[HSF] Deairing the heart
jbflegejr at aol.com
jbflegejr at aol.com
Tue Mar 6 21:17:49 EST 2007
Correction, table rotated to the right. John Flege
-----Original Message-----
From: jbflegejr at aol.com
To: OpenHeart-L at lists.hsforum.com
Sent: Tue, 6 Mar 2007 8:04 PM
Subject: Re: [HSF] Deairing the heart
Certainly intracoronary air obstructs small arteries and sometimes
even major ones that can be demonstrated by TEE resulting in myocardial
ischemia and heart failure which may reslove as the air is cleared.
Certainly cerebral arteries, large and small, may be temporarily
obstructed by air. Incidentally I have always thought that the most
effective way of deairing the heart was via the apex of the LV and the
roof of the left atrium which are the highest part of the heart, when
the heart is tipped up, the head put down, and the table rotated to the
left. John Flege.
-----Original Message-----
From: anianyanwu at hotmail.com
To: OpenHeart-L at lists.hsforum.com
Sent: Sun, 4 Mar 2007 6:03 PM
Subject: Re: AW: [HSF] Deairing the heart
Of course, the predominance of CABG studies in the literature casts
more doubt
on the deairing hypothesis (as imperative to minimizing neurological
injury).
Most CABG techniques do not entrain significant amount of air in the
heart yet
these are the patients who have been shown repeatedly to suffer a vast
range of
neurological injury ranging from neuropsychological impairment to
stroke and
gross encephaolopathy. These rates are more than seen with ASD or
primary mitral
surgery in which the left heart is full of air.
Maybe we are chasing the wrong villain - indeed I think this this is
likely so
and we will find in future that intracardiac air is not as significant
as we
believe. As Dr Frater says, I realize I am holding two conflicting
views in my
brain at the same time so I will continue using TEE for now! Maybe we
are
heading full circle to Don's thesis - probably more to do with the
heart-lung
machine and aorta than to do with (intracardiac) air...
Ani
----- Original Message -----
From: Ben Bidstrup<mailto:benjamin.bidstrup at bigpond.com>
To:
OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
Sent: Sunday, March 04, 2007 4:10 PM
Subject: Re: AW: [HSF] Deairing the heart
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<mailto:battr at medizin.uni-l
eipzig.de>>
> 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: 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.h
sforum.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<mailto
: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 at aol
com<mailto:Hgrmd at aol.com<mailto:Hgrmd at aol.com<mailto:Hgrmd at aol.com>>>
> To:
>OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailt
o:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mail
to:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mai
lto: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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