AW: [HSF] aortic root reimplantation and Rv dysfx

[Prasanna Simha]

Ani,
There are two ways to looking at it. One wrt the heart and one wrt the body.
What is "physiological about CPB?- nothing"
If we can reduce the perfusion time we can then  decrease the  net 
inflammatory response. On the other hand doing everything on a quite 
arrested heart gives us  time though we then have to up the ante on body 
and myocardial protection.
When I was a resident in training we used to have the "rush" mentality 
ingrained into us but then we were using terrible myocardial 
preservation methods and speed was essential (and was actually a matter 
of life and death). I do not think that this is the case now with 
current methods but it obviously better to have a shorter CPB run 
provided it does not sacrifice quality. If one is comfortable with 
offpump, one can do a good quality anastomosis wrt  both surgeon and 
target vessels and also hemodynamic stability is not compromised doing 
the CABG off pump may reduce CPB time aand the bodies inflammatory 
response. (Having said that I would  do them all on CPB  though in the 
offpump "craze" time we were doing it  as a hybrid without problems).
Prasanna

Ani Anyanwu wrote:
> Dear Roberto
>  
> I agree with what you say. In the present day of modern myocardial protection, there is generally no longer a need for speed or systemic hypothermia as a method of myocardial preservation. Obviously erdinc's situation is different as unpredictability of myocardial protection, logistic problems such as with breakdown in airconditioning and maybe varied ability to ensure good quality cardioplegia may mean speed and hypothermia continue to be important (such as in his recently reported AVR case). 
>  
> I discussed the issue of hybrid approaches recently with a colleague and would be interested to know other's opinions on it. I know for example Dr Salerno would likely advocate doing all the CABG without CPB then going on pump to do the rest beating. However, what does one gain with such hybrid approaches? In erdinc's case, the attempt to do the grafts beating heart, albeit on pump, probably worsened rather than helped the situation (for example, even perfused myocardium could become ischemic during LV distension). What specifically is the advantage of not clamping the heart and doing the CABG as the heart will be clamped anyway? With modern myocardial preservation, are the risks of the ischemia still time dependent? I can understand the logic of avoiding ischemia entirely as Salerno and some others would do, but if one is going to render the heart ischemic anyway, what is the down-fall of an extra 15 to 30 minutes of ischemia to additionally perform two grafts?
>  
> Ani
>
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