AW: [HSF] aortic root reimplantation and Rv dysfx

[erdinç naseri]

Ani,
Thanks for your explanations.I am still curious to know how you and other valuble members of this forum would conduct that case.
erdinc.> From: anianyanwu at hotmail.com> To: openheart-l at lists.hsforum.com> Subject: RE: AW: [HSF] aortic root reimplantation and Rv dysfx> Date: Wed, 5 Sep 2007 22:21:37 +0000> > Erdinc> > Sorry to hear outcome of your patient. I fully understand what you mean when you say there are problems specific to less privileged parts of the world. Most who have only lived and worked in rich or privileged nations would not comprehend the degree of constraint you face in doing these complex cases. I trained and worked in a third world country where it is barely possible to safely undertake even closed heart surgery. I remember once have a child die in my hands of anemia because of no access to immediate blood transfusion, i have been in operations where the power supply is lost and surgery has to be continued with aid of flash-lights and non-electronic instruments. I have worked on both ends of the spectrum; however it must be said that to be doing the sort of complex surgery you do, many would actually regard you as privileged. Be assured that you have all our respect and when we ask questions it is for the academic interest and to learn/educate ourselves and not a direct criticism of your practice. As regards your AVR case - remember I said I doubt the patient would have survived in my hands as I do not have the ability to operate that rapidly.> > I am no longer convinced though of this time dependent factor in ischemic damage and subscribe to Salerno's teachings that any ischemia is bad. Beyond that with myocardial preservation I doubt there is much incremental harm. I was brought up in the London school of thought which was that speed is the most essential element in cardiac surgery. Indeed you dare not stop the operation to waste time giving cardioplegia (of course antegrade) as that itself would prolong the clamp time. The most important thing in a low EF case was a brief clamp time and in an elderly patient was a short CPB run. However when I came to North America, I learnt the art of myocardial preservation and have seen many an octogenarian with low EF having multiple procedures clamped for two to four hours. Indeed I operated on an 82 year old, low EF, recent MI, one kidney CABG*3, MV repair, TV repair, cryomaze with over 2 hours clamp last week and he is doing well. In UK few years ago such a patient in my hands would have had a 'quick' 3 vessel bypass and then the rest left to prayers including his significant valvar lesions.> > For the surgeon who has access to good preservation, I think the prime emphasis should in order be 1) myocardial preservation 2) Quality of surgery 3) Correcting all correctable lesions 4) Reducing exposure to heart-lung machine and a distant 5) will be speed.> > Ani> > > > > > From: enaseri at hotmail.com.tr> To: openheart-l at lists.hsforum.com> Subject: RE: AW: [HSF] aortic root reimplantation and Rv dysfx> Date: Wed, 5 Sep 2007 19:49:40 +0000> > > > > 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.> 1.hypothermia is a method of myocardial protection and its maintenance is only possible by systemic hypothermia.Speed is very useful as long as you can get a good result. > Obviously erdinc's situation is different as unpredictability of myocardial protection, logistic problems such as with breakdown in airconditioning > 2.There are problem specific to less privileged parts of the world and those who try to do their best for their patients with courage and sacrifice even in those conditions only deserve respect of their colleagues.> 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). > 3.I am very curious to know what would your strategy be in that 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). > 4.In this specific case the on pump beating heart was aborted seconds after LV dilatation.> 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> 5.If you arrest the heart with whatever method you use there is still a time dependent risk of myocardial damage> 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?> 6.15 plus 15 makes 30 ,30 plus 30 makes 60 and this goes indefinitely.> erdinc> _______________________________________________> 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> -----------------------------------------> _________________________________________________________________> 100’s of Music vouchers to be won with MSN Music> https://www.musicmashup.co.uk_______________________________________________> 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> -----------------------------------------