[HSF] Deairing the heart
Donald Ross
donross at bigpond.com
Thu Mar 8 19:06:57 EST 2007
Bob,
Another personal anecdote from yesteryear: I worked for a wise old
Lord Brock trained surgeon who flooded his field with CO2, as well as
a young gun who thought it was a waste of time. Of course being an
even younger and stupider I agreed with him and didn't realise how
prescient the wise one was till a few years ago. D'oh!
Don
On 08/03/2007, at 5:51 PM, rwmfglycar at aol.com wrote:
> Al Starr's first patient died of air embolism a couple of weeks
> before the first meeting on artificial heart valves in Chicago in
> Sep 1955.
> Roberto and James I have not yet found the reference to the
> experiments in which air was injected up dog carotids. I looked
> for our papers on echo in the OR (we had Mmode echo built into our
> two Electronics for Medicine monitoring machines in our OR's at
> Einstein in the mid seventies; maybe the world's first dedicated
> echo in a cardiac operating room). I could only find copies of two
> and I cannot identify the reference in question. Note that our
> first transesophageal echo's were obtained by tying an Mmode echo
> transducer to an early fiberoptic esophagoscope (no perforations
> ever!) and published in 1979.
> By the way Ani if you read the early papers you will find that
> there have always been many ways to approach the subject of
> evacuating the air. Most can be made to work quite well. Because
> there are many does not mean that the goal is invalid. I suspect
> that you are an impatient surgeon and frustrated by having to spend
> extra time when more bubbles show up on the echo after you have
> been through your routine air removing maneuvers. Almost certainly
> you have missed doing an essential part properly if this happens.
> The more experienced you are at these tricks the more often nothing
> is seen at their completion.
> Don't respond or I will regard you as wilfully obtuse.
> Which statement of mine does NOT mean that I do not fully
> acknowledge that we do not know what number of snow flakes bopping
> around in the ventricle or aorta at the end of a case will damage
> the brain. It is because they may that we persist.
> It is interesting that much of the early work on clearing
> intracavitary air was concerned with avoiding damage to the
> myocardium; we could see the heart, see the bubbles in surface
> blood vessels and see the deterioration in the myocardial squeeze.
> Our patients, because of many imperfections with our perfusion and
> anesthesia systems, were quite often a bit fuzzy for a day or two,
> so we had nothing to observe let alone measure. However we had done
> work on being sure that we had a filter on the arterial side of the
> bypass machine that would trap air. Classic studies from Stanford
> showed that air down the venous line would show up in the carotid
> arteries (detected by an early ultrasonic probe) very quickly in
> the absence of a filter.
> The late very great anatomy teacher, Stansfield of the Royal
> College of Surgeons, used ask to ask us "Gentlemen, what is the key
> to learning?" We knew well enough to answer in chorus "Eternal
> Repetition!"
> Bob
>
>
> -----Original Message-----
> From: battr at medizin.uni-leipzig.de
> To: OpenHeart-L at lists.hsforum.com
> Sent: Wed, 7 Mar 2007 3:41 PM
> Subject: AW: [HSF] Deairing the heart
>
>
> Prasanna,
> Do you know how did the first Starr valve patient die?
> Ask Bob!
> Roberto
>
> -----Ursprüngliche Nachricht-----
> Von: openheart-l-bounces at lists.hsforum.com
> [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von
> prasannasimha
> Gesendet: Mittwoch, 7. März 2007 15:09
> An: OpenHeart-L at lists.hsforum.com
> Betreff: Re: [HSF] Deairing the heart
>
> Having gone through various phases of teaching =- from being taught to
> being a teacher let me tell you one thing - when making residents
> do an
> ASD the one thing that I personally will do is deair even if
> everything
> else is done by the resident.
> I have seen enough residents having significant air embolisms during
> their learning curve that I insist on deairing once after they have
> done so.
> In fact GB Parulkar (our senior teacher in KEM) would come to just
> deair !!
> Being cavalier about deairing can and will cause problems. Most learn
> through the lessons learnt from their teachers but remember many have
> learnt this after paying a biter price.
> The original problems in CPB were often related directly to air
> embolism. See the articles by Gibbon, Clarence Dennis etc who realized
> that this was one of the most important steps (which now is considered
> routine). In fact Melrose developed "cardioplegia" not for myocardial
> protection but to develop a method to prevent "air embolism"
> Prasanna
> Ani Anyanwu wrote:
>> The numerous and highly variable views on this topic, to the
>> extent of
> even discussing how to put a needle in the aorta to extract air
> best (I must
> confess I was stunned at the seriousness many attach to this),
> consolidate
> my view that most of what we do in this regard (deairing) is either,
> ill-understood, inconsequential or irrelevant.
>>
>> My suspicion is that it doesn’t really matter what we do - so far
>> as one
> gets the gross air out, the rest is fine talk. I know I will as
> usually
> incur the wrath of my seniors, but if it is so crucial and as
> technical as
> list members portray, how come we are getting so many highly
> opinionated but
> varying views? Surely they can't all be right at the same time?
> Maybe they
> can all be wrong though...Of course the red flag is that
> practically no
> contributor on this has provided evidence (experimental or
> clinical) to
> justify their deairing strategy - at the end of the day it is just
> surgeon
> preference, voodoo or a recipe handed by our teachers. I suspect
> whatever
> one chooses (apart from ignoring the air) works, not because of
> what we do,
> but because of the attempts we make (by whatever means) to remove
> the air.
>>
>> Ani
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