[HSF] high flowWarm blood cardioplegia versus Salarenos technique

Sat May 5 18:53:12 EDT 2007

that is a magnificent figure prasanna ........... 16 min ? ........ total XC
? .... interrupted? .... that is a sewing machine speed ...  what is your
time now ...
I have observed C. Duran working like a real sewing machine in downloading a
valve, interrupted, whenever a repair failed. don't think I have ever seen a
faster speed. I insert valve prosthesis as inserting stitches in native ring
while my assistant is inserting stitches simultaneously in the prosthesis
..... never aproaching such figure .... I must see you sometime .....

NFA

On 4/20/07, prasannasimha <prasannasimha at gmail.com> wrote:
>
> That was supposed to be 16 -18 minutes (Not 116 !!)
> prasannasimha wrote:
> > Why did you choose Epi prophylactically ? ? I find that adding small
> > amount Dobut (3 mics)  gives a uniform vasodilatation,lower lactimes
> > post CPB compared to prophylactic Epi.
> > One way to avoid hyperkalemia with large volume plegia is to add
> > Insulin - 4-6 U in the 4 :1 cardioplegia bottle. This allows
> > simultaneous reduction of K while cardioplegia is delivered
> > proportional to the amount of K given. Also you can use cold blood
> > continuously instead of with K and the instruction is to give K only
> > if activity is seen With these I have cross clamped for over 6 hours
> > and yet have had normal K at the end of the procedure. As  have
> > mentioned I also use Esmolol and Adenosine which adds to the protection.
> > As far as time is concerned , precision is more important and while I
> > used to down valves with X clamps of 116-18 minutes when I was a
> > student  and using voodoo crystalloid cardioplegia I do not bother to
> > be speedy now (with current cardioplegic techniques) and speed is
> > achieved and not the objective.Roberto made a good presentation on
> > speed in cardiac surgery and is worth reading.
> > Plegia is the great leveler that  demolished the "men from the boys"
> era.
> > Prasanna
> >
> > Michael Firstenberg wrote:
> >> What I have learned over my brief few years is that if a little
> >> plegia is
> >> good - then more is better.  Cold antegrade, cold retro, down vein
> >> grafts,
> >> everywhere every 15-20 minutes or less if it is a good time (like
> >> putting
> >> the sutures thru a ring/valve), hot shot at the end, let the heart
> >> reperfuse
> >> for at least 15 minutes before weaning from CPB - pace/cardiovert if
> >> needed.  That's what I learned from Lytle and as a "new guy" with
> >> probably
> >> above average pump time - that philosophy has served me well (knock
> >> on wood)
> >> so far.  Yes, sometimes the K is a little high coming off, but that
> >> can be
> >> delt with.  My CABGx3, double valve (TVR-MVR), PFO, with +1 AI and 4
> >> hrs on
> >> pump (sorry - give a new guy a break) came off will only a little epi
> >> and
> >> nitro (probably not even needed, but didnt have a swan) last night
> >> and looks
> >> great this am walking the floors (better to be lucky than be good?).
> >>
> >> Pledgia is your friend - and a very good one at that.
> >>
> >> -michael
> >>
> >>
> >> On 4/20/07, Salerno, Tomas <TSalerno at med.miami.edu> wrote:
> >>>
> >>> I just want to make the point that patients seem to do better, and we
> >>> now have evidence from laboratory and clinical work, if the heart is
> >>> perfused for the most part of the operation.  Warm heart surgery, as
> >>> developed by us, was not designed to subjected the heart for period of
> >>> normothermic ischemia; however, we made the statement and had evidence
> >>> that, for short periods of time, warm arrest was actually better than
> >>> cold arrest, if the heart could be reperfused every 10 minutes.
> >>>
> >>> This chapter was closed however, when we abandoned potassium all
> >>> together from cardioplegia, and have perfused hearts with warm blood
> >>> ante/retro simultaneously. The manuscript is being submitted now on
> the
