[HSF] Deairing the heart

[hgrmd at aol.com]

Ani,
  You bring up good points.  However, I feel that the incidence of diffuse postop encephalopathy has diminished with TEE-guided air removal.  One thing I can bet is that you would want that used if it was your heart.  I don't know about you, but I can't spare any brain at the moment.
Hal 
 
-----Original Message-----
From: anianyanwu at hotmail.com
To: OpenHeart-L at lists.hsforum.com
Sent: Fri, 2 Mar 2007 8:10 AM
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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