AW: [HSF] Deairing the heart

Ani Anyanwu anianyanwu at hotmail.com
Sat Mar 3 09:51:09 EST 2007 

But Roberto how are you certain it is TEE that made this difference? I have seen a similar argument made by protagonists of blood cardioplegia (that better preservation has all but eliminated post op VF). There have been numerous changes in cardiac surgery in the last decade so it would be difficult to ascribe an effect to any one change except if there is indirect or direct supporting evidence. 

Don't get me wrong though - I would not envisage surgery without TEE and use it myself to deair everyday, but like the axiom goes half of what we do at anytime is of no benefit and some even harmful - I do not know where TEE deairing lies and certainly evidence of its benefit is at best circumstantial. However on an individual level I take yours and Hal's perspective that we should strive to get all the air out by whatever means. As Hall said it is possible to conduct an operation in a way that you do not have air in the heart at the end and that is regardless of TEE. TEE is one factor but maybe there are many others.

Ani
  ----- Original Message ----- 
  From: Dr. Roberto Battellini<mailto:battr at medizin.uni-leipzig.de> 
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
  Sent: Saturday, March 03, 2007 7:32 AM
  Subject: AW: AW: [HSF] Deairing the heart


  Ani,
  I disagree.There is difference before and after TEE.
  Since we make all our valves under TEE, we have reduced significantly the
  number of patients we had to defibrillate soon after surgery. We let run the
  needle vent until there are no more bubbles. Of course, it is very
  sensitive.
  Roberto

  -----Ursprüngliche Nachricht-----
  Von: openheart-l-bounces at lists.hsforum.com<mailto:openheart-l-bounces at lists.hsforum.com>
  [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Ani Anyanwu
  Gesendet: Freitag, 2. März 2007 14:10
  An: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
  Betreff: 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<mailto:Hgrmd at aol.com<mailto: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<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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