Re: [金山毒霸识别此邮件为垃圾邮件]RE: [HSF] v-feb after AVR+mitral repair+ACB to RCA.

[hgrmd at aol.com]

Ani,

  When I was in general surgery training, my favorite vascular attendings used to say, "I go slow so I can go fast".  He was locally reknowned for his speed and technical excellence.  However, during the delicate parts of the case, he went slowly and deliberately with no wasted movements.  That's the kind of surgeon I try to be, and that's the type of surgeon I would want operating on me.

Hal








-----Original Message-----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Wed, 9 Jan 2008 4:41 pm
Subject: RE: [金山毒霸识别此邮件为垃圾邮件]RE: [HSF] v-feb after AVR+mitral repair+ACB to RCA.



Steve

 do not actually think that the length of bypass time or cross clamp time 
atters provided it is below a critical threshold (maybe 4 to 5 hours depending 
n the patient) except in unique situations (maybe such as the severely 
epressed ventricle, questionable myocardial protection, vasoplegic patients, 
atients in liver failure etc). I looked at our local experience over 6 years 
nd there was no independent association between length of bypass and operative 
ortality except when the bypass time rose above 5 hours (unpublished data) - 
owever even in those long bypass runs I do not think CPB was wholly to blame 
ut rather a long pump run is often a surrogate for some other intraoperative 
roblem or complexity of surgery which themselves result in poor outcome.

n our center, pump runs of 3 to 4 hours are an almost daily occurrence. Indeed 
r Zhou talks of Carpentier doing a mitral with 2.5 hr cross-clamp many years 
go but that is still the case in my center - we just published our series on 
arlow repair and the median bypass time was 3 hrs (i.e. half were on bypass 
onger than 3 hours).

ersonally I do not want a quick operation. I do not want my mammary taken in 8 
inutes, my CABG completed skin to skin in 2 hours or my mitral valve sewn in in 
0 minutes. Given a choice I would prefer an operation of moderate length to a 
uick one (obviously i do not want a long one if I can avoid it). We just did a 
hird time reop mitral replacement in a patient with paravalvar leak - our clamp 
ime was 126 minutes. In the previous two operations (done within last 18 
onths) the clamp times were 29 minutes and 40 minutes. Both were complicated by 
arly papravalvar leak. The last procedure had 12 sutures round the valve which 
ay not be adequate considering the indication of paravalvar leak - somehow i 
eel if the surgeon had taken a bit more time, the paravalvar leak could have 
een avoided.

egarding again your patient, we cannot say the ECG is normal if there was 
entricular arrhythmia - in a patient who has had CABG, coronary ischemia must 
till be high on the list of potential causes. Also as was discussed before echo 
annot rule out tamponade and in some cases as Ed pointed out in (see previous 
hread on cardiac arrest post CABG), a clot can cause localized graft 
ompression without cardiac tamponade.

