[HSF] Embol-X
Ben Bidstrup
benjamin.bidstrup at bigpond.com
Fri Mar 2 08:28:20 EST 2007
We are making the assumption that it is a 'surgically correctable'
issue. There are many other facets of neuro-injury. Firstly, stroke
as such is merely one end of a huge spectrum of injury. We will just
stick to the brain at present. Cardiac surgery with or without the
pump is a major insult on the human organism (not rocket science) .
Overt stroke is something we see and cannot run away from. The other
end is the very subtle injury that Murkin, Stump, Newman, Baker and
many others far more intelligent than me, debate, define and try and
measure. We 'simple' clinicians cannot see these changes. In between
is the transient confusion, the short term memory changes, the minor
visual changes etc. Some we can detect - Dad is a little less sure of
things, the lawyer who cannot argue the way he used to (that is no
bad thing!) the accountant that loses some of his arithmetic skills,
others we don't especially in a 15 minute followup where we are
looking at the wounds, asking about exercise, pain angina SOB, meds.
The aetiology of these is fully yet to be elucidated. It ranges from
the aorta, cannulae, filters and the complex range of biochemical and
cellular changes that occur during surgery.
We are however the captains of the ship, We wear all the problems and
agonise over them as we see the patient and the family every day.
In a true multidisciplinary M&M meeting, do we (you) look at the
printout from the anesthesia monitor, the pump system looking at
flows, pressures etc (not the hand recorded one) . And that is only
one perspective.
We can do the same with each system. The kidney - we look at just
serum creatinine for example. That only tells us a small part of the
picture. The heart - we have had the debate about the best method of
decreasing myocardial damage. Tomas' beating heart perfusion, OPCAB
with or without shunt, cardioplegia, cold tepid warm, Hi K, Low K, no
K, additives and adjuncts (insulin, allopurinol to name but a few),
antegrade retrograde, volume and timing. We put this all into a
multi-variable logistic regression model (in our brain). The
coefficients for each variable are something we all weight
differently - depending on our own prejudices and beliefs and come up
with an answer (for Hal it is aprotinin highly weighted for ATN,
Tomas; cardioplegia for myocardial protection, Don; anaortic surgery
etc). And as noted above, how do we measure the outcomes - very
crudely.
So does that help us answer why your patient had a stroke in a
seemingly otherwise straightforward operation. No, but it does
explain why we must in our informed consent process we tell the
patient and their family there is a risk of x or y happening. And it
happens despite all our best intentions, skill etc. Trouble is the
bottom dwellers do not appreciate that. Try and explain probability
theory to an 80 year old farmer from the hills. And one of our
'colleagues' will say that is experimental, or I would not do it that
way.
We should be using the James Reason 'defence.'; (Swiss Cheese theory
of all the holes lining up for a critical incident to occur -
http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html for
an overview.) I think in some instances it is wrong to call some
things an error as it is not necessarily a human failing that caused
the problem but being in the wrong place at the wrong time. But we
have the Blame game!
And onto the merry-go-round we all jump yet again.
