[HSF] New case- CAD + Leriche

Mon May 19 20:35:01 EDT 2008

If you haven't made a big difference in a "8cm" LV, you need destination therapy for a long term result. Short term support is a surgical ego thing. Dion said this in a different way at AATS.
tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Sunday, May 18, 2008 2:08:31 PM
Subject: RE: [HSF] New case- CAD + Leriche

> Ani- Interesting, are you saying that every pt with low EF and difficulty coming off pump you would preferentially put in a VAD instead of trying a balloon first?> > tom

Yes I am toying with that idea. 

If EF is very low, heart very dilated (8cm+) and I have not done much to improve it acutely  (esp if repaired the mitral which would acutely depress the heart function), and it is a patient I would ideally transplant but can't (typically because too old) then yes. I did one such case few weeks ago where I went straight to tandem heart - actually did so pre-emptively - and post-op course was amazingly benign. In that case I did not mess around with a balloon. 

I actually think the balloon will become extinct as a means for circulatory support (will remain used for myocardial ischemia) once effective low-profile percutaneous VADs are established and proven.

Ani

> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] New case- CAD + Leriche> Date: Sun, 18 May 2008 14:54:24 -0400> From: tdmartin2000 at aol.com> CC: > > Ani- Interesting, are you saying that every pt with low EF and difficulty coming off pump you would preferentially put in a VAD instead of trying a balloon first?> > tom> > > -----Original Message-----> From: Ani Anyanwu <anianyanwu at hotmail.com>> To: openheart-l at lists.hsforum.com> Sent: Fri, 16 May 2008 8:53 am> Subject: RE: [HSF] New case- CAD + Leriche> > > > > I worry about not having a good and safe way to use a IABP and the possibility > of severe lower extem ischemia if we have any problem with low output. > > > Tom> > > Dr Martin> > In such a case we would go straight to temporary mechanical support (LVAD) and > not mess around with IABP if we have low-output. > > Few reasons for this rationale: 1) In reality IABP is probably of limited > effectiveness in increasing cardiac output except if
 cause is myocardial > ischemia 2) Avoids risk of vascular complications 3) The alternative - IABP with > high dose catecholamines causes selective vasoconstriction in some vascular beds > and may predispose to renal, hepatic, gastrointestinal and limb complications. > We feel that having a patient with a good cardiac output from the onset, without > need for vasoconstrictors may be preferable for organ perfusion and may prevent > decline into multi-organ failure. > > In this setting we leave the VAD in for 3 to 4 days then explant - at this time > myocardial stunning should subside, as should bleeding and need for > transfusions, the patient can be diuresed to a nice low CVP and such a short > period will hopefully avoid VAD related complications.> > Ani> > > > > To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] New case- CAD + Leriche> > Date: Fri, 16 May 2008 07:51:32 -0400> From: tdmartin2000 at aol.com> CC: > > > Gentlemen> Thanks for the input so
 soon. To answer some of the questions posed > so far- he does pass the eyeball test and in fact works at the info desk at our > hospital, he does smoke but "down to 5 a day", his mitral and aortic valves are > OK and I think the low if may be secondary to his MI, his legs are fairly > ischemic and currently I do not know the status of his vessels below the > inguinal lig. I have thought about all of these approaches and am considering > either ax-fem (which I am not?a real fan of) or combined ABF/CAB which I have > done on several occasions.> I worry about not having a good and safe way to use > a IABP and the possibility of severe lower extem ischemia if we have any problem > with low output. > No one has addressed the issue of timing yet in the face of a > nonQ infarct?> > Tom> > > -----Original Message-----> From: Hgrmd at aol.com> To: > OpenHeart-L at lists.hsforum.com> Sent: Fri, 16 May 2008 7:05 am> Subject: Re: > [HSF] New case- CAD + Leriche> > > >
 John,> Agree with your comments except for > the ascending aortic graft to the > iliac. Guaranteed much simpler is a > conventional axillary (either right or > left) > bifemoral bypass. Ax-fems have > been used for years with good results. For > the first 8 years of my practice, > at least half of my time was spent doing > peripheral vascular surgery (I still > do a few carotids). I don't currently > read much about vascular surgery, but I > know that this is a simple, relatively > atraumatic procedure. BTW, do you know > of any studies comparing the 2 > techniques?> > Hal> > > > **************Wondering > what's for Dinner Tonight? Get new twists on family > favorites at AOL Food. > > (http://food.aol.com/dinner-tonight?NCID=aolfod00030000000001)> > _______________________________________________> OpenHeart-L mailing list> > > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE > email address, or to view archives:>
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