>
> No, I do not believe flows are mandatory.    In some cases, they can
> encourage you
> to re-clamp and re-graft a vessel that is perfectly fine, but grafted
> to a small target, or
> one with diffuse disease, or competition.
>
>>
>> 4.  What do you accept as good flow vs bad flow"?
>>
>
> I get nervous below 10 cc/min or with a bad sounding audible
> waveform....
>
>>
>>
>> On on-pumps, where is (usually) quality of anastomosis is not in
>> question,
>> how do you interpret the numbers?
>>
>
> It can be subjective.   Yes, we tend to believe a number and try to
> make that
> number correlate with something, especially by plugging the number
> into a
> database and then running an analysis.
>
> However, there are pitfalls of measuring flows.    If the probe does
> not fit the vessel
> snugly, the flows are down.   If the probe is at a bad angle to the
> flow, the values are less.
> If the pressure is down, if the probe is turned around, then the
> results are spurious.
>
> I know that if I put the probe on 5 different times, I get 5
> different values.    What does this mean?
> I sometimes don't know.    So, if the graft is mechanically perfect,
> and the heart is doiing great, I
> don't measure.    If there is unusually contractility, arrythmias,
> filling pressures, I start looking
> and measure flows.    But I rarely need to revise a graft.  I usually
> find something besides a bad
> distal.    Usually a kink.
>
> Hope this helps.
>
>
> Mark
>
>
>>
>>
>> I do want to elicit the response from American surgeons  regarding  
>> the
>> medico-legal implications.
>>
>>
>>
>> Thanks!
>>
>>
>>
>> Ajit Damle
>>
>>
>>
>>
>>
>> Also,
>>
>>
>>
>> How  many of American surgeons routinely measure the flow, with what
>>
>> device, what criteria?
>>
>>
>>
>> Thans, guys, I nees help
>>
>>
>>
>> Ajit Damle
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>
>>
>> -----Original Message-----
>> From: openheart-l-bounces at lists.hsforum.com
>> [mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Donald
>> Ross
>> Sent: Thursday, May 24, 2007 6:40 PM
>> To: OpenHeart-L at lists.hsforum.com
>> Subject: [HSF] help with flow probe
>>
>>
>>
>> We have just acquired a Medistim flow  probe ( partly in response to
>>
>> Thomas's credo ) and I have a few questions for the experts.
>>
>> What is the lower limit of flow which would trigger a re-anastomosis?
>>
>> Is this level modified by the size of the target artery?
>>
>> If the flow is at this low level for arterial grafts, would you wait
>>
>> for a while and retest incase the low flow is due to arterial spasm?
>>
>> Do you ever inject dilators in such a graft?
>>
>> Do you always test with proximal occlusion?
>>
>> Can you actually determine whether a coronary lesion is significant
>>
>> enough to support an arterial graft by comparing flow with and
>>
>> without proximal coronary occlusion.
>>
>> Would you ever replace such graft with a SVG?
>>
>> Thanks,
>>
>> Don
>>
>> _______________________________________________
>>
>> OpenHeart-L mailing list
>>
>>
>>
>> Send postings to:
>>
>>  OpenHeart-L at lists.hsforum.com
>>
>>
>>
>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>>
>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>
>>
>>
>> All messages transmitted by the OpenHeart-L are subject to the
>> policies and
>>
>> disclaimers posted at:
>>
>> http://www.hsforum.com/listdisclaim
>>
>> -----------------------------------------
>>
>> _______________________________________________
>> OpenHeart-L mailing list
>>
>> Send postings to:
>>  OpenHeart-L at lists.hsforum.com
>>
>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>
>> All messages transmitted by the OpenHeart-L are subject to the
>> policies and
>> disclaimers posted at:
>> http://www.hsforum.com/listdisclaim
>> -----------------------------------------
>
> Mark M. Levinson, MD
> Founder, Editor-in-Chief,
> The Heart Surgery Forum
> WWW: <http://www.hsforum.com>
> Email: <mmLevinson at hsforum.com>
>
>
>
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
>  OpenHeart-L at lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the  
> policies
> and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
>  OpenHeart-L at lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the  
> policies
> and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------
>
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
>  OpenHeart-L at lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the  
> policies
> and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
>  OpenHeart-L at lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the  
> policies and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------