[HSF] Crystalloid versus blood cardioplegia

Tue Aug 11 22:12:17 EDT 2009

Well, you are a professor, shoot! 
Something more than a binary classification (simple or complex) would at least be more interesting.

tea

________________________________
From: "Rwmfglycar at aol.com" <Rwmfglycar at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Tuesday, August 11, 2009 10:34:47 PM
Subject: Re: [HSF] Crystalloid versus blood cardioplegia

Hal, please that was not heat. I am totally realistic about the real  
picture. Warm  (not all of them Beating )heart surgeons are well below the  radar 
screen.  Just stick my old stuff in a "you never know when this may  become 
relevant file". 
I had a list something like Ani's. I concentrated on the procedures  that 
were needed to get a satisfactory  valve and gave each a value of 1.  
Generally the complex cases had a score of 5. A triangular resection and  an 
annuloplasty got a score of 2. 
Bob

In a message dated 8/12/2009 3:39:58 A.M. South Africa Standard Time,  
Hgrmd at aol.com writes:

Ed,
To me, complex repairs are those in which more than just  a ring is  
carried out.  Granted, a simple P2 resection probably  shouldn't  be in the 
same 
category as a sliding leaflet plasty with  chordal transfer to the  
anterior 
leaflet.  
It's a  little painful getting heat from Bob, a surgeon whom I  revere.  
However, he still has to admit that the beating heart guys remain  a  
distinct 
minority.  Not just slow, pedantic surgeons, but plenty of  very  fast, 
fantastic surgeons (Mohr, Vanermen, Dreyfus, David) don't  use warm beating 

heart.  Today, I saw an 84 yo lady in the  office whose mitral valve I  
repaired 
over 4.5 years ago.  Her  latest echo revealed an EF of 55% with  trace MR. 

How much  better would the EF have been with beating  heart?  Would the  
repair have looked as good?  Anecdotal, yes,  but...  BTW,  do you do a lot 
of 
beating heart repairs?

Hal

In a  message dated 8/11/2009 7:16:42 P.M. Eastern Daylight Time,  
dukeb60 at aol.com writes:

Hal,
When you say "complex mitral  repair" what exactly  does that include?  
Resections?  Chords?  Leaflet extensions?  I'm curious to know what you 
consider  
complex.

Ed

-----Original  Message-----
From:  Rwmfglycar at aol.com
To:  OpenHeart-L at lists.hsforum.com
Sent: Tue, Aug 11,  2009 5:59  pm
Subject: Re: [HSF] Crystalloid versus blood  cardioplegia

Hal, 
I very  carefully  phrased my post as a neutral statement. My technique was 

hybrid in  that I could switch to a bloodless field if I wanted to. I  was  

certainly repairing > 90% of degenerative pathologies.  Remember I was  
using  
chordal replacement  for  anterior pathology before  starting Goretex, and  
that  we  introduced dedicated echo into  our operating rooms in the  
70's.  
It 
is too late to get  together the evidence for  success at this  stage of 
the 
continuous  warm myocardial  protection that I used from around  1990 to 
2002.
What  you  are saying is that the most popular techniques used by the    
surgeons who perform at televised educational sessions whether  for  
promotional, 

commercial or advertising purposes,  or for the shear love  of  teaching,  
include general body  cold and intermittent cold  cardiolplegic  solutions 
with  a 

variety of compositions  and  with or without blood  given retrogade , 
antegrade and by  both routes. Since in the modern  era of  earlier 
indication for  

mitral repair surgery it  takes bad mistakes to kill  someone, the  
mortality 
rate is  very low, and with referral patt
erns properly  leading to  
concentration of cases in the hands of fewer surgeons,  the  early  rates 
of 
succesful 
incompetence correction are  better and better. We  do not know what the 
longterm results of  the  current practice are and will not  for a long 
time 
and  
may never know  in our lifetimes. For the time being the  popularity 
contest 
is won  by  Cold. Good luck to all. Just  remember  that in science and  
pseudoscience there is always the  possibility of an  alternative  better 
answer. 
Bob
If you  had asked a hedge fund operator how to get  the best results in the 

financial market 3 years ago the popularity  contest would have  yielded 
one 

answer. Now the answer is  different.  By the  way I know there is an 
element  
of the  smartass in this  reply

In a message dated 8/11/2009 5:14:19 P.M.  South Africa  Standard Time,  
hgrmd at aol.com  writes:

Bob,
Other than  a well known surgeon in Tokyo (can't  recall  his name off  
hand), 
I haven't seen a. well known surgeon do a  complex  mitral  repair under 
beating heart conditions. In addition, I  can't think of any large  
published 
series with a high repair  rate  for complex degenerative MR in which  they 
were 
done  under warm  beating heart conditions.

