AW: AW: [HSF] Deairing the heart

Salerno, Tomas TSalerno at med.miami.edu
Sat Mar 3 12:26:17 EST 2007 

I agree with the statement that VF occurring at any time during cardioplegic arrest, or beating valvular surgery, is a sign of something gone wrong in the myocardium, usually ischemia. One would not accept seizures occurring during any time of CPB, but one accepts VF!   During beating valvular surgery, VF is very rare and when it occurs it is usually due to lower flows either antegrade or retrograde, and the treatment, besides defibrillation, is to increase flows if possible. 
 
Tomas

________________________________

From: openheart-l-bounces at lists.hsforum.com on behalf of prasannasimha
Sent: Sat 3/3/2007 7:34 AM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: AW: AW: [HSF] Deairing the heart



Roberto,
How much can you attribute to air and how much to changing/ evolving
cardioplegic techniques ? (Fibrillation after removing the X Clamp)
I remember that when we shifted from home made crystalloid to St Thomas
crystalloid in the early '90's (We then started getting DBL ampoule's)
we had a dramatic reduction in necessity of defibrillation after
removing the cross clamp. In fact I consider requirement of
defibrillation after removing the cross clamp a sign of inadequate
myocardial preservation.
Prasanna

Dr. Roberto Battellini wrote:
> 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] Im Auftrag von Ani Anyanwu
> Gesendet: Freitag, 2. März 2007 14:10
> An: 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>
>   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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