AW: [HSF] Deairing the heart

[Salerno, Tomas]

I have used beating heart surgery for all valvular and other complex
procedures. One of the major concerns about this technique, is air
embolization. Over 400 consecutive cases, there is not one case that air
has been a factor. I have simply not seen air embolization in these
cases. I do not use C02, but I am obsessive about de-airing the heart.

Tomas

-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Ani Anyanwu
Sent: Friday, March 02, 2007 8:10 AM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: AW: [HSF] Deairing the heart

But Hal I would question the relevance of subtle neurological changes
that require a battery of sophisticated tests to demonstrate. A lot of
these changes IMHO are integral to having artificial extracorporeal
circulation and indeed MRI studies show changes in many patients with no
neurological complications. Air and embolism are an integral part of CBP
and in most cases are likely of no or of minimal consequence. Obviously
though we must exclude gross air bubbles and our deairing approach,
including CO2 and TEE is very similar to yours. 

However, I think to a great degree air is an invention of TEE and most
of what we see on TEE or strive to achieve with TEE is of little
relevance above that which can be determined clinically as in Novick's
practice or in the practice of the 1980s. Like you I vent the root up to
15 mins after coming of bypass and I suspect in most patients this will
be sufficient to deal with any rogue bubbles that failed deairing -
regardless of the presence of TEE.

I am not sure there is any direct evidence that the incidence of
neurological complication or neuropsychometric deficit has changed with
the advent of TEE or that the incidence is different in centers that
routinely use TEE and centers that don't. Those surgeons in life courses
who don't seem to deair properly may not necessarily be harming their
patients. In my previous center (Harefield with Yacoub) we generally
ignored the snowstorms seen on TEE and apparently (I know I know) to no
consequence.

Ani


----- Original Message ----- 
  From: Hgrmd at aol.com<mailto:Hgrmd at aol.com> 
  To:
OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
  Sent: Friday, March 02, 2007 7:33 AM
  Subject: Re: AW: [HSF] Deairing the heart


  Bill,
    I'm somewhat surprised that you don't use CO2, because it definitely
does 
  reduce or eliminate air emboli.  Your stroke rate is laudible.
However, I 
  assume you are talking about fixed deficits only.  Air emboli  often
present as 
  a diffuse encephalopathy with no focal deficits. Unless you are
having a 
  battery of neurologic exams done on your postop patients, I wouldn't
place too 
  much credence in the amount of brain damage you currently think is
being 
  inflicted on your patients. As we all know in adult cardiac surgery,
subtle 
  permanent personality changes may be the only manifestation of
perioperative 
  neurologic injury. Those usually aren't factored into the postop
stroke rate. 
  Perhaps your kids would do better in the 1st grade if you  considered
adding this to 
  your technique.  I know that you can't really  monitor its effect
since I 
  presume you don't have a TEE scope small enough to  acommodate an
infant.  For 
  your larger patients, I would definitely  consider using a pediatric
scope.
  Hal
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