Making the same mistake over again is not experience
>I don't think simple is the correct word. My criticism is from the
>agnostic perspective. I am left wondering when one claims over and
>over the cause of a recurrent complication and does nothing about
>it. Is the proclaimer ignorant (of the facts) or stupid (keeps doing
>the same mistake over and over)? Agnosticism seems perferrable. Why
>not always cannulate the innominate and see if you stop having "left
>sided cannula emboli"? tea ----- Original Message ---- From: Ani
>Anyanwu <anianyanwu at hotmail.com> To: OpenHeart-L at lists.hsforum.com
>Sent: Wednesday, February 28, 2007 9:59:56 PM Subject: Re: [HSF]
>Embol-X Tea I see your line of thinking but unfortunately I am just
>a simple surgeon so in simple terms I just assumed that a focal
>head lesion with radiologic features of infarction in a patient with
>no vascular disease is most likely due to embolism. Of course I
>would like to explain it otherwise (CPB and cannula), except I am at
>loss of explanation why a general disease (CPB) should produce such
>a focal lesion. I fully agree with your writings and those of Don
>and others that avoiding all aortic manipulation is the way to go
>for CABG, but for now we have to resort to CPB for MV repair (unless
>you suggest we do not do it at all?). As for your anaortic
>stroke,however - it will come one day - cerebral doppler have shown
>microembolization when the heart is lifted for OPCAB and besides
>many of your patients will have carotid disease. The expectation
>however is that you will see this much less frequently than your
>colleagues who use CPB. Ani ----- Original Message ----- From:
>Tea Acuff<mailto:tacuff at swbell.net> To:
>OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
>Sent: Wednesday, February 28, 2007 10:30 PM Subject: Re: [HSF]
>Embol-X I think this line of thinking is a bunch of bunk. Embolus
>from what, how, and where? It can likely be contributed somehow to
>opening and perfusing the heart which is why I like to to take CPB
>and its cannula out of the equation if possible. I would listen to
>my partners and mentors use this logic, and wonder why they were so
>perceptive. Then when I would do my off pump, anaortic operation,
>and have a fatal "left sided embolic stroke", I remember how smart
>all our critics were. If you really believe it why do you even
>cannulate if not absolutely necessary (obviously not this case but
>your previous thread?). tea ----- Original Message ---- From:
>Ani Anyanwu <anianyanwu at hotmail.com<mailto:anianyanwu at hotmail.com>>
>To:
>OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
>Sent: Wednesday, February 28, 2007 9:05:31 PM Subject: Re: [HSF]
>Embol-X Thanks Hal One was clearly an infarct likely from
>embolism; the other (who is recovering) has had two normal CTs (had
>MRI today - awaiting results). Both left sided so in line with
>embolization. Neither had any reason in surgery to suspect potential
>for embolus, both were FED. I suppose a bit of fat can dislodge when
>closing LA and cause havoc. Ani ----- Original Message -----
>From:
>hgrmd at aol.com<mailto:hgrmd at aol.com<mailto:hgrmd at aol.com%3Cmailto:hgrmd at aol.com>>
>To:
>OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com%3Cmailto:OpenHeart-L at lists.hsforum.com>>
>Sent: Wednesday, February 28, 2007 9:52 PM Subject: Re: [HSF]
>Embol-X Ani, Sorry to hear about your patients. Were they
>definitely embolic strokes on CT? Actually, I don't routinely use
>Embolex unless the valve, either mitral or aortic, has a lot of
>calcium. In those types of cases, I often can see at least a couple
>of flecks in the screen. Occasionally, 2-4mm bit of debris is
>found, something that would have definitely caused a big stroke if
>it went to the head. I probably wouldn't use it on a routine
>myxomatous repair. Maybe I should include them as well. Thanks for
>sharing your painful experience. I trust and respect doctors and
>institutions that have no problem revealing warts and all. Hal
>-----Original Message----- From:
>anianyanwu at hotmail.com<mailto:anianyanwu at hotmail.com<mailto:anianyanwu at hotmail.com%3Cmailto:anianyanwu at hotmail.com>>
>To:
>OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com%3Cmailto:OpenHeart-L at lists.hsforum.com>>
>Sent: Wed, 28 Feb 2007 9:38 PM Subject: Re: [HSF] Embol-X I
>would like to know list members experience in using the Embol-X
>intra-aortic filter - indications and capture rate. I know some
>- notably Hal - have said they use it on all valves - what
>prompted this? I ask because in the last two weeks we have had
>two devastating strokes in 40 year olds undergoing degenerative
>mitral repair, having not had a single stroke in almost 300
>degenerative repairs in our institution the preceding 2 years and
>am wondering if one should consider using this device routinely. At
>present we have used it only in cases with high embolic risk and
>even then our yield has been low. Thank you Ani Anyanwu
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--
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon
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