ni

> From: stevecx at jlonline.com> To: OpenHeart-L at lists.hsforum.com> Subject: Re: 
金山毒霸识别此邮件为垃圾邮件]RE: [HSF] v-feb after AVR+mitral repair+ACB to RCA.> Date: Wed, 
 Jan 2008 07:18:52 +0800> CC: > > Thank u very much for your comments, Ani. > > 
here was nothing special during the surgery. Just regular AVR and mitral ring 
epair, and single bypass. And tricucpid repair without ring. > > Though we have 
retty good cardiaplegia to protect hte heart, I still believe if we can do the 
ame ferpect surgery, short cross clamp time and short pump run will be better 
han longer. Do you agree?> > During his first night, I was think if we need 
e-open to check. But is seems no indicated for graft failur ( Normal EKG), 
ormal echo ( no temponate), normal valve function. What to do if re-open? > > 
ust cuirious about why that happen. I may get cath for himm before send him 
ome. > > Thanks again for your comments > > Steve> > ----- Original Message 
---- > From: "Ani Anyanwu" <anianyanwu at hotmail.com>> To: <openheart-l at lists.hsforum.com>> 
ent: Wednesday, January 09, 2008 6:46 AM> Subject: [金山毒霸识别此邮件为垃圾邮件]RE: [HSF] 
-feb after AVR+mitral repair+ACB to RCA.> > > Steve> > One thing that strikes 
e in your post is the emphasis placed on time. While you did not provide us 
ith critical information regarding the conduct of the surgery (such as vaalve 
mplanted, implantation techniques, repair technique, myocardial preservation 
tc) you mention the 85 minute clamp, that patient was back in ICU at 2pm and 
xtubated at 6pm. Although this may not be the case here it seems that as 
urgeons we tend to use (rapid) time as a surrogate for a measure of excellence 
n execution or outcome of a procedure. The assumption is that if the operation 
as accomplished expeditiously then it was done well (as most perfusionists and 
nesthesiologists believe). > > I think there is inherent danger in our emphasis 
n time. Does it matter really how long a heart was clamped? One could argue the 
ontrary that in a bid to perform expeditious surgery one is more likely to omit 
r overlook a fine detail that could end up with major complication, something a 
aw not infrequently in London as surgical speed was considered by many an 
ssence of cardiac surgery. Personally I would rather more than 85 minutes of 
lamp was spent doing my AVR, mitral repair and single vessel bypass, so I am 
ot sure all would necessarily agree that the short clamp time is a measure of a 
ell conducted and uncomplicated procedure.> > Like others I would continue to 
e worried about this patient. As the cause of these arrhythmias has not been 
stablished they may well recur again. I am curious to know though what the 
houghts were when he was having arrhythmias - if he was defibrillated 20 times 
n a few hours, would that not be an indication for either cardiac 
atheterization or surgical re-exploration? As he did not have arrhythmias 
efore surgery should we not assume - until proven otherwise -that the something 
one at surgery was the direct cause and thus must be excluded? A normal echo 
ould not mean much here as an echo could not really diagnose any (surgical) 
ause of arrythmia. Good to hear the patient did okay. In this case wishful 
hinking prevailed but if the outcome had been bad, it would have been difficult 
o 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 
an 2008 06:59:46 +0800> CC: > Subject: [HSF] v-feb after AVR+mitral repair+ACB 
o RCA.> > Dear Members:> > 65 years male with severe AI and mitral regarg ( +++ 
o ++++), EF 40%, single RCA 80% stenosis, some PVC on EKG, got AVR+ mitral 
epair and ACB to RCA last week. He went smoothly during surgery and X'clamp is 
5 mins. Off CPB OK, TEE: no mitral regarg, AVR ok. leave v-pacing wire on just 
n case ( which is our regular thing for all valve cases). Back to ICU in about 
4:00 with Dopo about 4 mic/kg. Wake up in about 18:00 and extubated then. 
verything went fine until about 20:00, got v-tach and then v-fib. De-dib, back 
o sinus with stable hemodynemics. Put on Lidocane, K+ level OK, ABG OK, then 
-dib again and again for about 5 to 9 times, then put on Amikedalon ( moy not 
orrect spelling). Check X-ray OK., Check echo both AVR and mitral are ok, with 
F 38%. Hemodynemic stable. Urin out put OK. Be sedated with propfin and be 
ntubated again. But still many times v-fib, need de-fib for about 20 times in 
hat evening. The next morning, check echo again, everything fine with EF about 
0%. Put IABP anyway. V-fib about 5 times during the 1 POD, and 3 times in the 
vening. Then 2 times in the 2 POD. then fine. stop sedated and then Extubed in 
he 4 POD and then IABP withdrow there after. Then went well and back to the 
loor. > > Not sure what cause the v-tech and v-fib. > > Any comments?> > Thank 
ou in advance> > > Steve> _________________________________________________________________> 
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