Hal  

Hal
Sent from my Verizon  Wireless  BlackBerry

-----Original  Message-----
From:  Rwmfglycar at aol.com

Date: Tue, 11 Aug 2009  09:17:05 
To:  <OpenHeart-L at lists.hsforum.com>
Subject: Re: [HSF]  Crystalloid  versus blood cardioplegia

I gently remind  you20that you  are  treating this as an all or nothing  
decision. You are thinking  in  straight lines which are very  rare in 
human 

anatomy 
and  biology.  When over a 12 year  period I was doing most of my mitral  
cases with  mostly  retrograde continuous warm I would never hesitate  to 
stop  the  
perfusion for five minutes if I thought the  exposure  was  not ideal.  We  
found no evidence of an  effect  of these brief interruptions on  
myocardial 

performance.  Nor did I feel that I could not achieve the  repair I  
wanted.  
Actually I liked the fact that the ventricular  muscle had more  tone if 
it 
was 
perfused and beating.I  could not turn  it inside  out the way this  can be 
done  
with a heart in complete  diastolic arrest.
Funnily enough  the only consistent straight line in  the  body that I know 
is  
a loadbearing chorda in the filled  normal  beating  heart.  (Watch Gerda 
van 
Ryk's movies). 
Nor  am I for one  second recommending my method to anyone. We are  
dealing  
with so many  variables that every one of you develops a  personal answer  
to 
the  challenge of simultaneous  complete  repair and perfect maintenance of 

myocardial  function. I have  repeated my rule many times on this forum: if 

you  
come  into the operating room without myocardial or  inotropes  failure,  
you  
leave it without failure  or  inotropes.
Bob

In a message dated 8/11/2009  8:36:10 A.M.  South  Africa Standard Time,  
grescigno at mac.com  writes:0A
Hal,

I  am very curious  to see a video of  implantation of  neochordae with  
continuous perfusion and the  heart beating.... If you have  to  operate 
the 
undersigned,  please stop the heart  and repair my valve as  better  as you 

can!

Giuseppe

On  Tuesday,  11  August, 2009, at 01:01AM, <Hgrmd at aol.com>  wrote:
>Dave,
>  The problem with Salerno's  technique,  IMHO,  is that it is more  
difficult
>to do some of  the  more complex  techniques under warm, bloody,  beating
>heart  conditions.  For  example, I've yet to  see a paper in which  a  
high 

mitral
>repair  rate is  done with  this  technique.
>
>Hal
>
>
>In  a message  dated  8/10/2009 5:00:03 P.M. Eastern Daylight  Time,
>drdharris at yahoo.co.uk writes:
>
>Agreed,  I  think the major impact is the normothermic,  normokalaemic  
gentle
>  reperfusion. Buckberg and  Beyersdorf have  experimentally shown 
recovery  

of
> dogs hearts after 6  hours  of ischemia using  this technique. This is  
what
>we  also see when  we  have complex, long procedures. I am sure that  
there  
is
>some  (maybe minimal) benefit with the non-ischemic  completely  perfused
>Salerno  technique. More  research  is needed to  confirm  how much the 
benefit  is,
>and  whether the  possibility of technical  difficulties with longer  
bypass
>times  may  offset  this potential    benefit.
>Dave
>
>,
>---  On Mon, 10/8/09,    hgrmd at aol.com <hgrmd at aol.com>  wrote:
>
>
>From:  hgrmd at aol.com    <hgrmd at aol.com>
>Subject
: Re: [HSF]    Crystalloid  versus blood  cardioplegia
>To:    OpenHeart-L at lists.hsforum.com
>Date: Monday, 10 August,    2009,  5:21  PM
>
>
>Dave,
>Nice  description  of  your  technique.  Dr. Salerno does  take it one  
step
>further, but I  believe it  makes doing a  technically  perfect job (e.g. 

