[HSF] high flowWarm blood cardioplegia versus Salarenos technique

Sun May 6 03:43:41 EDT 2007

I I quite agree that speed is loony with modern techniques of myocardial
preservations. Nevertheless, I think there is a lot to learn from you more
than one can get on HSF cyberspace. Certainly One should come to observe
your practice if ever making it to India.

NFA

On 5/5/07, psimha <prasannasimha at gmail.com> wrote:
>
> Nasser that was continuous not interrupted. !! That too aeons ago. The
> whole point of the discussion was that speed is loony with modern
> cardioplegia (Those where with voodoo home made 3 AM cocktail
> cardioplegia which all KEMites would remember (Guess who got yelled at
> if the heart did not come off CPB - the poor resident in charge of
> making the stupid cocktail)
> Prasanna
> Nasser F. Abou'Seada wrote:
> > 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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> >> >>> >>
> >> >>> >>
> >> >>> >
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> >> >>
> >> >
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> >> >
> >>
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> >
> >
> >
>
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-- 
Nasser  F.  Abou'Seada,
MB,ChB,MD,FRCSEd,ChM,ChD C/Th,
FICS,FISCVS,FSSRCTS,FHMS,MESC