From grescigno at mac.com Thu Jan 1 11:07:28 2009 From: grescigno at mac.com (Macbook) Date: Thu Jan 1 05:08:41 2009 Subject: [HSF] Happy New Year to all. In-Reply-To: References: Message-ID: Hi Michael, a happy New Year to you and all the members. Giuseppe Il giorno 31/dic/08, alle ore 21:54, Michael Firstenberg ha scritto: > I am wishing all of my HSF friends a happy healthy new year with > patent > grafts, leak-free valves, good hemodynamics and hemostasis and most > importantly Peace for all in 2009 > > Which brings me to a question - with the end of the year - does > anyone want > to share the most important thing they have learned or read about > during > 2008 Anything that changes the way that you might practice or > even see the > world. > > > -michael > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From nkkejriwal at gmail.com Fri Jan 2 20:26:21 2009 From: nkkejriwal at gmail.com (nand kejriwal) Date: Fri Jan 2 02:26:49 2009 Subject: [HSF] Happy New Year to all. In-Reply-To: References: Message-ID: Dear Michael Thanks for your message of greetings which I heartily reciprocate. I liked the leak free and patent grafts stuff. Very innoative. Nand On Thu, Jan 1, 2009 at 9:54 AM, Michael Firstenberg wrote: > I am wishing all of my HSF friends a happy healthy new year with patent > grafts, leak-free valves, good hemodynamics and hemostasis and most > importantly Peace for all in 2009 > > Which brings me to a question - with the end of the year - does anyone want > to share the most important thing they have learned or read about during > 2008 Anything that changes the way that you might practice or even see > the > world. > > > -michael > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > From prasannasimha at gmail.com Fri Jan 2 13:19:08 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Fri Jan 2 02:49:37 2009 Subject: [HSF] Happy New Year to all. In-Reply-To: References: Message-ID: <89c4ed2d0901012349k309f54beme4fc78546d3c294@mail.gmail.com> Oops I had sent an email sharp at 12 midnight Indian standard time but it did not seem to reach. Happy New Year to all HSFers. Prasanna On Fri, Jan 2, 2009 at 12:56 PM, nand kejriwal wrote: > Dear Michael > > Thanks for your message of greetings which I heartily reciprocate. > > I liked the leak free and patent grafts stuff. Very innoative. > > > > Nand > > On Thu, Jan 1, 2009 at 9:54 AM, Michael Firstenberg >wrote: > > > I am wishing all of my HSF friends a happy healthy new year with patent > > grafts, leak-free valves, good hemodynamics and hemostasis and most > > importantly Peace for all in 2009 > > > > Which brings me to a question - with the end of the year - does anyone > want > > to share the most important thing they have learned or read about during > > 2008 Anything that changes the way that you might practice or even see > > the > > world. > > > > > > -michael > > _______________________________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@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@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 > ----------------------------------------- > -- Prasanna Simha M From pfvil at intramed.net Fri Jan 2 12:29:43 2009 From: pfvil at intramed.net (Dr Patricio Villanueva) Date: Fri Jan 2 09:30:12 2009 Subject: [HSF] Happy New Year Message-ID: Happy New Year for all my colleagues, my best wishes for all, and there families Patricio Villanueva From Rwmfglycar at aol.com Fri Jan 2 22:29:50 2009 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Fri Jan 2 22:30:25 2009 Subject: [HSF] Request for SJM data from Prasanna Message-ID: Dear Prasanna, By way of starting thr New Year right here are the St Jude numbers I promised to send you weeks ago. Six month echocardiographic data JTCVS v.122;695 125 patients echocardiographic data Standard cuff ((SC) and Hemodynamic Plus (HP) 21SC 21HP 23SC 23HP Card Output 5.43 4.66 6.17 4.82 Peak Grad 24.6 18.3 24.7 16.8 Mean Grad 17.8 12.6 17.5 12.1 Eff Or. Area 1.49 1.57 1.67 1.69 P values showed significant difference for Peak and Mean Gradients for 21 SC v. 21 HP 21 HP v 23 SC 23 SC v. 23 HP The Eff Or Areas were in each column better than the preceding column but not significantly so. This is not surprising; there are extra assumptions and calculations in developing the number we call EOA. That is why I have always asked to be told what the gradients and the cardiac outputs are. They are purer numbers and are after all what the ventricle understands. It's question is how hard am I working to decrease my cavity. size? You said you did not need the Regent data but the mean gradients are in single digits even the EOA's are significantly greater; e.g. 2.0 for the 21 Bob (I still owe you thoughts on rheumatic calcification) **************New year...new news. Be the first to know what is making headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) From tacuff at swbell.net Fri Jan 2 20:40:35 2009 From: tacuff at swbell.net (Tea Acuff) Date: Fri Jan 2 23:41:03 2009 Subject: [HSF] The world is round not flat Message-ID: <295977.19458.qm@web81602.mail.mud.yahoo.com> The problem that you discuss in both the predicate and the postulate seems to me to be analogous to the problem of abstract calculation in the Roman Empire. They were more than capable if they were counting actual objects, but the inability to understand the mathematical necessity of maintaining a space with "nothing" left them incapable of understanding the more interesting possible among the actual. Tea Sent from my iPhone On Dec 30, 2008, at 1:05 PM, wftjrtyler@aol.com wrote: Dear Tea, Beneath the exasperatingly brilliant expose' of false authority(prophets?) of our craft,I sense a man of deep faith Cordially, bill -----Original Message----- From: Tea Acuff To: OpenHeart-L Sent: Tue, 30 Dec 2008 12:26 pm Subject: [HSF] The world is round not flat I have an interesting "case" that points to the problem of assuming we "operate" in the same dimensions because we use the same language and same tools. A medical friend was sharing her experience of a close relative on the other side of the world who had a heart attack on the day of her arrival to her home town. He was given thrombolysis for ST changes of an "anterior wall" MI (V2-V5?changes). He was later taken to the cath lab where his LAD was found to be "open" and his RCA "closed" (verbal report) but nondominate. Interestingly 30 years ago his father at the patient's age?had an MI and has been treated without invasive diagnosis or treatment and is still alive details unknown. The patient was told that medical therapy (statins) was all that was necessary, but if he were in the USA a stent would be done. ? She?gave me a copy the cath which showed a large LAD which was either normal or mild disease with a large PL branch and smaller branching PDA of the circ also without disease.? However, a smaller in size diagonal had a 70-80% stenosis with multiple "left handed" branches that supplied the OM distribution and was the only "vessel" between the large LAD and large PL , that is all the "diagonal and high OMs" came off this smaller?in diameter?but multibranching vessel. The patient has chest discomfort with vigorous walking. I told her I would "do something" to the "diagonal" as her doctors predicted if it were me and I had the resourses. She said resources were not a problem. Interestingly the discussion turned to God and religion and although my friend is a Christian, she is the Vishnu (my term for her "supportive" role) of the whole family and if she says anything to the family to warn or inform him, it will destroy the whole sense well being of the family. She says that the doctors will not listen to her particular since they "predicted" my response. She says she respects the "polytheistic" (multiple role/powers of different actors) society?and will talk to the business associates o f the family member to try to inform them in that way. I said monotheism does have the problem of duality in that the potential?rescuer or provider is also the potential destroyer. Is this "mono" system best to use a more ambiguous term for?an important conceptual point to those that would design?or judge healthcare delivery? This seems to represent well my contention that our categories, language,?dimensions and their predictive powers are not straight lines but if not curves at least spirals. It perhaps does matter that the patient is not my mine and not in my "system", no matter the complete agreement that the USA "over" does and diagonals don't "deserve" intervention. I would "over" treat this patient. tea _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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@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 ----------------------------------------- From nfaabouseada at gmail.com Fri Jan 2 23:08:03 2009 From: nfaabouseada at gmail.com (Nasser F Abou'Seada) Date: Sat Jan 3 00:08:39 2009 Subject: [HSF] The world is round not flat In-Reply-To: <295977.19458.qm@web81602.mail.mud.yahoo.com> References: <295977.19458.qm@web81602.mail.mud.yahoo.com> Message-ID: Mmmmm .... very well said Tea. NFA -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Tea Acuff Sent: Friday, January 02, 2009 10:41 PM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] The world is round not flat The problem that you discuss in both the predicate and the postulate seems to me to be analogous to the problem of abstract calculation in the Roman Empire. They were more than capable if they were counting actual objects, but the inability to understand the mathematical necessity of maintaining a space with "nothing" left them incapable of understanding the more interesting possible among the actual. Tea Sent from my iPhone On Dec 30, 2008, at 1:05 PM, wftjrtyler@aol.com wrote: Dear Tea, Beneath the exasperatingly brilliant expose' of false authority(prophets?) of our craft,I sense a man of deep faith Cordially, bill -----Original Message----- From: Tea Acuff To: OpenHeart-L Sent: Tue, 30 Dec 2008 12:26 pm Subject: [HSF] The world is round not flat I have an interesting "case" that points to the problem of assuming we "operate" in the same dimensions because we use the same language and same tools. A medical friend was sharing her experience of a close relative on the other side of the world who had a heart attack on the day of her arrival to her home town. He was given thrombolysis for ST changes of an "anterior wall" MI (V2-V5?changes). He was later taken to the cath lab where his LAD was found to be "open" and his RCA "closed" (verbal report) but nondominate. Interestingly 30 years ago his father at the patient's age?had an MI and has been treated without invasive diagnosis or treatment and is still alive details unknown. The patient was told that medical therapy (statins) was all that was necessary, but if he were in the USA a stent would be done. ? She?gave me a copy the cath which showed a large LAD which was either normal or mild disease with a large PL branch and smaller branching PDA of the circ also without disease.? However, a smaller in size diagonal had a 70-80% stenosis with multiple "left handed" branches that supplied the OM distribution and was the only "vessel" between the large LAD and large PL , that is all the "diagonal and high OMs" came off this smaller?in diameter?but multibranching vessel. The patient has chest discomfort with vigorous walking. I told her I would "do something" to the "diagonal" as her doctors predicted if it were me and I had the resourses. She said resources were not a problem. Interestingly the discussion turned to God and religion and although my friend is a Christian, she is the Vishnu (my term for her "supportive" role) of the whole family and if she says anything to the family to warn or inform him, it will destroy the whole sense well being of the family. She says that the doctors will not listen to her particular since they "predicted" my response. She says she respects the "polytheistic" (multiple role/powers of different actors) society?and will talk to the business associates o f the family member to try to inform them in that way. I said monotheism does have the problem of duality in that the potential?rescuer or provider is also the potential destroyer. Is this "mono" system best to use a more ambiguous term for?an important conceptual point to those that would design?or judge healthcare delivery? This seems to represent well my contention that our categories, language,?dimensions and their predictive powers are not straight lines but if not curves at least spirals. It perhaps does matter that the patient is not my mine and not in my "system", no matter the complete agreement that the USA "over" does and diagonals don't "deserve" intervention. I would "over" treat this patient. tea _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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@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@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 ----------------------------------------- From mmlevinson at hsforum.com Sat Jan 3 00:33:13 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Sat Jan 3 01:33:43 2009 Subject: [HSF] Pulm Vein Ablation In-Reply-To: <5C78C0ED019646DD8781DCD47E0EE47D@yourg8he5gjrox> References: <5C78C0ED019646DD8781DCD47E0EE47D@yourg8he5gjrox> Message-ID: <3315EE6A-F6E8-40BC-B809-918C80F2C75A@hsforum.com> On Dec 12, 2008, at 6:18 PM, Ajit Damle wrote: > Also, everyone is welcome to jump in and tell me about your > experiences. > > Ajit > > I have now performed 2 total Cox-Maze IV procedures using the subxiphoid technique with normothermic CPB and the ATS Medical Argon cryoablation probe . Both had LA appendage ligations using EndoGIA 4.8 mm staples. For all my other open heart cases (CABG, Valves), I use 2 Endoloops to ligate the LA appendage externally Mark Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From mmlevinson at hsforum.com Sat Jan 3 00:48:44 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Sat Jan 3 01:49:04 2009 Subject: [HSF] Pulm Vein Ablation In-Reply-To: References: Message-ID: <4559B34A-9FA0-455E-A01F-C4296EDDAB5D@hsforum.com> On Dec 13, 2008, at 12:11 PM, DukeB60@aol.com wrote: > > After very a very lengthy search for the optimal lesion set and > energy > source, I am convinced the lesion set is well established for > chronic AF and > that is the full Cox Maze III. Everything else falls short. The > only energy > source that allows the full lesion set by itself is cryo. and even > Cox in his > original reports relied upon cryo. to complete his mitral isthmus > lesions. > All the other energy source fail to reproduce a Cox Maze III and in > so doing > have suggested that the complete lesion set is unnecessary to met > it's > respective limitation. > > > Ed: I agree entirely with your analysis. Incomplete Maze lesion sets give incomplete results and we are now seeing this in the reports of various partial Maze procedures. In addition, there is no way to complete the traditional Maze without cryoablation of the peri- annular / isthmus tissues, and thus I choose to perform the entire Maze-IV lesion set with the argon cryo probe on every case. Since I do not have the skill or the case volume to perfect the lateral mini-thoracotomy approach, I have chosen to use the subxiphoid for my lone a-fib cases and so far it has been going well. Mark Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From mmlevinson at hsforum.com Sat Jan 3 00:51:23 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Sat Jan 3 01:51:41 2009 Subject: [HSF] Durability - Rheumatic Mitral repairs In-Reply-To: <89c4ed2d0812131021o3f9e72c1v34698381116ec89e@mail.gmail.com> References: <89c4ed2d0812131021o3f9e72c1v34698381116ec89e@mail.gmail.com> Message-ID: On Dec 13, 2008, at 12:21 PM, Prasanna Simha M wrote: > You can do what Mark Levinson does place p12 sutres out and P3 inside > to make an eccentric ring with a symmetric ring. > Still works well for me..."micro-sizing" of the ring. Most commonly at the P2-P3 junction or mid P-3. Placing the sutures onto the inside rim of the Physio-Ring advances that tissue forward by 2 to 3 mm only, and sometimes corrects for the known tethering here that others treat with fancier techniques... This has been very reliable and easy for me....and no reoperations Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From mmlevinson at hsforum.com Sat Jan 3 01:06:40 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Sat Jan 3 02:07:01 2009 Subject: [HSF] Durability - Rheumatic Mitral repairs In-Reply-To: References: <89c4ed2d0812131811o3798e113xe964c7058397b7c9@mail.gmail.com> Message-ID: <5DB50687-DA2D-4D8A-A69F-CA1E26675A17@hsforum.com> On Dec 14, 2008, at 8:16 AM, erdin? naseri wrote: > > Prasanna and Hal and everybody, > Tha lady is a fragile 80 y/o from rural part of the region I work. > She has been in class III for the last several months and in the > last months had 2 bouts of syncope ( one in our hospital waiting for > CAG).She can't afford to buy an apicoaortic conduiy. Her TTE and CT > predict that a conventional AVR will lead to at best a protracted > convalescence if not death.Now, we have the following choices: > 1. leave her without surgery > 2. proceed with a conventional AVR + /- ascending aortic > andarterectomy or replacement? > 3.Anastomoze a conduit to the apex of the heart .Implant a valve in > the distal 2 cm of the graft.Anastomoze a same size graft to the > descending aorta and anastmoze 2 conduits to each other? > Any other possibility? > erdinc > > ----------------------------------------- If she cannot pay for the Medtronic apical-aortic conduit, I wonder how she can pay for the conduits and valve you would need for strategy #3 above. If not, then consider fem-fem bypass and hypothermic arrest, open the calcified aorta and perform a local endarterectomy, sew a graft to the distal aorta and then perform a conventional AVR and finally sew the graft to the supracoronary aorta. If the base of the aorta is also porcelenized, then a Bentall would be best. You can also make a tube graft from a sheet of glutaraldehyde preserved bovine pericardium and this may cost less than a Dacron graft but be useable as an ascending aortic replacement.... Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From mmlevinson at hsforum.com Sat Jan 3 01:25:25 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Sat Jan 3 02:25:44 2009 Subject: [HSF] Durability - Rheumatic Mitral repairs In-Reply-To: <89c4ed2d0812170500i4754bfafq81b90093ecc1cee7@mail.gmail.com> References: <247539702-1229434813-cardhu_decombobulator_blackberry.rim.net-1127898139-@bxe016.bisx.prod.on.blackberry> <89c4ed2d0812161804jbb0cac9nc5664ac3f225cfac@mail.gmail.com> <9CDFBF29F4284555970E7EE1FB452532@AbouSeadaN> <89c4ed2d0812170500i4754bfafq81b90093ecc1cee7@mail.gmail.com> Message-ID: <8366D37D-8C1E-49BF-A75D-8104EB59723C@hsforum.com> On Dec 17, 2008, at 7:00 AM, Prasanna Simha M wrote: > Nasser, I do not use commercial rings and a large portions of my > patients are obviously rheumatic. I still prefer to place a ring in > most cases now. I used to make the ring with steel and Goretex but now > fashion it with steel and the neck line double lumen catheter. In > fact the latter method amkes an excellent ring and I am having good > results with it. > extremely cheap and easy to make too.The rings have been also stable > in their function > Prasanna For many years, I watched Lester Savage make his own annuloplasty rings by rolling a piece of fillamentous Dacron fabric into a tight tube held by interrupted stitches and then sewn into position with horizontal mattress sutures. It was (in essence), an incomplete, flexible ring made from inexpensive materials. His results were good but never published. Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From mmlevinson at hsforum.com Sat Jan 3 01:30:40 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Sat Jan 3 02:31:00 2009 Subject: [HSF] STS In-Reply-To: <33B7C3B48D3840BAAE970FF577B4E9DC@yourg8he5gjrox> References: <33B7C3B48D3840BAAE970FF577B4E9DC@yourg8he5gjrox> Message-ID: On Dec 26, 2008, at 7:01 AM, Ajit Damle wrote: > I sent an e-mail to see if HSFers want to get together in San > Francisco. Let > me know and then I can make some arrangements. Please count me in......I look forward to seeing all of you there.. Mark > > > Ajit Damle > > Chuck Douville > Bill Novak > Chand Ramaiah > Hal Roberts > Ajit Damle > Tea Acuff > JohnGoldblatt > Antonio Laudito > Barry Mahon > > Nine names, that is plenty. Anyone else wants to join in, you are > welcome. > > Tell me how we should do it. > > 1. I do not think I can get a medical company to arrange this, so we > will > end up paying for ourselves. > > 2. This is California. I can find about wine tasting, or the very > least, > get some good wines to sample. I may be a world authority on the > vintage > Chateau Fargo, terrier North Dakota, but I am open to suggestions! > > 3. I suggest that we all participate in the discussion. Each of us can > describe a personal clinical experience of an avoidable error or > undesirable > situation. Each participant will have 2 minutes to describe it and > there > will be three minutes of discussion. That will be a total of 45 > minutes for > 9 participants. > > 4. Time. There are a lot of event in the evening. Will a late > afternoon work > better? > > Ajit Damle > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From mmlevinson at hsforum.com Sat Jan 3 01:50:57 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Sat Jan 3 02:51:17 2009 Subject: [HSF] Afib Procedures and Conduction Disease In-Reply-To: References: Message-ID: On Dec 24, 2008, at 10:23 AM, Michael Firstenberg wrote: > > I think letting some of these little ol ladies hang-out in a slow > junctional > rhythm is a bad idea - particularly as they are recovering from > whatever > else we have done to them. Many of them have pretty significant > diastolic > dysfunction (doesnt everyone these day) and their cardiac output are > very > heart rate dependent. Their bodies are use to seeing rates in the > 70-80 > and if their cardiac output drops by 40-50% because of a drop in > heart rate > they dont like it and we get problems like renal failure and > sometimes even > syncope. Fruthermore, just because we watch them for a few days in a > tightly controlled environement such as a hospital that does not > mean they > will not have brady episodes at home which may result in a chronic > slow > decline - if not an acute problem. They need that safety net for > the sinus > node problems > > I did a simple and successful mitral repair years ago and the lady was in slow junctional rhythm postop. I used a temporary pacemaker and waited until her junctional rate gradually came up and did everything to avoid a permanent pacer since I felt this dysfunction would recover. She was in the hospital more than 10 days just waiting. Finally, after cardiology clearance, we all agreed she could go home with a stable junctional rhythym about 60 / minutes and no pacemaker. She was found dead at home about 2 weeks later. I put in permanent pacemakers not as a sign of defeat but as a safety net. And I pace the patients at 80/min to increase their cardiac output and help relieve symptoms of fatigue and CHF. After a month I drop the rate back down. I think you can decrease our incidence of pacemaker insertion post-Maze if you and to wait longer and accept lower heart rates. But is it worth it? In my opinion...no. The current generation of pacemakers and leads are so reliable and physiologic that I do not consider a pacemaker a disadvantage, and in many cases it is advantageous. Atrial pacing may actually help maintain atrial contractions and prevent breakthrough a-fib as well. And now you can get intra-cardiac event monitoring and prove whether they have bursts of afib or not! Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From prasannasimha at gmail.com Sat Jan 3 13:56:20 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sat Jan 3 03:32:00 2009 Subject: [HSF] Durability - Rheumatic Mitral repairs In-Reply-To: <5DB50687-DA2D-4D8A-A69F-CA1E26675A17@hsforum.com> References: <89c4ed2d0812131811o3798e113xe964c7058397b7c9@mail.gmail.com> <5DB50687-DA2D-4D8A-A69F-CA1E26675A17@hsforum.com> Message-ID: <89c4ed2d0901030026n15739aa4vff88f21a334692@mail.gmail.com> The cost of a valve + conduit is much less than a preformed valved conduit. That is marketing reality. Prasanna On Sat, Jan 3, 2009 at 12:36 PM, Mark Levinson wrote: > > On Dec 14, 2008, at 8:16 AM, erdin? naseri wrote: > > >> Prasanna and Hal and everybody, >> Tha lady is a fragile 80 y/o from rural part of the region I work. She has >> been in class III for the last several months and in the last months had 2 >> bouts of syncope ( one in our hospital waiting for CAG).She can't afford to >> buy an apicoaortic conduiy. Her TTE and CT predict that a conventional AVR >> will lead to at best a protracted convalescence if not death.Now, we have >> the following choices: >> 1. leave her without surgery >> 2. proceed with a conventional AVR + /- ascending aortic andarterectomy or >> replacement? >> 3.Anastomoze a conduit to the apex of the heart .Implant a valve in the >> distal 2 cm of the graft.Anastomoze a same size graft to the descending >> aorta and anastmoze 2 conduits to each other? >> Any other possibility? >> erdinc >> >> ----------------------------------------- >> > > > If she cannot pay for the Medtronic apical-aortic conduit, I wonder how she > can pay for the conduits and valve you would need for strategy #3 above. > If not, then consider fem-fem bypass and hypothermic arrest, open the > calcified aorta and perform a local endarterectomy, sew a graft to the > distal aorta and then perform a conventional AVR and finally sew the graft > to the supracoronary aorta. If the base of the aorta is also > porcelenized, then a Bentall would be best. > > You can also make a tube graft from a sheet of glutaraldehyde preserved > bovine pericardium and this may cost less than a Dacron graft but be useable > as an ascending aortic replacement.... > > > > Mark Levinson, MD. > Founder, Editor-in-Chief > The Heart Surgery Forum(R) > Multimedia Cardiothoracic Journal > URL: http://www.hsforum.com > URL: http://newoptionsinheartsurgery.com > Emali: mmlevinson@hsforum.com > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > anddisclaimers posted at: > > http://www.hsforum.com/listdisclaim > ----------------------------------------- > -- Prasanna Simha M From nfaabouseada at gmail.com Sat Jan 3 02:26:16 2009 From: nfaabouseada at gmail.com (Nasser F Abou'Seada) Date: Sat Jan 3 03:32:23 2009 Subject: [HSF] Durability - Rheumatic Mitral repairs In-Reply-To: <8366D37D-8C1E-49BF-A75D-8104EB59723C@hsforum.com> References: <247539702-1229434813-cardhu_decombobulator_blackberry.rim.net-1127898139-@bxe016.bisx.prod.on.blackberry><89c4ed2d0812161804jbb0cac9nc5664ac3f225cfac@mail.gmail.com><9CDFBF29F4284555970E7EE1FB452532@AbouSeadaN><89c4ed2d0812170500i4754bfafq81b90093ecc1cee7@mail.gmail.com> <8366D37D-8C1E-49BF-A75D-8104EB59723C@hsforum.com> Message-ID: <86D528D900EA41CCB03FE8D595622B41@AbouSeadaN> That seems a very interesting technique. NFA -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Mark Levinson Sent: Saturday, January 03, 2009 1:25 AM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Durability - Rheumatic Mitral repairs On Dec 17, 2008, at 7:00 AM, Prasanna Simha M wrote: > Nasser, I do not use commercial rings and a large portions of my > patients are obviously rheumatic. I still prefer to place a ring in > most cases now. I used to make the ring with steel and Goretex but now > fashion it with steel and the neck line double lumen catheter. In > fact the latter method amkes an excellent ring and I am having good > results with it. > extremely cheap and easy to make too.The rings have been also stable > in their function > Prasanna For many years, I watched Lester Savage make his own annuloplasty rings by rolling a piece of fillamentous Dacron fabric into a tight tube held by interrupted stitches and then sewn into position with horizontal mattress sutures. It was (in essence), an incomplete, flexible ring made from inexpensive materials. His results were good but never published. Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery ForumR Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From prasannasimha at gmail.com Sat Jan 3 14:19:00 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sat Jan 3 03:49:29 2009 Subject: [HSF] Request for SJM data from Prasanna In-Reply-To: References: Message-ID: <89c4ed2d0901030049r1bc7b90bteb03706330a9d38f@mail.gmail.com> Thanks Dr Frater. Prasanna On Sat, Jan 3, 2009 at 8:59 AM, wrote: > Dear Prasanna, > By way of starting thr New Year right here are the St Jude numbers I > promised to send you weeks ago. > Six month echocardiographic data JTCVS v.122;695 125 patients > echocardiographic data > Standard cuff ((SC) and Hemodynamic Plus (HP) > > 21SC 21HP > 23SC 23HP > Card Output 5.43 4.66 > 6.17 4.82 > Peak Grad 24.6 18.3 > 24.7 16.8 > Mean Grad 17.8 12.6 > 17.5 > 12.1 > Eff Or. Area 1.49 1.57 > 1.67 1.69 > > P values showed significant difference for Peak and Mean Gradients for > 21 SC v. 21 HP > 21 HP v 23 SC > 23 SC v. 23 HP > The Eff Or Areas were in each column better than the preceding column but > not significantly so. This is not surprising; there are extra assumptions > and > calculations in developing the number we call EOA. That is why I have > always > asked to be told what the gradients and the cardiac outputs are. They are > purer numbers and are after all what the ventricle understands. It's > question is > how hard am I working to decrease my cavity. > size? > You said you did not need the Regent data but the mean gradients are in > single digits even the EOA's are significantly greater; e.g. 2.0 for the > 21 > Bob > (I still owe you thoughts on rheumatic calcification) > > **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > -- Prasanna Simha M From prasannasimha at gmail.com Sat Jan 3 14:18:13 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sat Jan 3 03:56:20 2009 Subject: [HSF] Durability - Rheumatic Mitral repairs In-Reply-To: <86D528D900EA41CCB03FE8D595622B41@AbouSeadaN> References: <247539702-1229434813-cardhu_decombobulator_blackberry.rim.net-1127898139-@bxe016.bisx.prod.on.blackberry> <89c4ed2d0812161804jbb0cac9nc5664ac3f225cfac@mail.gmail.com> <9CDFBF29F4284555970E7EE1FB452532@AbouSeadaN> <89c4ed2d0812170500i4754bfafq81b90093ecc1cee7@mail.gmail.com> <8366D37D-8C1E-49BF-A75D-8104EB59723C@hsforum.com> <86D528D900EA41CCB03FE8D595622B41@AbouSeadaN> Message-ID: <89c4ed2d0901030048o1277560cob94b1a4787639d31@mail.gmail.com> I have used the dacron/Goretex and pericardial roll but why I liked the rigidity of adding steel was the unique abilty of annular remodelling compared to the "cantilever arch" principle that any flexible ring ends up with. In rheumatics this can be a problem. Prasanna On Sat, Jan 3, 2009 at 1:56 PM, Nasser F Abou'Seada wrote: > That seems a very interesting technique. > > NFA > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com > [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Mark Levinson > Sent: Saturday, January 03, 2009 1:25 AM > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] Durability - Rheumatic Mitral repairs > > > On Dec 17, 2008, at 7:00 AM, Prasanna Simha M wrote: > > > Nasser, I do not use commercial rings and a large portions of my > > patients are obviously rheumatic. I still prefer to place a ring in > > most cases now. I used to make the ring with steel and Goretex but now > > fashion it with steel and the neck line double lumen catheter. In > > fact the latter method amkes an excellent ring and I am having good > > results with it. > > extremely cheap and easy to make too.The rings have been also stable > > in their function > > Prasanna > > > For many years, I watched Lester Savage make his own annuloplasty rings > by rolling a piece of fillamentous Dacron fabric into a tight tube > held by interrupted stitches > and then sewn into position with horizontal mattress sutures. It was > (in essence), an > incomplete, flexible ring made from inexpensive materials. His > results were good but > never published. > > > Mark Levinson, MD. > Founder, Editor-in-Chief > The Heart Surgery ForumR > Multimedia Cardiothoracic Journal > URL: http://www.hsforum.com > URL: http://newoptionsinheartsurgery.com > Emali: mmlevinson@hsforum.com > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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 > ----------------------------------------- > -- Prasanna Simha M From Hgrmd at aol.com Sat Jan 3 06:31:40 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sat Jan 3 06:33:30 2009 Subject: [HSF] Pulm Vein Ablation Message-ID: Mark, I saw your talk about the subxiphoid approach for coronary revascularization at the last HSF dinner. For the life of me, I can't figure out how you would be able to safely get in and out of the atria with that approach. Please elaborate. BTW, Happy New Year. Glad you've resurfaced. Hal In a message dated 1/3/2009 1:49:58 A.M. Eastern Standard Time, mmlevinson@hsforum.com writes: On Dec 13, 2008, at 12:11 PM, DukeB60@aol.com wrote: > > After very a very lengthy search for the optimal lesion set and > energy > source, I am convinced the lesion set is well established for > chronic AF and > that is the full Cox Maze III. Everything else falls short. The > only energy > source that allows the full lesion set by itself is cryo. and even > Cox in his > original reports relied upon cryo. to complete his mitral isthmus > lesions. > All the other energy source fail to reproduce a Cox Maze III and in > so doing > have suggested that the complete lesion set is unnecessary to met > it's > respective limitation. > > > Ed: I agree entirely with your analysis. Incomplete Maze lesion sets give incomplete results and we are now seeing this in the reports of various partial Maze procedures. In addition, there is no way to complete the traditional Maze without cryoablation of the peri- annular / isthmus tissues, and thus I choose to perform the entire Maze-IV lesion set with the argon cryo probe on every case. Since I do not have the skill or the case volume to perfect the lateral mini-thoracotomy approach, I have chosen to use the subxiphoid for my lone a-fib cases and so far it has been going well. Mark Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- **************New year...new news. Be the first to know what is making headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) From Hgrmd at aol.com Sat Jan 3 06:37:10 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sat Jan 3 06:38:13 2009 Subject: [HSF] Afib Procedures and Conduction Disease Message-ID: Mark, My sentiments exactly. Unfortunately, I still get a little grief from some cardiologists when this occurs. Also, in this new era of living with the STS database, insertion of a pacemaker counts as a "bring back" for an open heart case. i.e, it's looked at the same as if the patient had been brought back for bleeding, reop, etc. Absurd don't you think? Hal In a message dated 1/3/2009 2:53:05 A.M. Eastern Standard Time, mmlevinson@hsforum.com writes: On Dec 24, 2008, at 10:23 AM, Michael Firstenberg wrote: > > I think letting some of these little ol ladies hang-out in a slow > junctional > rhythm is a bad idea - particularly as they are recovering from > whatever > else we have done to them. Many of them have pretty significant > diastolic > dysfunction (doesnt everyone these day) and their cardiac output are > very > heart rate dependent. Their bodies are use to seeing rates in the > 70-80 > and if their cardiac output drops by 40-50% because of a drop in > heart rate > they dont like it and we get problems like renal failure and > sometimes even > syncope. Fruthermore, just because we watch them for a few days in a > tightly controlled environement such as a hospital that does not > mean they > will not have brady episodes at home which may result in a chronic > slow > decline - if not an acute problem. They need that safety net for > the sinus > node problems > > I did a simple and successful mitral repair years ago and the lady was in slow junctional rhythm postop. I used a temporary pacemaker and waited until her junctional rate gradually came up and did everything to avoid a permanent pacer since I felt this dysfunction would recover. She was in the hospital more than 10 days just waiting. Finally, after cardiology clearance, we all agreed she could go home with a stable junctional rhythym about 60 / minutes and no pacemaker. She was found dead at home about 2 weeks later. I put in permanent pacemakers not as a sign of defeat but as a safety net. And I pace the patients at 80/min to increase their cardiac output and help relieve symptoms of fatigue and CHF. After a month I drop the rate back down. I think you can decrease our incidence of pacemaker insertion post-Maze if you and to wait longer and accept lower heart rates. But is it worth it? In my opinion...no. The current generation of pacemakers and leads are so reliable and physiologic that I do not consider a pacemaker a disadvantage, and in many cases it is advantageous. Atrial pacing may actually help maintain atrial contractions and prevent breakthrough a-fib as well. And now you can get intra-cardiac event monitoring and prove whether they have bursts of afib or not! Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- **************New year...new news. Be the first to know what is making headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) From benjamin.bidstrup at bigpond.com Sat Jan 3 23:30:10 2009 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Sat Jan 3 08:30:43 2009 Subject: [HSF] Afib Procedures and Conduction Disease In-Reply-To: References: Message-ID: <8C81C23D-F3E4-4155-A498-7E2D4023856F@bigpond.com> In this day and age, the stigma attached to a take back needs to be removed entirely. It is much worse to fill a patient full of blood products and have the short term risks and long term mortality and QOL effects impact on outcomes, than a takeback that if done early (within a few hours) with out the usually ineffective products poured in is low risk and takes little time as usually all the team is available. In the near future, I predict we will be looking at outcomes in a slightly different way - composites of mortality, extended time in ICU use of blood products, ventilator time. These of course will be linked to premorbid conditions such as renal failure, use of antiplatelet agents, and COPD. Ben Bidstrup FRACS FRCSEd FEBCTS Cardiothoracic Surgeon On 03/01/2009, at 9:37 PM, hgrmd@aol.com wrote: > Mark, > My sentiments exactly. Unfortunately, I still get a little grief > from > some cardiologists when this occurs. Also, in this new era of > living with the > STS database, insertion of a pacemaker counts as a "bring back" for > an open > heart case. i.e, it's looked at the same as if the patient had > been brought > back for bleeding, reop, etc. Absurd don't you think? > > Hal > > > In a message dated 1/3/2009 2:53:05 A.M. Eastern Standard Time, > mmlevinson@hsforum.com writes: > > > On Dec 24, 2008, at 10:23 AM, Michael Firstenberg wrote: >> >> I think letting some of these little ol ladies hang-out in a slow >> junctional >> rhythm is a bad idea - particularly as they are recovering from >> whatever >> else we have done to them. Many of them have pretty significant >> diastolic >> dysfunction (doesnt everyone these day) and their cardiac output are >> very >> heart rate dependent. Their bodies are use to seeing rates in the >> 70-80 >> and if their cardiac output drops by 40-50% because of a drop in >> heart rate >> they dont like it and we get problems like renal failure and >> sometimes even >> syncope. Fruthermore, just because we watch them for a few days >> in a >> tightly controlled environement such as a hospital that does not >> mean they >> will not have brady episodes at home which may result in a chronic >> slow >> decline - if not an acute problem. They need that safety net for >> the sinus >> node problems >> >> > > I did a simple and successful mitral repair years ago and the lady > was > in > slow junctional rhythm postop. I used a temporary pacemaker and > waited > until her junctional rate gradually came up and did everything to > avoid > a permanent pacer since I felt this dysfunction would recover. She > was in the hospital > more than 10 days just waiting. Finally, after > cardiology clearance, we all agreed she could go home with a stable > junctional rhythym about 60 / minutes and no pacemaker. She was > found dead at home > about 2 weeks later. > > I put in permanent pacemakers not as a sign of defeat but as a > safety > net. And I pace the patients at 80/min to increase their cardiac > output > and help relieve symptoms of fatigue and CHF. After a month > I drop the rate back down. > > I think you can decrease our incidence of pacemaker insertion post- > Maze > if you and to wait longer and accept lower heart rates. But is it > worth it? In my opinion...no. > The current generation of pacemakers and leads are so reliable and > physiologic > that I do not consider a pacemaker a disadvantage, and in many cases > it is > advantageous. Atrial pacing may actually help maintain atrial > contractions > and prevent breakthrough a-fib as well. > > And now you can get intra-cardiac event monitoring and prove whether > they have bursts of afib or not! > > > > Mark Levinson, MD. > Founder, Editor-in-Chief > The Heart Surgery Forum? > Multimedia Cardiothoracic Journal > URL: http://www.hsforum.com > URL: http://newoptionsinheartsurgery.com > Emali: mmlevinson@hsforum.com > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > **************New year...new news. Be the first to know what is > making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From Rwmfglycar at aol.com Sat Jan 3 10:24:41 2009 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Sat Jan 3 10:25:44 2009 Subject: [HSF] Durability - Rheumatic Mitral repairs Message-ID: In a message dated 1/3/2009 2:08:19 A.M. Eastern Standard Time, mmlevinson@hsforum.com writes: You can also make a tube graft from a sheet of glutaraldehyde preserved bovine pericardium and this may cost less than a Dacron graft but be useable as an ascending aortic replacement.... Mark, Making an aortic tube out of tanned pericardium, especially one that has a curve to it, let alone sinuses, is not that easy. Doing it pretanning and using mandrils can make it easier. With appropriate preop measurements available it could be done without costing bypass time. Have you ever done it? If so, have you any follow up? A company in Belo Horizonte (Brasil) made a very elegant corrugated bovine pericardial aortic graft 10 years or more ago but they never exported it. As an aside, what surgeons, trying to help their patients, do free hand in the operating room without any of the controls , rules, prohibitions, validations, structured literature searches kept up to date to last week, that regulators require of manufacturers is fascinating Bob Disclosure: Pericardium has been a lifetime hobby **************New year...new news. Be the first to know what is making headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) From Rwmfglycar at aol.com Sat Jan 3 10:26:19 2009 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Sat Jan 3 10:28:10 2009 Subject: [HSF] Request for SJM data from Prasanna Message-ID: Prasanna I see that the numbers got com **************New year...new news. Be the first to know what is making headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) From ichfno at aol.com Sat Jan 3 09:33:21 2009 From: ichfno at aol.com (ICHFNO) Date: Sat Jan 3 10:34:27 2009 Subject: [HSF] STS In-Reply-To: References: <33B7C3B48D3840BAAE970FF577B4E9DC@yourg8he5gjrox>, Message-ID: <119c1b92.fa10.4a42.b161.9ba1abec87b4@aol.com> Mark; I will not be arriving to SFO until 8 p.m. on Sunday night, Monday night is the International Workforce meeting, so for me Tuesday night is all that is open. Bill Novick In a message dated 01/03/09 01:31:53 Central Standard Time, mmlevinson@hsforum.com writes: On Dec 26, 2008, at 7:01 AM, Ajit Damle wrote: > I sent an e-mail to see if HSFers want to get together in San > Francisco. Let > me know and then I can make some arrangements. Please count me in......I look forward to seeing all of you there.. Mark > > > Ajit Damle > > Chuck Douville > Bill Novak > Chand Ramaiah > Hal Roberts > Ajit Damle > Tea Acuff > JohnGoldblatt > Antonio Laudito > Barry Mahon > > Nine names, that is plenty. Anyone else wants to join in, you are > welcome. > > Tell me how we should do it. > > 1. I do not think I can get a medical company to arrange this, so we > will > end up paying for ourselves. > > 2. This is California. I can find about wine tasting, or the very > least, > get some good wines to sample. I may be a world authority on the > vintage > Chateau Fargo, terrier North Dakota, but I am open to suggestions! > > 3. I suggest that we all participate in the discussion. Each of us can > describe a personal clinical experience of an avoidable error or > undesirable > situation. Each participant will have 2 minutes to describe it and > there > will be three minutes of discussion. That will be a total of 45 > minutes for > 9 participants. > > 4. Time. There are a lot of event in the evening. Will a late > afternoon work > better? > > Ajit Damle > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From Rwmfglycar at aol.com Sat Jan 3 10:58:22 2009 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Sat Jan 3 10:59:26 2009 Subject: [HSF] Request for SJM data from Prasanna Message-ID: Prasanna I see that the numbers are completely screwed up in your reply. Did they reach you intact? Bob **************New year...new news. Be the first to know what is making headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) From tacuff at swbell.net Sat Jan 3 07:59:14 2009 From: tacuff at swbell.net (Tea Acuff) Date: Sat Jan 3 11:00:43 2009 Subject: [HSF] Durability - Rheumatic Mitral repairs Message-ID: <434982.71569.qm@web81606.mail.mud.yahoo.com> The nice thing about you, Bob, is not your lack of bias, but the multipicity of your bias. My mother, on the other hand, knows little of the competing agendas in surgery, but thinks that everything I do is marvelous. Which would you trust to advise you (trick question)? Tea Sent from my iPhone On Jan 3, 2009, at 9:24 AM, Rwmfglycar@aol.com wrote: In a message dated 1/3/2009 2:08:19 A.M. Eastern Standard Time, mmlevinson@hsforum.com writes: You can also make a tube graft from a sheet of glutaraldehyde preserved bovine pericardium and this may cost less than a Dacron graft but be useable as an ascending aortic replacement.... Mark, Making an aortic tube out of tanned pericardium, especially one that has a curve to it, let alone sinuses, is not that easy. Doing it pretanning and using mandrils can make it easier. With appropriate preop measurements available it could be done without costing bypass time. Have you ever done it? If so, have you any follow up? A company in Belo Horizonte (Brasil) made a very elegant corrugated bovine pericardial aortic graft 10 years or more ago but they never exported it. As an aside, what surgeons, trying to help their patients, do free hand in the operating room without any of the controls , rules, prohibitions, validations, structured literature searches kept up to date to last week, that regulators require of manufacturers is fascinating Bob Disclosure: Pericardium has been a lifetime hobby **************New year...new news. Be the first to know what is making headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From tacuff at swbell.net Sat Jan 3 08:08:35 2009 From: tacuff at swbell.net (Tea Acuff) Date: Sat Jan 3 11:10:05 2009 Subject: [HSF] Request for SJM data from Prasanna Message-ID: <487516.46723.qm@web81604.mail.mud.yahoo.com> Yes. It was kind of a fun puzzle. But what does the data mean vis a vis the implanting surgeon? That is, is this not a statement of the obvious: some valves have bigger holes but the biggest variable ("no thing") is the surgeon? Tea Sent from my iPhone On Jan 3, 2009, at 9:26 AM, Rwmfglycar@aol.com wrote: Prasanna I see that the numbers got com **************New year...new news. Be the first to know what is making headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From tacuff at swbell.net Sat Jan 3 08:12:53 2009 From: tacuff at swbell.net (Tea Acuff) Date: Sat Jan 3 11:14:13 2009 Subject: [HSF] Afib Procedures and Conduction Disease Message-ID: <407801.51026.qm@web81604.mail.mud.yahoo.com> So you also predict that the world is round? Tea Sent from my iPhone On Jan 3, 2009, at 7:30 AM, Ben Bidstrup wrote: In this day and age, the stigma attached to a take back needs to be removed entirely. It is much worse to fill a patient full of blood products and have the short term risks and long term mortality and QOL effects impact on outcomes, than a takeback that if done early (within a few hours) with out the usually ineffective products poured in is low risk and takes little time as usually all the team is available. In the near future, I predict we will be looking at outcomes in a slightly different way - composites of mortality, extended time in ICU use of blood products, ventilator time. These of course will be linked to premorbid conditions such as renal failure, use of antiplatelet agents, and COPD. Ben Bidstrup FRACS FRCSEd FEBCTS Cardiothoracic Surgeon On 03/01/2009, at 9:37 PM, hgrmd@aol.com wrote: Mark, My sentiments exactly. Unfortunately, I still get a little grief from some cardiologists when this occurs. Also, in this new era of living with the STS database, insertion of a pacemaker counts as a "bring back" for an open heart case. i.e, it's looked at the same as if the patient had been brought back for bleeding, reop, etc. Absurd don't you think? Hal In a message dated 1/3/2009 2:53:05 A.M. Eastern Standard Time, mmlevinson@hsforum.com writes: On Dec 24, 2008, at 10:23 AM, Michael Firstenberg wrote: I think letting some of these little ol ladies hang-out in a slow junctional rhythm is a bad idea - particularly as they are recovering from whatever else we have done to them. Many of them have pretty significant diastolic dysfunction (doesnt everyone these day) and their cardiac output are very heart rate dependent. Their bodies are use to seeing rates in the 70-80 and if their cardiac output drops by 40-50% because of a drop in heart rate they dont like it and we get problems like renal failure and sometimes even syncope. Fruthermore, just because we watch them for a few days in a tightly controlled environement such as a hospital that does not mean they will not have brady episodes at home which may result in a chronic slow decline - if not an acute problem. They need that safety net for the sinus node problems I did a simple and successful mitral repair years ago and the lady was in slow junctional rhythm postop. I used a temporary pacemaker and waited until her junctional rate gradually came up and did everything to avoid a permanent pacer since I felt this dysfunction would recover. She was in the hospital more than 10 days just waiting. Finally, after cardiology clearance, we all agreed she could go home with a stable junctional rhythym about 60 / minutes and no pacemaker. She was found dead at home about 2 weeks later. I put in permanent pacemakers not as a sign of defeat but as a safety net. And I pace the patients at 80/min to increase their cardiac output and help relieve symptoms of fatigue and CHF. After a month I drop the rate back down. I think you can decrease our incidence of pacemaker insertion post-Maze if you and to wait longer and accept lower heart rates. But is it worth it? In my opinion...no. The current generation of pacemakers and leads are so reliable and physiologic that I do not consider a pacemaker a disadvantage, and in many cases it is advantageous. Atrial pacing may actually help maintain atrial contractions and prevent breakthrough a-fib as well. And now you can get intra-cardiac event monitoring and prove whether they have bursts of afib or not! Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- **************New year...new news. Be the first to know what is making headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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@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 ----------------------------------------- From robertobattellini at hotmail.com Sat Jan 3 18:05:08 2009 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Sat Jan 3 12:06:01 2009 Subject: [HSF] for Bob In-Reply-To: References: Message-ID: Bob, I had once in the late 80`s the opportunity to use one of these corrugated bovine pericardium prosthesis for a Type A Dissection, it was excellent to sew it with 4 x 0 Prolene,then I never more heard about it. Roberto> From: Rwmfglycar@aol.com> Date: Sat, 3 Jan 2009 10:24:41 -0500> Subject: Re: [HSF] Durability - Rheumatic Mitral repairs> To: OpenHeart-L@lists.hsforum.com> CC: > > > In a message dated 1/3/2009 2:08:19 A.M. Eastern Standard Time, > mmlevinson@hsforum.com writes:> > You can also make a tube graft from a sheet of glutaraldehyde > preserved bovine pericardium and this may cost less than a Dacron > graft but be useable as an ascending aortic replacement....> > > > > > > Mark,> Making an aortic tube out of tanned pericardium, especially one that has a > curve to it, let alone sinuses, is not that easy. Doing it pretanning and > using mandrils can make it easier. With appropriate preop measurements available > it could be done without costing bypass time.> Have you ever done it? If so, have you any follow up?> > A company in Belo Horizonte (Brasil) made a very elegant corrugated bovine > pericardial aortic graft 10 years or more ago but they never exported it.> > As an aside, what surgeons, trying to help their patients, do free hand in > the operating room without any of the controls , rules, prohibitions, > validations, structured literature searches kept up to date to last week, that > regulators require of manufacturers is fascinating> Bob> Disclosure: Pericardium has been a lifetime hobby> **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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> ----------------------------------------- From robertobattellini at hotmail.com Sat Jan 3 18:15:57 2009 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Sat Jan 3 12:16:45 2009 Subject: [HSF] Durability - Mitral repairs In-Reply-To: <454854.53740.qm@web26702.mail.ukl.yahoo.com> References: <454854.53740.qm@web26702.mail.ukl.yahoo.com> Message-ID: I am very glad to read this mail, as I opeerated last friday a patient with aortic stenosis, mitral insuff and 3 vessel disease.I did AVR, 3 bypasses and in the mitral: A2 and A3 had broken cordae, and the whole posterior annulus was calcified.So I made 8 new cordae with Mohr?s technique (published recently in How to-do-it in the Annals by Cleveland Group), and did no ring.Left with MI I?. Roberto> Date: Thu, 18 Dec 2008 23:31:46 +0000> From: drdharris@yahoo.co.uk> Subject: RE: [HSF] Durability - Rheumatic Mitral repairs> To: OpenHeart-L@lists.hsforum.com> CC: > > I think Nasser is referring to the equivocal cases where most people would do no repair, ie 1+ tricuspid regurg. In this case a De Vega is surely better than nothing. A lot of surgeons would try to spare a ring in these cases and therefore do nothing. Furthermore, in Johannesburg and Cape Town, for many years a modified De Vega has been used, using a double row of sutures re-inforced with pledgets, with good results. As we know, felt pledgets stick very good to tissues with time, and become rock hard.....Donald Ross senior says he hated them! Our approach is a ring with moderate to severe regurg, and a modified De Vega for ALL other cases having a mitral procedure.> > Concerning rings for mitrals, there is still some controversy:> At the Egyptian society meeting in 2005, Bernard Eisenmann presented 491 mitral repairs with 15 yr follow up. Of these, 282 had no ring placed, and 225 of this group with no ring had isolated posterior leaflet prolapse. These patients had freedom of re-operation of 96.5% at 10 yrs, and 92.5%at 15 yrs. 15 of these patients were re-operated. 25 of the 209 patients who had a ring were re-operated.> > They conclude that the annulus was rarely (2 cases of those with no ring) involved in recurrent insufficiency, and the usual factor was a chordal or leaflet one. > > Dave> > > > Dr. David G. Harris, FCS, MMED,> Cardiothoracic Surgeon > Suite 207 > Kuils River Private Hospital, > PO Box 1200, Kuils River, 7579, Cape Town, South Africa. > Tel > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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> ----------------------------------------- From msfirst at gmail.com Sat Jan 3 12:20:22 2009 From: msfirst at gmail.com (Michael Firstenberg) Date: Sat Jan 3 12:20:50 2009 Subject: [HSF] Afib Procedures and Conduction Disease In-Reply-To: References: Message-ID: Hal, My question then is what do they expect? If a patient needs a pacemaker, they need a pacemaker. Is it your (our?) fault if they also need an ICD? When you say they give your grief - what exactly do they say? Do they understand what a problem is and how they get treated? I bet, for example many of the AVRs that you have done who needed a pacemaker afterward, probably needed one beforehand - (maybe even their conduction disease which prompted the work-up and the obvious treatable problem was the aortic stenosis but no one found the conduction disease until the patient was in a tele unit for a week... I could be a little more critical, but wont). But, it also begs the question - since you say that you get sent many patients in which the referring wants a specific procedure (like a mini) - what do they give as the reason. Why do Cardiologist want us to do mini's? -michael On Sat, Jan 3, 2009 at 6:37 AM, wrote: > Mark, > My sentiments exactly. Unfortunately, I still get a little grief from > some cardiologists when this occurs. Also, in this new era of living with > the > STS database, insertion of a pacemaker counts as a "bring back" for an > open > heart case. i.e, it's looked at the same as if the patient had been > brought > back for bleeding, reop, etc. Absurd don't you think? > > Hal > > > In a message dated 1/3/2009 2:53:05 A.M. Eastern Standard Time, > mmlevinson@hsforum.com writes: > > > On Dec 24, 2008, at 10:23 AM, Michael Firstenberg wrote: > > > > I think letting some of these little ol ladies hang-out in a slow > > junctional > > rhythm is a bad idea - particularly as they are recovering from > > whatever > > else we have done to them. Many of them have pretty significant > > diastolic > > dysfunction (doesnt everyone these day) and their cardiac output are > > very > > heart rate dependent. Their bodies are use to seeing rates in the > > 70-80 > > and if their cardiac output drops by 40-50% because of a drop in > > heart rate > > they dont like it and we get problems like renal failure and > > sometimes even > > syncope. Fruthermore, just because we watch them for a few days in a > > tightly controlled environement such as a hospital that does not > > mean they > > will not have brady episodes at home which may result in a chronic > > slow > > decline - if not an acute problem. They need that safety net for > > the sinus > > node problems > > > > > > I did a simple and successful mitral repair years ago and the lady was > in > slow junctional rhythm postop. I used a temporary pacemaker and waited > until her junctional rate gradually came up and did everything to avoid > a permanent pacer since I felt this dysfunction would recover. She > was in the hospital > more than 10 days just waiting. Finally, after > cardiology clearance, we all agreed she could go home with a stable > junctional rhythym about 60 / minutes and no pacemaker. She was > found dead at home > about 2 weeks later. > > I put in permanent pacemakers not as a sign of defeat but as a safety > net. And I pace the patients at 80/min to increase their cardiac > output > and help relieve symptoms of fatigue and CHF. After a month > I drop the rate back down. > > I think you can decrease our incidence of pacemaker insertion post-Maze > if you and to wait longer and accept lower heart rates. But is it > worth it? In my opinion...no. > The current generation of pacemakers and leads are so reliable and > physiologic > that I do not consider a pacemaker a disadvantage, and in many cases > it is > advantageous. Atrial pacing may actually help maintain atrial > contractions > and prevent breakthrough a-fib as well. > > And now you can get intra-cardiac event monitoring and prove whether > they have bursts of afib or not! > > > > Mark Levinson, MD. > Founder, Editor-in-Chief > The Heart Surgery Forum(R) > Multimedia Cardiothoracic Journal > URL: http://www.hsforum.com > URL: http://newoptionsinheartsurgery.com > Emali: mmlevinson@hsforum.com > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > From v_tall_e at hotmail.com Sat Jan 3 17:22:52 2009 From: v_tall_e at hotmail.com (Vitaly Demyanchuk) Date: Sat Jan 3 12:23:42 2009 Subject: [HSF] Photos In-Reply-To: <407801.51026.qm@web81604.mail.mud.yahoo.com> References: <407801.51026.qm@web81604.mail.mud.yahoo.com> Message-ID: Dear Colleagues, I am searching for the photos of famous surgeons who created a history of systemic-to-pulmonary shunts for treatment of tetralogy of Fallot. I would like to put all of these photos into my article. I have already had Dr.Taussig, Blalock, Cooley, Brock, de Leval. What I need: Dr Klinner W, Potts WJ, Waterstone DJ, Davidson JS, Sellors TH. photos. Any images or links would be greatly appreciated! Acknowledgment - I guarantee. Sincerely, Vitaly Demyanchuk Kyiv Heat Center UKRAINE _________________________________________________________________ Life on your PC is safer, easier, and more enjoyable with Windows Vista?. http://clk.atdmt.com/MRT/go/127032870/direct/01/ From nkkejriwal at gmail.com Sun Jan 4 19:24:34 2009 From: nkkejriwal at gmail.com (nand kejriwal) Date: Sun Jan 4 01:25:05 2009 Subject: [HSF] Photos In-Reply-To: References: <407801.51026.qm@web81604.mail.mud.yahoo.com> Message-ID: Dear Vitaly You will find the photos of Potts and Sellors in the book Landmarks in cardiac surgery by Stephen Westaby. nand On Sun, Jan 4, 2009 at 6:22 AM, Vitaly Demyanchuk wrote: > > Dear Colleagues, > > > I am searching for the photos of famous surgeons who created a history of > systemic-to-pulmonary shunts for treatment of tetralogy of Fallot. I would > like to put all of these photos into my article. I have already had > Dr.Taussig, Blalock, Cooley, Brock, de Leval. What I need: > > Dr Klinner W, Potts WJ, Waterstone DJ, Davidson JS, Sellors TH. photos. > > Any images or links would be greatly appreciated! > Acknowledgment - I guarantee. > > Sincerely, > > > Vitaly Demyanchuk > Kyiv Heat Center > UKRAINE > > > > _________________________________________________________________ > Life on your PC is safer, easier, and more enjoyable with Windows Vista(R). > > http://clk.atdmt.com/MRT/go/127032870/direct/01/_______________________________________________ > OpenHeart-Lmailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > From Rwmfglycar at aol.com Sun Jan 4 08:01:23 2009 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Sun Jan 4 08:02:24 2009 Subject: [HSF] Request for SJM data from Prasanna Message-ID: In a message dated 1/3/2009 11:11:40 A.M. Eastern Standard Time, tacuff@swbell.net writes: Yes. It was kind of a fun puzzle. But what does the data mean vis a vis the implanting surgeon? That is, is this not a statement of the obvious: some valves have bigger holes but the biggest variable ("no thing") is the surgeon? Tea You are absolutely right, the size of the hole of a mechanical valve is the most important determinant of forward flow performance. Remember first the importance of the relationship between mounting size and internal orifice, and then that the size of the hole is not determined just by the internal diameter of the housing. The shape of the orifice can make a difference and the occluder must be factored in. Different occluders produce different effects on transvalvular flow, with varying degrees of turbulence. Then there is the obligatory closing volume (i.e. the flow back through the orifice that is necessary to close it; done so much better by nature) and the leakage during closure which can be zero or a definitely measurable amount. Engineers like to put all this together, into what they call Energy Loss. In vitro performance can be very precisely measured. and differences between two designs clearly shown. Clinically the noninvasive measurements are far less precise. You have suggested that surgeons have an effect on valve performance. The great majority of surgeons handle aortic valve replacement very well but you are right; the surgeon can interfere with the hemodynamic result in a number of ways which if I were to describe them would be a lecture. In the aortic position the single most common error in performance is failure to decalcify the annulus completely. I would add only that this longheld opinion has been confirmed during the last nine years of consulting for a valve company. Bob **************New year...new news. Be the first to know what is making headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) From tacuff at swbell.net Sun Jan 4 07:03:52 2009 From: tacuff at swbell.net (Tea Acuff) Date: Sun Jan 4 10:05:20 2009 Subject: [HSF] Request for SJM data from Prasanna Message-ID: <462968.48508.qm@web81605.mail.mud.yahoo.com> Could you elaborate on failure to decalcify especially since Cooley is quoted as saying too much is the worst error? Obviously your point that in vivo " sizes" are different and one would "assume" the gradient is the market for the heart, but should not the surgeon not fit what will easily go or enlarge to fit what will easily go instead of rt21 vs pq23 vs xz22? Tea Sent from my iPhone On Jan 4, 2009, at 7:01 AM, Rwmfglycar@aol.com wrote: In a message dated 1/3/2009 11:11:40 A.M. Eastern Standard Time, tacuff@swbell.net writes: Yes. It was kind of a fun puzzle. But what does the data mean vis a vis the implanting surgeon? That is, is this not a statement of the obvious: some valves have bigger holes but the biggest variable ("no thing") is the surgeon? Tea You are absolutely right, the size of the hole of a mechanical valve is the most important determinant of forward flow performance. Remember first the importance of the relationship between mounting size and internal orifice, and then that the size of the hole is not determined just by the internal diameter of the housing. The shape of the orifice can make a difference and the occluder must be factored in. Different occluders produce different effects on transvalvular flow, with varying degrees of turbulence. Then there is the obligatory closing volume (i.e. the flow back through the orifice that is necessary to close it; done so much better by nature) and the leakage during closure which can be zero or a definitely measurable amount. Engineers like to put all this together, into what they call Energy Loss. In vitro performance can be very precisely measured. and differences between two designs clearly shown. Clinically the noninvasive measurements are far less precise. You have suggested that surgeons have an effect on valve performance. The great majority of surgeons handle aortic valve replacement very well but you are right; the surgeon can interfere with the hemodynamic result in a number of ways which if I were to describe them would be a lecture. In the aortic position the single most common error in performance is failure to decalcify the annulus completely. I would add only that this longheld opinion has been confirmed during the last nine years of consulting for a valve company. Bob **************New year...new news. Be the first to know what is making headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From prasannasimha at gmail.com Sun Jan 4 20:53:47 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sun Jan 4 10:30:19 2009 Subject: [HSF] Request for SJM data from Prasanna In-Reply-To: References: Message-ID: <89c4ed2d0901040723v7e766d6ejb5f2d337519565cb@mail.gmail.com> They came zig zag but I could figure it out !! Thanks Dr Frater. Prasanna On Sat, Jan 3, 2009 at 9:28 PM, wrote: > Prasanna I see that the numbers are completely screwed up in your reply. > Did they reach you intact? > Bob > **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > -- Prasanna Simha M From robertobattellini at hotmail.com Sun Jan 4 18:16:03 2009 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Sun Jan 4 12:16:52 2009 Subject: [HSF] decalcifying the aortic annulus: opinions In-Reply-To: <462968.48508.qm@web81605.mail.mud.yahoo.com> References: <462968.48508.qm@web81605.mail.mud.yahoo.com> Message-ID: Tea, We agree in Germany that the annulus should be completely decalcified but without going into the annulus.May be Cooley saw some disasters? Too much is an error, too less also.Exactly is better.We operate the valves with loupes. May be bob should write THAT "lecture" Roberto> Date: Sun, 4 Jan 2009 07:03:52 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] Request for SJM data from Prasanna> To: OpenHeart-L@lists.hsforum.com> CC: > > Could you elaborate on failure to decalcify especially since Cooley is quoted as saying too much is the worst error?