[HSF] On pump beating heart
Donald Ross
donross at bigpond.com
Thu Mar 1 16:53:42 EST 2007
Hey, Ani , look at the thread: "On pump beating heart"
If there is an aneurysm or localised dead heart or MR opcabers
quickly become oncabers.
Don
On 01/03/2007, at 1:59 PM, Ani Anyanwu wrote:
> One problem I see with advocating aggressive regimes for
> accomplishing Off-pump revascularization in the sick ventricle with
> low EF is that it diverts this away from surgery for heart failure
> (which it is) to surgery for angina or MI prophylaxis (which it
> isn't).
>
> The drive to do OPCAB in these patients results in a new group of
> under-treated heart failure patients. The treatment of these
> patients is often multimodal and not infrequently should include
> mitral valve repair and sometimes LV remodeling or tricuspid valve
> repair even. By pursuing OPCAB with zeal in this group I suspect
> some surgeons are under-treating the associated lesions. As a
> transplant surgeon, I see patients now and then who have had CABG
> (on or off) and had the mitral neglected and progressed in heart
> failure, with essentially a wasted operation. My view is if a
> patient needs an IABP overnight to accomplish an OPCAB then he is
> probably having the wrong operation.
>
> Ani
> ----- Original Message -----
> From: David Harris<mailto:drdharris at yahoo.co.uk>
> To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-
> L at lists.hsforum.com>
> Sent: Wednesday, February 28, 2007 3:56 PM
> Subject: Re: [HSF] On pump beating heart
>
>
> I agree with pre-op balloon in all these patients with
> EF around 20. I think you have only one chance with
> these patients. Then you can see if you can do them
> off pump, and if not, do them beating on pump. The
> timing of the balloon is important, they need at least
> overnight, but no longer. Some low dose dobutamine
> also helps, and by the time the operation time comes
> around, the heart has decreased in size. Another
> choice for all left side vessels is to do it all
> through a thoracotomy, so you need not displace the
> heart and cause hemodynamic chaos. Proximal grafts
> onto the left subclavian can also classify this as an
> `anaortic` CABG
>
>
> --- Donald Ross <donross at bigpond.com<mailto:donross at bigpond.com>>
> wrote:
>
>> Ben,
>> Can't agree; if that was the case the problem would
>> come on earlier.
>> The lad grafts take ~ 5min including placement of
>> shunt. Check out
>> the "real time lima to LAD "at "movies " at
>> beating-heart.com hardly long enough to bother a
>> myocyte. Can't do
>> much about the anaesthetic unless you practice in
>> India where
>> epidurals suffice.
>> I think the diastolic augmentation of the balloon
>> helps to belt
>> blood down spasmy imas.
>> Don
>> On 28/02/2007, at 7:21 PM, Ben Bidstrup wrote:
>>
>>> I think it is more than that. In poor LVs even a
>> small amount of
>>> depression by transient ischaemia to the LAD
>> despite shunts can
>>> lead to the need for more support. There is likely
>> to be some
>>> oedema after revascularisation, and the impact of
>> anaesthesia needs
>>> consideration also.
>>>
>>>
>>>> Prasanna,
>>>> I did talk to Dr Bhattacharya at the meeting in
>> Mumbai, I now know
>>>> since my registrar confirmed his distinguished
>> appearance.
>>>> He must be slick to use the RIMA exclusively for
>> his T graft .
>>>> He did, however mention that he uses the balloon
>> for sick hearts
>>>> which perhaps is the reason for his 100% record.
>>>> Now that I am reminded of this I will do the same
>> for my next <20%
>>>> EF patient since the last two done bh on pump
>> needed post op
>>>> balloons... not immediately but after a few
>> hours. I suspect the
>>>> reason relates to transient ima hypoperfusion
>> which intolerant
>>>> of the low mean pressure of some low EF hearts.
>>>> Don
>>>> On 27/02/2007, at 11:49 PM, prasannasimha wrote:
>>>>
>>>>> He practices in Mumbai.(He visits multiple
>> hospitals including
>>>>> Breach Candy hospital etc)
>>>>> Prasanna
>>>>> Donald Ross wrote:
>>>>>> Prasanna,
>>>>>> Who publishes series of individual cases no
>> matter how pretty
>>>>>> the clinical results?
