[HSF] New case- CAD + Leriche

Tue May 20 12:37:25 EDT 2008

I in turn agree that empeller punps will replace IABP for support but not ischemia. However there is an "if and only if" to this. We have to have better understand what are the parameters of "successful" short tem support. Unfortunately the obvious answer (short term results) is, I think and you imply, inadequate to answer questions for meaningful indications which will require long term thinking.
tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Tuesday, May 20, 2008 9:37:28 AM
Subject: RE: [HSF] New case- CAD + Leriche

I agree with what you say Tea, and that was my view on the patient but I was in the minority. For these end-stage heart failure patients, we take a multidisciplinary approach and make decisions as a team and we would generally go with the team decision. In this case the majority opinion was that if we could safely eliminate the MR then he would feel better. So far (in his second month only now) that has been the case, but my view was that his ventricle rather than the MR would be the overriding determinant of his symptom status so any benefit will be short-lived. We all agreed this surgery would not prolong his life. The short term support was to allow him to 'survive' surgery and not to treat the heart failure in any way.

Ani

> Date: Mon, 19 May 2008 19:35:01 -0700> From: tacuff at swbell.net> Subject: Re: [HSF] New case- CAD + Leriche> To: OpenHeart-L at lists.hsforum.com> CC: > > 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:>> 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> > -----------------------------------------> > _______________________________________________> > 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
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