> Obviously your point that in vivo " sizes" are different and one would "assume" the gradient is the market for the heart, but should not the surgeon not fit what will easily go or enlarge to fit what will easily go instead of rt21 vs pq23 vs xz22?> Tea> > Sent from my iPhone> > On Jan 4, 2009, at 7:01 AM, Rwmfglycar@aol.com wrote:> > > In a message dated 1/3/2009 11:11:40 A.M. Eastern Standard Time, > tacuff@swbell.net writes:> > Yes. It was kind of a fun puzzle. But what does the data mean vis a vis the > implanting surgeon? That is, is this not a statement of the obvious: some > valves have bigger holes but the biggest variable ("no thing") is the surgeon?> Tea > > > > You are absolutely right, the size of the hole of a mechanical valve is the > most important determinant of forward flow performance. Remember first the > importance of the relationship between mounting size and internal orifice, and > then that the size of the hole is not determined just by the internal > diameter of the housing. The shape of the orifice can make a difference and the > occluder must be factored in. Different occluders produce different effects on > transvalvular flow, with varying degrees of turbulence. Then there is the > obligatory closing volume (i.e. the flow back through the orifice that is > necessary to close it; done so much better by nature) and the leakage during closure > which can be zero or a definitely measurable amount. Engineers like to put > all this together, into what they call Energy Loss. In vitro performance can > be very precisely measured. and differences between two designs clearly shown. > Clinically the noninvasive measurements are far less precise. You have > suggested that surgeons have an effect on valve performance.> The great majority of surgeons handle aortic valve replacement very > well but you are right; the surgeon can interfere with the hemodynamic result in > a number of ways which if I were to describe them would be a lecture. In the > aortic position the single most common error in performance is failure to > decalcify the annulus completely. I would add only that this longheld opinion > has been confirmed during the last nine years of consulting for a valve > company.> Bob> **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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> ----------------------------------------- From prasannasimha at gmail.com Sun Jan 4 22:45:47 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sun Jan 4 12:21:36 2009 Subject: [HSF] Request for SJM data from Prasanna In-Reply-To: <89c4ed2d0901040723v7e766d6ejb5f2d337519565cb@mail.gmail.com> References: <89c4ed2d0901040723v7e766d6ejb5f2d337519565cb@mail.gmail.com> Message-ID: <89c4ed2d0901040915q4a6d96ebya080f205a6a5b612@mail.gmail.com> Are the EOA's published for mitral valves too ? Prasanna On Sun, Jan 4, 2009 at 8:53 PM, Prasanna Simha M wrote: > They came zig zag but I could figure it out !! > Thanks Dr Frater. > Prasanna > > > On Sat, Jan 3, 2009 at 9:28 PM, wrote: > >> Prasanna I see that the numbers are completely screwed up in your reply. >> Did they reach you intact? >> Bob >> **************New year...new news. Be the first to know what is making >> headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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 >> ----------------------------------------- >> > > > > -- > Prasanna Simha M > -- Prasanna Simha M From otto at iafrica.com Sun Jan 4 19:57:17 2009 From: otto at iafrica.com (Otto Thaning) Date: Sun Jan 4 12:57:49 2009 Subject: [HSF] Photos References: <407801.51026.qm@web81604.mail.mud.yahoo.com> Message-ID: Dear Vitally, Could you share your photos of Dr.Taussig, Blalock, Cooley, Brock, de Leval with us on the HSF? Regards OTTO THANING Cape Town Dear Colleagues, I am searching for the photos of famous surgeons who created a history of systemic-to-pulmonary shunts for treatment of tetralogy of Fallot. I would like to put all of these photos into my article. I have already had Dr.Taussig, Blalock, Cooley, Brock, de Leval. What I need: Dr Klinner W, Potts WJ, Waterstone DJ, Davidson JS, Sellors TH. photos. Any images or links would be greatly appreciated! Acknowledgment - I guarantee. Sincerely, Vitaly Demyanchuk Kyiv Heat Center UKRAINE _________________________________________________________________ Life on your PC is safer, easier, and more enjoyable with Windows Vista?. http://clk.atdmt.com/MRT/go/127032870/direct/01/_______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From Hgrmd at aol.com Sun Jan 4 15:26:04 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Jan 4 15:27:06 2009 Subject: [HSF] Afib Procedures and Conduction Disease Message-ID: Michael, You are really expanding the scope of this thread. The cardiologists don't get angry when my mazes need a pacer, they just needle me a little. I patiently point out that lots of these patients probably don't even have an SA node. The maze just unroofs the problem. Frankly, I don't really care what they think since the patients do just fine with a pacer. Cardiologists and patients do ask for mini procedures with regularity. I offer them if I think they are appropriate. For example, one of the cases I'm doing tomorrow is a 47 yo lady with severe MR and mod-severe AI. She inquired about the case being done minimally. I told her my rationale for recommending sternotomy. No problem. Hal In a message dated 1/3/2009 12:21:54 P.M. Eastern Standard Time, msfirst@gmail.com writes: Hal, My question then is what do they expect? If a patient needs a pacemaker, they need a pacemaker. Is it your (our?) fault if they also need an ICD? When you say they give your grief - what exactly do they say? Do they understand what a problem is and how they get treated? I bet, for example many of the AVRs that you have done who needed a pacemaker afterward, probably needed one beforehand - (maybe even their conduction disease which prompted the work-up and the obvious treatable problem was the aortic stenosis but no one found the conduction disease until the patient was in a tele unit for a week... I could be a little more critical, but wont). But, it also begs the question - since you say that you get sent many patients in which the referring wants a specific procedure (like a mini) - what do they give as the reason. Why do Cardiologist want us to do mini's? -michael On Sat, Jan 3, 2009 at 6:37 AM, wrote: > Mark, > My sentiments exactly. Unfortunately, I still get a little grief from > some cardiologists when this occurs. Also, in this new era of living with > the > STS database, insertion of a pacemaker counts as a "bring back" for an > open > heart case. i.e, it's looked at the same as if the patient had been > brought > back for bleeding, reop, etc. Absurd don't you think? > > Hal > > > In a message dated 1/3/2009 2:53:05 A.M. Eastern Standard Time, > mmlevinson@hsforum.com writes: > > > On Dec 24, 2008, at 10:23 AM, Michael Firstenberg wrote: > > > > I think letting some of these little ol ladies hang-out in a slow > > junctional > > rhythm is a bad idea - particularly as they are recovering from > > whatever > > else we have done to them. Many of them have pretty significant > > diastolic > > dysfunction (doesnt everyone these day) and their cardiac output are > > very > > heart rate dependent. Their bodies are use to seeing rates in the > > 70-80 > > and if their cardiac output drops by 40-50% because of a drop in > > heart rate > > they dont like it and we get problems like renal failure and > > sometimes even > > syncope. Fruthermore, just because we watch them for a few days in a > > tightly controlled environement such as a hospital that does not > > mean they > > will not have brady episodes at home which may result in a chronic > > slow > > decline - if not an acute problem. They need that safety net for > > the sinus > > node problems > > > > > > I did a simple and successful mitral repair years ago and the lady was > in > slow junctional rhythm postop. I used a temporary pacemaker and waited > until her junctional rate gradually came up and did everything to avoid > a permanent pacer since I felt this dysfunction would recover. She > was in the hospital > more than 10 days just waiting. Finally, after > cardiology clearance, we all agreed she could go home with a stable > junctional rhythym about 60 / minutes and no pacemaker. She was > found dead at home > about 2 weeks later. > > I put in permanent pacemakers not as a sign of defeat but as a safety > net. And I pace the patients at 80/min to increase their cardiac > output > and help relieve symptoms of fatigue and CHF. After a month > I drop the rate back down. > > I think you can decrease our incidence of pacemaker insertion post-Maze > if you and to wait longer and accept lower heart rates. But is it > worth it? In my opinion...no. > The current generation of pacemakers and leads are so reliable and > physiologic > that I do not consider a pacemaker a disadvantage, and in many cases > it is > advantageous. Atrial pacing may actually help maintain atrial > contractions > and prevent breakthrough a-fib as well. > > And now you can get intra-cardiac event monitoring and prove whether > they have bursts of afib or not! > > > > Mark Levinson, MD. > Founder, Editor-in-Chief > The Heart Surgery Forum(R) > Multimedia Cardiothoracic Journal > URL: http://www.hsforum.com > URL: http://newoptionsinheartsurgery.com > Emali: mmlevinson@hsforum.com > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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 ----------------------------------------- **************New year...new news. Be the first to know what is making headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) From ebender001 at me.com Sun Jan 4 14:43:32 2009 From: ebender001 at me.com (Edward Bender) Date: Sun Jan 4 15:47:52 2009 Subject: [HSF] Epicardial atrial leads Message-ID: A few days ago I operated on a 57 year old renal dialysis patient with MRSA endocarditis of the aortic valve. In the OR I found that the entire non-coronary leaflet and parts of the other leaflets were replaced with vegetation. Additionally, the vegetations had eroded through the membranous septum into the right atrium, causing a ?Gerbode defect.? Interestingly, his pre-op EKG?s were (computer read with a perfunctory doctor signature due to a wiggly baseline) listed as atrial fib. He was obviously in third degree heart block. After the repair, I placed ventricular epicardial screw in leads (along with temporary wires) for eventual permanent pacemaker. I would like to stay out of the venous system for now due to ongoing need for dialysis access. Is there a purpose built epicardial atrial pacer lead on the market? I was thinking about using a transvenous active lead but screwing it into the outside of the atrium, but I did not have one available at the time. Ed Bender, MD From Hgrmd at aol.com Sun Jan 4 16:24:58 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Jan 4 16:25:30 2009 Subject: [HSF] Epicardial atrial leads Message-ID: Ed, Interesting case. I had a similar one about a year and a half ago. I don't know about the atrial epicardial lead. However, my question to you is whether you are sure the patient is adequately debrided. Did you open up the RA and make sure all of the infection was removed? The case I had also ended up involving the anterior leaflet of the tricuspid. Hal In a message dated 1/4/2009 3:48:52 P.M. Eastern Standard Time, ebender001@me.com writes: A few days ago I operated on a 57 year old renal dialysis patient with MRSA endocarditis of the aortic valve. In the OR I found that the entire non-coronary leaflet and parts of the other leaflets were replaced with vegetation. Additionally, the vegetations had eroded through the membranous septum into the right atrium, causing a ?Gerbode defect.? Interestingly, his pre-op EKG?s were (computer read with a perfunctory doctor signature due to a wiggly baseline) listed as atrial fib. He was obviously in third degree heart block. After the repair, I placed ventricular epicardial screw in leads (along with temporary wires) for eventual permanent pacemaker. I would like to stay out of the venous system for now due to ongoing need for dialysis access. Is there a purpose built epicardial atrial pacer lead on the market? I was thinking about using a transvenous active lead but screwing it into the outside of the atrium, but I did not have one available at the time. Ed Bender, MD _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- **************New year...new news. Be the first to know what is making headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) From ebender001 at me.com Sun Jan 4 15:45:00 2009 From: ebender001 at me.com (Edward Bender) Date: Sun Jan 4 16:45:34 2009 Subject: [HSF] Epicardial atrial leads In-Reply-To: Message-ID: Hal: Excellent point. I did indeed open the right atrium and removed a component of the vegetation (like a dumbbell shape with the membranous septum the narrow part). I trimmed back the tricuspid annulus until I got to normal looking tissue (not much debridement). Ed Bender, MD On 1/4/09 3:24 PM, "Harold Roberts" wrote: > Ed, > Interesting case. I had a similar one about a year and a half ago. I > don't know about the atrial epicardial lead. However, my question to you is > whether you are sure the patient is adequately debrided. Did you open up the > RA > and make sure all of the infection was removed? The case I had also ended > up involving the anterior leaflet of the tricuspid. > > Hal > > > In a message dated 1/4/2009 3:48:52 P.M. Eastern Standard Time, > ebender001@me.com writes: > > A few days ago I operated on a 57 year old renal dialysis patient with MRSA > endocarditis of the aortic valve. In the OR I found that the entire > non-coronary leaflet and parts of the other leaflets were replaced with > vegetation. Additionally, the vegetations had eroded through the membranous > septum into the right atrium, causing a ?Gerbode defect.? Interestingly, > his pre-op EKG?s were (computer read with a perfunctory doctor signature due > to a wiggly baseline) listed as atrial fib. He was obviously in third > degree heart block. After the repair, I placed ventricular epicardial screw > in leads (along with temporary wires) for eventual permanent pacemaker. I > would like to stay out of the venous system for now due to ongoing need for > dialysis access. > > Is there a purpose built epicardial atrial pacer lead on the market? I was > thinking about using a transvenous active lead but screwing it into the > outside of the atrium, but I did not have one available at the time. > > Ed Bender, MD > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From hgrmd at aol.com Sun Jan 4 22:16:59 2009 From: hgrmd at aol.com (hgrmd@aol.com) Date: Sun Jan 4 17:17:20 2009 Subject: [HSF] Epicardial atrial leads In-Reply-To: References: Message-ID: <2038914021-1231107410-cardhu_decombobulator_blackberry.rim.net-1465904755-@bxe016.bisx.prod.on.blackberry> Ed, Thanks, I knew you knew better than to stay out of the RA. I have seen that omission done with predictably bad results. Hal Sent from my Verizon Wireless BlackBerry -----Original Message----- From: Edward Bender Date: Sun, 04 Jan 2009 15:45:00 To: HSF List Subject: Re: [HSF] Epicardial atrial leads Hal: Excellent point. I did indeed open the right atrium and removed a component of the vegetation (like a dumbbell shape with the membranous septum the narrow part). I trimmed back the tricuspid annulus until I got to normal looking tissue (not much debridement). Ed Bender, MD On 1/4/09 3:24 PM, "Harold Roberts" wrote: > Ed, > Interesting case. I had a similar one about a year and a half ago. I > don't know about the atrial epicardial lead. However, my question to you is > whether you are sure the patient is adequately debrided. Did you open up the > RA > and make sure all of the infection was removed? The case I had also ended > up involving the anterior leaflet of the tricuspid. > > Hal > > > In a message dated 1/4/2009 3:48:52 P.M. Eastern Standard Time, > ebender001@me.com writes: > > A few days ago I operated on a 57 year old renal dialysis patient with MRSA > endocarditis of the aortic valve. In the OR I found that the entire > non-coronary leaflet and parts of the other leaflets were replaced with > vegetation. Additionally, the vegetations had eroded through the membranous > septum into the right atrium, causing a ?Gerbode defect.? Interestingly, > his pre-op EKG?s were (computer read with a perfunctory doctor signature due > to a wiggly baseline) listed as atrial fib. He was obviously in third > degree heart block. After the repair, I placed ventricular epicardial screw > in leads (along with temporary wires) for eventual permanent pacemaker. I > would like to stay out of the venous system for now due to ongoing need for > dialysis access. > > Is there a purpose built epicardial atrial pacer lead on the market? I was > thinking about using a transvenous active lead but screwing it into the > outside of the atrium, but I did not have one available at the time. > > Ed Bender, MD >_______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) >_______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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 ----------------------------------------- From anianyanwu at hotmail.com Sun Jan 4 23:10:05 2009 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Sun Jan 4 18:10:53 2009 Subject: [HSF] Epicardial atrial leads In-Reply-To: References: Message-ID: Ed For the less experienced amongst us could you please explain the operation you did, findings and procedures, in detail? Thanks Ani > Date: Sun, 4 Jan 2009 15:45:00 -0600> Subject: Re: [HSF] Epicardial atrial leads> From: ebender001@me.com> To: OpenHeart-L@lists.hsforum.com> CC: > > Hal:> Excellent point. I did indeed open the right atrium and removed a component> of the vegetation (like a dumbbell shape with the membranous septum the> narrow part). I trimmed back the tricuspid annulus until I got to normal> looking tissue (not much debridement).> > Ed Bender, MD> > > On 1/4/09 3:24 PM, "Harold Roberts" wrote:> > > Ed,> > Interesting case. I had a similar one about a year and a half ago. I> > don't know about the atrial epicardial lead. However, my question to you is> > whether you are sure the patient is adequately debrided. Did you open up the> > RA > > and make sure all of the infection was removed? The case I had also ended> > up involving the anterior leaflet of the tricuspid.> > > > Hal> > > > > > In a message dated 1/4/2009 3:48:52 P.M. Eastern Standard Time,> > ebender001@me.com writes:> > > > A few days ago I operated on a 57 year old renal dialysis patient with MRSA> > endocarditis of the aortic valve. In the OR I found that the entire> > non-coronary leaflet and parts of the other leaflets were replaced with> > vegetation. Additionally, the vegetations had eroded through the membranous> > septum into the right atrium, causing a ?Gerbode defect.? Interestingly,> > his pre-op EKG?s were (computer read with a perfunctory doctor signature due> > to a wiggly baseline) listed as atrial fib. He was obviously in third> > degree heart block. After the repair, I placed ventricular epicardial screw> > in leads (along with temporary wires) for eventual permanent pacemaker. I> > would like to stay out of the venous system for now due to ongoing need for> > dialysis access.> > > > Is there a purpose built epicardial atrial pacer lead on the market? I was> > thinking about using a transvenous active lead but screwing it into the> > outside of the atrium, but I did not have one available at the time.> > > > Ed Bender, MD> > _______________________________________________> > OpenHeart-L mailing list> > > > Send postings to:> > OpenHeart-L@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> > -----------------------------------------> > > > **************New year...new news. Be the first to know what is making> > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026)> > _______________________________________________> > OpenHeart-L mailing list> > > > Send postings to:> > OpenHeart-L@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@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> ----------------------------------------- _________________________________________________________________ Imagine a life without walls.? See the possibilities. http://clk.atdmt.com/UKM/go/122465943/direct/01/ From Scott.Silvestry at jefferson.edu Sun Jan 4 18:59:30 2009 From: Scott.Silvestry at jefferson.edu (Scott Silvestry) Date: Sun Jan 4 19:01:14 2009 Subject: [HSF] Epicardial atrial leads Message-ID: <20090104185930.AHW80807@parkcity.jefferson.edu> Ed: We use Medtronic epicardial leads (SEW ON) with steroid eluting epicardial tips for a and v applications. (Model 4965 4968 or similiar). I can get the exact model number if interested ( the adult size is 53 cm I think) Our pediatric colleages have suggested these are more durable but I believe the literature is mixed with evidence to back this supposition up. Some have suggested with these leads, the threshold is higher and may increase generator changes over a lifetime ( as compared to screw on). Scott ---- Original message ---- >Date: Sun, 04 Jan 2009 14:43:32 -0600 >From: Edward Bender >Subject: [HSF] Epicardial atrial leads >To: HSF List > >A few days ago I operated on a 57 year old renal dialysis patient with MRSA >endocarditis of the aortic valve. In the OR I found that the entire >non-coronary leaflet and parts of the other leaflets were replaced with >vegetation. Additionally, the vegetations had eroded through the membranous >septum into the right atrium, causing a ?Gerbode defect.? Interestingly, >his pre-op EKG?s were (computer read with a perfunctory doctor signature due >to a wiggly baseline) listed as atrial fib. He was obviously in third >degree heart block. After the repair, I placed ventricular epicardial screw >in leads (along with temporary wires) for eventual permanent pacemaker. I >would like to stay out of the venous system for now due to ongoing need for >dialysis access. > >Is there a purpose built epicardial atrial pacer lead on the market? I was >thinking about using a transvenous active lead but screwing it into the >outside of the atrium, but I did not have one available at the time. > >Ed Bender, MD >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: > OpenHeart-L@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 >----------------------------------------- From Scott.Silvestry at jefferson.edu Sun Jan 4 19:01:11 2009 From: Scott.Silvestry at jefferson.edu (Scott Silvestry) Date: Sun Jan 4 19:01:31 2009 Subject: [HSF] Epicardial atrial leads Message-ID: <20090104190111.AHW80842@parkcity.jefferson.edu> Which is why my mentor always double cannulated for aortic endocarditis... Nice Job Ed Scott ---- Original message ---- >Date: Sun, 4 Jan 2009 22:16:59 +0000 >From: hgrmd@aol.com >Subject: Re: [HSF] Epicardial atrial leads >To: OpenHeart-L@lists.hsforum.com > >Ed, > Thanks, I knew you knew better than to stay out of the RA. I have seen that omission done with predictably bad results. > >Hal >Sent from my Verizon Wireless BlackBerry > >-----Original Message----- >From: Edward Bender > >Date: Sun, 04 Jan 2009 15:45:00 >To: HSF List >Subject: Re: [HSF] Epicardial atrial leads > > >Hal: >Excellent point. I did indeed open the right atrium and removed a component >of the vegetation (like a dumbbell shape with the membranous septum the >narrow part). I trimmed back the tricuspid annulus until I got to normal >looking tissue (not much debridement). > >Ed Bender, MD > > >On 1/4/09 3:24 PM, "Harold Roberts" wrote: > >> Ed, >> Interesting case. I had a similar one about a year and a half ago. I >> don't know about the atrial epicardial lead. However, my question to you is >> whether you are sure the patient is adequately debrided. Did you open up the >> RA >> and make sure all of the infection was removed? The case I had also ended >> up involving the anterior leaflet of the tricuspid. >> >> Hal >> >> >> In a message dated 1/4/2009 3:48:52 P.M. Eastern Standard Time, >> ebender001@me.com writes: >> >> A few days ago I operated on a 57 year old renal dialysis patient with MRSA >> endocarditis of the aortic valve. In the OR I found that the entire >> non-coronary leaflet and parts of the other leaflets were replaced with >> vegetation. Additionally, the vegetations had eroded through the membranous >> septum into the right atrium, causing a ?Gerbode defect.? Interestingly, >> his pre-op EKG?s were (computer read with a perfunctory doctor signature due >> to a wiggly baseline) listed as atrial fib. He was obviously in third >> degree heart block. After the repair, I placed ventricular epicardial screw >> in leads (along with temporary wires) for eventual permanent pacemaker. I >> would like to stay out of the venous system for now due to ongoing need for >> dialysis access. >> >> Is there a purpose built epicardial atrial pacer lead on the market? I was >> thinking about using a transvenous active lead but screwing it into the >> outside of the atrium, but I did not have one available at the time. >> >> Ed Bender, MD >>_______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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 >> ----------------------------------------- >> >> **************New year...new news. Be the first to know what is making >> headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) >>_______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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@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@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 >----------------------------------------- From ebender001 at me.com Sun Jan 4 18:34:13 2009 From: ebender001 at me.com (Edward Bender) Date: Sun Jan 4 19:34:49 2009 Subject: [HSF] Epicardial atrial leads In-Reply-To: <20090104185930.AHW80807@parkcity.jefferson.edu> Message-ID: Scott: Thanks for the info. If these are the "fish hook" type of leads, then I think I know where to get them. If I am wrong, please send me details. I appreciate it. Ed Bender, MD On 1/4/09 5:59 PM, "Scott Silvestry" wrote: > > Ed: > > We use Medtronic epicardial leads (SEW ON) with steroid eluting epicardial > tips for a and v applications. (Model 4965 4968 or similiar). I can get the > exact model number if interested ( the adult size is 53 cm I think) > > Our pediatric colleages have suggested these are more durable but I believe > the literature is mixed with evidence to back this supposition up. Some have > suggested with these leads, the threshold is higher and may increase generator > changes over a lifetime ( as compared to screw on). > > > Scott > ---- Original message ---- >> Date: Sun, 04 Jan 2009 14:43:32 -0600 >> From: Edward Bender >> Subject: [HSF] Epicardial atrial leads >> To: HSF List >> >> A few days ago I operated on a 57 year old renal dialysis patient with MRSA >> endocarditis of the aortic valve. In the OR I found that the entire >> non-coronary leaflet and parts of the other leaflets were replaced with >> vegetation. Additionally, the vegetations had eroded through the membranous >> septum into the right atrium, causing a ?Gerbode defect.? Interestingly, >> his pre-op EKG?s were (computer read with a perfunctory doctor signature due >> to a wiggly baseline) listed as atrial fib. He was obviously in third >> degree heart block. After the repair, I placed ventricular epicardial screw >> in leads (along with temporary wires) for eventual permanent pacemaker. I >> would like to stay out of the venous system for now due to ongoing need for >> dialysis access. >> >> Is there a purpose built epicardial atrial pacer lead on the market? I was >> thinking about using a transvenous active lead but screwing it into the >> outside of the atrium, but I did not have one available at the time. >> >> Ed Bender, MD >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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@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 > ----------------------------------------- From jpym at erols.com Sun Jan 4 19:40:48 2009 From: jpym at erols.com (John Pym) Date: Sun Jan 4 19:41:16 2009 Subject: [HSF] Epicardial atrial leads In-Reply-To: References: Message-ID: Ed You could use the epicardial pad electrode on the RA or else "off-label" use of a transvenous electrode. Use a passive (tined) steroid-eluting lead such as a Medtronic 4074 (with a relatively short inter-electrode spacing) in an atrial tunnel (fold the atrial wall around it with a few 5/0 prolene mattress sutures). Chronic thresholds are better than with the pad electrode in my (obviously limited) experience - I recently changed a device with this configuration at 3 years with a threshold < 1 V @ 0.5 msec. John Pym On Sun, Jan 4, 2009 at 3:43 PM, Edward Bender wrote: > A few days ago I operated on a 57 year old renal dialysis patient with MRSA > endocarditis of the aortic valve. In the OR I found that the entire > non-coronary leaflet and parts of the other leaflets were replaced with > vegetation. Additionally, the vegetations had eroded through the > membranous > septum into the right atrium, causing a ?Gerbode defect.? Interestingly, > his pre-op EKG?s were (computer read with a perfunctory doctor signature > due > to a wiggly baseline) listed as atrial fib. He was obviously in third > degree heart block. After the repair, I placed ventricular epicardial > screw > in leads (along with temporary wires) for eventual permanent pacemaker. I > would like to stay out of the venous system for now due to ongoing need for > dialysis access. > > Is there a purpose built epicardial atrial pacer lead on the market? I was > thinking about using a transvenous active lead but screwing it into the > outside of the atrium, but I did not have one available at the time. > > Ed Bender, MD > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > -- John Pym MB, BS, FRACS, FRCSC, FACS Professor of Surgery From ebender001 at me.com Sun Jan 4 18:54:01 2009 From: ebender001 at me.com (Edward Bender) Date: Sun Jan 4 19:54:28 2009 Subject: [HSF] Epicardial atrial leads In-Reply-To: Message-ID: John: Thanks. I wish I had better foresight. Ed Bender, MD On 1/4/09 6:40 PM, "John Pym" wrote: > Ed > > You could use the epicardial pad electrode on the RA or else "off-label" use > of a transvenous electrode. Use a passive (tined) steroid-eluting lead such > as a Medtronic 4074 (with a relatively short inter-electrode spacing) in an > atrial tunnel (fold the atrial wall around it with a few 5/0 prolene > mattress sutures). Chronic thresholds are better than with the pad electrode > in my (obviously limited) experience - I recently changed a device with this > configuration at 3 years with a threshold < 1 V @ 0.5 msec. > > John Pym > > On Sun, Jan 4, 2009 at 3:43 PM, Edward Bender wrote: > >> A few days ago I operated on a 57 year old renal dialysis patient with MRSA >> endocarditis of the aortic valve. In the OR I found that the entire >> non-coronary leaflet and parts of the other leaflets were replaced with >> vegetation. Additionally, the vegetations had eroded through the >> membranous >> septum into the right atrium, causing a ?Gerbode defect.? Interestingly, >> his pre-op EKG?s were (computer read with a perfunctory doctor signature >> due >> to a wiggly baseline) listed as atrial fib. He was obviously in third >> degree heart block. After the repair, I placed ventricular epicardial >> screw >> in leads (along with temporary wires) for eventual permanent pacemaker. I >> would like to stay out of the venous system for now due to ongoing need for >> dialysis access. >> >> Is there a purpose built epicardial atrial pacer lead on the market? I was >> thinking about using a transvenous active lead but screwing it into the >> outside of the atrium, but I did not have one available at the time. >> >> Ed Bender, MD >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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 >> ----------------------------------------- >> > > From ebender001 at me.com Sun Jan 4 18:52:59 2009 From: ebender001 at me.com (Edward Bender) Date: Sun Jan 4 19:57:05 2009 Subject: [HSF] Epicardial atrial leads In-Reply-To: Message-ID: Ani: I would hardly think of you as less experienced. The TEE in the OR showed the vegetation on the aortic valve, but the anesthesiologist and I thought that there was a tricuspid vegetation also - hence bicaval cannulation. (Never underestimate the value of intraoperative TEE!) I opened the aorta in a standard fashion for AVR. Valve inspected and removed in the usual fashion except that the non-coronary leaf was a bulky mass of vegetation which was adherent to but pulled away from the membranous septum. This left a little bit of mass attached to the septum. I pulled this away and it was like uncorking a small bottle neck, exposing a hole about the size of a pencil eraser with blood coming out of it when probed. The edges of the hole were very necrotic, so I debrided every bit of necrotic tissue I could find. I was left with a big defect involving about one-half the annulus and the membranous septum, but with firm healthy appearing tissue. I fashioned a bovine pericardial patch into a wide oval shape and started at the right coronary end of the defect, sewing the deep (ventricular/mitral) portion first with a running 4-0 prolene. I then ran the upper (annular) edge of the patch in a similar fashion. The valve "annulus" was then sized and I placed a 21 mm Magna. The only additional care taken was to make sure the coronary ostia were not encroached upon (not difficult). I closed the aortotomy in the usual fashion and unclamped the aorta. Caval snares were snugged, and I opened the right atrium to inspect the tricuspid vaalve, which had a normal appearance except for the following. At around the septal-anterior commisure on the atrial wall was a vegetation. I simply plucked out the mass and this revealed the cut edges of the membranous septum I had debrided, the base of which was my patch (with no bleeding - mirabile dictu).I cleaned up these edges, got a gram stain of the tissue which showed no bacteria (for what that's worth), closed the atrium, de-aired, and came off bypass, av sequentially pacing. Some other points were: 1. I swabbed all operated surfaces with 100% betadine solution (since my former boss, Bob Karp, used to do this) 2. Placed a ventricular screw in lead and buried it under the skin for future retrieval (tomorrow). 