[HSF] CABG for ischaemic cardiomopathy
Tea Acuff
tacuff at swbell.net
Sat Mar 3 15:27:03 EST 2007
We know and have known since the 80s that patients with poor LV function have potentially the greatest benefit from revascularization but the greatest risk. We also have known that those with reversible ischemia contribute the vast majority of this beneficial effect. Based on older technology (nuclear studies) those patients without reversible ischemia DID NOT benefit from surgery but still were high risk.
Cardiac MR has much better resolution and is more sensitive in selecting patients with possible benefit (ie reversible ischemia) based on the thickness of transmural scarring. Undoubtedly better and more frequent use of the modality will improve our results. Why do we persist in doing a $30,000 operation instead of a $800 CMR? We always get a $3000 cath do we not? We can also see if they have mitral regurgiation, TR, RV ventricular asynchrony, RV or LV distention or are a possible candidate for SVR which is safer than opening the LV for a look. ( I would recommend to Hal and others to prophylactically use the CPB if planning to look into the LV during an off pump procedure. The risk is higher if you decide to go on pump after one opens the LV.) Volume loading of the LV or RV is a prognostic marker for poor short and long term outcomes. One would like the planned procedure to have some plan to reduce this volume as this should be a primary outcome of that procedure if
possible.
IABP may help temporarily mitigate this volume effect preop, but other mechanical (eg external counter pulsation) or medical treatment may better unload the marginal patient. This will require measurement and diagnosis before entering the operative suite. As always finding any of these patients with with exactly similar clinical parameters, but less acutely decompensated (acuity) will lead to better outcomes. To improve the results of this class of ventricular dysfunction requires NOT ONLY finding them in the ICU or OR, but also as out patients. Don't except someone else to select all your patients and expect excellent outcomes.
tea
----- Original Message ----
From: Donald Ross <donross at bigpond.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Thursday, March 1, 2007 8:02:30 PM
Subject: Re: [HSF] CABG for ischaemic cardiomopathy
Erdinc,
We can get PET scans at another hospital but rarely do so.
My indications are usually clinical.
There seem to be two categories:
1. patients with little or no angina but with a history of episodic
dyspnoea. These do well as the low EF is due to ischaema
2. those with a recent infarct but no aneurysm who you hope have
hibernating myocardium. These patients are a struggle as the muscle
often takes several days to come good.
There is no doubt you will eventually fail if you keep pushing the
indications.
I don't have any experience with correlating PET results to operability.
Can anyone out there help?
Notwithstanding the opinion of Ani and Hal my impression is that
avoiding cardioplegia in these patients results in a smoother operation.
After all there is always a troponin leak after cardioplegia but not
after bh surgery. The stuff comes from unhappy myocytes.
So why not try to keep the little darlings happy?
Don
On 01/03/2007, at 10:52 PM, erdinç naseri wrote:
> Dear Don,
> In your practice what myocardial reserve invesdtigations are done
> for the patients with EF of 20-25 which are candidates for OPCAB .
>
> erdinc
>
>> From: Donald Ross <donross at bigpond.com>
>> Reply-To: OpenHeart-L at lists.hsforum.com
>> To: OpenHeart-L at lists.hsforum.com
>> Subject: Re: [HSF] On pump beating heart
>> Date: Wed, 28 Feb 2007 18:29:52 +1100
>>
>> 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.
>>>>> You should see Dr Bhattacharya doing a multivessel total
>>>>> arterial revascularization on a 10 - 15 % EF heart being done
>>>>> effortlessly to believe it. He has probably the worlds largest
>>>>> "individual surgeon" series of OPCAB's and unfortunately the
>>>>> blessed man doesn't publish. Watching him do an OPCAB is like
>>>>> seeing an orchestra play.
>>>>> Prasanna
>>>>>
>>>>> Ani Anyanwu wrote:
>>>>>> Off-pump surgery is sometimes also a crime against the human -
>>>>>> I have seen several cases where the heart, or the entire
>>>>>> patient, has suffered because of reluctance and refusal of
>>>>>> the surgeon to accept conversion to CPB. It cuts both ways
>>>>>> (some patients also suffer by having on-pump CABG). We should
>>>>>> not be evangelists for a technique but for the patient. The
>>>>>> patient couldn't care less whether we used CPB or not - all
>>>>>> they want is a lasting operation at low risk so our primary
>>>>>> aim should be to deliver this goal.
>>>>>>
>>>>>> Ani
>>>>>> ----- Original Message ----- From:
>>>>>> NielsB at aol.com<mailto:NielsB at aol.com> To: OpenHeart-
>>>>>> L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
>>>>>> Sent: Tuesday, February 27, 2007 3:09 AM
>>>>>> Subject: Re: [HSF] On pump beating heart
>>>>>>
>>>>>>
>>>>>> Who said it is?. It is not a crime against humanity but in
>>>>>> some cases it is a crime against a human. The heart lung
>>>>>> machine is a tool among many others, very frequently a very
>>>>>> important one. But it is not some holy grail either. We use
>>>>>> it when we need it, for CABG this is not so common, then the
>>>>>> stabilizer is a better tool in my humble opinion.
>>>>>>
>>>>>>
>>>>>> Jacob Bergsland
>>>>>>
>>>>>>
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