[HSF] On pump beating heart
hgrmd at aol.com
hgrmd at aol.com
Thu Mar 1 01:20:25 EST 2007
Tea,
You must have only been half listening during my talk on ischemic MR. Elefteriades used to write that those fancy Yale vein grafts alone were uniformly effective in resolving significant preop ischemic MR. Though I haven't seen it in print, I did notice that he was recently a pro debater for repairing ischemic MR at the time of surgery. The spotty results seen with ischemic MR repair are more historic in my view and personal experience. I've implanted over 200 ETlogix rings the past 3 years with only one reop. Though the data isn't completely worked up, I believe the results are quite acceptable. You can go on and think that you're doing a great job just revascularizing a sick ventricle, off pump, while ignoring significant MR. I do believe that your views on this subject are, thankfully, becoming the minority. Do OPCAB when CABG alone is indicated. Learn to recognize that the majority of bad LV's from ischemia have clinically significant MR that will not resolve with CABG alone.
Hal
-----Original Message-----
From: tacuff at swbell.net
To: OpenHeart-L at lists.hsforum.com
Sent: Wed, 28 Feb 2007 11:13 PM
Subject: Re: [HSF] On pump beating heart
Interesting argument here, too.
I think it is pretty hard to blame the OPCABers for poor treatment for ischemic
related CHF. We were pretty bad at it long before off pump was a baby. You even
are following the old, and incorrect dictums, concerning the role of
revascularization for CHF. CHF, at least in the states, is mostly ischemic
disease. Many patients will get better with revascularization alone, if properly
evaluated. I do agree with your point that we do a very poor job of evaluating
these patients, however. You point dismissing CABG is likely wrong and lacking
in self awareness if you think that many of the poor ventricles that had CABG
and mitral repairs don't also come back with worse ventricles and recurrent MR a
couple of years later. You are again right in that CHF is complex disease and
requires many considerations leaving some patients with good options and others
with none.
As a young pup who may have always been at the source of knowledge, I would
encourage you to reflect upon and, if you get chance, be that laggard, the local
MD , to see what you would do with a different set of resources.
Logically the wrong diagnosis usually leads to the wrong operation. You are
suggesting that our technical limitation of operations is leading to poor
treatment. This is a more complex interaction, but it is my impression that
(based on the surgical options you listed) our problems are more related to the
former problem (complete diagnosis of pathophysiology) and lack of seeing the
benefit of other techniques than our fixation of technique that is lacking.
Surely habit makes your argument important, however.
I think that you are barking up the wrong tree, but agree with the barking.
Incidentally, I find the IABP for OPCAB almost always unnecessary (and much less
necessary than any arrest technique) , and perhaps logically the wrong support
for the dilated heart, but as you see it has a strong contingent. I find it
quite unproductive to do other than point to other contrary experiences.
Yours,
tea
----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Wednesday, February 28, 2007 8:59:57 PM
Subject: Re: [HSF] On pump beating heart
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<mailto: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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=== 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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