3. Changed instruments after dealing with infected stuff. I hope this is clear. Ed Bender, MD On 1/4/09 5:10 PM, "Ani Anyanwu" wrote: > > Ed > > For the less experienced amongst us could you please explain the operation you > did, findings and procedures, in detail? > > Thanks > > Ani >> Date: Sun, 4 Jan 2009 15:45:00 -0600> Subject: Re: [HSF] Epicardial atrial >> leads> From: ebender001@me.com> To: OpenHeart-L@lists.hsforum.com> CC: > > >> Hal:> Excellent point. I did indeed open the right atrium and removed a >> component> of the vegetation (like a dumbbell shape with the membranous >> septum the> narrow part). I trimmed back the tricuspid annulus until I got to >> normal> looking tissue (not much debridement).> > Ed Bender, MD> > > On >> 1/4/09 3:24 PM, "Harold Roberts" wrote:> > > Ed,> > >> Interesting case. I had a similar one about a year and a half ago. I> > don't >> know about the atrial epicardial lead. However, my question to you is> > >> whether you are sure the patient is adequately debrided. Did you open up the> >> > RA > > and make sure all of the infection was removed? The case I had also >> ended> > up involving the anterior leaflet of the tricuspid.> > > > Hal> > > >> > > > In a message dated 1/4/2009 3:48:52 P.M. Eastern Standard Time,> > >> ebender001@me.com writes:> > > > A few days ago I operated on a 57 year old >> renal dialysis patient with MRSA> > endocarditis of the aortic valve. In the >> OR I found that the entire> > non-coronary leaflet and parts of the other >> leaflets were replaced with> > vegetation. Additionally, the vegetations had >> eroded through the membranous> > septum into the right atrium, causing a >> ?Gerbode defect.? Interestingly,> > his pre-op EKG?s were (computer read with >> a perfunctory doctor signature due> > to a wiggly baseline) listed as atrial >> fib. He was obviously in third> > degree heart block. After the repair, I >> placed ventricular epicardial screw> > in leads (along with temporary wires) >> for eventual permanent pacemaker. I> > would like to stay out of the venous >> system for now due to ongoing need for> > dialysis access.> > > > Is there a >> purpose built epicardial atrial pacer lead on the market? I was> > thinking >> about using a transvenous active lead but screwing it into the> > outside of >> the atrium, but I did not have one available at the time.> > > > Ed Bender, >> MD> > _______________________________________________> > OpenHeart-L mailing >> list> > > > Send postings to:> > OpenHeart-L@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> > >> -----------------------------------------> > > > **************New year...new >> news. Be the first to know what is making> > headlines. >> (http://www.aol.com/?ncid=emlcntaolcom00000026)> > >> _______________________________________________> > OpenHeart-L mailing list> >> > > > Send postings to:> > OpenHeart-L@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@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> >> ----------------------------------------- > _________________________________________________________________ > Imagine a life without walls.? See the possibilities. > http://clk.atdmt.com/UKM/go/122465943/direct/01/______________________________ > _________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From hgrmd at aol.com Mon Jan 5 01:09:44 2009 From: hgrmd at aol.com (hgrmd@aol.com) Date: Sun Jan 4 20:11:05 2009 Subject: [HSF] Epicardial atrial leads In-Reply-To: References: Message-ID: <1810278978-1231117774-cardhu_decombobulator_blackberry.rim.net-1796562693-@bxe016.bisx.prod.on.blackberry> Ed, The only criticism I can offer is that you probably should have completely debrided the left and right sides prior to reconstructing anything. That way, you avoid having to remove infected tissue in proximity to a freshly placed patch. Hal Sent from my Verizon Wireless BlackBerry -----Original Message----- From: Edward Bender Date: Sun, 04 Jan 2009 18:52:59 To: HSF List Subject: Re: [HSF] Epicardial atrial leads Ani: I would hardly think of you as less experienced. The TEE in the OR showed the vegetation on the aortic valve, but the anesthesiologist and I thought that there was a tricuspid vegetation also - hence bicaval cannulation. (Never underestimate the value of intraoperative TEE!) I opened the aorta in a standard fashion for AVR. Valve inspected and removed in the usual fashion except that the non-coronary leaf was a bulky mass of vegetation which was adherent to but pulled away from the membranous septum. This left a little bit of mass attached to the septum. I pulled this away and it was like uncorking a small bottle neck, exposing a hole about the size of a pencil eraser with blood coming out of it when probed. The edges of the hole were very necrotic, so I debrided every bit of necrotic tissue I could find. I was left with a big defect involving about one-half the annulus and the membranous septum, but with firm healthy appearing tissue. I fashioned a bovine pericardial patch into a wide oval shape and started at the right coronary end of the defect, sewing the deep (ventricular/mitral) portion first with a running 4-0 prolene. I then ran the upper (annular) edge of the patch in a similar fashion. The valve "annulus" was then sized and I placed a 21 mm Magna. The only additional care taken was to make sure the coronary ostia were not encroached upon (not difficult). I closed the aortotomy in the usual fashion and unclamped the aorta. Caval snares were snugged, and I opened the right atrium to inspect the tricuspid vaalve, which had a normal appearance except for the following. At around the septal-anterior commisure on the atrial wall was a vegetation. I simply plucked out the mass and this revealed the cut edges of the membranous septum I had debrided, the base of which was my patch (with no bleeding - mirabile dictu).I cleaned up these edges, got a gram stain of the tissue which showed no bacteria (for what that's worth), closed the atrium, de-aired, and came off bypass, av sequentially pacing. Some other points were: 1. I swabbed all operated surfaces with 100% betadine solution (since my former boss, Bob Karp, used to do this) 2. Placed a ventricular screw in lead and buried it under the skin for future retrieval (tomorrow). 3. Changed instruments after dealing with infected stuff. I hope this is clear. Ed Bender, MD On 1/4/09 5:10 PM, "Ani Anyanwu" wrote: > > Ed > > For the less experienced amongst us could you please explain the operation you > did, findings and procedures, in detail? > > Thanks > > Ani >> Date: Sun, 4 Jan 2009 15:45:00 -0600> Subject: Re: [HSF] Epicardial atrial >> leads> From: ebender001@me.com> To: OpenHeart-L@lists.hsforum.com> CC: > > >> Hal:> Excellent point. I did indeed open the right atrium and removed a >> component> of the vegetation (like a dumbbell shape with the membranous >> septum the> narrow part). I trimmed back the tricuspid annulus until I got to >> normal> looking tissue (not much debridement).> > Ed Bender, MD> > > On >> 1/4/09 3:24 PM, "Harold Roberts" wrote:> > > Ed,> > >> Interesting case. I had a similar one about a year and a half ago. I> > don't >> know about the atrial epicardial lead. However, my question to you is> > >> whether you are sure the patient is adequately debrided. Did you open up the> >> > RA > > and make sure all of the infection was removed? The case I had also >> ended> > up involving the anterior leaflet of the tricuspid.> > > > Hal> > > >> > > > In a message dated 1/4/2009 3:48:52 P.M. Eastern Standard Time,> > >> ebender001@me.com writes:> > > > A few days ago I operated on a 57 year old >> renal dialysis patient with MRSA> > endocarditis of the aortic valve. In the >> OR I found that the entire> > non-coronary leaflet and parts of the other >> leaflets were replaced with> > vegetation. Additionally, the vegetations had >> eroded through the membranous> > septum into the right atrium, causing a >> ?Gerbode defect.? Interestingly,> > his pre-op EKG?s were (computer read with >> a perfunctory doctor signature due> > to a wiggly baseline) listed as atrial >> fib. He was obviously in third> > degree heart block. After the repair, I >> placed ventricular epicardial screw> > in leads (along with temporary wires) >> for eventual permanent pacemaker. I> > would like to stay out of the venous >> system for now due to ongoing need for> > dialysis access.> > > > Is there a >> purpose built epicardial atrial pacer lead on the market? I was> > thinking >> about using a transvenous active lead but screwing it into the> > outside of >> the atrium, but I did not have one available at the time.> > > > Ed Bender, >> MD> >_______________________________________________> > OpenHeart-L mailing >> list> > > > Send postings to:> > OpenHeart-L@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> > >> -----------------------------------------> > > > **************New year...new >> news. Be the first to know what is making> > headlines. >> (http://www.aol.com/?ncid=emlcntaolcom00000026)> > >>_______________________________________________> > OpenHeart-L mailing list> >> > > > Send postings to:> > OpenHeart-L@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@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> >> ----------------------------------------- >_________________________________________________________________ > Imagine a life without walls.? See the possibilities. > http://clk.atdmt.com/UKM/go/122465943/direct/01/______________________________ >_________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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 ----------------------------------------- From anianyanwu at hotmail.com Mon Jan 5 01:38:42 2009 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Sun Jan 4 20:39:10 2009 Subject: [HSF] Epicardial atrial leads In-Reply-To: References: Message-ID: Ed Thanks a lot for the description - very valuable for discussion too. I presume that means some of the aortic valve sutures passed through the patch? I wonder what yours (and others) opinions are regarding continuous vs interrupted sutures for the patch. Would any argue for reconstructing the whole defect and valve with extended homograft (root) or is that just talk for textbooks and live courses? FInally did you grow bacteria from the abcess and does that influence your duration of antibiotic therapy? Ani > Date: Sun, 4 Jan 2009 18:52:59 -0600> Subject: Re: [HSF] Epicardial atrial leads> From: ebender001@me.com> To: OpenHeart-L@lists.hsforum.com> CC: > > Ani:> I would hardly think of you as less experienced.> The TEE in the OR showed the vegetation on the aortic valve, but the> anesthesiologist and I thought that there was a tricuspid vegetation also -> hence bicaval cannulation. (Never underestimate the value of intraoperative> TEE!)> I opened the aorta in a standard fashion for AVR. Valve inspected and> removed in the usual fashion except that the non-coronary leaf was a bulky> mass of vegetation which was adherent to but pulled away from the membranous> septum. This left a little bit of mass attached to the septum. I pulled> this away and it was like uncorking a small bottle neck, exposing a hole> about the size of a pencil eraser with blood coming out of it when probed.> The edges of the hole were very necrotic, so I debrided every bit of> necrotic tissue I could find. I was left with a big defect involving about> one-half the annulus and the membranous septum, but with firm healthy> appearing tissue. I fashioned a bovine pericardial patch into a wide oval> shape and started at the right coronary end of the defect, sewing the deep> (ventricular/mitral) portion first with a running 4-0 prolene. I then ran> the upper (annular) edge of the patch in a similar fashion.> > The valve "annulus" was then sized and I placed a 21 mm Magna. The only> additional care taken was to make sure the coronary ostia were not> encroached upon (not difficult).> > I closed the aortotomy in the usual fashion and unclamped the aorta. Caval> snares were snugged, and I opened the right atrium to inspect the tricuspid> vaalve, which had a normal appearance except for the following. At around> the septal-anterior commisure on the atrial wall was a vegetation. I simply> plucked out the mass and this revealed the cut edges of the membranous> septum I had debrided, the base of which was my patch (with no bleeding -> mirabile dictu).I cleaned up these edges, got a gram stain of the tissue> which showed no bacteria (for what that's worth), closed the atrium,> de-aired, and came off bypass, av sequentially pacing.> > Some other points were: 1. I swabbed all operated surfaces with 100%> betadine solution (since my former boss, Bob Karp, used to do this)> 2. Placed a ventricular screw in lead and buried it under the skin for> future retrieval (tomorrow). 3. Changed instruments after dealing with> infected stuff.> > I hope this is clear.> > Ed Bender, MD> > > On 1/4/09 5:10 PM, "Ani Anyanwu" wrote:> > > > > Ed> > > > For the less experienced amongst us could you please explain the operation you> > did, findings and procedures, in detail?> > > > Thanks> > > > Ani> >> Date: Sun, 4 Jan 2009 15:45:00 -0600> Subject: Re: [HSF] Epicardial atrial> >> leads> From: ebender001@me.com> To: OpenHeart-L@lists.hsforum.com> CC: > >> >> Hal:> Excellent point. I did indeed open the right atrium and removed a> >> component> of the vegetation (like a dumbbell shape with the membranous> >> septum the> narrow part). I trimmed back the tricuspid annulus until I got to> >> normal> looking tissue (not much debridement).> > Ed Bender, MD> > > On> >> 1/4/09 3:24 PM, "Harold Roberts" wrote:> > > Ed,> >> >> Interesting case. I had a similar one about a year and a half ago. I> > don't> >> know about the atrial epicardial lead. However, my question to you is> >> >> whether you are sure the patient is adequately debrided. Did you open up the>> >> > RA > > and make sure all of the infection was removed? The case I had also> >> ended> > up involving the anterior leaflet of the tricuspid.> > > > Hal> > >> >> > > > In a message dated 1/4/2009 3:48:52 P.M. Eastern Standard Time,> >> >> ebender001@me.com writes:> > > > A few days ago I operated on a 57 year old> >> renal dialysis patient with MRSA> > endocarditis of the aortic valve. In the> >> OR I found that the entire> > non-coronary leaflet and parts of the other> >> leaflets were replaced with> > vegetation. Additionally, the vegetations had> >> eroded through the membranous> > septum into the right atrium, causing a> >> ?Gerbode defect.? Interestingly,> > his pre-op EKG?s were (computer read with> >> a perfunctory doctor signature due> > to a wiggly baseline) listed as atrial> >> fib. He was obviously in third> > degree heart block. After the repair, I> >> placed ventricular epicardial screw> > in leads (along with temporary wires)> >> for eventual permanent pacemaker. I> > would like to stay out of the venous> >> system for now due to ongoing need for> > dialysis access.> > > > Is there a> >> purpose built epicardial atrial pacer lead on the market? I was> > thinking> >> about using a transvenous active lead but screwing it into the> > outside of> >> the atrium, but I did not have one available at the time.> > > > Ed Bender,> >> MD> > _______________________________________________> > OpenHeart-L mailing> >> list> > > > Send postings to:> > OpenHeart-L@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> >> >> -----------------------------------------> > > > **************New year...new> >> news. Be the first to know what is making> > headlines.> >> (http://www.aol.com/?ncid=emlcntaolcom00000026)> >> >> _______________________________________________> > OpenHeart-L mailing list>> >> > > > Send postings to:> > OpenHeart-L@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@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>> >> -----------------------------------------> > _________________________________________________________________> > Imagine a life without walls. See the possibilities.> > http://clk.atdmt.com/UKM/go/122465943/direct/01/______________________________> > _________________> > OpenHeart-L mailing list> > > > Send postings to:> > OpenHeart-L@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@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> ----------------------------------------- _________________________________________________________________ Get Windows Live Messenger on your Mobile http://clk.atdmt.com/UKM/go/msnnkmgl0010000001ukm/direct/01/ From ebender001 at me.com Sun Jan 4 19:51:17 2009 From: ebender001 at me.com (Edward Bender) Date: Sun Jan 4 20:55:28 2009 Subject: [HSF] Epicardial atrial leads In-Reply-To: <1810278978-1231117774-cardhu_decombobulator_blackberry.rim.net-1796562693-@bxe016.bisx.prod.on.blackberry> Message-ID: Hal: I agree with your criticism. Next time! Ed Bender, MD On 1/4/09 7:09 PM, "Harold Roberts" wrote: > Ed, > The only criticism I can offer is that you probably should have completely > debrided the left and right sides prior to reconstructing anything. That way, > you avoid having to remove infected tissue in proximity to a freshly placed > patch. > > Hal > Sent from my Verizon Wireless BlackBerry > > -----Original Message----- > From: Edward Bender > > Date: Sun, 04 Jan 2009 18:52:59 > To: HSF List > Subject: Re: [HSF] Epicardial atrial leads > > > Ani: > I would hardly think of you as less experienced. > The TEE in the OR showed the vegetation on the aortic valve, but the > anesthesiologist and I thought that there was a tricuspid vegetation also - > hence bicaval cannulation. (Never underestimate the value of intraoperative > TEE!) > I opened the aorta in a standard fashion for AVR. Valve inspected and > removed in the usual fashion except that the non-coronary leaf was a bulky > mass of vegetation which was adherent to but pulled away from the membranous > septum. This left a little bit of mass attached to the septum. I pulled > this away and it was like uncorking a small bottle neck, exposing a hole > about the size of a pencil eraser with blood coming out of it when probed. > The edges of the hole were very necrotic, so I debrided every bit of > necrotic tissue I could find. I was left with a big defect involving about > one-half the annulus and the membranous septum, but with firm healthy > appearing tissue. I fashioned a bovine pericardial patch into a wide oval > shape and started at the right coronary end of the defect, sewing the deep > (ventricular/mitral) portion first with a running 4-0 prolene. I then ran > the upper (annular) edge of the patch in a similar fashion. > > The valve "annulus" was then sized and I placed a 21 mm Magna. The only > additional care taken was to make sure the coronary ostia were not > encroached upon (not difficult). > > I closed the aortotomy in the usual fashion and unclamped the aorta. Caval > snares were snugged, and I opened the right atrium to inspect the tricuspid > vaalve, which had a normal appearance except for the following. At around > the septal-anterior commisure on the atrial wall was a vegetation. I simply > plucked out the mass and this revealed the cut edges of the membranous > septum I had debrided, the base of which was my patch (with no bleeding - > mirabile dictu).I cleaned up these edges, got a gram stain of the tissue > which showed no bacteria (for what that's worth), closed the atrium, > de-aired, and came off bypass, av sequentially pacing. > > Some other points were: 1. I swabbed all operated surfaces with 100% > betadine solution (since my former boss, Bob Karp, used to do this) > 2. Placed a ventricular screw in lead and buried it under the skin for > future retrieval (tomorrow). 3. Changed instruments after dealing with > infected stuff. > > I hope this is clear. > > Ed Bender, MD > > > On 1/4/09 5:10 PM, "Ani Anyanwu" wrote: > >> >> Ed >> >> For the less experienced amongst us could you please explain the operation >> you >> did, findings and procedures, in detail? >> >> Thanks >> >> Ani >>> Date: Sun, 4 Jan 2009 15:45:00 -0600> Subject: Re: [HSF] Epicardial atrial >>> leads> From: ebender001@me.com> To: OpenHeart-L@lists.hsforum.com> CC: > > >>> Hal:> Excellent point. I did indeed open the right atrium and removed a >>> component> of the vegetation (like a dumbbell shape with the membranous >>> septum the> narrow part). I trimmed back the tricuspid annulus until I got >>> to >>> normal> looking tissue (not much debridement).> > Ed Bender, MD> > > On >>> 1/4/09 3:24 PM, "Harold Roberts" wrote:> > > Ed,> > >>> Interesting case. I had a similar one about a year and a half ago. I> > >>> don't >>> know about the atrial epicardial lead. However, my question to you is> > >>> whether you are sure the patient is adequately debrided. Did you open up >>> the> >>>> RA > > and make sure all of the infection was removed? The case I had also >>> ended> > up involving the anterior leaflet of the tricuspid.> > > > Hal> > > >>>>>> In a message dated 1/4/2009 3:48:52 P.M. Eastern Standard Time,> > >>> ebender001@me.com writes:> > > > A few days ago I operated on a 57 year old >>> renal dialysis patient with MRSA> > endocarditis of the aortic valve. In the >>> OR I found that the entire> > non-coronary leaflet and parts of the other >>> leaflets were replaced with> > vegetation. Additionally, the vegetations had >>> eroded through the membranous> > septum into the right atrium, causing a >>> ?Gerbode defect.? Interestingly,> > his pre-op EKG?s were (computer read >>> with >>> a perfunctory doctor signature due> > to a wiggly baseline) listed as atrial >>> fib. He was obviously in third> > degree heart block. After the repair, I >>> placed ventricular epicardial screw> > in leads (along with temporary wires) >>> for eventual permanent pacemaker. I> > would like to stay out of the venous >>> system for now due to ongoing need for> > dialysis access.> > > > Is there a >>> purpose built epicardial atrial pacer lead on the market? I was> > thinking >>> about using a transvenous active lead but screwing it into the> > outside of >>> the atrium, but I did not have one available at the time.> > > > Ed Bender, >>> MD> >_______________________________________________> > OpenHeart-L mailing >>> list> > > > Send postings to:> > OpenHeart-L@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> > >>> -----------------------------------------> > > > **************New >>> year...new >>> news. Be the first to know what is making> > headlines. >>> (http://www.aol.com/?ncid=emlcntaolcom00000026)> > >>> _______________________________________________> > OpenHeart-L mailing list> >>>>>> Send postings to:> > OpenHeart-L@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@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> >>> ----------------------------------------- >> _________________________________________________________________ >> Imagine a life without walls.? See the possibilities. >> http://clk.atdmt.com/UKM/go/122465943/direct/01/_____________________________>> _ >> _________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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@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@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 > ----------------------------------------- From ebender001 at me.com Sun Jan 4 20:00:20 2009 From: ebender001 at me.com (Edward Bender) Date: Sun Jan 4 21:04:30 2009 Subject: [HSF] Epicardial atrial leads In-Reply-To: Message-ID: Ani: Valve sutures di go thru the patch, but not just the patch. They also went thru aortic wall adjacent to what used to be the annulus. I think I know what you are intimating when discussing interrupted vs. continuous suture (one bad or broken segment equals a real bad day). I can only say that I was really impressed with the strength of the remaining tissue borders, and I took very deep bites. Also, making the patch wide eliminated all tension that I could determine might be a problem (especially at the mitral valve). I felt that I could have made the mitral valve incompetent by using a narrow patch. I just remember sewing VSD patches continuously on softer tissue in pediatric cases (I imagine this is still done, Bill?). If I used a homograft, I am sure that there would not have been enough homograft tissue (mitral curtain, muscle) to fill the gap- this was really big. I like it for annular abcesses alone. Finally, the stuff grew out MRSA. I will leave it to the ID guys to come up with a suitable range of antibiotic duration and opt for the longest possible (no independent knowledge of this). Ed Bender, MD On 1/4/09 7:38 PM, "Ani Anyanwu" wrote: > > Ed > > Thanks a lot for the description - very valuable for discussion too. I presume > that means some of the aortic valve sutures passed through the patch? I wonder > what yours (and others) opinions are regarding continuous vs interrupted > sutures for the patch. Would any argue for reconstructing the whole defect and > valve with extended homograft (root) or is that just talk for textbooks and > live courses? FInally did you grow bacteria from the abcess and does that > influence your duration of antibiotic therapy? > > Ani >> Date: Sun, 4 Jan 2009 18:52:59 -0600> Subject: Re: [HSF] Epicardial atrial >> leads> From: ebender001@me.com> To: OpenHeart-L@lists.hsforum.com> CC: > > >> Ani:> I would hardly think of you as less experienced.> The TEE in the OR >> showed the vegetation on the aortic valve, but the> anesthesiologist and I >> thought that there was a tricuspid vegetation also -> hence bicaval >> cannulation. (Never underestimate the value of intraoperative> TEE!)> I >> opened the aorta in a standard fashion for AVR. Valve inspected and> removed >> in the usual fashion except that the non-coronary leaf was a bulky> mass of >> vegetation which was adherent to but pulled away from the membranous> septum. >> This left a little bit of mass attached to the septum. I pulled> this away >> and it was like uncorking a small bottle neck, exposing a hole> about the >> size of a pencil eraser with blood coming out of it when probed.> The edges >> of the hole were very necrotic, so I debrided every bit of> necrotic tissue I >> could find. I was left with a big defect involving about> one-half the >> annulus and the membranous septum, but with firm healthy> appearing tissue. I >> fashioned a bovine pericardial patch into a wide oval> shape and started at >> the right coronary end of the defect, sewing the deep> (ventricular/mitral) >> portion first with a running 4-0 prolene. I then ran> the upper (annular) >> edge of the patch in a similar fashion.> > The valve "annulus" was then sized >> and I placed a 21 mm Magna. The only> additional care taken was to make sure >> the coronary ostia were not> encroached upon (not difficult).> > I closed the >> aortotomy in the usual fashion and unclamped the aorta. Caval> snares were >> snugged, and I opened the right atrium to inspect the tricuspid> vaalve, >> which had a normal appearance except for the following. At around> the >> septal-anterior commisure on the atrial wall was a vegetation. I simply> >> plucked out the mass and this revealed the cut edges of the membranous> >> septum I had debrided, the base of which was my patch (with no bleeding -> >> mirabile dictu).I cleaned up these edges, got a gram stain of the tissue> >> which showed no bacteria (for what that's worth), closed the atrium,> >> de-aired, and came off bypass, av sequentially pacing.> > Some other points >> were: 1. I swabbed all operated surfaces with 100%> betadine solution (since >> my former boss, Bob Karp, used to do this)> 2. Placed a ventricular screw in >> lead and buried it under the skin for> future retrieval (tomorrow). 3. >> Changed instruments after dealing with> infected stuff.> > I hope this is >> clear.> > Ed Bender, MD> > > On 1/4/09 5:10 PM, "Ani Anyanwu" >> wrote:> > > > > Ed> > > > For the less experienced >> amongst us could you please explain the operation you> > did, findings and >> procedures, in detail?> > > > Thanks> > > > Ani> >> Date: Sun, 4 Jan 2009 >> 15:45:00 -0600> Subject: Re: [HSF] Epicardial atrial> >> leads> From: >> ebender001@me.com> To: OpenHeart-L@lists.hsforum.com> CC: > >> >> Hal:> >> Excellent point. I did indeed open the right atrium and removed a> >> >> component> of the vegetation (like a dumbbell shape with the membranous> >> >> septum the> narrow part). I trimmed back the tricuspid annulus until I got >> to> >> normal> looking tissue (not much debridement).> > Ed Bender, MD> > > >> On> >> 1/4/09 3:24 PM, "Harold Roberts" wrote:> > > Ed,> >> >> >> Interesting case. I had a similar one about a year and a half ago. I> > >> don't> >> know about the atrial epicardial lead. However, my question to you >> is> >> >> whether you are sure the patient is adequately debrided. Did you >> open up the>> >> > RA > > and make sure all of the infection was removed? The >> case I had also> >> ended> > up involving the anterior leaflet of the >> tricuspid.> > > > Hal> > >> >> > > > In a message dated 1/4/2009 3:48:52 P.M. >> Eastern Standard Time,> >> >> ebender001@me.com writes:> > > > A few days ago >> I operated on a 57 year old> >> renal dialysis patient with MRSA> > >> endocarditis of the aortic valve. In the> >> OR I found that the entire> > >> non-coronary leaflet and parts of the other> >> leaflets were replaced with> >> > vegetation. Additionally, the vegetations had> >> eroded through the >> membranous> > septum into the right atrium, causing a> >> ?Gerbode defect.? >> Interestingly,> > his pre-op EKG?s were (computer read with> >> a perfunctory >> doctor signature due> > to a wiggly baseline) listed as atrial> >> fib. He >> was obviously in third> > degree heart block. After the repair, I> >> placed >> ventricular epicardial screw> > in leads (along with temporary wires)> >> for >> eventual permanent pacemaker. I> > would like to stay out of the venous> >> >> system for now due to ongoing need for> > dialysis access.> > > > Is there a> >> >> purpose built epicardial atrial pacer lead on the market? I was> > >> thinking> >> about using a transvenous active lead but screwing it into the> >> > outside of> >> the atrium, but I did not have one available at the time.> > >> > > Ed Bender,> >> MD> > _______________________________________________> > >> OpenHeart-L mailing> >> list> > > > Send postings to:> > >> OpenHeart-L@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> >> >> >> -----------------------------------------> > > > **************New >> year...new> >> news. Be the first to know what is making> > headlines.