AW: [HSF] Deairing the heart: chasing the wrong villain

Wed Mar 7 21:13:23 EST 2007

I think that Ani needs to perform a series valve  cases with normal aorta
and without deairing the heart and looking what happens...
Roberto

-----Ursprüngliche Nachricht-----
Von: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von
jbflegejr at aol.com
Gesendet: Mittwoch, 7. März 2007 02:05
An: OpenHeart-L at lists.hsforum.com
Betreff: 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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  --
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  Consultant Cardiothoracic Surgeon
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