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[Ani Anyanwu]

Steve
 
I do not actually think that the length of bypass time or cross clamp time matters provided it is below a critical threshold (maybe 4 to 5 hours depending on the patient) except in unique situations (maybe such as the severely depressed ventricle, questionable myocardial protection, vasoplegic patients, patients in liver failure etc). I looked at our local experience over 6 years and there was no independent association between length of bypass and operative mortality except when the bypass time rose above 5 hours (unpublished data) - however even in those long bypass runs I do not think CPB was wholly to blame but rather a long pump run is often a surrogate for some other intraoperative problem or complexity of surgery which themselves result in poor outcome.
 
In our center, pump runs of 3 to 4 hours are an almost daily occurrence. Indeed Dr Zhou talks of Carpentier doing a mitral with 2.5 hr cross-clamp many years ago but that is still the case in my center - we just published our series on Barlow repair and the median bypass time was 3 hrs (i.e. half were on bypass longer than 3 hours).
 
Personally I do not want a quick operation. I do not want my mammary taken in 8 minutes, my CABG completed skin to skin in 2 hours or my mitral valve sewn in in 20 minutes. Given a choice I would prefer an operation of moderate length to a quick one (obviously i do not want a long one if I can avoid it). We just did a third time reop mitral replacement in a patient with paravalvar leak - our clamp time was 126 minutes. In the previous two operations (done within last 18 months) the clamp times were 29 minutes and 40 minutes. Both were complicated by early papravalvar leak. The last procedure had 12 sutures round the valve which may not be adequate considering the indication of paravalvar leak - somehow i feel if the surgeon had taken a bit more time, the paravalvar leak could have been avoided.
 
Regarding again your patient, we cannot say the ECG is normal if there was ventricular arrhythmia - in a patient who has had CABG, coronary ischemia must still be high on the list of potential causes. Also as was discussed before echo cannot rule out tamponade and in some cases as Ed pointed out in (see previous thread on cardiac arrest post CABG), a clot can cause localized graft compression without cardiac tamponade.
 
Ani



> From: stevecx at jlonline.com> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [½ðɽ¶¾°Ôʶ±ð´ËÓʼþΪÀ¬»øÓʼþ]RE: [HSF] v-feb after AVR+mitral repair+ACB to RCA.> Date: Wed, 9 Jan 2008 07:18:52 +0800> CC: > > Thank u very much for your comments, Ani. > > There was nothing special during the surgery. Just regular AVR and mitral ring repair, and single bypass. And tricucpid repair without ring. > > Though we have pretty good cardiaplegia to protect hte heart, I still believe if we can do the same ferpect surgery, short cross clamp time and short pump run will be better than longer. Do you agree?> > During his first night, I was think if we need re-open to check. But is seems no indicated for graft failur ( Normal EKG), normal echo ( no temponate), normal valve function. What to do if re-open? > > Just cuirious about why that happen. I may get cath for himm before send him home. > > Thanks again for your comments > > Steve> > ----- Original Message ----- > From: "Ani Anyanwu" <anianyanwu at hotmail.com>> To: <openheart-l at lists.hsforum.com>> Sent: Wednesday, January 09, 2008 6:46 AM> Subject: [½ðɽ¶¾°Ôʶ±ð´ËÓʼþΪÀ¬»øÓʼþ]RE: [HSF] v-feb after AVR+mitral repair+ACB to RCA.> > > Steve> > One thing that strikes me in your post is the emphasis placed on time. While you did not provide us with critical information regarding the conduct of the surgery (such as vaalve implanted, implantation techniques, repair technique, myocardial preservation etc) you mention the 85 minute clamp, that patient was back in ICU at 2pm and extubated at 6pm. Although this may not be the case here it seems that as surgeons we tend to use (rapid) time as a surrogate for a measure of excellence in execution or outcome of a procedure. The assumption is that if the operation was accomplished expeditiously then it was done well (as most perfusionists and anesthesiologists believe). > > I think there is inherent danger in our emphasis on time. Does it matter really how long a heart was clamped? One could argue the contrary that in a bid to perform expeditious surgery one is more likely to omit or overlook a fine detail that could end up with major complication, something a saw not infrequently in London as surgical speed was considered by many an essence of cardiac surgery. Personally I would rather more than 85 minutes of clamp was spent doing my AVR, mitral repair and single vessel bypass, so I am not sure all would necessarily agree that the short clamp time is a measure of a well conducted and uncomplicated procedure.> > Like others I would continue to be worried about this patient. As the cause of these arrhythmias has not been established they may well recur again. I am curious to know though what the thoughts were when he was having arrhythmias - if he was defibrillated 20 times in a few hours, would that not be an indication for either cardiac catheterization or surgical re-exploration? As he did not have arrhythmias before surgery should we not assume - until proven otherwise -that the something done at surgery was the direct cause and thus must be excluded? A normal echo would not mean much here as an echo could not really diagnose any (surgical) cause of arrythmia. Good to hear the patient did okay. In this case wishful thinking prevailed but if the outcome had been bad, it would have been difficult to justify not reopening the patient's chest on the first night.> > > Ani> > > > > > From: stevecx at jlonline.com> To: OpenHeart-L at lists.hsforum.com> Date: Tue, 8 Jan 2008 06:59:46 +0800> CC: > Subject: [HSF] v-feb after AVR+mitral repair+ACB to RCA.> > Dear Members:> > 65 years male with severe AI and mitral regarg ( +++ to ++++), EF 40%, single RCA 80% stenosis, some PVC on EKG, got AVR+ mitral repair and ACB to RCA last week. He went smoothly during surgery and X'clamp is 85 mins. Off CPB OK, TEE: no mitral regarg, AVR ok. leave v-pacing wire on just in case ( which is our regular thing for all valve cases). Back to ICU in about 14:00 with Dopo about 4 mic/kg. Wake up in about 18:00 and extubated then. Everything went fine until about 20:00, got v-tach and then v-fib. De-dib, back to sinus with stable hemodynemics. Put on Lidocane, K+ level OK, ABG OK, then v-dib again and again for about 5 to 9 times, then put on Amikedalon ( moy not correct spelling). Check X-ray OK., Check echo both AVR and mitral are ok, with EF 38%. Hemodynemic stable. Urin out put OK. Be sedated with propfin and be Intubated again. But still many times v-fib, need de-fib for about 20 times in that evening. The next morning, check echo again, everything fine with EF about 40%. Put IABP anyway. V-fib about 5 times during the 1 POD, and 3 times in the evening. Then 2 times in the 2 POD. then fine. stop sedated and then Extubed in the 4 POD and then IABP withdrow there after. Then went well and back to the floor. > > Not sure what cause the v-tech and v-fib. > > Any comments?> > Thank you in advance> > > Steve> _________________________________________________________________> Fancy some celeb spotting? > https://www.celebmashup.com_______________________________________________> 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> -----------------------------------------
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