> >>> clinical work, although the animal work was published recently in the
> >>> JTVS.  The reasons are many fold, but hemodilution, potassium
> overload,
> >>> and the fact that cardiac action promotes lymphatic drainage, all have
> >>> led me to believe that, if it is possible, the heart should be allowed
> >>> to beat during surgery.
> >>>
> >>> Certainly for most valves and other procedures, this is possible. If
> >>> not, there is always the option of arrest, either warm or cold,
> >>> intermittent or continuously, depending on the circumstances.  Cold
> >>> blood does not deliver oxygen, and if cold techniques are used, the
> >>> surgeon should monitor temperatures. If warm perfusion is used, with
> or
> >>> without potassium maximum flows should be used, since we have no way
> of
> >>> monitoring the heart currently.
> >>>
> >>> I have come full circle in my thinking about myocardial protection,
> and
> >>> perfusion comes close to the "ideal" method.
> >>>
> >>>
> >>> Tomas
> >>>
> >>> -----Original Message-----
> >>> From: openheart-l-bounces at lists.hsforum.com
> >>> [mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of
> >>> prasannasimha
> >>> Sent: Friday, April 20, 2007 8:28 AM
> >>> To: OpenHeart-L at lists.hsforum.com
> >>> Subject: Re: [HSF] high flowWarm blood cardioplegia versus Salarenos
> >>> technique
> >>>
> >>> The question you have to ask is what exactly is the point that is
> >>> making
> >>>
> >>> your current myocardial strategy unsatisfactory ? Analysis of that is
> >>> what is required.
> >>> Prasanna
> >>> prasannasimha wrote:
> >>> > James we went through all these cycles of variants over the years .
> >>> > The cold warm cold variants keep coming back in cycles like the
> skirt
> >>> > lengths in Fashion. I do not know how many years you have been in
> >>> > practice but you will see this cycle again and again !! I bet Dr
> >>> > Frater and Dr Salerno would be able to get a rough count of how many
> >>> > times the fashion came and went.
> >>> > My main reason for not using continuous warm - can be messy at
> times,
> >>> > higher amount of systemic K+ (even with simultaneous Insulin) and my
> >>> > personal belief that normothermic perfusion should not be
> >>> interrupted.
> >>> > My practice is to use cold plegia for the critical components, cold
> >>> > continuous when not doing important things (like taking sutures into
> >>> > the ring and tying knots, isothermic (whatever temp is systemic)
> >>> > perfusion during the maze/ closure of incisions so that the heart is
> >>> > actually beating by the time the cross clamp is removed. For this
> >>> time
> >>>
> >>> > it such that your temperature is around 32 Deg (even if lower - no
> >>> > harm) when you are doing continuous normokalemic perfusion) - I
> >>> made a
> >>>
> >>> > mistake in Croatia in the sense that I did not realize that they
> were
> >>> > referring to blood temperature and rectal temperatures whereas I am
> >>> > used to nasopharyngeal temperature. I was initially perplexed why I
> >>> > had a higher defib rate and then realized actually I was still very
> >>> > hypothermic. (Personally if a heart requires defibrillation  (unless
> >>> > it is due to some other reason) I strongly believe that
> cardioplegia/
> >>> > myocardial preservation strategy is suboptimal).
> >>> > I think Dr Salerno will say that continuous warm does not improve
> >>> > myocardial lymphatic flow.
> >>> >
> >>> > Prasanna
> >>> > james le wrote:
> >>> >> I wish to know whether  continuous, high flow, warm blood
> >>> >> cardioplegia  with will be as effective as salerenos  perfused
> >>> >> beating heart techniqe regarding mycardial protection.
> >>> >>        ---------------------------------
> >>> >> Ahhh...imagining that irresistible "new car" smell?
> >>> >>  Check outnew cars at Yahoo! Autos.
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-- 
Nasser  F.  Abou'Seada,
MB,ChB,MD,FRCSEd,ChM,ChD C/Th,
FICS,FISCVS,FSSRCTS,FHMS,MESC