> >> >> (http://www.aol.com/?ncid=emlcntaolcom00000026)> >> >> >> _______________________________________________> > OpenHeart-L mailing list>> >> >> > > > Send postings to:> > OpenHeart-L@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@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>> >> >> -----------------------------------------> > >> _________________________________________________________________> > Imagine >> a life without walls. See the possibilities.> > >> http://clk.atdmt.com/UKM/go/122465943/direct/01/_____________________________ >> _> > _________________> > OpenHeart-L mailing list> > > > Send postings to:> >> > OpenHeart-L@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@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> >> ----------------------------------------- > _________________________________________________________________ > Get Windows Live Messenger on your Mobile > http://clk.atdmt.com/UKM/go/msnnkmgl0010000001ukm/direct/01/__________________ > _____________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From prasannasimha at gmail.com Mon Jan 5 07:32:50 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sun Jan 4 21:23:57 2009 Subject: [HSF] Epicardial atrial leads In-Reply-To: References: Message-ID: <89c4ed2d0901041802k12a556e9w4850121b5aa79bbe@mail.gmail.com> They are available from medtronic. Prasanna On Mon, Jan 5, 2009 at 2:13 AM, Edward Bender wrote: > A few days ago I operated on a 57 year old renal dialysis patient with MRSA > endocarditis of the aortic valve. In the OR I found that the entire > non-coronary leaflet and parts of the other leaflets were replaced with > vegetation. Additionally, the vegetations had eroded through the > membranous > septum into the right atrium, causing a ?Gerbode defect.? Interestingly, > his pre-op EKG?s were (computer read with a perfunctory doctor signature > due > to a wiggly baseline) listed as atrial fib. He was obviously in third > degree heart block. After the repair, I placed ventricular epicardial > screw > in leads (along with temporary wires) for eventual permanent pacemaker. I > would like to stay out of the venous system for now due to ongoing need for > dialysis access. > > Is there a purpose built epicardial atrial pacer lead on the market? I was > thinking about using a transvenous active lead but screwing it into the > outside of the atrium, but I did not have one available at the time. > > Ed Bender, MD > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > -- Prasanna Simha M From Scott.Silvestry at jefferson.edu Sun Jan 4 22:21:18 2009 From: Scott.Silvestry at jefferson.edu (Scott Silvestry) Date: Sun Jan 4 22:23:01 2009 Subject: [HSF] Epicardial atrial leads Message-ID: <20090104222118.AHW83338@parkcity.jefferson.edu> Not fish hook style-see below http://www.medtronic.com/physician/brady/leads/capepi.html Scott ---- Original message ---- >Date: Mon, 5 Jan 2009 07:32:50 +0530 >From: "Prasanna Simha M" >Subject: Re: [HSF] Epicardial atrial leads >To: OpenHeart-L@lists.hsforum.com > >They are available from medtronic. >Prasanna > >On Mon, Jan 5, 2009 at 2:13 AM, Edward Bender wrote: > >> A few days ago I operated on a 57 year old renal dialysis patient with MRSA >> endocarditis of the aortic valve. In the OR I found that the entire >> non-coronary leaflet and parts of the other leaflets were replaced with >> vegetation. Additionally, the vegetations had eroded through the >> membranous >> septum into the right atrium, causing a ?Gerbode defect.? Interestingly, >> his pre-op EKG?s were (computer read with a perfunctory doctor signature >> due >> to a wiggly baseline) listed as atrial fib. He was obviously in third >> degree heart block. After the repair, I placed ventricular epicardial >> screw >> in leads (along with temporary wires) for eventual permanent pacemaker. I >> would like to stay out of the venous system for now due to ongoing need for >> dialysis access. >> >> Is there a purpose built epicardial atrial pacer lead on the market? I was >> thinking about using a transvenous active lead but screwing it into the >> outside of the atrium, but I did not have one available at the time. >> >> Ed Bender, MD >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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 >> ----------------------------------------- >> > > > >-- >Prasanna Simha M >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: > OpenHeart-L@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 >----------------------------------------- From damle at cableone.net Sun Jan 4 22:55:54 2009 From: damle at cableone.net (Ajit Damle) Date: Mon Jan 5 00:02:39 2009 Subject: [HSF] Epicardial atrial leads In-Reply-To: <20090104185930.AHW80807@parkcity.jefferson.edu> Message-ID: <85A83C48D30B430F8275CDF38D1BEC6B@yourg8he5gjrox> Scott, I differ. I have published my experience of medium term follow up of epicardial screw-in leads at the Cardiostim 2007, and STS 2008. The epicardial sew-on leads do have much less of a problem of increasing late thresholds as compared to the screw-in leads. This is largely because steroid tipped electrodes: the sew-on lead (Medtronic), has steroid eluting electrodes, screw-ins (Medtronic and Enpath- formerly Biomec, which also the Guidant brand) do not. My understanding is Biomec made a very concerted effort to get a steroid eluting screw-in lead through he FDA but withdrew the application because FDA did not allow comparison to the historical data (the steroid elution at a constant rate is a difficult engineering problem). The cost of mounting a new trial is prohibitive in relation to the market size of epicardial leads. Ed, 1. There are no specific atrial epicardial leads. The same Medtronic epicardial sew-onlead that you use for the ventricle has been used on the atria with good results. 3. If you do this intra-operative, make sure that you suture these leads to the lateral basel surface of the LV. A good landmark is just in front of the LA appendage between the OMs. The LV pacing is shown to be superior to the RV pacing, and may be almost as good as Bi-V pacing. If clinical and economical conditions permit, if you have wide QRS, >130 ms, Bi-V pacing would be a good choice, although untested. 3.The endocardial screw-in lead has been used on the atrium (and also on the ventricle). With steroid eluting tip, this is an attractive option. But again there are no published reports of reliability. The serious concern is lead fracture. If you look at the epicardial leads, the electrodes are at right angles to the lead. A straight configuration, like an endocardial lead has met with a high incidence of lead fracture. 4. For the same reason, after you suture on the epicardial lead, bring them out through an intercostal space towards the pacemaker area without any attempt to fix the lead to the chest wall, which might create a stress point at the junction of fixed and moving segments. The movement stress needs to be taken by the whole lead length. Ajit Damle (Butt frozen in North Dakota) -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Scott Silvestry Sent: Sunday, January 04, 2009 6:00 PM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Epicardial atrial leads Ed: We use Medtronic epicardial leads (SEW ON) with steroid eluting epicardial tips for a and v applications. (Model 4965 4968 or similiar). I can get the exact model number if interested ( the adult size is 53 cm I think) Our pediatric colleages have suggested these are more durable but I believe the literature is mixed with evidence to back this supposition up. Some have suggested with these leads, the threshold is higher and may increase generator changes over a lifetime ( as compared to screw on). Scott ---- Original message ---- >Date: Sun, 04 Jan 2009 14:43:32 -0600 >From: Edward Bender >Subject: [HSF] Epicardial atrial leads >To: HSF List > >A few days ago I operated on a 57 year old renal dialysis patient with MRSA >endocarditis of the aortic valve. In the OR I found that the entire >non-coronary leaflet and parts of the other leaflets were replaced with >vegetation. Additionally, the vegetations had eroded through the membranous >septum into the right atrium, causing a ?Gerbode defect.? Interestingly, >his pre-op EKG?s were (computer read with a perfunctory doctor signature due >to a wiggly baseline) listed as atrial fib. He was obviously in third >degree heart block. After the repair, I placed ventricular epicardial screw >in leads (along with temporary wires) for eventual permanent pacemaker. I >would like to stay out of the venous system for now due to ongoing need for >dialysis access. > >Is there a purpose built epicardial atrial pacer lead on the market? I was >thinking about using a transvenous active lead but screwing it into the >outside of the atrium, but I did not have one available at the time. > >Ed Bender, MD >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: > OpenHeart-L@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@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 ----------------------------------------- From mmlevinson at hsforum.com Mon Jan 5 00:24:08 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Mon Jan 5 01:24:38 2009 Subject: [HSF] Epicardial atrial leads In-Reply-To: References: Message-ID: On Jan 4, 2009, at 6:52 PM, Edward Bender wrote: > . I fashioned a bovine pericardial patch into a wide oval > shape When I do these, I just rinse the patch a little bit. Some residual glutaraldehyde is very bacteriocidal and these patches do not get infected. I have used them for reconstructing infected femoral/aortic graft sites and to date no infection on the bovine pericardium. That is one of the chief benefits of bovine pericardium over dacron in this situation. I think your patient will be just fine... Mark Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From mmlevinson at hsforum.com Mon Jan 5 00:29:49 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Mon Jan 5 01:30:10 2009 Subject: [HSF] Afib Procedures and Conduction Disease In-Reply-To: References: Message-ID: <57F0BA3D-97BA-457A-B5E6-50BFE98699EB@hsforum.com> On Jan 3, 2009, at 5:37 AM, Hgrmd@aol.com wrote: > Mark, > My sentiments exactly. Unfortunately, I still get a little grief > from > some cardiologists when this occurs. Also, in this new era of > living with the > STS database, insertion of a pacemaker counts as a "bring back" for > an open > heart case. i.e, it's looked at the same as if the patient had > been brought > back for bleeding, reop, etc. Absurd don't you think? Yes, absurd. I remember attending an STS database managers meeting several years back where an audience member asked "If my patient leaves the hospital and gets hit by a bus and dies, is this a surgical death". The answer at that time was "yes" and the database designers did not even entertain any thought of changing this. I think things have changed now, but we have very odd definitions of complications, and of course you are hinting at one. A pacemaker is a therapeutic intervention, not a takeback for complication (IMHO). Mark > > > Hal > > > In a message dated 1/3/2009 2:53:05 A.M. Eastern Standard Time, > mmlevinson@hsforum.com writes: > > > On Dec 24, 2008, at 10:23 AM, Michael Firstenberg wrote: >> >> I think letting some of these little ol ladies hang-out in a slow >> junctional >> rhythm is a bad idea - particularly as they are recovering from >> whatever >> else we have done to them. Many of them have pretty significant >> diastolic >> dysfunction (doesnt everyone these day) and their cardiac output are >> very >> heart rate dependent. Their bodies are use to seeing rates in the >> 70-80 >> and if their cardiac output drops by 40-50% because of a drop in >> heart rate >> they dont like it and we get problems like renal failure and >> sometimes even >> syncope. Fruthermore, just because we watch them for a few days >> in a >> tightly controlled environement such as a hospital that does not >> mean they >> will not have brady episodes at home which may result in a chronic >> slow >> decline - if not an acute problem. They need that safety net for >> the sinus >> node problems >> >> > > I did a simple and successful mitral repair years ago and the lady > was > in > slow junctional rhythm postop. I used a temporary pacemaker and > waited > until her junctional rate gradually came up and did everything to > avoid > a permanent pacer since I felt this dysfunction would recover. She > was in the hospital > more than 10 days just waiting. Finally, after > cardiology clearance, we all agreed she could go home with a stable > junctional rhythym about 60 / minutes and no pacemaker. She was > found dead at home > about 2 weeks later. > > I put in permanent pacemakers not as a sign of defeat but as a > safety > net. And I pace the patients at 80/min to increase their cardiac > output > and help relieve symptoms of fatigue and CHF. After a month > I drop the rate back down. > > I think you can decrease our incidence of pacemaker insertion post- > Maze > if you and to wait longer and accept lower heart rates. But is it > worth it? In my opinion...no. > The current generation of pacemakers and leads are so reliable and > physiologic > that I do not consider a pacemaker a disadvantage, and in many cases > it is > advantageous. Atrial pacing may actually help maintain atrial > contractions > and prevent breakthrough a-fib as well. > > And now you can get intra-cardiac event monitoring and prove whether > they have bursts of afib or not! > > > > Mark Levinson, MD. > Founder, Editor-in-Chief > The Heart Surgery Forum? > Multimedia Cardiothoracic Journal > URL: http://www.hsforum.com > URL: http://newoptionsinheartsurgery.com > Emali: mmlevinson@hsforum.com > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > **************New year...new news. Be the first to know what is > making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From mmlevinson at hsforum.com Mon Jan 5 01:06:52 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Mon Jan 5 02:07:17 2009 Subject: [HSF] Pulm Vein Ablation In-Reply-To: References: Message-ID: <5F829750-C935-4B38-9E60-220B1D425F58@hsforum.com> On Jan 3, 2009, at 5:31 AM, Hgrmd@aol.com wrote: > Mark, > I saw your talk about the subxiphoid approach for coronary > revascularization at the last HSF dinner. For the life of me, I > can't figure out how you > would be able to safely get in and out of the atria with that > approach. Please > elaborate. BTW, Happy New Year. Glad you've resurfaced. > > Hal > Hal: You know I am always "just below the surface!" To answer your question, I will start a new thread to keep this one uncluttered. Mark Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From mmlevinson at hsforum.com Mon Jan 5 02:12:23 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Mon Jan 5 03:12:52 2009 Subject: [HSF] Subxiphoid CryoMaze References: Message-ID: > > Mark, > I saw your talk about the subxiphoid approach for coronary > revascularization at the last HSF dinner. For the life of me, I > can't figure out how you > would be able to safely get in and out of the atria with that > approach. Please > elaborate. BTW, Happy New Year. Glad you've resurfaced. > > Hal > > Hal: Briefly, the approach is epicardial on the beating, empty heart using femoral-femoral bypass. The heart is exposed only by sternal lifting (double Rultracts). Both cavae are looped. The lesions are epicardial with the ATS argon cryo surgical instrument for 2 - 3 minutes each lesion. As I commented in an earlier posting, pulmonary vein isolation is *not* a Maze III - IV and likewise a Maze III is *not* just a pulmonary vein isolation. That said, Cox did not have the kind of event monitoring we have today to verify his 90+% success rate, but his procedure was established from over a decade of laboratory work in animal models of a-fib and then validated and finally matured in actual clinical cases. Hassaguerres' (sp) transcatheter pulmonary vein isolation report spawned a small "industrial revolution" in surgical instrumentation, but any procedures based on his identification of pulmonary vein triggers are far from a complete Maze. It is my personal belief that only a full Maze should be applied to the vast majority of potential patients (estimated at over 2 million) who have a-fib of various ages or types. Otherwise, surgeons have no hope of achieving results superior to our catheter colleagues. So.....I took Cox's publications and his surgical drawings and created a series of my own anatomic drawings (from the perspective of the subxiphoid exposure) and re-located his entire lesion set on my drawings using epicardial landmarks. Then I made sure I had the proper equipment to reach, encircle, and ablate every site on my map from the subxiphoid incision. I have now done 2 cases. The first is an 84 yo female in A-fib more than 25 years who also needed a 2 vessel CABG. She had preop bradycardia without meds, so I knew she would also have AV nodal dysfunction. I performed a subxiphoid 2 vessel CABG and Maze IV. She did need a pacer. Postop she was in a-fib for 3 weeks but was noted to have spontaneously converted to NSR on a post-pacer EKG, while on Amiodarone and Beta-blocker therapy. The second case is a 74 long distance runner ( > 54,000 miles logged over the past 20 years). He is a retired optometrist who presented with very symptomatic acute a-fib. His cardiologist did not want to place him on life-long beta blockers because they might affect his peak exertion and the patient refused Amiodarone because he had treated so many patients with Amio induced corneal deposits. Also, he did not want to be on permanent anticoagulation. I performed a subxiphoid complete Maze IV on the empty beating heart. He was transfered from ICU and walking unaided in the hallway 15 hours post-op (see below) and insisted he had no pain and took no pain pills. I almost sent him home on the first day, but waited to be extra cautious. He had higher than average pleural drainage numbers on POD #2 so we discharged him on day 3. He is still in stable NSR. Both patients had stapled amputation of the base of the LA appendage. The first lady was treated with Coumadin and developed bilateral hemothoraces requiring pleural drainage catheters and transfusions, but no lasting sequelae. She is currently asymptomatic, off Coumadin, with no neurologic events. The second patient was never treated with Coumadin. The advantage of this approach in my mind is the complete Maze IV lesion set (including bilateral PV encircling lesions, mitral isthmus lesion, flutter lines, medial tricuspid line, coronary sinus, etc.) while still avoiding sternotomy or bilateral thoracotomies, cardioplegic arrest, etc. The incision is 4 cm epigastric midline. LA appendage and ligament of Marshal division were done in both cases but we did not perform ganglionic mapping. However, the majority of tissue where the ganglionic plexi have been located were clearly within the "ice ball" created by the probe. I will have a movie of the procedure soon, I hope. Thanks, Mark Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com Subxiphoid CryoMaze Patient #2 .. 15 hours after surgery -------------- next part -------------- A non-text attachment was scrubbed... Name: DSC00295.jpg Type: image/jpeg Size: 133453 bytes Desc: not available Url : http://mmp.cjp.com/pipermail/openheart-l/attachments/20090105/0133a451/DSC00295-0001.jpg -------------- next part -------------- (with patient's permission) From mmlevinson at hsforum.com Mon Jan 5 02:14:02 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Mon Jan 5 03:14:22 2009 Subject: [HSF] Durability - Rheumatic Mitral repairs In-Reply-To: References: Message-ID: <0BE658B0-9298-4CFF-BA3D-E9E7B7A8135C@hsforum.com> On Jan 3, 2009, at 9:24 AM, rwmfglycar@aol.com wrote: > > > Mark, > Making an aortic tube out of tanned pericardium, especially one > that has a > curve to it, let alone sinuses, is not that easy. Bob: I was only suggesting a simple tube graft, not a sinus replacement. Sorry for the confusion.... Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From mmlevinson at hsforum.com Mon Jan 5 02:20:27 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Mon Jan 5 03:20:48 2009 Subject: [HSF] De Bakey caged disk valve In-Reply-To: <89c4ed2d0812161731i393932te1c3f7f6a46a76c3@mail.gmail.com> References: <3364651.1176601229469006681.JavaMail.defaultUser@defaultHost> <89c4ed2d0812161731i393932te1c3f7f6a46a76c3@mail.gmail.com> Message-ID: <5311A09A-66E1-4450-90C8-F8434AE1166B@hsforum.com> On Dec 16, 2008, at 7:31 PM, Prasanna Simha M wrote: > Debakey had quite a few Valves" including the Debakey surgitool valve > which had pins which self fixed in the annulus and caged disc valve . > Both were associated with strut fractures that you have described. > Prasanna Wasn't the Surgitool valve called the Magovern valve. I had to take one out for pannus and TIAs after 20+ years and I got the removal tool from George Magovern...... Interesting idea for its day, and now in the days of percutaneous valves, his device almost looks like a prediction of the future! Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From Rwmfglycar at aol.com Mon Jan 5 06:43:19 2009 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Mon Jan 5 06:43:56 2009 Subject: [HSF] longterm tetralogy result Message-ID: Dear folks, I had a great experience this weekend. I had a call from South Africa from a man in his 50's whose tetralogy was repaired in 1966. In that year my mother's friend Mary, with the advice of my mother who had been at the Mayo Clinic in the 20's, took her 10 year old son to have his Tetralogy repaired by John Kirklin. My mother decided to visit us in NY and also accompany Mary on her visit to Mayo. Young Nick had his tetralogy repaired succesfully. John told Mary that Nick had a blood vessel that had kept him alive. I presume this was a large collateral. Mary wrote a book about the experience which she called "The Vein of Life". (Like many lay people she mixed up vein and artery). The book was interesting in its description of an intense emotional attraction to Kirklin. She described it as like "falling in love". This was intriguing to me because , unlike Denton Cooley or Walt Lillehei or Chris Barnard around whom women regularly swooned, Kirklin could not be described as sexy. Pure love I suppose. Nick, who was severely disabled preop, is now 52 and continues to exercise without difficulty. An Arrhythmia which developed 15 years ago has been well controlled medically. And last year the Mayo Clinic sent him a long followup questionaire in South Africa. I had never met Nick but a nonmedical friend of mine noticed his scar and asked him about it and he spontaneously called me to tell me how grateful his mother had been for my mother's support. Bob **************New year...new news. Be the first to know what is making headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) From donross at bigpond.com Mon Jan 5 23:36:10 2009 From: donross at bigpond.com (Donald Ross) Date: Mon Jan 5 07:37:10 2009 Subject: [HSF] Subxiphoid CryoMaze In-Reply-To: References: Message-ID: <6830CD6A-8AE4-4566-8180-E05B142E7958@bigpond.com> > Lovely work, Mark. It sounds like you finally have the killer (pardon the adjective) application for your sub-x incision. I gave it up for cabg in favour of the lower hemisternotomy because ima harvest was just too much of a pain for me. I hope you get enough cases to validate your work. What does the stapled LAp look like on post op echo? Some HSF members leave it alone when they do a maze. I found the double endo looped LAp often had a small leak which freaked out the cards, so I have abandoned that as well. Don > Briefly, the approach is epicardial on the beating, empty heart > using femoral-femoral bypass. > The heart is exposed only by sternal lifting (double Rultracts). > Both cavae are looped. > > The lesions are epicardial with the ATS argon cryo surgical > instrument for 2 - 3 minutes each lesion. > > As I commented in an earlier posting, pulmonary vein isolation is > *not* a Maze III - IV and likewise a Maze III is *not* just a > pulmonary vein isolation. > That said, Cox did not have the kind of event monitoring we have > today to verify his 90+% success rate, but his procedure > was established from over a decade of laboratory work in animal > models of a-fib and then validated and finally matured > in actual clinical cases. Hassaguerres' (sp) transcatheter > pulmonary vein isolation report spawned a small "industrial > revolution" in > surgical instrumentation, but any procedures based on his > identification of pulmonary vein triggers are far from a complete > Maze. > > It is my personal belief that only a full Maze should be applied to > the vast majority of potential patients (estimated at over 2 > million) who have a-fib of various > ages or types. Otherwise, surgeons have no hope of achieving > results superior to our catheter colleagues. > > So.....I took Cox's publications and his surgical drawings and > created a series of my own anatomic drawings (from the > perspective of the subxiphoid exposure) and re-located his entire > lesion set on my drawings using epicardial landmarks. > Then I made sure I had the proper equipment to reach, encircle, and > ablate every site on my map from the subxiphoid incision. > > I have now done 2 cases. The first is an 84 yo female in A-fib > more than 25 years who also needed a 2 vessel CABG. > She had preop bradycardia without meds, so I knew she would also > have AV nodal dysfunction. I performed a > subxiphoid 2 vessel CABG and Maze IV. She did need a pacer. > Postop she was in a-fib for 3 weeks but was noted > to have spontaneously converted to NSR on a post-pacer EKG, while on > Amiodarone and Beta-blocker therapy. > > The second case is a 74 long distance runner ( > 54,000 miles logged > over the past 20 years). He is a retired optometrist > who presented with very symptomatic acute a-fib. His > cardiologist did not want to place him on life-long beta blockers > because they > might affect his peak exertion and the patient refused Amiodarone > because he had treated so many patients with Amio induced > corneal deposits. Also, he did not want to be on permanent > anticoagulation. > > I performed a subxiphoid complete Maze IV on the empty beating > heart. He was transfered from ICU and walking unaided > in the hallway 15 hours post-op (see below) and insisted he had no > pain and took no pain pills. I almost sent him home on the first > day, but waited > to be extra cautious. He had higher than average pleural drainage > numbers on POD #2 so we discharged him on day 3. He is still in > stable NSR. > > Both patients had stapled amputation of the base of the LA > appendage. The first lady was treated with Coumadin and developed > bilateral hemothoraces requiring pleural drainage catheters and > transfusions, but no lasting sequelae. She is > currently asymptomatic, off Coumadin, with no neurologic events. > The second patient was never treated with Coumadin. > > The advantage of this approach in my mind is the complete Maze IV > lesion set (including bilateral PV encircling lesions, mitral > isthmus lesion, > flutter lines, medial tricuspid line, coronary sinus, etc.) while > still avoiding sternotomy or bilateral thoracotomies, cardioplegic > arrest, etc. > > The incision is 4 cm epigastric midline. LA appendage and > ligament of Marshal division were done in both cases > but we did not perform ganglionic mapping. However, the majority > of tissue where the ganglionic plexi have been located were > clearly within the "ice ball" created by the probe. > > I will have a movie of the procedure soon, I hope. > > Thanks, > > Mark > > > Mark Levinson, MD. > Founder, Editor-in-Chief > The Heart Surgery Forum? > Multimedia Cardiothoracic Journal > URL: http://www.hsforum.com > URL: http://newoptionsinheartsurgery.com > Emali: mmlevinson@hsforum.com > > > Subxiphoid CryoMaze Patient #2 .. 15 hours after surgery > > > > > (with patient's permission) > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From prasannasimha at gmail.com Mon Jan 5 17:49:54 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Mon Jan 5 07:43:46 2009 Subject: [HSF] Epicardial atrial leads In-Reply-To: <20090104222118.AHW83338@parkcity.jefferson.edu> References: <20090104222118.AHW83338@parkcity.jefferson.edu> Message-ID: <89c4ed2d0901050419o5d838315u2ceecbdaf49570ea@mail.gmail.com> These are the same epicardial leads that we use (Capsure) (albeit occasionally) Prasanna On Mon, Jan 5, 2009 at 8:51 AM, Scott Silvestry < Scott.Silvestry@jefferson.edu> wrote: > > Not fish hook style-see below > > > http://www.medtronic.com/physician/brady/leads/capepi.html > > > Scott > > > ---- Original message ---- > >Date: Mon, 5 Jan 2009 07:32:50 +0530 > >From: "Prasanna Simha M" > >Subject: Re: [HSF] Epicardial atrial leads > >To: OpenHeart-L@lists.hsforum.com > > > >They are available from medtronic. > >Prasanna > > > >On Mon, Jan 5, 2009 at 2:13 AM, Edward Bender wrote: > > > >> A few days ago I operated on a 57 year old renal dialysis patient with > MRSA > >> endocarditis of the aortic valve. In the OR I found that the entire > >> non-coronary leaflet and parts of the other leaflets were replaced with > >> vegetation. Additionally, the vegetations had eroded through the > >> membranous > >> septum into the right atrium, causing a ?Gerbode defect.? > Interestingly, > >> his pre-op EKG?s were (computer read with a perfunctory doctor signature > >> due > >> to a wiggly baseline) listed as atrial fib. He was obviously in third > >> degree heart block. After the repair, I placed ventricular epicardial > >> screw > >> in leads (along with temporary wires) for eventual permanent pacemaker. > I > >> would like to stay out of the venous system for now due to ongoing need > for > >> dialysis access. > >> > >> Is there a purpose built epicardial atrial pacer lead on the market? I > was > >> thinking about using a transvenous active lead but screwing it into the > >> outside of the atrium, but I did not have one available at the time. > >> > >> Ed Bender, MD > >> _______________________________________________ > >> OpenHeart-L mailing list > >> > >> Send postings to: > >> OpenHeart-L@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 > >> ----------------------------------------- > >> > > > > > > > >-- > >Prasanna Simha M > >_______________________________________________ > >OpenHeart-L mailing list > > > >Send postings to: > > OpenHeart-L@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@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 > ----------------------------------------- > -- Prasanna Simha M From donross at bigpond.com Mon Jan 5 23:44:31 2009 From: donross at bigpond.com (Donald Ross) Date: Mon Jan 5 07:44:57 2009 Subject: [HSF] pericardial window for AF prophylaxis In-Reply-To: References: Message-ID: <47503D5A-9120-4AC3-8F8D-190009F0E3F3@bigpond.com> There is some evidence indicating a posterior pericardial window to allow efficient drainage of the pericardium reduces the incidence of post-op AF Has anyone any experience with this technique? Don From rsboova at comcast.net Mon Jan 5 12:53:33 2009 From: rsboova at comcast.net (rsboova@comcast.net) Date: Mon Jan 5 07:53:03 2009 Subject: [HSF] pericardial window for AF prophylaxis Message-ID: <716089214-1231159954-cardhu_decombobulator_blackberry.rim.net-1650263165-@bxe177.bisx.prod.on.blackberry> VGhlIG9ubHkgcmVwb3J0cyBJIGFtIGF3YXJlIG9mIGFzc29jaWF0ZWQgd2l0aCBwb3N0IG9wIGF0 ci4gRmliIHJlZHVjdGlvbiBlbXBsb3kgYW1pb2Rhcm9uZSBpbiBzb21lIHByb3RvY29sIEkuZS4g RWl0aGVyIHByZSBhbmQvb3IgcG9zdCBvcC4gUlNCDQotLS0tLS1PcmlnaW5hbCBNZXNzYWdlLS0t LS0tDQpGcm9tOiBEb25hbGQgUm9zcw0KU2VuZGVyOiBvcGVuaGVhcnQtbC1ib3VuY2VzQGxpc3Rz LmhzZm9ydW0uY29tDQpUbzogT3BlbkhlYXJ0LUxAbGlzdHMuaHNmb3J1bS5jb20NClJlcGx5VG86 IE9wZW5IZWFydC1MQGxpc3RzLmhzZm9ydW0uY29tDQpTdWJqZWN0OiBSZTogW0hTRl0gcGVyaWNh cmRpYWwgd2luZG93IGZvciBBRiBwcm9waHlsYXhpcw0KU2VudDogSmFuIDUsIDIwMDkgNzo0NCBB TQ0KDQpUaGVyZSBpcyBzb21lIGV2aWRlbmNlIGluZGljYXRpbmcgYSBwb3N0ZXJpb3IgcGVyaWNh cmRpYWwgd2luZG93IHRvICANCmFsbG93IGVmZmljaWVudCBkcmFpbmFnZSBvZiB0aGUgcGVyaWNh cmRpdW0gcmVkdWNlcyB0aGUgaW5jaWRlbmNlIG9mICANCnBvc3Qtb3AgQUYNCkhhcyBhbnlvbmUg YW55IGV4cGVyaWVuY2Ugd2l0aCB0aGlzIHRlY2huaXF1ZT8NCkRvbg0KX19fX19fX19fX19fX19f X19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX18NCk9wZW5IZWFydC1MIG1haWxpbmcgbGlz dA0KDQpTZW5kIHBvc3RpbmdzIHRvOg0KIE9wZW5IZWFydC1MQGxpc3RzLmhzZm9ydW0uY29tDQoN ClRvIFVOU1VCU0NSSUJFLCB0byBDSEFOR0UgZW1haWwgYWRkcmVzcywgb3IgdG8gdmlldyBhcmNo aXZlczoNCmh0dHA6Ly9tbXAuY2pwLmNvbS9tYWlsbWFuL2xpc3RpbmZvL29wZW5oZWFydC1sDQoN CkFsbCBtZXNzYWdlcyB0cmFuc21pdHRlZCBieSB0aGUgT3BlbkhlYXJ0LUwgYXJlIHN1YmplY3Qg dG8gdGhlIHBvbGljaWVzIGFuZCANCmRpc2NsYWltZXJzIHBvc3RlZCBhdDoNCmh0dHA6Ly93d3cu aHNmb3J1bS5jb20vbGlzdGRpc2NsYWltDQotLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0t LS0tLS0tLS0tLQ0KDQoNClNlbnQgZnJvbSBteSBWZXJpem9uIFdpcmVsZXNzIEJsYWNrQmVycnk= From hgrmd at aol.com Mon Jan 5 12:54:16 2009 From: hgrmd at aol.com (hgrmd@aol.com) Date: Mon Jan 5 07:54:34 2009 Subject: [HSF] Subxiphoid CryoMaze In-Reply-To: References: Message-ID: <1113788687-1231160046-cardhu_decombobulator_blackberry.rim.net-1760673732-@bxe016.bisx.prod.on.blackberry> Mark, Sorry, but I don't believe you can reliably create a transmural mitral isthmus lesion from an epicardial approach. The heat sink effect, particularly in thick atria, will prevent the endocardium from freezing. It also doesn't sound like you are doing a full set of lesions on the right side. In addition, no conclusions should be drawn on the basis of 1 chronic and 1 PAF case. It's an innovative, promising approach, but it's not a full set of transmural lesions in my opinion. Hal Sent from my Verizon Wireless BlackBerry -----Original Message----- From: Mark Levinson Date: Mon, 5 Jan 2009 02:12:23 To: Subject: [HSF] Subxiphoid CryoMaze > > Mark, > I saw your talk about the subxiphoid approach for coronary > revascularization at the last HSF dinner. For the life of me, I > can't figure out how you > would be able to safely get in and out of the atria with that > approach. Please > elaborate. BTW, Happy New Year. Glad you've resurfaced. > > Hal > > Hal: Briefly, the approach is epicardial on the beating, empty heart using femoral-femoral bypass. The heart is exposed only by sternal lifting (double Rultracts). Both cavae are looped. The lesions are epicardial with the ATS argon cryo surgical instrument for 2 - 3 minutes each lesion. As I commented in an earlier posting, pulmonary vein isolation is *not* a Maze III - IV and likewise a Maze III is *not* just a pulmonary vein isolation. That said, Cox did not have the kind of event monitoring we have today to verify his 90+% success rate, but his procedure was established from over a decade of laboratory work in animal models of a-fib and then validated and finally matured in actual clinical cases. Hassaguerres' (sp) transcatheter pulmonary vein isolation report spawned a small "industrial revolution" in surgical instrumentation, but any procedures based on his identification of pulmonary vein triggers are far from a complete Maze. It is my personal belief that only a full Maze should be applied to the vast majority of potential patients (estimated at over 2 million) who have a-fib of various ages or types. Otherwise, surgeons have no hope of achieving results superior to our catheter colleagues. So.....I took Cox's publications and his surgical drawings and created a series of my own anatomic drawings (from the perspective of the subxiphoid exposure) and re-located his entire lesion set on my drawings using epicardial landmarks. Then I made sure I had the proper equipment to reach, encircle, and ablate every site on my map from the subxiphoid incision. I have now done 2 cases. The first is an 84 yo female in A-fib more than 25 years who also needed a 2 vessel CABG. She had preop bradycardia without meds, so I knew she would also have AV nodal dysfunction. I performed a subxiphoid 2 vessel CABG and Maze IV. She did need a pacer. Postop she was in a-fib for 3 weeks but was noted to have spontaneously converted to NSR on a post-pacer EKG, while on Amiodarone and Beta-blocker therapy. The second case is a 74 long distance runner ( > 54,000 miles logged over the past 20 years). He is a retired optometrist who presented with very symptomatic acute a-fib. His cardiologist did not want to place him on life-long beta blockers because they might affect his peak exertion and the patient refused Amiodarone because he had treated so many patients with Amio induced corneal deposits. Also, he did not want to be on permanent anticoagulation. I performed a subxiphoid complete Maze IV on the empty beating heart. He was transfered from ICU and walking unaided in the hallway 15 hours post-op (see below) and insisted he had no pain and took no pain pills. I almost sent him home on the first day, but waited to be extra cautious. He had higher than average pleural drainage numbers on POD #2 so we discharged him on day 3. He is still in stable NSR. Both patients had stapled amputation of the base of the LA appendage. The first lady was treated with Coumadin and developed bilateral hemothoraces requiring pleural drainage catheters and transfusions, but no lasting sequelae. She is currently asymptomatic, off Coumadin, with no neurologic events. The second patient was never treated with Coumadin. The advantage of this approach in my mind is the complete Maze IV lesion set (including bilateral PV encircling lesions, mitral isthmus lesion, flutter lines, medial tricuspid line, coronary sinus, etc.) while still avoiding sternotomy or bilateral thoracotomies, cardioplegic arrest, etc. The incision is 4 cm epigastric midline. LA appendage and ligament of Marshal division were done in both cases but we did not perform ganglionic mapping. However, the majority of tissue where the ganglionic plexi have been located were clearly within the "ice ball" created by the probe. I will have a movie of the procedure soon, I hope. Thanks, Mark Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com Subxiphoid CryoMaze Patient #2 .. 