AW: [HSF] Cardiology strokes
Donald Ross
donross at bigpond.com
Mon Mar 5 16:06:47 EST 2007
Michael, you are correct.
One of our neurologists was commenting on how rarely he was called to
our ward these days.
Said that cardiology needed him every second week!
The cards don't however have any data on post-cath strokes because
they are not invasive ( Ha Ha ) and are therefore, not scrutinised by
their college or the public! They get their CME points going to
meetings on the tab of drug and stent manufacturers.
Don
On 05/03/2007, at 8:22 AM, Michael Firstenberg wrote:
> 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
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>>
>>
>> --
>> Ben Bidstrup FRACS FRCSEd FEBCTS
>> Consultant Cardiothoracic Surgeon
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