AW: [HSF] Twisting of Vein grafts

Tue Mar 13 15:59:34 EDT 2007

Agree with Dr.Bidstrup.100% off-pump,all the patients included (diffuse 
disease,intramural coronaries,tortous coronaries in fatty old ladies,...) 
average surgeon,average anesthetist.Something is missing in this equation.
erdinc

>From: Ben Bidstrup <benjamin.bidstrup at bigpond.com>
>Reply-To: OpenHeart-L at lists.hsforum.com
>To: OpenHeart-L at lists.hsforum.com
>Subject: RE: AW: [HSF] Twisting of Vein grafts
>Date: Tue, 13 Mar 2007 07:22:23 +1100
>
>Tomas,
>Be real, Less than 20% of CABG is done off pump around the world. You must 
>be living in a castle in the sky if you believe everyone does things your 
>way!
>There are as many methods of doing CABG as there are hot breakfasts served 
>at MacDonalds every morning.
>The best operation for a surgeon to do is the operation he does best. When 
>the s..t is hitting the fan, it is not the time to change everything (or 
>anything for that matter).
>Start doing new methods, but only where you have some room to move. Do the 
>beating heart surgery on a patient with a normal ventricle and simple 
>anatomy, not start with an EF of 10% , 4+MR and a LV aneurysm with AF.
>
>The advantage of this forum is that we can all espouse our methods (usually 
>in an anecdotal way without peer review of results) and those who 
>understand change and ways to improve outcomes and have the ability to 
>change and monitor the effects of change, can try it.
>All too often, something happens and rather  than a review of the exact 
>problem another layer of complexity gets added and also yet another slice 
>of cheese  with more holes in it.
>
>We try and use and evidence base, but all too often the evidence is too 
>sparse.
>
>
>>When injecting into a constructed anastomosis with vein, the pressure in
>>the serynge overcomes any obstruction in the distal bed, and this is not
>>a reliable method.
>>
>>Just for scientific purpose, any study that is done on coronary surgery
>>that involves patency by angiography post surgery, by definition will
>>need some form of quality control of the anastomoses prior to completion
>>of the operation. Otherwise if an anastomoses went down at time of
>>angiography, one never know if it was  already occluded when the chest
>>was closed.
>>
>>I keep hearing about injection of cardioplegia into the constructed
>>anastomoses of coronary grafts; are surgeons still putting patients on
>>pump for coronary surgery and administering cardioplegia?
>>
>>Tomas
>>
>>-----Original Message-----
>>From: openheart-l-bounces at lists.hsforum.com
>>[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Ben Bidstrup
>>Sent: Monday, March 12, 2007 3:06 PM
>>To: OpenHeart-L at lists.hsforum.com
>>Subject: Re: AW: [HSF] Twisting of Vein grafts
>>
>>David Taggart described its use a few weeks ago. Like most things it
>>takes some time and patience to get  it right, a bit like doing
>>coronaries.
>>Using the cardioplegia method, it will not tell if there is a 50%
>>stenosis at the anastomosis, nor can it distinguish from a technical
>>problem vs a distal bed issue, which in many cases can be the cause
>>of early failure.
>>
>>Like everything in health care, if some one can make a buck out of
>>it, they will try and make 2!
>>I use a syringe full of blood(y) saline injected by hand to do this.
>>It also gets the length right and avoids in most cases the potential
>>twisting. Can be done whilst retrograde cardioplegia is being given.
>>Also it saves on a complex and expensive octopus system many surgeons
>>use to infuse each graft after the distal is done but before the
>>proximals are done.
>>
>>
>>>Does anyone actually use the SPY system - I saw it attempted a few
>>times
>>>with little success before the stuff was tossed out of the room.
>>>
>>>Another issue is not just the cost of the meters (which are sometimes
>>free)
>>>- but more the cost of the probes and some of the marketing tools used
>>to
>>>abstract every last cent (US$) from hospitals.
>>>
>>>Obviously if there is a question, check it.  I (as I have been trained)
>>>flush plegia down each vein after the anastamosis and perfusion can
>>tell me
>>>the pressure and flow rates....
>>>
>>>
>>>-michael
>>>
>>>
>>>On 3/12/07, Salerno, Tomas <TSalerno at med.miami.edu> wrote:
>>>>
>>>>Dear Roberto:
>>>>
>>>>At least in principle, can we agree that quality control of the
>>>>anastomoses is something that should be mandatory? Same for Xray after
>>chest
>>>>tube insertion, central line insertion, angiogram after stenting,
>>etc, etc.
>>>>Angiogram in the operating room is not practical and most centers
>>cannot
>>  >>do it. SPY is an alternative.
>>>>
>>>>I realize that even in North America, majority of surgeons do not want
>>to
>>>>perform quality control of the anastomoses, the majority feeling that
>>they
>>>>do perfect anastomoses under magnification and see no need for extra
>>time
>>>>determining whether flow is present or not. I have been surprise when
>>doing
>>>>the easiest possible LIMA-LAD to find out that it is occluded! And my
>>first
>>>>reaction is to blame the flowmeter, since I do not believe it was
>>possible
>>>>that this anastomoses was occluded. Humble experience...
>>>>
>>>>
>>>>Tomas
>>>>
>>>>-----Original Message-----
>>>>From: openheart-l-bounces at lists.hsforum.com [mailto:
>>>>openheart-l-bounces at lists.hsforum.com] On Behalf Of Dr. Roberto
>>Battellini
>>>>Sent: Monday, March 12, 2007 11:16 AM
>>>>To: OpenHeart-L at lists.hsforum.com
>>>>Subject: AW: AW: [HSF] Twisting of Vein grafts
>>>>
>>>>You know as I know that we need an angiogram if we want perfection.
>>>>
>>>>BTW, we have 3 Flowmeters here, which we use in 100% of our cases, one
>>is
>>>>the Cardiosonix.
>>>>But WE are NOT the world, Tomas.
>>>>Roberto
>>>>
>>
>>--
>>Ben Bidstrup FRACS FRCSEd FEBCTS
>>Consultant Cardiothoracic Surgeon
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>
>--
>Ben Bidstrup FRACS FRCSEd FEBCTS
>Consultant Cardiothoracic Surgeon
>_______________________________________________
>OpenHeart-L mailing list
>
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>OpenHeart-L at lists.hsforum.com
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