15 hours after surgery From prasannasimha at gmail.com Mon Jan 5 18:38:52 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Mon Jan 5 08:09:21 2009 Subject: [HSF] Subxiphoid CryoMaze In-Reply-To: <1113788687-1231160046-cardhu_decombobulator_blackberry.rim.net-1760673732-@bxe016.bisx.prod.on.blackberry> References: <1113788687-1231160046-cardhu_decombobulator_blackberry.rim.net-1760673732-@bxe016.bisx.prod.on.blackberry> Message-ID: <89c4ed2d0901050508v44f7b055w831f819ab3125925@mail.gmail.com> I was going to voice similar concerns. I had tried epicardial right with endocardial left and that gave a lower conversion rate. I am sceptical of lesser mazes for this reason. I am not sure about the statement that Cox had less rigorously evaluated maze success. He did extensive work during that time to prove electrical and mechanical afib success measurements are directly attributable to Cox. Prasanna On Mon, Jan 5, 2009 at 6:24 PM, wrote: > Mark, > Sorry, but I don't believe you can reliably create a transmural mitral > isthmus lesion from an epicardial approach. The heat sink effect, > particularly in thick atria, will prevent the endocardium from freezing. It > also doesn't sound like you are doing a full set of lesions on the right > side. In addition, no conclusions should be drawn on the basis of 1 chronic > and 1 PAF case. It's an innovative, promising approach, but it's not a full > set of transmural lesions in my opinion. > > Hal > Sent from my Verizon Wireless BlackBerry > > -----Original Message----- > From: Mark Levinson > > Date: Mon, 5 Jan 2009 02:12:23 > To: > Subject: [HSF] Subxiphoid CryoMaze > > > > > > Mark, > > I saw your talk about the subxiphoid approach for coronary > > revascularization at the last HSF dinner. For the life of me, I > > can't figure out how you > > would be able to safely get in and out of the atria with that > > approach. Please > > elaborate. BTW, Happy New Year. Glad you've resurfaced. > > > > Hal > > > > > > Hal: > > Briefly, the approach is epicardial on the beating, empty heart using > femoral-femoral bypass. > The heart is exposed only by sternal lifting (double Rultracts). > Both cavae are looped. > > The lesions are epicardial with the ATS argon cryo surgical instrument > for 2 - 3 minutes each lesion. > > As I commented in an earlier posting, pulmonary vein isolation is > *not* a Maze III - IV and likewise a Maze III is *not* just a > pulmonary vein isolation. > That said, Cox did not have the kind of event monitoring we have today > to verify his 90+% success rate, but his procedure > was established from over a decade of laboratory work in animal models > of a-fib and then validated and finally matured > in actual clinical cases. Hassaguerres' (sp) transcatheter > pulmonary vein isolation report spawned a small "industrial > revolution" in > surgical instrumentation, but any procedures based on his > identification of pulmonary vein triggers are far from a complete Maze. > > It is my personal belief that only a full Maze should be applied to > the vast majority of potential patients (estimated at over 2 million) > who have a-fib of various > ages or types. Otherwise, surgeons have no hope of achieving results > superior to our catheter colleagues. > > So.....I took Cox's publications and his surgical drawings and created > a series of my own anatomic drawings (from the > perspective of the subxiphoid exposure) and re-located his entire > lesion set on my drawings using epicardial landmarks. > Then I made sure I had the proper equipment to reach, encircle, and > ablate every site on my map from the subxiphoid incision. > > I have now done 2 cases. The first is an 84 yo female in A-fib more > than 25 years who also needed a 2 vessel CABG. > She had preop bradycardia without meds, so I knew she would also have > AV nodal dysfunction. I performed a > subxiphoid 2 vessel CABG and Maze IV. She did need a pacer. > Postop she was in a-fib for 3 weeks but was noted > to have spontaneously converted to NSR on a post-pacer EKG, while on > Amiodarone and Beta-blocker therapy. > > The second case is a 74 long distance runner ( > 54,000 miles logged > over the past 20 years). He is a retired optometrist > who presented with very symptomatic acute a-fib. His cardiologist > did not want to place him on life-long beta blockers because they > might affect his peak exertion and the patient refused Amiodarone > because he had treated so many patients with Amio induced > corneal deposits. Also, he did not want to be on permanent > anticoagulation. > > I performed a subxiphoid complete Maze IV on the empty beating > heart. He was transfered from ICU and walking unaided > in the hallway 15 hours post-op (see below) and insisted he had no > pain and took no pain pills. I almost sent him home on the first > day, but waited > to be extra cautious. He had higher than average pleural drainage > numbers on POD #2 so we discharged him on day 3. He is still in > stable NSR. > > Both patients had stapled amputation of the base of the LA > appendage. The first lady was treated with Coumadin and developed > bilateral hemothoraces requiring pleural drainage catheters and > transfusions, but no lasting sequelae. She is > currently asymptomatic, off Coumadin, with no neurologic events. > The second patient was never treated with Coumadin. > > The advantage of this approach in my mind is the complete Maze IV > lesion set (including bilateral PV encircling lesions, mitral isthmus > lesion, > flutter lines, medial tricuspid line, coronary sinus, etc.) while > still avoiding sternotomy or bilateral thoracotomies, cardioplegic > arrest, etc. > > The incision is 4 cm epigastric midline. LA appendage and ligament > of Marshal division were done in both cases > but we did not perform ganglionic mapping. However, the majority of > tissue where the ganglionic plexi have been located were > clearly within the "ice ball" created by the probe. > > I will have a movie of the procedure soon, I hope. > > Thanks, > > Mark > > > Mark Levinson, MD. > Founder, Editor-in-Chief > The Heart Surgery Forum(R) > Multimedia Cardiothoracic Journal > URL: http://www.hsforum.com > URL: http://newoptionsinheartsurgery.com > Emali: mmlevinson@hsforum.com > > > Subxiphoid CryoMaze Patient #2 .. 15 hours after surgery > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > -- Prasanna Simha M From prasannasimha at gmail.com Mon Jan 5 17:30:48 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Mon Jan 5 08:15:30 2009 Subject: [HSF] longterm tetralogy result In-Reply-To: References: Message-ID: <89c4ed2d0901050400p1f38ca5ep91ab1c6acb9ee64f@mail.gmail.com> That is wondrful and I was born in 1966. Prasanna On Mon, Jan 5, 2009 at 5:13 PM, wrote: > Dear folks, > I had a great experience this weekend. I had a call from South Africa from > a > man in his 50's whose tetralogy was repaired in 1966. In that year my > mother's friend Mary, with the advice of my mother who had been at the > Mayo Clinic > in the 20's, took her 10 year old son to have his Tetralogy repaired by > John > Kirklin. My mother decided to visit us in NY and also accompany Mary on her > visit to Mayo. Young Nick had his tetralogy repaired succesfully. John told > Mary that Nick had a blood vessel that had kept him alive. I presume this > was > a large collateral. Mary wrote a book about the experience which she > called > "The Vein of Life". (Like many lay people she mixed up vein and artery). > The > book was interesting in its description of an intense emotional attraction > to Kirklin. She described it as like "falling in love". This was > intriguing to > me because , unlike Denton Cooley or Walt Lillehei or Chris Barnard around > whom women regularly swooned, Kirklin could not be described as sexy. Pure > love I suppose. > Nick, who was severely disabled preop, is now 52 and continues to > exercise > without difficulty. An Arrhythmia which developed 15 years ago has been > well > controlled medically. And last year the Mayo Clinic sent him a long > followup > questionaire in South Africa. I had never met Nick but a nonmedical friend > of mine noticed his scar and asked him about it and he spontaneously > called me > to tell me how grateful his mother had been for my mother's support. > Bob > **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > -- Prasanna Simha M From tacuff at swbell.net Mon Jan 5 07:56:58 2009 From: tacuff at swbell.net (Tea Acuff) Date: Mon Jan 5 10:57:27 2009 Subject: [HSF] pericardial window for AF prophylaxis Message-ID: <622950.61843.qm@web81606.mail.mud.yahoo.com> If this would be true, closing the pericardium to prevent most of the blood from getting there from the sternotomy should help as should say a right minithorocotomy. I think there is some support for those. Tea Sent from my iPhone On Jan 5, 2009, at 6:44 AM, Donald Ross wrote: There is some evidence indicating a posterior pericardial window to allow efficient drainage of the pericardium reduces the incidence of post-op AF Has anyone any experience with this technique? Don _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 anddisclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From tacuff at swbell.net Mon Jan 5 08:00:01 2009 From: tacuff at swbell.net (Tea Acuff) Date: Mon Jan 5 11:00:29 2009 Subject: [HSF] decalcifying the aortic annulus: opinions Message-ID: <333124.9117.qm@web81603.mail.mud.yahoo.com> The Goldilocks Effect. Is that literature a German report, Roberto? Tea Sent from my iPhone On Jan 4, 2009, at 11:16 AM, Roberto Battellini wrote: Tea, We agree in Germany that the annulus should be completely decalcified but without going into the annulus.May be Cooley saw some disasters? Too much is an error, too less also.Exactly is better.We operate the valves with loupes. May be bob should write THAT "lecture" Roberto> Date: Sun, 4 Jan 2009 07:03:52 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] Request for SJM data from Prasanna> To: OpenHeart-L@lists.hsforum.com> CC: > > Could you elaborate on failure to decalcify especially since Cooley is quoted as saying too much is the worst error?> Obviously your point that in vivo " sizes" are different and one would "assume" the gradient is the market for the heart, but should not the surgeon not fit what will easily go or enlarge to fit what will easily go instead of rt21 vs pq23 vs xz22?> Tea> > Sent from my iPhone> > On Jan 4, 2009, at 7:01 AM, Rwmfglycar@aol.com wrote:> > > In a message dated 1/3/2009 11:11:40 A.M. Eastern Standard Time, > tacuff@swbell.net writes:> > Yes. It was kind of a fun puzzle. But what does the data mean vis a vis the > implanting surgeon? That is, is this not a statement of the obvious: some > valves have bigger holes but the biggest variable ("no thing") is the surgeon?> Tea > > > > You are absolutely right, the size of the hole of a mechanical valve is the > most important determinant of forward flow performance. Remember first the > importance of the relationship between mounting size and internal orifice, and > then that the size of the hole is not determined just by the internal > diameter of the housing. The shape of the orifice can make a difference and the > occluder must be factored in. Different occluders produce different effects on > transvalvular flow, with varying degrees of turbulence. Then there is the > obligatory closing volume (i.e. the flow back through the orifice that is > necessary to close it; done so much better by nature) and the leakage during closure > which can be zero or a definitely measurable amount. Engineers like to put > all this together, into what they call Energy Loss. In vitro performance can > be very precisely measured. and differences between two designs clearly shown. > Clinically the noninvasive measurements are far less precise. You have > suggested that surgeons have an effect on valve performance.> The great majority of surgeons handle aortic valve replacement very > well but you are right; the surgeon can interfere with the hemodynamic result in > a number of ways which if I were to describe them would be a lecture. In the > aortic position the single most common error in performance is failure to > decalcify the annulus completely. I would add only that this longheld opinion > has been confirmed during the last nine years of consulting for a valve > company.> Bob> **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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@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 ----------------------------------------- From GoldmanS at MLHS.ORG Mon Jan 5 09:59:00 2009 From: GoldmanS at MLHS.ORG (Goldman, Scott) Date: Mon Jan 5 12:00:17 2009 Subject: [HSF] decalcifying the aortic annulus: opinions Message-ID: Try using a CUSA. Takes only the calcium and leaves all normal tissue behind. Scott -----Original Message----- From: "Tea Acuff" Subj: Re: [HSF] decalcifying the aortic annulus: opinions Date: Mon Jan 5, 2009 9:00 am Size: 4K To: "OpenHeart-L@lists.hsforum.com" The Goldilocks Effect. Is that literature a German report, Roberto? Tea Sent from my iPhone On Jan 4, 2009, at 11:16 AM, Roberto Battellini wrote: Tea, We agree in Germany that the annulus should be completely decalcified but without going into the annulus.May be Cooley saw some disasters? Too much is an error, too less also.Exactly is better.We operate the valves with loupes. May be bob should write THAT "lecture" Roberto> Date: Sun, 4 Jan 2009 07:03:52 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] Request for SJM data from Prasanna> To: OpenHeart-L@lists.hsforum.com> CC: > > Could you elaborate on failure to decalcify especially since Cooley is quoted as saying too much is the worst error?> Obviously your point that in vivo " sizes" are different and one would "assume" the gradient is the market for the heart, but should not the surgeon not fit what will easily go or enlarge to fit what will easily go instead of rt21 vs pq23 vs xz22?> Tea> > Sent from my iPhone> > On Jan 4, 2009, at 7:01 AM, Rwmfglycar@aol.com wrote:> > > In a message dated 1/3/2009 11:11:40 A.M. Eastern Standard Time, > tacuff@swbell.net writes:> > Yes. It was kind of a fun puzzle. But what does the data mean vis a vis the > implanting surgeon? That is, is this not a statement of the obvious: some > valves have bigger holes but the biggest variable ("no thing") is the surgeon?> Tea > > > > You are absolutely right, the size of the hole of a mechanical valve is the > most important determinant of forward flow performance. Remember first the > importance of the relationship between mounting size and internal orifice, and > then that the size of the hole is not determined just by the internal > diameter of the housing. The shape of the orifice can make a difference and the > occluder must be factored in. Different occluders produce different effects on > transvalvular flow, with varying degrees of turbulence. Then there is the > obligatory closing volume (i.e. the flow back through the orifice that is > necessary to close it; done so much better by nature) and the leakage during closure > which can be zero or a definitely measurable amount. Engineers like to put > all this together, into what they call Energy Loss. In vitro performance can > be very precisely measured. and differences between two designs clearly shown. > Clinically the noninvasive measurements are far less precise. You have > suggested that surgeons have an effect on valve performance.> The great majority of surgeons handle aortic valve replacement very > well but you are right; the surgeon can interfere with the hemodynamic result in > a number of ways which if I were to describe them would be a lecture. In the > aortic position the single most common error in performance is failure to > decalcify the annulus completely. I would add only that this longheld opinion > has been confirmed during the last nine years of consulting for a valve > company.> Bob> **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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@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@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 ----------------------------------------- From tacuff at swbell.net Mon Jan 5 10:13:26 2009 From: tacuff at swbell.net (Tea Acuff) Date: Mon Jan 5 13:13:54 2009 Subject: [HSF] longterm tetralogy result Message-ID: <433199.80678.qm@web81605.mail.mud.yahoo.com> A very interesting story, Bob. Our view of medicine is, to use Wild Bill's phrase, "exasperatingly" myopic. Even your qualifier concerning the technical faux pas on vein for artery, while explanatory, is myopic. Certainly we doctors?do the same with or without effect: pop off MR, Cox lesion, De Vega, failure to protect the RA as cause of Afib, etc. I wonder if this patient even got the "right" operation based on our present frame of mind. On the other hand this represents the patient's story to which we are largely blind. This view is represented by the "The Wounded Story Teller" (by Arthur Frank) in which those that we alter their lives make new sense(s) of their "stories" or lives. In fact this is a story about "the wounded mother" of the wounded child as only in the end do we see a redaction of the patient himself. He retells his mother's story from his childhood. How often do we hear that some "doctorkinder" did not go into the interesting field of pediatrics because they couldn't talk to the mothers? You yourself were not the "physician"?of the story, but were told the story, son to son, as it turns out. If I may suggest this is a "great experience" for you as your mother could have have even recently remembered the story (since the patient is in SA perhaps he told her personally) and your mother was in essence a care giver.?Also personally to you?this patient has now lived nearly as long with an imperfect operation as your own dear father did without access to even an imperfect one. How could the stories have been changed and retold? As an aside?did I tell the story of my first hearing, also recently of an event from the 1960's,?of the JFK assination story and my "connection" to the story? Afterall, which is in the most important part of a medical story, the technical corrections that we or at least I?impose upon my wife's stories, or the story as it is told? We have discussed this on HSF in a different form: history verses technical data points. What is more important, the CT scan or the story that comes with it? Are we correct is separating the technical from the story? I have talked endlessly about the errors that we make in the name of the technical. I think that Ben is correct but not broad?enough in the likely expansion of our data bases to include much more that would be story like material. We need flesh?on those bones to make them alive for both us and our patients.? Recently I came across a new word for me?in a financial news letter. I try on words?like others do shoes. I walk around in them for a while?to see if they fit me or express my feelings or, perhaps, reform my feet.? The word was used to describe an economic?"sage". Raconteur was the word.?If it were English in origin, it might?mean accountant, one who recounts. But this word derives?from old French (the world is not flat!) and means one who re (r) tells (acont). Not tells, but retells, that is a storyteller. We love you, Bob, not merely for your profound technical expertise or what might be called your medical accounting skills. You love you, Bob, especially because you are?a raconteur. One of the best raconteurs I have ever seen in field that desperately needs them. Thank you for giving us something to both recount and retell, Bob, tea ________________________________ From: "Rwmfglycar@aol.com" To: OpenHeart-L@lists.hsforum.com Sent: Monday, January 5, 2009 5:43:19 AM Subject: Re: [HSF] longterm tetralogy result Dear? folks, I had a great experience this weekend. I had a call from South Africa from? a man in his 50's whose tetralogy was repaired in 1966. In that year my mother's? friend Mary, with the advice of? my mother who had been at the Mayo Clinic? in the 20's, took her 10 year old son to have his Tetralogy repaired by John? Kirklin. My mother decided to visit us in NY and also accompany Mary on her? visit to Mayo. Young Nick had his tetralogy repaired succesfully. John told? Mary that Nick had a blood vessel that had kept him? alive.? I presume this was a large collateral.? Mary wrote a book about the? experience which she called "The Vein of Life". (Like many lay people she mixed? up vein and artery). The book was interesting in its description of? an intense emotional attraction to Kirklin. She described it as like? "falling in love". This was intriguing to me because , unlike Denton? Cooley or Walt Lillehei or Chris Barnard around whom women? regularly swooned, Kirklin could not be described as sexy. Pure love I? suppose. Nick, who was severely disabled preop, is now 52 and continues? to exercise without difficulty. An Arrhythmia which developed 15 years? ago? has been well controlled medically. And last year the Mayo Clinic? sent him a long followup questionaire in South Africa. I had never met Nick? but a nonmedical friend of mine noticed his scar and asked him about it and he? spontaneously called me to tell me how grateful his mother had been for my? mother's support. Bob **************New year...new news.? Be the first to know what is making headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From tacuff at swbell.net Mon Jan 5 10:16:41 2009 From: tacuff at swbell.net (Tea Acuff) Date: Mon Jan 5 13:17:10 2009 Subject: [HSF] decalcifying the aortic annulus: opinions Message-ID: <971442.44312.qm@web81608.mail.mud.yahoo.com> I agree. However, at least until I am reeducated I find it unnecessary in the aortic position but more useful in the mitral where calification so redundant. tea ________________________________ From: "Goldman, Scott" To: OpenHeart-L@lists.hsforum.com; OpenHeart-L@lists.hsforum.com Sent: Monday, January 5, 2009 10:59:00 AM Subject: Re: [HSF] decalcifying the aortic annulus: opinions Try using a CUSA. Takes only the calcium and leaves all normal tissue behind. Scott -----Original Message----- From:? "Tea Acuff" Subj:? Re: [HSF] decalcifying the aortic annulus:? opinions Date:? Mon Jan 5, 2009 9:00 am Size:? 4K To:? "OpenHeart-L@lists.hsforum.com" The Goldilocks Effect. Is that literature a German report, Roberto? Tea Sent from my iPhone On Jan 4, 2009, at 11:16 AM, Roberto Battellini wrote: Tea, We agree in Germany that the annulus should be completely decalcified but without going into the annulus.May be Cooley saw some disasters? Too much is an error, too less also.Exactly is better.We operate the valves with loupes. May be bob should write THAT "lecture" Roberto> Date: Sun, 4 Jan 2009 07:03:52 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] Request for SJM data from Prasanna> To: OpenHeart-L@lists.hsforum.com> CC: > > Could you elaborate on failure to decalcify especially since Cooley is quoted as saying too much is the worst error?> Obviously your point that in vivo " sizes" are different and one would "assume" the gradient is the market for the heart, but should not the surgeon not fit what will easily go or enlarge to fit what will easily go instead of rt21 vs pq23 vs xz22?> Tea> > Sent from my iPhone> > On Jan 4, 2009, at 7:01 AM, Rwmfglycar@aol.com wrote:> > > In a message dated 1/3/2009 11:11:40 A.M. Eastern Standard Time, > tacuff@swbell.net writes:> > Yes. It was kind of a fun puzzle. But what does the data mean vis a vis the > implanting surgeon? That is, is this not a statement of the obvious: some > valves have bigger holes but the biggest variable ("no thing") is the surgeon?> Tea > > > > You are absolutely right, the size of the hole of a mechanical valve is the > most important determinant of forward flow performance. Remember first the > importance of the relationship between mounting size and internal orifice, and > then that the size of the hole is not determined just by the internal > diameter of the housing. The shape of the orifice can make a difference and the > occluder must be factored in. Different occluders produce different effects on > transvalvular flow, with varying degrees of turbulence. Then there is the > obligatory closing volume (i.e. the flow back through the orifice that is > necessary to close it; done so much better by nature) and the leakage during closure > which can be zero or a definitely measurable amount. Engineers like to put > all this together, into what they call Energy Loss. In vitro performance can > be very precisely measured. and differences between two designs clearly shown. > Clinically the noninvasive measurements are far less precise. You have > suggested that surgeons have an effect on valve performance.> The great majority of surgeons handle aortic valve replacement very > well but you are right; the surgeon can interfere with the hemodynamic result in > a number of ways which if I were to describe them would be a lecture. In the > aortic position the single most common error in performance is failure to > decalcify the annulus completely. I would add only that this longheld opinion > has been confirmed during the last nine years of consulting for a valve > company.> Bob> **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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@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@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@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 ----------------------------------------- From tacuff at swbell.net Mon Jan 5 10:24:42 2009 From: tacuff at swbell.net (Tea Acuff) Date: Mon Jan 5 13:25:11 2009 Subject: [HSF] STS Message-ID: <556121.60384.qm@web81601.mail.mud.yahoo.com> So should I arrange for a suite or something for afternoon wine, say Sunday (I can't do Tues) or something else? Or do you prefer to do it, Ajit? tea From hgrmd at aol.com Mon Jan 5 18:27:41 2009 From: hgrmd at aol.com (hgrmd@aol.com) Date: Mon Jan 5 13:29:12 2009 Subject: [HSF] STS Message-ID: <438175900-1231180063-cardhu_decombobulator_blackberry.rim.net-1478998483-@bxe016.bisx.prod.on.blackberry> Do the Sunday afternoon, right after Tech-Con, don't you think? Hal ------Original Message------ From: Tea Acuff Sender: openheart-l-bounces@lists.hsforum.com To: OpenHeart-L ReplyTo: OpenHeart-L@lists.hsforum.com Sent: Jan 5, 2009 1:24 PM Subject: [HSF] STS So should I arrange for a suite or something for afternoon wine, say Sunday (I can't do Tues) or something else? Or do you prefer to do it, Ajit? tea _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- Sent from my Verizon Wireless BlackBerry From Scott.Silvestry at jefferson.edu Mon Jan 5 13:38:39 2009 From: Scott.Silvestry at jefferson.edu (Scott Silvestry) Date: Mon Jan 5 13:39:09 2009 Subject: [HSF] pericardial window for AF prophylaxis Message-ID: <20090105133839.AHX08456@parkcity.jefferson.edu> Don: I remember the presentation at the ?STS four years ago or so. The abstract and article link are below. On the basis of this article I emulate on of my mentors and place a 24 silastic tube ( heparin bonded) in all patients and leave this one longest if drainage is a concern. The numbers in this study are small but no smaller than some of the amiodarone studies.... Effects of posterior pericardiotomy on the incidence of pericardial effusion and atrial fibrillation after coronary revascularization. Ekim H, Kutay V, Hazar A, Akbayrak H, Ba?el H, Tuncer M. Department of Cardiovascular Surgery, Y?z?nc? Y?l University, Van, Turkey. drhasanekim@yahoo.com BACKGROUND: The aim of this prospective, randomized study was to assess the efficacy of posterior pericardiotomy in decreasing the prevalence of pericardial effusion and postoperative atrial fibrillation (AF). MATERIAL/METHODS: The study was performed in 100 patients who underwent elective coronary artery bypass grafting surgery (CABG) between October 2003 and July 2005. They were randomized to receive posterior pericardiotomy (Group A) or no posterior pericardiotomy (Group B). A 4-cm longitudinal incision was made parallel and posterior to the left phrenic nerve, extending from the left inferior pulmonary vein to the diaphragm in group A patients. Posterior pericardiotomy was not performed in group B patients. RESULTS: Early pericardial effusion developed in 6 patients (12%) of group A and 21 patients (42%) of group B; no late pericardial effusion developed in group A, but did in 3 patients (6%) of group B. The number of patients who developed postoperative AF was significantly lower in the fenestration group compared with the control group (10% vs. 30%, p < 0.010). The overall incidence of supraventricular tachycardia in patients with early pericardial effusion was significantly higher than in patients without early pericardial effusion (18 patients vs. 9 patients). CONCLUSIONS: These findings suggest that posterior pericardiotomy reduces the prevalence of early pericardial effusion and related AF by improving pericardial drainage in patients undergoing coronary artery bypass surgery. http://journals.indexcopernicus.com/fulltxt.php?ICID=459198 From msfirst at gmail.com Mon Jan 5 13:45:22 2009 From: msfirst at gmail.com (Michael Firstenberg) Date: Mon Jan 5 13:45:52 2009 Subject: [HSF] pericardial window for AF prophylaxis In-Reply-To: <20090105133839.AHX08456@parkcity.jefferson.edu> References: <20090105133839.AHX08456@parkcity.jefferson.edu> Message-ID: so, in your experience - does it help? On Mon, Jan 5, 2009 at 1:38 PM, Scott Silvestry < Scott.Silvestry@jefferson.edu> wrote: > Don: > > I remember the presentation at the ?STS four years ago or so. > > The abstract and article link are below. > > On the basis of this article I emulate on of my mentors and place a 24 > silastic tube ( heparin bonded) in all patients and leave this one longest > if drainage is a concern. > > > The numbers in this study are small but no smaller than some of the > amiodarone studies.... > > > > > > > Effects of posterior pericardiotomy on the incidence of pericardial > effusion and atrial fibrillation after coronary revascularization. > Ekim H, Kutay V, Hazar A, Akbayrak H, Ba?el H, Tuncer M. > > Department of Cardiovascular Surgery, Y?z?nc? Y?l University, Van, Turkey. > drhasanekim@yahoo.com > > BACKGROUND: The aim of this prospective, randomized study was to assess the > efficacy of posterior pericardiotomy in decreasing the prevalence of > pericardial effusion and postoperative atrial fibrillation (AF). > MATERIAL/METHODS: The study was performed in 100 patients who underwent > elective coronary artery bypass grafting surgery (CABG) between October 2003 > and July 2005. They were randomized to receive posterior pericardiotomy > (Group A) or no posterior pericardiotomy (Group B). A 4-cm longitudinal > incision was made parallel and posterior to the left phrenic nerve, > extending from the left inferior pulmonary vein to the diaphragm in group A > patients. Posterior pericardiotomy was not performed in group B patients. > RESULTS: Early pericardial effusion developed in 6 patients (12%) of group A > and 21 patients (42%) of group B; no late pericardial effusion developed in > group A, but did in 3 patients (6%) of group B. The number of patients who > developed postoperative AF was significantly lower in the fenestration group > compared with the control group (10% vs. 30%, p < 0.010). The overall > incidence of supraventricular tachycardia in patients with early pericardial > effusion was significantly higher than in patients without early pericardial > effusion (18 patients vs. 9 patients). CONCLUSIONS: These findings suggest > that posterior pericardiotomy reduces the prevalence of early pericardial > effusion and related AF by improving pericardial drainage in patients > undergoing coronary artery bypass surgery. > > > > http://journals.indexcopernicus.com/fulltxt.php?ICID=459198 > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > From robertobattellini at hotmail.com Mon Jan 5 20:08:32 2009 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Mon Jan 5 14:09:20 2009 Subject: [HSF] decalcifying the aortic annulus: opinions In-Reply-To: <971442.44312.qm@web81608.mail.mud.yahoo.com> References: <971442.44312.qm@web81608.mail.mud.yahoo.com> Message-ID: Again, you, friends of Verk?rzungen, (abbreviations) (Vita brevis) we do not understand them CUSA is a Verk?rzung, Bob said we should promote comprehension.... What is a CUSA? an ultrashall decalzificator???? Roberto> Date: Mon, 5 Jan 2009 10:16:41 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> To: OpenHeart-L@lists.hsforum.com> CC: > > I agree. However, at least until I am reeducated I find it unnecessary in the aortic position but more useful in the mitral where calification so redundant.