complex
>mitral  repair)  problematic.  Nevertheless,  continuous warm  blood 
during  

the
>easy,  terminal portion of the  clamp  yields a toned,  perky heart that 
is
>usually  ready to  wean  within a few  minutes after the clamp is    
removed.
>
>Hal
>Sent  from my Verizon  Wireless  BlackBerry
>
>-----Original    Message-----
>From: David  Harris    <drdharris at yahoo.co.uk>
>
>Date: Mon, 10 Aug    2009  14:11:27
>To:      <OpenHeart-L at lists.hsforum.com>
>Subject: RE: [HSF]    Crystalloid  versus  blood  cardioplegia
>
>
>Oh,  yes it definitely  is  controlled. Even more  so than allowing  the
>perfusionist  (or  different perfusionists) to  reperfuse  /  underperfuse 

at 
their
>leisure. I  have often found that the  perfusionists may  not  perfuse
>sufficiently, and then  fibrillation ensues. The  temperature  is  
controlled, as I    only
>perfuse once temp is 34, to prevent VF.  Hence  timing  of  rewarming is
>important. The pressure  is  controlled,  and  should be more  constant, 
as 
we  are
>very  strict  about  keeping the mean arterial P  around 60 to  70.  The  
pressure
>can also be  measured in one of the side  ports of the  octopus,  and  in 
the
>retrograde
. The  retrograde usually  measures  40 to 50 using this  
technique.

>There  is  definitely less flow  and  pressure compared to taking  the  
clamp 

off, as
>the flow  is  restricted  by the lumen of the smaller  tubing, and  there  
is  

a
>pressure drop caused by the  resistance of the  tubing  (longer,  and  the
>divisions). The  only  thing we cannot  control is the  composition of  the
>perfusate.  Substrate  enhancement has been shown  to  be beneficial, but  

how
>much? The main benefit  seems to be from gentle  reperfusion  for 20 min, 

avoiding
>the sudden surge of  free    radicals.
>``Controlled pressure perfusion  seems  to be  superior  to  fixed flow
>reperfusion ``- Buckberg. With  this in  mind  we do not  necessarily 
have  

to
>reperfuse with any specific flow,  or  measure  the flow. This simple 
method always
>works  well for me. by the  time  the  clamp is ready to come off, the  
heart  
is
>already beating  strongly.
>I  am  sure Tom  salerno will agree, he published this  with  Buckberg in  

1994,
>although  he now takes it one  step    further.
>
>
>Dave
>
>
>--- On    Mon,  10/8/09, Ani Anyanwu  <anianyanwu at hotmail.com>    wrote:
>
>
>From:  Ani Anyanwu    <anianyanwu at hotmail.com>
>Subject: RE: [HSF]    Crystalloid  versus blood cardioplegia
>To: "open  heart  list"    <openheart-l at lists.hsforum.com>
>Date:  Monday,  10  August, 2009,  1:35  AM
>
>
>What  you  describe  though is not really  controlled  reperfusion.  
Controlle
d
>reperfusion denotes  some  control over the pressure,  temperature  and
>constituents of the  reperfusate. Reperfusing via  the  arterial line is 
not 
much
>different  from taking  the  clamp  of as the reperfusate is the  same
>temeperature,  pressure and  composition with the  systemic      blood.
>
>
>
>Ani
>
>
>>    Date:  Sun, 9 Aug 2009 21:52:16  +0000
>> From:  drdharris at yahoo.co.uk
>> Subject: RE: [HSF]  Crystalloid  versus  blood cardioplegia
>> To:  OpenHeart-L at lists.hsforum.com
>>  CC:
>>
>>  Hal  said
>>
>>
>>
>>  OK.  As  I've said  before, I generally give  warm
>>  >  continuous blood when  closing the aorta, LA, or doing  the  
proximals,
>just
>>  > before  removing the  clamp.
>>
>>    Agree
>> If you look at  the literature, and from my  personal  experience,  
giving  
a
>controlled  reperfusion (Beyersdorf has again  written  a  recent  
article) 

is
>the only thing that really  makes a    difference.
>> Regarding  overdose  cardio[plegia: there  are  articles in the  
literature
>warning about  this  (demonstrated  in  dog experiments).
>>
>> What I  do  is  attach an octopus  perfusor to the arterial line,  
attach  
it
>to the grafts and  cor  sinus (or  aorta  in a mitral), and  open it 
during 
the
>final stages  -  it  saves the  perfusionist the hassle, and  ensures  
adequate
>perfusion, and  allows  the  perfusionist to open  the root  vent via  the
>cardioplegis  line.
>>
>>    Dave
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