AW: [HSF] Deairing the heart

[Mark Levinson]

On Mar 2, 2007, at 6:02 AM, Dr. Roberto Battellini wrote:

>
I have a de-airing routine that I have been using unchanged for about  
15 years, and with intraopTEE, I rarely see air in the chambers.

I use a dual lumen aortic plegia catheter, with one channel on  
suction and the other as inflow for the plegia.   I do all my cases with
a single cross clamp technique.

Whether an open chamber (valve) or closed (CABG), I use the same de- 
airing routine in every single case without exception.   After the  
completion of the
surgical repair, I ask the perfusionist to put suction on the aortic  
root catheter.    If I have an LV vent (via RSPV),  this line is  
clamped  initially.

Then anesthesia gives a Valsalva breath at my request.    This  
dislodges air and blood from the pulmonary veins and displaces them  
into the LV.   I put my hand
behind the LV and after the breath is let down, I gently compress the  
LV manually and massage the contents into the base of the aorta where  
they are retrieved by the
root suction.

I continue repeating these Valsalva breaths followed by LV manual  
compression for 8 or 10 repetitions.     If the heart is totally  
collapsed during this, I need
to put some volume into the heart to wash the air through, so I  
impede venous return slightly to give volume to the RV and then  
compress the heart to massage the volume across to the LA and then  
repeat the Valsalva steps.      This also has the added benefit of re- 
expanding any atelectasis at the same time.

Then I give hot shot reperfusion for 3 minutes, then K free blood for  
3 minutes.  The root vent is clamped during reperfusion.  After  
releasing the cross-clamp, I place the aortic root (and if present,  
the RSPV vent) back on suction....

After the heart is beating, I ask anesthesia to start ventilating at  
50% of the anticipated tidal volumes while my vents are on  
suction.    At this stage TEE almost
never shows air.     When going to 100% of tidal volume,  
occassionally we see a few bubbles, but nothing like what I am used  
to seeing on
TEE during live teleconferences by the experts, etc.

I do not use CO2.       With the technique described, air has been so  
minimal.

Hope this helps....

Mark M. Levinson, MD
Founder, Editor-in-Chief,
The Heart Surgery Forum
WWW: <http://www.hsforum.com>
Email: <mmLevinson at hsforum.com>