> > tea> > > > > ________________________________> From: "Goldman, Scott" > To: OpenHeart-L@lists.hsforum.com; OpenHeart-L@lists.hsforum.com> Sent: Monday, January 5, 2009 10:59:00 AM> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> > Try using a CUSA. Takes only the calcium and leaves all normal tissue behind.> > Scott > > -----Original Message-----> > From: "Tea Acuff" > Subj: Re: [HSF] decalcifying the aortic annulus: opinions> Date: Mon Jan 5, 2009 9:00 am> Size: 4K> To: "OpenHeart-L@lists.hsforum.com" > > The Goldilocks Effect. Is that literature a German report, Roberto? > Tea > > Sent from my iPhone > > On Jan 4, 2009, at 11:16 AM, Roberto Battellini wrote: > > > Tea, > We agree in Germany that the annulus should be completely decalcified but without going into the annulus.May be Cooley saw some disasters? > Too much is an error, too less also.Exactly is better.We operate the valves with loupes. > > May be bob should write THAT "lecture" > Roberto> Date: Sun, 4 Jan 2009 07:03:52 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] Request for SJM data from Prasanna> To: OpenHeart-L@lists.hsforum.com> CC: > > Could you elaborate on failure to decalcify especially since Cooley is quoted as saying too much is the worst error?> Obviously your point that in vivo " sizes" are different and one would "assume" the gradient is the market for the heart, but should not the surgeon not fit what will easily go or enlarge to fit what will easily go instead of rt21 vs pq23 vs xz22?> Tea> > Sent from my iPhone> > On Jan 4, 2009, at 7:01 AM, Rwmfglycar@aol.com wrote:> > > In a message dated 1/3/2009 11:11:40 A.M. Eastern Standard Time, > tacuff@swbell.net writes:> > Yes. It was kind of a fun puzzle. But what does the data mean vis a vis the > implanting surgeon? That is, is this not a statement of the obvious: some > valves have bigger holes but the biggest variable ("no thing") is the surgeon?> Tea > > > > > You are absolutely right, the size of the hole of a mechanical valve is the > most important determinant of forward flow performance. Remember first the > importance of the relationship between mounting size and internal orifice, and > then that the size of the hole is not determined just by the internal > diameter of the housing. The shape of the orifice can make a difference and the > occluder must be factored in. Different occluders produce different effects on > transvalvular flow, with varying degrees of turbulence. Then there is the > obligatory closing volume (i.e. the flow back through the orifice that is > necessary to close it; done so much better by nature) and the leakage during closure > which can be zero or a definitely measurable amount. Engineers like to put > all this together, into what they call Energy Loss. In vitro performance can > be very precisely measured. and differences between two designs clearly shown. > Clinically the > noninvasive measurements are far less precise. You have > suggested that surgeons have an effect on valve performance.> The great majority of surgeons handle aortic valve replacement very > well but you are right; the surgeon can interfere with the hemodynamic result in > a number of ways which if I were to describe them would be a lecture. In the > aortic position the single most common error in performance is failure to > decalcify the annulus completely. I would add only that this longheld opinion > has been confirmed during the last nine years of consulting for a valve > company.> Bob> **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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@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@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@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@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> ----------------------------------------- From robertobattellini at hotmail.com Mon Jan 5 20:09:55 2009 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Mon Jan 5 14:10:24 2009 Subject: [HSF] decalcifying the aortic annulus: opinions-OT In-Reply-To: <333124.9117.qm@web81603.mail.mud.yahoo.com> References: <333124.9117.qm@web81603.mail.mud.yahoo.com> Message-ID: of exactitude, Tea> Date: Mon, 5 Jan 2009 08:00:01 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> To: OpenHeart-L@lists.hsforum.com> CC: > > The Goldilocks Effect. Is that literature a German report, Roberto?> Tea> > Sent from my iPhone> > On Jan 4, 2009, at 11:16 AM, Roberto Battellini wrote:> > > Tea,> We agree in Germany that the annulus should be completely decalcified but without going into the annulus.May be Cooley saw some disasters?> Too much is an error, too less also.Exactly is better.We operate the valves with loupes.> > May be bob should write THAT "lecture"> Roberto> Date: Sun, 4 Jan 2009 07:03:52 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] Request for SJM data from Prasanna> To: OpenHeart-L@lists.hsforum.com> CC: > > Could you elaborate on failure to decalcify especially since Cooley is quoted as saying too much is the worst error?> Obviously your point that in vivo " sizes" are different and one would "assume" the gradient is the market for the heart, but should not the surgeon not fit what will easily go or enlarge to fit what will easily go instead of rt21 vs pq23 vs xz22?> Tea> > Sent from my iPhone> > On Jan 4, 2009, at 7:01 AM, Rwmfglycar@aol.com wrote:> > > In a message dated 1/3/2009 11:11:40 A.M. Eastern Standard Time, > tacuff@swbell.net writes:> > Yes. It was kind of a fun puzzle. But what does the data mean vis a vis the > implanting surgeon? That is, is this not a statement of the obvious: some > valves have bigger holes but the biggest variable ("no thing") is the surgeon?> Tea > > > >> You are absolutely right, the size of the hole of a mechanical valve is the > most important determinant of forward flow performance. Remember first the > importance of the relationship between mounting size and internal orifice, and > then that the size of the hole is not determined just by the internal > diameter of the housing. The shape of the orifice can make a difference and the > occluder must be factored in. Different occluders produce different effects on > transvalvular flow, with varying degrees of turbulence. Then there is the > obligatory closing volume (i.e. the flow back through the orifice that is > necessary to close it; done so much better by nature) and the leakage during closure > which can be zero or a definitely measurable amount. Engineers like to put > all this together, into what they call Energy Loss. In vitro performance can > be very precisely measured. and differences between two designs clearly shown. > Clinically the> noninvasive measurements are far less precise. You have > suggested that surgeons have an effect on valve performance.> The great majority of surgeons handle aortic valve replacement very > well but you are right; the surgeon can interfere with the hemodynamic result in > a number of ways which if I were to describe them would be a lecture. In the > aortic position the single most common error in performance is failure to > decalcify the annulus completely. I would add only that this longheld opinion > has been confirmed during the last nine years of consulting for a valve > company.> Bob> **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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@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@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> ----------------------------------------- From wftjrtyler at aol.com Mon Jan 5 14:43:58 2009 From: wftjrtyler at aol.com (wftjrtyler@aol.com) Date: Mon Jan 5 14:45:01 2009 Subject: [HSF] De Bakey caged disk valve Message-ID: Perhaps you are referring to the Beall valve. A caged disc valve with the lowest hemolysis rate in the world.....for the first twenty minutes. Dr. Frater, am I right? bill turner In a message dated 1/5/2009 2:22:21 A.M. Central Standard Time, mmlevinson@hsforum.com writes: On Dec 16, 2008, at 7:31 PM, Prasanna Simha M wrote: > Debakey had quite a few Valves" including the Debakey surgitool valve > which had pins which self fixed in the annulus and caged disc valve . > Both were associated with strut fractures that you have described. > Prasanna Wasn't the Surgitool valve called the Magovern valve. I had to take one out for pannus and TIAs after 20+ years and I got the removal tool from George Magovern...... Interesting idea for its day, and now in the days of percutaneous valves, his device almost looks like a prediction of the future! Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- **************New year...new news. Be the first to know what is making headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) From tacuff at swbell.net Mon Jan 5 13:38:59 2009 From: tacuff at swbell.net (Tea Acuff) Date: Mon Jan 5 16:41:17 2009 Subject: [HSF] decalcifying the aortic annulus: opinions Message-ID: <932261.79815.qm@web81607.mail.mud.yahoo.com> I don't what it stands for. It is like a blunt harmonic scapel that was used initially for liver (and brain?) resection. It vibrates out the parenchemal cells but leaves the collagen to secure closure of the residual resection. It also melts the calcium and leaves the annulus on mitral surgery. Tea Sent from my iPhone On Jan 5, 2009, at 1:08 PM, Roberto Battellini wrote: Again, you, friends of Verk?rzungen, (abbreviations) (Vita brevis) we do not understand them CUSA is a Verk?rzung, Bob said we should promote comprehension.... What is a CUSA? an ultrashall decalzificator???? Roberto> Date: Mon, 5 Jan 2009 10:16:41 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> To: OpenHeart-L@lists.hsforum.com> CC: > > I agree. However, at least until I am reeducated I find it unnecessary in the aortic position but more useful in the mitral where calification so redundant.> > tea> > > > > ________________________________> From: "Goldman, Scott" > To: OpenHeart-L@lists.hsforum.com; OpenHeart-L@lists.hsforum.com> Sent: Monday, January 5, 2009 10:59:00 AM> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> > Try using a CUSA. Takes only the calcium and leaves all normal tissue behind.> > Scott > > -----Original Message-----> > From: "Tea Acuff" > Subj: Re: [HSF] decalcifying the aortic annulus: opinions> Date: Mon Jan 5, 2009 9:00 am> Size: 4K> To: "OpenHeart-L@lists.hsforum.com" > > The Goldilocks Effect. Is that literature a German report, Roberto? > Tea > > Sent from my iPhone > > On Jan 4, 2009, at 11:16 AM, Roberto Battellini wrote: > > > Tea, > We agree in Germany that the annulus should be completely decalcified but without going into the annulus.May be Cooley saw some disasters? > Too much is an error, too less also.Exactly is better.We operate the valves with loupes. > > May be bob should write THAT "lecture" > Roberto> Date: Sun, 4 Jan 2009 07:03:52 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] Request for SJM data from Prasanna> To: OpenHeart-L@lists.hsforum.com> CC: > > Could you elaborate on failure to decalcify especially since Cooley is quoted as saying too much is the worst error?> Obviously your point that in vivo " sizes" are different and one would "assume" the gradient is the market for the heart, but should not the surgeon not fit what will easily go or enlarge to fit what will easily go instead of rt21 vs pq23 vs xz22?> Tea> > Sent from my iPhone> > On Jan 4, 2009, at 7:01 AM, Rwmfglycar@aol.com wrote:> > > In a message dated 1/3/2009 11:11:40 A.M. Eastern Standard Time, > tacuff@swbell.net writes:> > Yes. It was kind of a fun puzzle. But what does the data mean vis a vis the > implanting surgeon? That is, is this not a statement of the obvious: some > valves have bigger holes but the biggest variable ("no thing") is the surgeon?> Tea > > > > > You are absolutely right, the size of the hole of a mechanical valve is the > most important determinant of forward flow performance. Remember first the > importance of the relationship between mounting size and internal orifice, and > then that the size of the hole is not determined just by the internal > diameter of the housing. The shape of the orifice can make a difference and the > occluder must be factored in. Different occluders produce different effects on > transvalvular flow, with varying degrees of turbulence. Then there is the > obligatory closing volume (i.e. the flow back through the orifice that is > necessary to close it; done so much better by nature) and the leakage during closure > which can be zero or a definitely measurable amount. Engineers like to put > all this together, into what they call Energy Loss. In vitro performance can > be very precisely measured. and differences between two designs clearly shown. > Clinically the > noninvasive measurements are far less precise. You have > suggested that surgeons have an effect on valve performance.> The great majority of surgeons handle aortic valve replacement very > well but you are right; the surgeon can interfere with the hemodynamic result in > a number of ways which if I were to describe them would be a lecture. In the > aortic position the single most common error in performance is failure to > decalcify the annulus completely. I would add only that this longheld opinion > has been confirmed during the last nine years of consulting for a valve > company.> Bob> **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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@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@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@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@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@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 ----------------------------------------- From JBechler at samhealth.org Mon Jan 5 13:54:00 2009 From: JBechler at samhealth.org (JBechler@samhealth.org) Date: Mon Jan 5 16:54:48 2009 Subject: [HSF] decalcifying the aortic annulus: opinions In-Reply-To: <932261.79815.qm@web81607.mail.mud.yahoo.com> Message-ID: <0F5939061646D2428807FE24C47B2F3C8FDBDC@SHSMAILVS01.int.samhealth.net> CUSA Cavitron Ultrasonic Surgical Aspirator More information available here: http://www.radionics.com/products/cusa/excel.shtml Jan -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Tea Acuff Sent: Monday, January 05, 2009 1:39 PM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] decalcifying the aortic annulus: opinions I don't what it stands for. It is like a blunt harmonic scapel that was used initially for liver (and brain?) resection. It vibrates out the parenchemal cells but leaves the collagen to secure closure of the residual resection. It also melts the calcium and leaves the annulus on mitral surgery. Tea Sent from my iPhone On Jan 5, 2009, at 1:08 PM, Roberto Battellini wrote: Again, you, friends of Verk?rzungen, (abbreviations) (Vita brevis) we do not understand them CUSA is a Verk?rzung, Bob said we should promote comprehension.... What is a CUSA? an ultrashall decalzificator???? Roberto> Date: Mon, 5 Jan 2009 10:16:41 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> To: OpenHeart-L@lists.hsforum.com> CC: > > I agree. However, at least until I am reeducated I find it unnecessary in the aortic position but more useful in the mitral where calification so redundant.> > tea> > > > > ________________________________> From: "Goldman, Scott" > To: OpenHeart-L@lists.hsforum.com; OpenHeart-L@lists.hsforum.com> Sent: Monday, January 5, 2009 10:59:00 AM> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> > Try using a CUSA. Takes only the calcium and leaves all normal tissue behind.> > Scott > > -----Original Message-----> > From: "Tea Acuff" > Subj: Re: [HSF] decalcifying the aortic annulus: opinions> Date: Mon Jan 5, 2009 9:00 am> Size: 4K> To: "OpenHeart-L@lists.hsforum.com" > > The Goldilocks Effect. Is that literature a German report, Roberto? > Tea > > Sent from my iPhone > > On Jan 4, 2009, at 11:16 AM, Roberto Battellini wrote: > > > Tea, > We agree in Germany that the annulus should be completely decalcified but without going into the annulus.May be Cooley saw some disasters? > Too much is an error, too less also.Exactly is better.We operate the valves with loupes. > > May be bob should write THAT "lecture" > Roberto> Date: Sun, 4 Jan 2009 07:03:52 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] Request for SJM data from Prasanna> To: OpenHeart-L@lists.hsforum.com> CC: > > Could you elaborate on failure to decalcify especially since Cooley is quoted as saying too much is the worst error?> Obviously your point that in vivo " sizes" are different and one would "assume" the gradient is the market for the heart, but should not the surgeon not fit what will easily go or enlarge to fit what will easily go instead of rt21 vs pq23 vs xz22?> Tea> > Sent from my iPhone> > On Jan 4, 2009, at 7:01 AM, Rwmfglycar@aol.com wrote:> > > In a message dated 1/3/2009 11:11:40 A.M. Eastern Standard Time, > tacuff@swbell.net writes:> > Yes. It was kind of a fun puzzle. But what does the data mean vis a vis the > implanting surgeon? That is, is this not a statement of the obvious: some > valves have bigger holes but the biggest variable ("no thing") is the surgeon?> Tea > > > > > You are absolutely right, the size of the hole of a mechanical valve is the > most important determinant of forward flow performance. Remember first the > importance of the relationship between mounting size and internal orifice, and > then that the size of the hole is not determined just by the internal > diameter of the housing. The shape of the orifice can make a difference and the > occluder must be factored in. Different occluders produce different effects on > transvalvular flow, with varying degrees of turbulence. Then there is the > obligatory closing volume (i.e. the flow back through the orifice that is > necessary to close it; done so much better by nature) and the leakage during closure > which can be zero or a definitely measurable amount. Engineers like to put > all this together, into what they call Energy Loss. In vitro performance can > be very precisely measured. and differences between two designs clearly shown. > Clinically the > noninvasive measurements are far less precise. You have > suggested that surgeons have an effect on valve performance.> The great majority of surgeons handle aortic valve replacement very > well but you are right; the surgeon can interfere with the hemodynamic result in > a number of ways which if I were to describe them would be a lecture. In the > aortic position the single most common error in performance is failure to > decalcify the annulus completely. I would add only that this longheld opinion > has been confirmed during the last nine years of consulting for a valve > company.> Bob> **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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@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@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@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@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@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@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 ----------------------------------------- Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. From chand.ramaiah at uky.edu Mon Jan 5 17:09:32 2009 From: chand.ramaiah at uky.edu (Ramaiah, Chandrashekar) Date: Mon Jan 5 17:10:04 2009 Subject: [HSF] STS In-Reply-To: <556121.60384.qm@web81601.mail.mud.yahoo.com> References: <556121.60384.qm@web81601.mail.mud.yahoo.com> Message-ID: <3ACC54310BF13645A0D12496D7CA94E5F9EBFA78@EX7FM04.ad.uky.edu> Tea, Sunday afternoon sounds great to me. (is it too early for Tea's party!) Chand -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Tea Acuff Sent: Monday, January 05, 2009 1:25 PM To: OpenHeart-L Subject: [HSF] STS So should I arrange for a suite or something for afternoon wine, say Sunday (I can't do Tues) or something else? Or do you prefer to do it, Ajit? tea _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From valdretemd at shaw.ca Mon Jan 5 14:26:06 2009 From: valdretemd at shaw.ca (V. Aldrete, M.D.) Date: Mon Jan 5 17:27:33 2009 Subject: [HSF] De Bakey caged disk valve In-Reply-To: References: Message-ID: I am sending these pictures again, for those of you that did not see them. The first one is the Beall-Edwards Valve , second the McGovern sutureless valve and last the McGovern-Crombie valve. I also have pictures of the DeBakey-Surgitool, Harken, Hufnagel and Kalke plus many of the more modern valves, should you want to see them please let me know, for it is best to send them directly to your inboxes, as the quality of the old pictures gets very bad as the files are shrunk to fit the HSF list. Cheers, Victor -------------- next part -------------- A non-text attachment was scrubbed... Name: BEALL-EDWARDS copy.jpg Type: image/jpeg Size: 157162 bytes Desc: not available Url : http://mmp.cjp.com/pipermail/openheart-l/attachments/20090105/5e8b075c/BEALL-EDWARDScopy-0001.jpg -------------- next part -------------- I am resending one picture at a time due to file size. This is Beall- Edwards. On Jan 5, 2009, at 11:43 AM, wftjrtyler@aol.com wrote: > Perhaps you are referring to the Beall valve. A caged disc valve > with the > lowest hemolysis rate in the world.....for the first twenty > minutes. Dr. > Frater, am I right? bill turner > > > In a message dated 1/5/2009 2:22:21 A.M. Central Standard Time, > mmlevinson@hsforum.com writes: > > > On Dec 16, 2008, at 7:31 PM, Prasanna Simha M wrote: > >> Debakey had quite a few Valves" including the Debakey surgitool >> valve >> which had pins which self fixed in the annulus and caged disc >> valve . >> Both were associated with strut fractures that you have described. >> Prasanna > > Wasn't the Surgitool valve called the Magovern valve. > > I had to take one out for pannus and TIAs after 20+ years and I > got the > removal tool from George Magovern...... > > Interesting idea for its day, and now in the days of percutaneous > valves, his > device almost looks like a prediction of the future! > > Mark Levinson, MD. > Founder, Editor-in-Chief > The Heart Surgery Forum? > Multimedia Cardiothoracic Journal > URL: http://www.hsforum.com > URL: http://newoptionsinheartsurgery.com > Emali: mmlevinson@hsforum.com > > > ----------------------------------------- From valdretemd at shaw.ca Mon Jan 5 14:26:45 2009 From: valdretemd at shaw.ca (V. Aldrete, M.D.) Date: Mon Jan 5 17:27:56 2009 Subject: [HSF] De Bakey caged disk valve In-Reply-To: References: Message-ID: <0C2C4380-9AF5-45F8-99AB-A7F3CDCC9287@shaw.ca> I am sending these pictures again, for those of you that did not see them. The first one is the Beall-Edwards Valve , second the McGovern sutureless valve and last the McGovern-Crombie valve. I also have pictures of the DeBakey-Surgitool, Harken, Hufnagel and Kalke plus many of the more modern valves, should you want to see them please let me know, for it is best to send them directly to your inboxes, as the quality of the old pictures gets very bad as the files are shrunk to fit the HSF list. Cheers, Victor -------------- next part -------------- A non-text attachment was scrubbed... Name: MACGOVERN copy.jpg Type: image/jpeg Size: 184304 bytes Desc: not available Url : http://mmp.cjp.com/pipermail/openheart-l/attachments/20090105/c53f1c3a/MACGOVERNcopy-0001.jpg -------------- next part -------------- I am resending one picture at a time due to file size. Sutureless McGovern. On Jan 5, 2009, at 11:43 AM, wftjrtyler@aol.com wrote: > Perhaps you are referring to the Beall valve. A caged disc valve > with the > lowest hemolysis rate in the world.....for the first twenty > minutes. Dr. > Frater, am I right? bill turner > > > In a message dated 1/5/2009 2:22:21 A.M. Central Standard Time, > mmlevinson@hsforum.com writes: > > > On Dec 16, 2008, at 7:31 PM, Prasanna Simha M wrote: > >> Debakey had quite a few Valves" including the Debakey surgitool >> valve >> which had pins which self fixed in the annulus and caged disc >> valve . >> Both were associated with strut fractures that you have described. >> Prasanna > > Wasn't the Surgitool valve called the Magovern valve. > > I had to take one out for pannus and TIAs after 20+ years and I > got the > removal tool from George Magovern...... > > Interesting idea for its day, and now in the days of percutaneous > valves, his > device almost looks like a prediction of the future! > > Mark Levinson, MD. > Founder, Editor-in-Chief > The Heart Surgery Forum? > Multimedia Cardiothoracic Journal > URL: http://www.hsforum.com > URL: http://newoptionsinheartsurgery.com > Emali: mmlevinson@hsforum.com > > > ----------------------------------------- From valdretemd at shaw.ca Mon Jan 5 14:27:18 2009 From: valdretemd at shaw.ca (V. Aldrete, M.D.) Date: Mon Jan 5 17:28:01 2009 Subject: [HSF] De Bakey caged disk valve In-Reply-To: References: Message-ID: <921E5461-9D3A-4DE4-A2F7-45377C8E332C@shaw.ca> I am sending these pictures again, for those of you that did not see them. The first one is the Beall-Edwards Valve , second the McGovern sutureless valve and last the McGovern-Crombie valve. I also have pictures of the DeBakey-Surgitool, Harken, Hufnagel and Kalke plus many of the more modern valves, should you want to see them please let me know, for it is best to send them directly to your inboxes, as the quality of the old pictures gets very bad as the files are shrunk to fit the HSF list. Cheers, Victor -------------- next part -------------- A non-text attachment was scrubbed... Name: MAGOVERN-CROMIE copy.jpg Type: image/jpeg Size: 145794 bytes Desc: not available Url : http://mmp.cjp.com/pipermail/openheart-l/attachments/20090105/aa549bfe/MAGOVERN-CROMIEcopy-0001.jpg -------------- next part -------------- Last of the three. On Jan 5, 2009, at 11:43 AM, wftjrtyler@aol.com wrote: > Perhaps you are referring to the Beall valve. A caged disc valve > with the > lowest hemolysis rate in the world.....for the first twenty > minutes. Dr. > Frater, am I right? bill turner > > > In a message dated 1/5/2009 2:22:21 A.M. Central Standard Time, > mmlevinson@hsforum.com writes: > > > On Dec 16, 2008, at 7:31 PM, Prasanna Simha M wrote: > >> Debakey had quite a few Valves" including the Debakey surgitool >> valve >> which had pins which self fixed in the annulus and caged disc >> valve . >> Both were associated with strut fractures that you have described. >> Prasanna > > Wasn't the Surgitool valve called the Magovern valve. > > I had to take one out for pannus and TIAs after 20+ years and I > got the > removal tool from George Magovern...... > > Interesting idea for its day, and now in the days of percutaneous > valves, his > device almost looks like a prediction of the future! > > Mark Levinson, MD. > Founder, Editor-in-Chief > The Heart Surgery Forum? > Multimedia Cardiothoracic Journal > URL: http://www.hsforum.com > URL: http://newoptionsinheartsurgery.com > Emali: mmlevinson@hsforum.com > > > ----------------------------------------- From valdretemd at shaw.ca Mon Jan 5 14:37:27 2009 From: valdretemd at shaw.ca (V. Aldrete, M.D.) Date: Mon Jan 5 17:37:46 2009 Subject: [HSF] decalcifying the aortic annulus: opinions In-Reply-To: <0F5939061646D2428807FE24C47B2F3C8FDBDC@SHSMAILVS01.int.samhealth.net> References: <0F5939061646D2428807FE24C47B2F3C8FDBDC@SHSMAILVS01.int.samhealth.net> Message-ID: <3475ECD3-4249-48DD-8D0B-3334F7E34F95@shaw.ca> I googled CUSA and got over 2 million hits. Here are the most prominent, now that we know what was being talked about. Calgary United Soccer Association (CUSA) Carleton University Students? Association?s (CUSA) Credit Union Software and Services - CUSA CUSA - Chinese Undergraduate Student Association at UW - Madison Colchester United Supporters Association. Acronyms are indeed a problem for communication. On Jan 5, 2009, at 1:54 PM, JBechler@samhealth.org wrote: > CUSA > > Cavitron Ultrasonic Surgical Aspirator > > More information available here: http://www.radionics.com/products/cusa/excel.shtml > > Jan > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com > ] On Behalf Of Tea Acuff > Sent: Monday, January 05, 2009 1:39 PM > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] decalcifying the aortic annulus: opinions > > I don't what it stands for. It is like a blunt harmonic scapel that > was used initially for liver (and brain?) resection. It vibrates > out the parenchemal cells but leaves the collagen to secure closure > of the residual resection. It also melts the calcium and leaves the > annulus on mitral surgery. > Tea > Sent from my iPhone > > On Jan 5, 2009, at 1:08 PM, Roberto Battellini > wrote: > > > Again, you, friends of Verk?rzungen, (abbreviations) (Vita brevis) > we do not understand them > CUSA is a Verk?rzung, Bob said we should promote comprehension.... > > What is a CUSA? an ultrashall decalzificator???? > > Roberto> Date: Mon, 5 Jan 2009 10:16:41 -0800> From: > tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic > annulus: opinions> To: OpenHeart-L@lists.hsforum.com> CC: > > I > agree. However, at least until I am reeducated I find it unnecessary > in the aortic position but more useful in the mitral where > calification so redundant.> > tea> > > > > > ________________________________> From: "Goldman, Scott" >> To: OpenHeart-L@lists.hsforum.com; OpenHeart-L@lists.hsforum.com> > Sent: Monday, January 5, 2009 10:59:00 AM> Subject: Re: [HSF] > decalcifying the aortic annulus: opinions> > Try using a CUSA. Takes > only the calcium and leaves all normal tissue behind.> > Scott > > > -----Original Message-----> > From: "Tea Acuff" > > Subj: Re: [HSF] decalcifying the aortic > annulus: opinions> Date: Mon Jan 5, 2009 9:00 am> Size: 4K> To: "OpenHeart-L@lists.hsforum.com > " > > The Goldilocks Effect. Is that > literature a German report, Roberto? > Tea > > Sent from my iPhone > > > On Jan 4, 2009, at 11:16 AM, Roberto Battellini > wrote: > > > Tea, > We agree in Germany that the annulus should be > completely decalcified but without going into the annulus.May be > Cooley saw some disasters? > Too much is an error, too less > also.Exactly is better.We operate the valves with loupes. > > May be > bob should write THAT "lecture" > Roberto> Date: Sun, 4 Jan 2009 > 07:03:52 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] Request > for SJM data from Prasanna> To: OpenHeart-L@lists.hsforum.com> CC: > > > Could you elaborate on failure to decalcify especially since > Cooley is quoted as saying too much is the worst error?