[HSF] On pump beating heart

[David Harris]

I`m sure we ALL agree with you.
However, many patients only have hibernating
myocardium, which will improve (usually) with
revascularisation, especially if done without
crossclamp, whether on or off pump. Thus avoiding
cardioplegia, apoptosis, non recovery and fibrosis. 
A pre-operative IABP and dobutamine will help
evaluation on the day of surgery: if there is
hibernation (or stunning!)then the ventricle should be
smaller and well contracting. If the ventricle is
still dilated then my usual practice has been to go on
pump, insert LV vent, and assess for LV aneurysm...I
have done a lot of Dor`s on the beating heart in cases
where an LV aneurysm has not been diagnosed pre-op.

As for the mitral valve...in OUR practice we do NOT
see progression of mitral valve disease as a rule
after revascularisation alone. The literature supports
this (apart from Carpentier`s data), for example: 

Revascularisation alone (without mitral valve repair)
suffices in patients with Advanced ischaemic
cardiomyopathy and mild-to-moderate mitral
regurgitation. George Tolis and others, including
Elefteriades. Ann Thorac Surg 2002; 74: 1476-81.  
They had excellent results, and a 1% mortality in this
group, which they achieved (they used crystalloid
cardioplegia) would possibly have risen dramatically
if the patients were burdoned by the additional
ischaemia associated with a mitral repair. Long term
ventricular function will also be worse, especially in
these patients if they are clamped longer. If it was
me having the procedure, I would rather live to fight
another day with an EF of 40% and a slightly leaky
valve (which could be corrected easily later on
beating heart via thoracotomy), than suffer misery
with a competent valve but an EF still around 20!
David


--- hgrmd at aol.com wrote:

> Damn right, Ani!!  You are absolutely right.  In my
> experience, it is uncommon for a patient with an EF
> of 20% to not have at least moderate MR.  Unless the
> patient has a hostile aorta, that should be fixed. 
> Don't forget to repair LV aneurysms.  Finally, add
> permanent epicardial LV leads for eventual bi-v ICD.
>  A "down and dirty" OPCAB in this scenario is
> definitely undertreating the patient in most
> instances.
> Hal 
>  
> -----Original Message-----
> From: anianyanwu at hotmail.com
> To: OpenHeart-L at lists.hsforum.com
> Sent: Wed, 28 Feb 2007 9:59 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.
> 
=== 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