[ 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.

[Mitch Lirtzman]

I agree with Hal completely. " Go fast when you can go fast. Go slow when 
you have to go slow." ECONOMY OF MOTION! I learned that at Rush across the 
street from Cook County a little bit before Hal got there.
Mitch At 05:03 PM 1/9/2008, you wrote:

>Ani,
>
>Â  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ortality except when the bypass time rose above 5 hours (unpublished data) -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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