AW: [HSF] Deairing the heart
Michael Firstenberg
msfirst at gmail.com
Sun Mar 4 16:22:05 EST 2007
Wait a minute - we are not the only ones to blame for CVA's.
Though I have no claim to actual data - but how many times have you
guys admitted a patient after a cath - and as a little bonus gotten a
CVA/TIA or even a good ol' fashion dissection? Unfortunately,
sometimes these "problems" are not often obvious for a couple of days
after the procedures.......
-michael
On Mar 4, 2007, at 4:10 PM, Ben Bidstrup wrote:
> To get a handle on some of these devices and techniques, we must
> look more widely.
>
>
> We cannot even guess at the incidence of neuropsych damage after
> valve surgery. All but a few of the papers have been on CABG
> patients. So we do like many other groups, extrapolate from the
> many CABG studies done on this. How representative are these
> patients of the real world? Look at the paper mentioned recently
> from van Dijk in JAMA.
> Does this include use or avoidance of cardiotomy suction? How is
> venting handled? Suck like h..l to keep the heart empty and get
> lots of air/blood interface or
> gently when there is blood pooled.
> What has happened to the incidence of stroke over time, perhaps the
> crudest marker we can use? Whose data do we use? That is a
> question a brief search was not easily answered. A report from the
> New York database on CABG reported a 1.4% incidence. In a review
> from Johns Hopkins on AVR CABG patients (233) there was an
> incidence of approx 14% across the groups with grafts. However no
> longitudinal information. (Kobayashi Ann Thorac Surg
> 2007;83:969-978) .
>
> So how do we tell the difference that CO2 displacement, TEE or
> other maneuvers make? Does Embolex make a difference? TEA has
> commented that we do all sorts of things for all sorts of reasons.
>
> Shann and a team reviewed the evidence for reduction of
> neurological injury recent;y (Shann J Thorac Cardiovasc Surg
> 2006;132:283-290). If we believe in evidence based medicine than
> there are a few recommendations to be looked at. However, TEE for
> assessment of de-airing was not included. Nor was CO2. Many of the
> studies used applied only to CABG patients.
>
>
>
>
>
>
>
>> 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@
>> 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
>> <BR><BR><BR>**************************************<BR> AOL now
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>
>
> --
> Ben Bidstrup FRACS FRCSEd FEBCTS
> Consultant Cardiothoracic Surgeon
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