>>>>>> Even if they are put into print many wont
>> believe them ( Hal et
>>>>>> al ) or take any notice unless there has been
>> some some attempt
>>>>>> at science, some hypothesis formulated , some
>> conclusion to be
>>>>>> elucidated.
>>>>>> This wonderful surgeon/orchestral conductor
>> can't publish his
>>>>>> beautiful playing.
>>>>>> All one can do is to take your advice and visit
>> the man.
>>>>>> So, where does he work?
>>>>>> Don
>>>>>> PS I thought he used a balloon instead of
>> bypass in crook cases
>>>>>> which I believe is probably more morbid than
>> cpb.
>>>>>>
>>>>>> On 27/02/2007, at 10:45 PM, prasannasimha
>> wrote:
>>>>>>
>>>>>>> The worst possible scenario is a person
>> wanting to complete a
>>>>>>> 100 % OPCAB experience in time for a
>> conference etc and
>>>>>>> refusing to go on pump or at least institute
>> an IABP while the
>>>>>>> heart is demanding it !!. Saying this, in
>> isolated CABG's not
>>>>>>> in cardiogenic shock, inability to displace
>> the heart during
>>>>>>> OPCAB is more often an expression of failure
>> of the surgeon -
>>>>>>> anesthesiologist team to understand what is
>> going on.
>>>>>>> You should see Dr Bhattacharya doing a
>> multivessel total
>>>>>>> arterial revascularization on a 10 - 15 % EF
>> heart being done
>>>>>>> effortlessly to believe it. He has probably
>> the worlds largest
>>>>>>> "individual surgeon" series of OPCAB's and
>> unfortunately the
>>>>>>> blessed man doesn't publish. Watching him do
>> an OPCAB is like
>>>>>>> seeing an orchestra play.
>>>>>>> Prasanna
>>>>>>>
>>>>>>> Ani Anyanwu wrote:
>>>>>>>> Off-pump surgery is sometimes also a crime
>> against the human -
>>>>>>>> I have seen several cases where the heart, or
>> the entire
>>>>>>>> patient, has suffered because of reluctance
>> and refusal of the
>>>>>>>> surgeon to accept conversion to CPB. It cuts
>> both ways (some
>>>>>>>> patients also suffer by having on-pump CABG).
>> We should not be
>>>>>>>> evangelists for a technique but for the
>> patient. The patient
>>>>>>>> couldn't care less whether we used CPB or not
>> - all they want
>>>>>>>> is a lasting operation at low risk so our
>> primary aim should
>>>>>>>> be to deliver this goal.
>>>>>>>>
>>>>>>>> Ani
>>>>>>>> ----- Original Message ----- From:
>>>>>>>> NielsB at aol.com<mailto:NielsB at aol.com<mailto:NielsB at aol.com<mail
>>>>>>>> to:NielsB at aol.com>> To:
>> OpenHeart-
>>>>>>>>
>>
> L at lists.hsforum.com<mailto:OpenHeart-
> L at lists.hsforum.com<mailto:L at lists.hsforum.com<mailto:OpenHeart-
> L at lists.hsforum.com>>
>>
>>>>>>>> Sent: Tuesday, February 27, 2007 3:09 AM
>>>>>>>> Subject: Re: [HSF] On pump beating heart
>>>>>>>>
>>>>>>>>
>>>>>>>> Who said it is?. It is not a crime against
>> humanity but in
>>>>>>>> some cases it is a crime against a human.
>> The heart lung
>>>>>>>> machine is a tool among many others, very
>> frequently a very
>>>>>>>> important one. But it is not some holy grail
>> either. We use
>>>>>>>> it when we need it, for CABG this is not so
>> common, then the
>>>>>>>> stabilizer is a better tool in my humble
>> opinion.
>>>>>>>>
>>>>>>>>
>>>>>>>> Jacob Bergsland
>>>>>>>>
>>>>>>>>
>>>>>>>> **************************************
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>>>>>>>> www.aol.com/<http://www.aol.com/>>.
>>>>>>>>
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> === 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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