AW: [HSF] Deairing the heart
Michael Firstenberg
msfirst at gmail.com
Sun Mar 4 17:29:30 EST 2007
yes - we bare many crosses on behalf of our friends and colleagues.
michael
On Mar 4, 2007, at 5:04 PM, Ben Bidstrup wrote:
> But we wear it even in those circumstances.
>
>> 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:Hgrm
>>>> d 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
>>>> <BR><BR><BR>**************************************<BR> AOL now
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>>>>
>>>> email to everyone. Find out more about what's free from AOL at
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>>>> www.aol.com/>>.
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>>>
>>>
>>> --
>>> Ben Bidstrup FRACS FRCSEd FEBCTS
>>> Consultant Cardiothoracic Surgeon
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>
>
> --
> Ben Bidstrup FRACS FRCSEd FEBCTS
> Consultant Cardiothoracic Surgeon
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