[HSF] high flowWarm blood cardioplegia versus Salarenos technique

Sun May 6 05:28:59 EDT 2007

surely prasanna ..... be careful ... I do enjoy indian food ... eat too much
...

NFA

On 5/6/07, prasannasimha <prasannasimha at gmail.com> wrote:
>
> You are welcome any time.
> Prasanna
> Nasser F. Abou'Seada wrote:
> > 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.
> >> >> >>> >> _______________________________________________
> >> >> >>> >> OpenHeart-L mailing list
> >> >> >>> >>
> >> >> >>> >> Send postings to:
> >> >> >>> >>  OpenHeart-L at lists.hsforum.com
> >> >> >>> >>
> >> >> >>> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >> >> >>> >> http://mmp.cjp.com/mailman/listinfo/openheart-l
> >> >> >>> >>
> >> >> >>> >> All messages transmitted by the OpenHeart-L are subject to
> the
> >> >> >>> >> policies and disclaimers posted at:
> >> >> >>> >> http://www.hsforum.com/listdisclaim
> >> >> >>> >> -----------------------------------------
> >> >> >>> >>
> >> >> >>> >>
> >> >> >>> >>
> >> >> >>> >
> >> >> >>> > _______________________________________________
> >> >> >>> > OpenHeart-L mailing list
> >> >> >>> >
> >> >> >>> > Send postings to:
> >> >> >>> > OpenHeart-L at lists.hsforum.com
> >> >> >>> >
> >> >> >>> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >> >> >>> > http://mmp.cjp.com/mailman/listinfo/openheart-l
> >> >> >>> >
> >> >> >>> > All messages transmitted by the OpenHeart-L are subject to the
> >> >> >>> > policies and disclaimers posted at:
> >> >> >>> > http://www.hsforum.com/listdisclaim
> >> >> >>> > -----------------------------------------
> >> >> >>> >
> >> >> >>> >
> >> >> >>>
> >> >> >>> _______________________________________________
> >> >> >>> OpenHeart-L mailing list
> >> >> >>>
> >> >> >>> Send postings to:
> >> >> >>> OpenHeart-L at lists.hsforum.com
> >> >> >>>
> >> >> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >> >> >>> http://mmp.cjp.com/mailman/listinfo/openheart-l
> >> >> >>>
> >> >> >>> All messages transmitted by the OpenHeart-L are subject to the
> >> >> policies
> >> >> >>> and
> >> >> >>> disclaimers posted at:
> >> >> >>> http://www.hsforum.com/listdisclaim
> >> >> >>> -----------------------------------------
> >> >> >>> _______________________________________________
> >> >> >>> OpenHeart-L mailing list
> >> >> >>>
> >> >> >>> Send postings to:
> >> >> >>> OpenHeart-L at lists.hsforum.com
> >> >> >>>
> >> >> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >> >> >>> http://mmp.cjp.com/mailman/listinfo/openheart-l
> >> >> >>>
> >> >> >>> All messages transmitted by the OpenHeart-L are subject to the
> >> >> policies
> >> >> >>> and
> >> >> >>> disclaimers posted at:
> >> >> >>> http://www.hsforum.com/listdisclaim
> >> >> >>> -----------------------------------------
> >> >> >>>
> >> >> >> _______________________________________________
> >> >> >> OpenHeart-L mailing list
> >> >> >>
> >> >> >> Send postings to:
> >> >> >> OpenHeart-L at lists.hsforum.com
> >> >> >>
> >> >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >> >> >> http://mmp.cjp.com/mailman/listinfo/openheart-l
> >> >> >>
> >> >> >> All messages transmitted by the OpenHeart-L are subject to the
> >> >> >> policies and disclaimers posted at:
> >> >> >> http://www.hsforum.com/listdisclaim
> >> >> >> -----------------------------------------
> >> >> >>
> >> >> >>
> >> >> >
> >> >> > _______________________________________________
> >> >> > OpenHeart-L mailing list
> >> >> >
> >> >> > Send postings to:
> >> >> > OpenHeart-L at lists.hsforum.com
> >> >> >
> >> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >> >> > http://mmp.cjp.com/mailman/listinfo/openheart-l
> >> >> >
> >> >> > All messages transmitted by the OpenHeart-L are subject to the
> >> >> > policies and disclaimers posted at:
> >> >> > http://www.hsforum.com/listdisclaim
> >> >> > -----------------------------------------
> >> >> >
> >> >> >
> >> >>
> >> >> _______________________________________________
> >> >> OpenHeart-L mailing list
> >> >>
> >> >> Send postings to:
> >> >> OpenHeart-L at lists.hsforum.com
> >> >>
> >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >> >> http://mmp.cjp.com/mailman/listinfo/openheart-l
> >> >>
> >> >> All messages transmitted by the OpenHeart-L are subject to the
> >> policies
> >> >> and
> >> >> disclaimers posted at:
> >> >> http://www.hsforum.com/listdisclaim
> >> >> -----------------------------------------
> >> >>
> >> >
> >> >
> >> >
> >>
> >> _______________________________________________
> >> OpenHeart-L mailing list
> >>
> >> Send postings to:
> >> OpenHeart-L at lists.hsforum.com
> >>
> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >> http://mmp.cjp.com/mailman/listinfo/openheart-l
> >>
> >> All messages transmitted by the OpenHeart-L are subject to the policies
> >> and
> >> disclaimers posted at:
> >> http://www.hsforum.com/listdisclaim
> >> -----------------------------------------
> >>
> >
> >
> >
>
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
> OpenHeart-L at lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the policies
> and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------
>

-- 
Nasser  F.  Abou'Seada,
MB,ChB,MD,FRCSEd,ChM,ChD C/Th,
FICS,FISCVS,FSSRCTS,FHMS,MESC