> Obviously > your point that in vivo " sizes" are different and one would > "assume" the gradient is the market for the heart, but should not > the surgeon not fit what will easily go or enlarge to fit what will > easily go instead of rt21 vs > pq23 vs xz22?> Tea> > Sent from my iPhone> > On Jan 4, 2009, at 7:01 > AM, Rwmfglycar@aol.com wrote:> > > In a message dated 1/3/2009 > 11:11:40 A.M. Eastern Standard Time, > tacuff@swbell.net writes:> > > Yes. It was kind of a fun puzzle. But what does the data mean vis a > vis the > implanting surgeon? That is, is this not a statement of > the obvious: some > valves have bigger holes but the biggest > variable ("no thing") is the surgeon?> Tea > > > > > You are > absolutely right, the size of the hole of a mechanical valve is the > > most important determinant of forward flow performance. Remember > first the > importance of the relationship between mounting size and > internal orifice, and > then that the size of the hole is not > determined just by the internal > diameter of the housing. The shape > of the orifice can make a difference and the > occluder must be > factored in. Different occluders produce different effects on > > transvalvular flow, with varying degrees of > turbulence. Then there is the > obligatory closing volume (i.e. the > flow back through the orifice that is > necessary to close it; done > so much better by nature) and the leakage during closure > which can > be zero or a definitely measurable amount. Engineers like to put > > all this together, into what they call Energy Loss. In vitro > performance can > be very precisely measured. and differences > between two designs clearly shown. > Clinically the > noninvasive > measurements are far less precise. You have > suggested that > surgeons have an effect on valve performance.> The great majority of > surgeons handle aortic valve replacement very > well but you are > right; the surgeon can interfere with the hemodynamic result in > a > number of ways which if I were to describe them would be a lecture. > In the > aortic position the single most common error in performance > is failure to > decalcify the annulus completely. I would add only > that this longheld opinion > has been > confirmed during the last nine years of consulting for a valve > > company.> Bob> **************New year...new news. Be the first to > know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026 > )> _______________________________________________> OpenHeart-L > mailing list> > Send postings to:> OpenHeart-L@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@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@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@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@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@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@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@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 > ----------------------------------------- > > > Confidentiality Notice: This e-mail message, including any > attachments, is > for the sole use of the intended recipient(s) and may contain > confidential > and privileged information. Any unauthorized review, use, disclosure > or > distribution is prohibited. If you are not the intended recipient, > please > contact the sender by reply e-mail and destroy all copies of the > original > message. > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From msfirst at gmail.com Mon Jan 5 17:54:59 2009 From: msfirst at gmail.com (Michael Firstenberg) Date: Mon Jan 5 17:55:32 2009 Subject: [HSF] STS In-Reply-To: <3ACC54310BF13645A0D12496D7CA94E5F9EBFA78@EX7FM04.ad.uky.edu> References: <556121.60384.qm@web81601.mail.mud.yahoo.com> <3ACC54310BF13645A0D12496D7CA94E5F9EBFA78@EX7FM04.ad.uky.edu> Message-ID: Tea or Tea's? -michael. On Jan 5, 2009, at 5:09 PM, "Ramaiah, Chandrashekar" wrote: > Tea, > Sunday afternoon sounds great to me. > (is it too early for Tea's party!) > > Chand > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com > ] On Behalf Of Tea Acuff > Sent: Monday, January 05, 2009 1:25 PM > To: OpenHeart-L > Subject: [HSF] STS > > So should I arrange for a suite or something for afternoon wine, say > Sunday (I can't do Tues) or something else? Or do you prefer to do > it, Ajit? > > tea > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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 > ----------------------------------------- From GoldmanS at MLHS.ORG Mon Jan 5 18:07:43 2009 From: GoldmanS at MLHS.ORG (Goldman, Scott) Date: Mon Jan 5 18:13:43 2009 Subject: [HSF] decalcifying the aortic annulus: opinions References: <932261.79815.qm@web81607.mail.mud.yahoo.com> Message-ID: <6764E7F21669F64C81BBE14C902CDEDD042BBA85@TLH-MAIL.ad.mlhs.org> Cavitron Ultrasonic Surgical Aspirator. It was reported by Cleveland Clinic about 15 years ago for decalcifying stenotic aortic valves. It worked well but the valves all became incompetent after several months. It works great on the annulus. Scott -----Original Message----- From: openheart-l-bounces@lists.hsforum.com on behalf of Tea Acuff Sent: Mon 1/5/2009 4:38 PM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] decalcifying the aortic annulus: opinions I don't what it stands for. It is like a blunt harmonic scapel that was used initially for liver (and brain?) resection. It vibrates out the parenchemal cells but leaves the collagen to secure closure of the residual resection. It also melts the calcium and leaves the annulus on mitral surgery. Tea Sent from my iPhone On Jan 5, 2009, at 1:08 PM, Roberto Battellini wrote: Again, you, friends of Verk?rzungen, (abbreviations) (Vita brevis) we do not understand them CUSA is a Verk?rzung, Bob said we should promote comprehension.... What is a CUSA? an ultrashall decalzificator???? Roberto> Date: Mon, 5 Jan 2009 10:16:41 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> To: OpenHeart-L@lists.hsforum.com> CC: > > I agree. However, at least until I am reeducated I find it unnecessary in the aortic position but more useful in the mitral where calification so redundant.> > tea> > > > > ________________________________> From: "Goldman, Scott" > To: OpenHeart-L@lists.hsforum.com; OpenHeart-L@lists.hsforum.com> Sent: Monday, January 5, 2009 10:59:00 AM> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> > Try using a CUSA. Takes only the calcium and leaves all normal tissue behind.> > Scott > > -----Original Message-----> > From: "Tea Acuff" > Subj: Re: [HSF] decalcifying the aortic annulus: opinions> Date: Mon Jan 5, 2009 9:00 am> Size: 4K> To: "OpenHeart-L@lists.hsforum.com" > > The Goldilocks Effect. Is that literature a German report, Roberto? > Tea > > Sent from my iPhone > > On Jan 4, 2009, at 11:16 AM, Roberto Battellini wrote: > > > Tea, > We agree in Germany that the annulus should be completely decalcified but without going into the annulus.May be Cooley saw some disasters? > Too much is an error, too less also.Exactly is better.We operate the valves with loupes. > > May be bob should write THAT "lecture" > Roberto> Date: Sun, 4 Jan 2009 07:03:52 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] Request for SJM data from Prasanna> To: OpenHeart-L@lists.hsforum.com> CC: > > Could you elaborate on failure to decalcify especially since Cooley is quoted as saying too much is the worst error?> Obviously your point that in vivo " sizes" are different and one would "assume" the gradient is the market for the heart, but should not the surgeon not fit what will easily go or enlarge to fit what will easily go instead of rt21 vs pq23 vs xz22?> Tea> > Sent from my iPhone> > On Jan 4, 2009, at 7:01 AM, Rwmfglycar@aol.com wrote:> > > In a message dated 1/3/2009 11:11:40 A.M. Eastern Standard Time, > tacuff@swbell.net writes:> > Yes. It was kind of a fun puzzle. But what does the data mean vis a vis the > implanting surgeon? That is, is this not a statement of the obvious: some > valves have bigger holes but the biggest variable ("no thing") is the surgeon?> Tea > > > > > You are absolutely right, the size of the hole of a mechanical valve is the > most important determinant of forward flow performance. Remember first the > importance of the relationship between mounting size and internal orifice, and > then that the size of the hole is not determined just by the internal > diameter of the housing. The shape of the orifice can make a difference and the > occluder must be factored in. Different occluders produce different effects on > transvalvular flow, with varying degrees of turbulence. Then there is the > obligatory closing volume (i.e. the flow back through the orifice that is > necessary to close it; done so much better by nature) and the leakage during closure > which can be zero or a definitely measurable amount. Engineers like to put > all this together, into what they call Energy Loss. In vitro performance can > be very precisely measured. and differences between two designs clearly shown. > Clinically the > noninvasive measurements are far less precise. You have > suggested that surgeons have an effect on valve performance.> The great majority of surgeons handle aortic valve replacement very > well but you are right; the surgeon can interfere with the hemodynamic result in > a number of ways which if I were to describe them would be a lecture. In the > aortic position the single most common error in performance is failure to > decalcify the annulus completely. I would add only that this longheld opinion > has been confirmed during the last nine years of consulting for a valve > company.> Bob> **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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@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@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@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@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@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@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 ----------------------------------------- From gabuin at intramed.net Mon Jan 5 22:07:27 2009 From: gabuin at intramed.net (gustavo abuin) Date: Mon Jan 5 19:09:56 2009 Subject: [HSF] subxiphoid approach for CABG References: Message-ID: <002d01c96f9b$2506dab0$2e9512be@LIBERTAD> Dr. Levinson: 1)do you perform this approach with standard surgical instruments and if you don?t can you tell us where we can buy them? Please, can explain us the tips of mammary artery harvest and the surgical devices you use. It seems to me an interesting approach. 2) Do you have try to dissect the gastroepiploic artery from this approach ant put the vessel in the lad, pda or elsewhere? 3) What about the posoperative pain. Less, equal, more pain? 4) Do you have noted a reduction in mediastinal infections doing this approach? Thanks in advance. Gustavo Abuin From donross at bigpond.com Tue Jan 6 11:22:25 2009 From: donross at bigpond.com (Donald Ross) Date: Mon Jan 5 19:22:55 2009 Subject: [HSF] pericardial window for AF prophylaxis In-Reply-To: <20090105133839.AHX08456@parkcity.jefferson.edu> References: <20090105133839.AHX08456@parkcity.jefferson.edu> Message-ID: <1B2CDBDF-A9C9-40E3-A357-AC1B15E21AE4@bigpond.com> Scott, Thanks for the reference. I tried it a few times, threading a fine drain through the window via the pericardium to the base of the L pleural cavity. I figured that to be reliable the pleural cavity adjacent to the pericardotomy needed to be reliably drained. I presume any benefit would be due to the absence of organising / lysing blood around the L atrium. It is a bit of a fiddle to get it just right so I was interested to see whether others had tried it. I have been in the habit of leaving a (14F "Redivac" ) multi-holed drain in the posterior pericardium. My AF rate remains around 20% despite beta blockers and posterior pericardial drains. Don On 06/01/2009, at 5:38 AM, Scott Silvestry wrote: > Don: > > I remember the presentation at the ?STS four years ago or so. > > The abstract and article link are below. > > On the basis of this article I emulate on of my mentors and place a > 24 silastic tube ( heparin bonded) in all patients and leave this > one longest if drainage is a concern. > > > The numbers in this study are small but no smaller than some of the > amiodarone studies.... > > > > > > > Effects of posterior pericardiotomy on the incidence of pericardial > effusion and atrial fibrillation after coronary revascularization. > Ekim H, Kutay V, Hazar A, Akbayrak H, Ba?el H, Tuncer M. > > Department of Cardiovascular Surgery, Y?z?nc? Y?l University, > Van, Turkey. drhasanekim@yahoo.com > > BACKGROUND: The aim of this prospective, randomized study was to > assess the efficacy of posterior pericardiotomy in decreasing the > prevalence of pericardial effusion and postoperative atrial > fibrillation (AF). MATERIAL/METHODS: The study was performed in 100 > patients who underwent elective coronary artery bypass grafting > surgery (CABG) between October 2003 and July 2005. They were > randomized to receive posterior pericardiotomy (Group A) or no > posterior pericardiotomy (Group B). A 4-cm longitudinal incision was > made parallel and posterior to the left phrenic nerve, extending > from the left inferior pulmonary vein to the diaphragm in group A > patients. Posterior pericardiotomy was not performed in group B > patients. RESULTS: Early pericardial effusion developed in 6 > patients (12%) of group A and 21 patients (42%) of group B; no late > pericardial effusion developed in group A, but did in 3 patients > (6%) of group B. The number of patients who developed postoperative > AF was significantly lower in the fenestration group compared with > the control group (10% vs. 30%, p < 0.010). The overall incidence of > supraventricular tachycardia in patients with early pericardial > effusion was significantly higher than in patients without early > pericardial effusion (18 patients vs. 9 patients). CONCLUSIONS: > These findings suggest that posterior pericardiotomy reduces the > prevalence of early pericardial effusion and related AF by improving > pericardial drainage in patients undergoing coronary artery bypass > surgery. > > > > http://journals.indexcopernicus.com/fulltxt.php?ICID=459198 > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From prasannasimha at gmail.com Tue Jan 6 07:56:57 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Mon Jan 5 21:27:26 2009 Subject: [HSF] Image of the week Aotic root abscess Message-ID: <89c4ed2d0901051826j298211fn9f945d23dddee7bf@mail.gmail.com> Image sent by Roberto. He will discuss the case. -- Prasanna Simha M -------------- next part -------------- A non-text attachment was scrubbed... Name: Aortic root abscess.jpg Type: image/jpeg Size: 29086 bytes Desc: not available Url : http://mmp.cjp.com/pipermail/openheart-l/attachments/20090106/c3223eb6/Aorticrootabscess-0001.jpg From rwmfglycar at aol.com Mon Jan 5 21:27:10 2009 From: rwmfglycar at aol.com (rwmfglycar@aol.com) Date: Mon Jan 5 21:28:19 2009 Subject: [HSF] decalcifying the aortic annulus: opinions In-Reply-To: <3475ECD3-4249-48DD-8D0B-3334F7E34F95@shaw.ca> References: <0F5939061646D2428807FE24C47B2F3C8FDBDC@SHSMAILVS01.int.samhealth.net> <3475ECD3-4249-48DD-8D0B-3334F7E34F95@shaw.ca> Message-ID: <8CB3DBD6947C6C5-CC0-1856@Webmail-mg01.sim.aol.com> Dear Dr Andrete thank you for reinforcintg my boring objection to acronyms. Ultrsonic debrifdement of aortic leaflets? using the socalled CUSA instrument resulted in late leaflet perforations. Bob -----Original Message----- From: V. Aldrete, M.D. To: OpenHeart-L@lists.hsforum.com Sent: Mon, 5 Jan 2009 5:37 pm Subject: Re: [HSF] decalcifying the aortic annulus: opinions I googled CUSA and got over 2 million hits. Here are the most prominent, now that we know what was being talked about.? ? Calgary United Soccer Association (CUSA)? Carleton University Students? Association?s (CUSA)? Credit Union Software and Services - CUSA? CUSA - Chinese Undergraduate Student Association at UW - Madison? Colchester United Supporters Association.? ? Acronyms are indeed a problem for communication.? ? On Jan 5, 2009, at 1:54 PM, JBechler@samhealth.org wrote:? ? > CUSA? >? > Cavitron Ultrasonic Surgical Aspirator? >? > More information available here: http://www.radionics.com/products/cusa/excel.shtml? >? > Jan? >? > -----Original Message-----? > From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com> ] On Behalf Of Tea Acuff? > Sent: Monday, January 05, 2009 1:39 PM? > To: OpenHeart-L@lists.hsforum.com? > Subject: Re: [HSF] decalcifying the aortic annulus: opinions? >? > I don't what it stands for. It is like a blunt harmonic scapel that > was used initially for liver (and brain?) resection. It vibrates > out the parenchemal cells but leaves the collagen to secure closure > of the residual resection. It also melts the calcium and leaves the > annulus on mitral surgery.? > Tea? > Sent from my iPhone? >? > On Jan 5, 2009, at 1:08 PM, Roberto Battellini > wrote:? >? >? > Again, you, friends of Verk?rzungen, (abbreviations) (Vita brevis) > we do not understand them? > CUSA is a Verk?rzung, Bob said we should promote comprehension....? >? > What is a CUSA? an ultrashall decalzificator????? >? > Roberto> Date: Mon, 5 Jan 2009 10:16:41 -0800> From: > tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic > annulus: opinions> To: OpenHeart-L@lists.hsforum.com> CC: > > I > agree. However, at least until I am reeducated I find it unnecessary > in the aortic position but more useful in the mitral where > calification so redundant.> > tea> > > > > > ________________________________> From: "Goldman, Scott" >> To: OpenHeart-L@lists.hsforum.com; OpenHeart-L@lists.hsforum.com> > Sent: Monday, January 5, 2009 10:59:00 AM> Subject: Re: [HSF] > decalcifying the aortic annulus: opinions> > Try using a CUSA. Takes > only the calcium and leaves all normal tissue behind.> > Scott > > > -----Original Message-----> > From: "Tea Acuff" > > Subj: Re: [HSF] decalcifying the aortic > annulus: opinions> Date: Mon Jan 5, 2009 9:00 am> Size: 4K> To: "OpenHeart-L@lists.hsforum.com> " > > The Goldilocks Effect. Is thatC2 > literature a German report, Roberto? > Tea > > Sent from my iPhone > > > On Jan 4, 2009, at 11:16 AM, Roberto Battellini > wrote: > > > Tea, > We agree in Germany that the annulus should be > completely decalcified but without going into the annulus.May be > Cooley saw some disasters? > Too much is an error, too less > also.Exactly is better.We operate the valves with loupes. > > May be > bob should write THAT "lecture" > Roberto> Date: Sun, 4 Jan 2009 > 07:03:52 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] Request > for SJM data from Prasanna> To: OpenHeart-L@lists.hsforum.com> CC: > > > Could you elaborate on failure to decalcify especially since > Cooley is quoted as saying too much is the worst error?> Obviously > your point that in vivo " sizes" are different and one would > "assume" the gradient is the market for the heart, but should not > the surgeon not fit what will easily go or enlarge to fit what will > easily go instead of rt21 vs? > pq23 vs xz22?> Tea> > Sent from my iPhone> > On Jan 4, 2009, at 7:01 > AM, Rwmfglycar@aol.com wrote:> > > In a message dated 1/3/2009 > 11:11:40 A.M. Eastern Standard Time, > tacuff@swbell.net writes:> > > Yes. It was kind of a fun puzzle. But what does the data mean vis a > vis the > implanting surgeon? That is, is this not a statement of > the obvious: some > valves have bigger holes but the biggest > variable ("no thing") is the surgeon?> Tea > > > > > You are > abs olutely right, the size of the hole of a mechanical valve is the > > most important determinant of forward flow performance. Remember > first the > importance of the relationship between mounting size and > internal orifice, and > then that the size of the hole is not > determined just by the internal > diameter of the housing. The shape > of the orifice can make a difference and the > occluder must be > factored in. Different occluders produce different effects on > > transvalvular flow, with varying degrees of? > turbulence. Then there is the > obligatory closing volume (i.e. the > flow back through the orifice that is > necessary to close it; done > so much better by nature) and the leakage during closure > which can > be zero or a definitely measurable amount. Engineers like to put > > all this together, into what they call Energy Loss. In vitro > performance can > be very precisely measured. and differences > between two designs clearly shown. > Clinically the > noninvasive > measurements are far less precise. You have > suggested that > surgeons have an effect on valve performance.> The great majority of > surgeons handle aortic valve replacement very > well but you are > right; the surgeon can interfere with the hemodynamic result in > a > number of ways which if I were to describe them would be a lecture. > In the > aortic position the single most common error in performance > is failure to > decalcify the annulus completely. I would add only > that this longheld op inion > has been? > confirmed during the last nine years of consulting for a valve > > company.> Bob> **************New year...new news. Be the first to > know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026> )> _______________________________________________> OpenHeart-L > mailing list> > Send postings to:> OpenHeart-L@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@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@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=2 0postings to: > OpenHeart-L@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@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@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@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.hsfor um.com/listdisclaim? > -----------------------------------------? >? > _______________________________________________? > OpenHeart-L mailing list? >? > Send postings to:? > OpenHeart-L@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? > -----------------------------------------? >? >? > Confidentiality Notice: This e-mail message, including any > attachments, is? > for the sole use of the intended recipient(s) and may contain > confidential? > and privileged information. Any unauthorized review, use, disclosure > or? > distribution is prohibited. If you are not the intended recipient, > please? > contact the sender by reply e-mail and destroy all copies of the > original? > message.? > _______________________________________________? > OpenHeart-L mailing list? >? > Send postings to:? > OpenHeart-L@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@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 anddisclaimers posted at:? http://www.hsforum.com/listdisclaim? -----------------------------------------? From rwmfglycar at aol.com Mon Jan 5 21:34:23 2009 From: rwmfglycar at aol.com (rwmfglycar@aol.com) Date: Mon Jan 5 21:35:29 2009 Subject: [HSF] De Bakey caged disk valve In-Reply-To: <0C2C4380-9AF5-45F8-99AB-A7F3CDCC9287@shaw.ca> References: <0C2C4380-9AF5-45F8-99AB-A7F3CDCC9287@shaw.ca> Message-ID: <8CB3DBE6BCED03A-CC0-18BB@Webmail-mg01.sim.aol.com> I waqs not aware that its hemolysis wasany worse than other contemporary valves. Its teflon disc wore out very quickly developing where it rubbed against the cage.The insufficiency resulting from this produced hemolysis needless to say. I once walked by accident into a sales meeting being held in conjunction with one of our national meetings. I left after I had heard a surgeon tell the swales folks that all this talk about disc wear was exaggerated. Bob -----Original Message----- From: V. Aldrete, M.D. To: OpenHeart-L@lists.hsforum.com Sent: Mon, 5 Jan 2009 5:26 pm Subject: Re: [HSF] De Bakey caged disk valve I am sending these pictures again, for those of you that did not see them. The first one is the Beall-Edwards Valve , second the McGovern sutureless valve and last the McGovern-Crombie valve. I also have pictures of the DeBakey-Surgitool, Harken, Hufnagel and Kalke plus many of the more modern valves, should you want to see them please let me know, for it is best to send them directly to your inboxes, as the quality of the old pictures gets very bad as the files are shrunk to fit the HSF list.? ? Cheers,? ? Victor? I am resending one picture at a time due to file size. Sutureless McGovern.? On Jan 5, 2009, at 11:43 AM, wftjrtyler@aol.com wrote:? ? > Perhaps you are referring to the Beall valve. A caged disc valve > with the? > lowest hemolysis rate in the world.....for the first twenty > minutes. Dr.? > Frater, am I right ? bill turner? >? >? > In a message dated 1/5/2009 2:22:21 A.M. Central Standard Time,? > mmlevinson@hsforum.com writes:? >? >? > On Dec 16, 2008, at 7:31 PM, Prasanna Simha M wrote:? >? >> Debakey had quite a few Valves" including the Debakey surgitool >> valve? >> which had pins which self fixed in the annulus and caged disc >> valve .? >> Both were associated with strut fractures that you have described.? >> Prasanna? >? > Wasn't the Surgitool valve called the Magovern valve.? >? > I had to take one out for pannus and TIAs after 20+ years and I > got the? > removal tool from George Magovern......? >? > Interesting idea for its day, and now in the days of percutaneous? > valves, his? > device almost looks like a prediction of the future!? >? > Mark Levinson, MD.? > Founder, Editor-in-Chief? > The Heart Surgery Forum?? > Multimedia Cardiothoracic Journal? > URL: http://www.hsforum.com? > URL: http://newoptionsinheartsurgery.com? > Emali: mmlevinson@hsforum.com? >? >? > -----------------------------------------? _______________________________________________ penHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: ttp://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and isclaimers posted at: ttp://www.hsforum.com/listdisclaim ---------------------------------------- [Image Rem oved] From tdmartin2000 at aol.com Mon Jan 5 23:00:23 2009 From: tdmartin2000 at aol.com (tdmartin2000@aol.com) Date: Mon Jan 5 23:01:33 2009 Subject: [HSF] STS In-Reply-To: <3ACC54310BF13645A0D12496D7CA94E5F9EBFA78@EX7FM04.ad.uky.edu> References: <556121.60384.qm@web81601.mail.mud.yahoo.com> <3ACC54310BF13645A0D12496D7CA94E5F9EBFA78@EX7FM04.ad.uky.edu> Message-ID: <8CB3DCA6F413735-F7C-E95@Webmail-mg20.sim.aol.com> Sorry but I won't be able to make Sunday Tom?Martin U of Florida -----Original Message----- From: Ramaiah, Chandrashekar To: OpenHeart-L@lists.hsforum.com Sent: Mon, 5 Jan 2009 5:09 pm Subject: RE: [HSF] STS Tea, Sunday afternoon sounds great to me. (is it too early for Tea's party!) Chand -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Tea Acuff Sent: Monday, January 05, 2009 1:25 PM To: OpenHeart-L Subject: [HSF] STS So should I arrange for a suite or something for afternoon wine, say Sunday (I can't do Tues) or something else? Or do you prefer to do it, Ajit? tea _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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@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 ----------------------------------------- From mmlevinson at hsforum.com Mon Jan 5 22:46:23 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Mon Jan 5 23:46:52 2009 Subject: [HSF] pericardial window for AF prophylaxis In-Reply-To: <47503D5A-9120-4AC3-8F8D-190009F0E3F3@bigpond.com> References: <47503D5A-9120-4AC3-8F8D-190009F0E3F3@bigpond.com> Message-ID: <33B4CB40-7C9F-4457-95B9-42C5C620937C@hsforum.com> On Jan 5, 2009, at 6:44 AM, Donald Ross wrote: > There is some evidence indicating a posterior pericardial window to > allow efficient drainage of the pericardium reduces the incidence of > post-op AF > Has anyone any experience with this technique? > Don > Alex Zablonski in New Jersey swears this prevents a-fib and he was intending to publish his work, but I don't remember seeing it in print. He puts a posterior left pleural drain in every case.. Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From Scott.Silvestry at jefferson.edu Tue Jan 6 00:17:56 2009 From: Scott.Silvestry at jefferson.edu (Scott Silvestry) Date: Tue Jan 6 00:19:39 2009 Subject: [HSF] pericardial window for AF prophylaxis Message-ID: <20090106001756.AHX27402@parkcity.jefferson.edu> No control group and we use amiodarone liberally given PAPABEAR and all. My Afib rate is about 12%. But I don;t know what "mine" is supposed to be. Scott ---- Original message ---- >Date: Mon, 5 Jan 2009 13:45:22 -0500 >From: "Michael Firstenberg" >Subject: Re: [HSF] pericardial window for AF prophylaxis >To: OpenHeart-L@lists.hsforum.com > >so, in your experience - does it help? > >On Mon, Jan 5, 2009 at 1:38 PM, Scott Silvestry < >Scott.Silvestry@jefferson.edu> wrote: > >> Don: >> >> I remember the presentation at the ?STS four years ago or so. >> >> The abstract and article link are below. >> >> On the basis of this article I emulate on of my mentors and place a 24 >> silastic tube ( heparin bonded) in all patients and leave this one longest >> if drainage is a concern. >> >> >> The numbers in this study are small but no smaller than some of the >> amiodarone studies.... >> >> >> >> >> >> >> Effects of posterior pericardiotomy on the incidence of pericardial >> effusion and atrial fibrillation after coronary revascularization. >> Ekim H, Kutay V, Hazar A, Akbayrak H, Ba?el H, Tuncer M. >> >> Department of Cardiovascular Surgery, Y?z?nc? Y?l University, Van, Turkey. >> drhasanekim@yahoo.com >> >> BACKGROUND: The aim of this prospective, randomized study was to assess the >> efficacy of posterior pericardiotomy in decreasing the prevalence of >> pericardial effusion and postoperative atrial fibrillation (AF). >> MATERIAL/METHODS: The study was performed in 100 patients who underwent >> elective coronary artery bypass grafting surgery (CABG) between October 2003 >> and July 2005. They were randomized to receive posterior pericardiotomy >> (Group A) or no posterior pericardiotomy (Group B). A 4-cm longitudinal >> incision was made parallel and posterior to the left phrenic nerve, >> extending from the left inferior pulmonary vein to the diaphragm in group A >> patients. Posterior pericardiotomy was not performed in group B patients. >> RESULTS: Early pericardial effusion developed in 6 patients (12%) of group A >> and 21 patients (42%) of group B; no late pericardial effusion developed in >> group A, but did in 3 patients (6%) of group B. The number of patients who >> developed postoperative AF was significantly lower in the fenestration group >> compared with the control group (10% vs. 30%, p < 0.010). The overall >> incidence of supraventricular tachycardia in patients with early pericardial >> effusion was significantly higher than in patients without early pericardial >> effusion (18 patients vs. 9 patients). CONCLUSIONS: These findings suggest >> that posterior pericardiotomy reduces the prevalence of early pericardial >> effusion and related AF by improving pericardial drainage in patients >> undergoing coronary artery bypass surgery. >> >> >> >> http://journals.indexcopernicus.com/fulltxt.php?ICID=459198 >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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@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 >----------------------------------------- From mmlevinson at hsforum.com Mon Jan 5 23:51:13 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Tue Jan 6 00:51:39 2009 Subject: [HSF] Subxiphoid CryoMaze In-Reply-To: <1113788687-1231160046-cardhu_decombobulator_blackberry.rim.net-1760673732-@bxe016.bisx.prod.on.blackberry> References: <1113788687-1231160046-cardhu_decombobulator_blackberry.rim.net-1760673732-@bxe016.bisx.prod.on.blackberry> Message-ID: <964A5E61-FF7F-4B97-9730-825B0103966B@hsforum.com> On Jan 5, 2009, at 6:54 AM, Hgrmd@aol.com wrote: > Mark, > Sorry, but I don't believe you can reliably create a transmural > mitral isthmus lesion from an epicardial approach. The heat sink > effect, particularly in thick atria, will prevent the endocardium > from freezing. Hal: Thanks for your thoughtful response. I had the advantage of spending 1 month in London, Ontario in 1987 with Gerard Guiraudon. Gerard was a marvelous anatomist and I spent many days in the autopsy lab dissecting hearts with him. As you know, Gerard reported a lifetime experience of 300+ WPW ablations on the beating heart using cryosurgical lesions in the AV groove. I watched several of these cases. He would sublux the apex (a maneuver that is now routine in OPCAB) and dissect the AV groove and then map the position of the earliest activation. The ablation was performed epicardially along the mitral or tricuspid annulus with a liquid nitrogen probe that, at best, could reach -70 F. The heart was full and thus there was always an active endocardial heat sink from the flowing blood. Despite this, he could document ablation of the WPW pathways in every case, and did not leave the OR until pre-excitation disappeared and pacing proved the pathway was ablated. His recurrance rate was very low (but I don't have the papers here with me right now). Anatomically these accessory pathways were small bands of residual conductive muscle in the subendocardium crossing the (otherwise) fibrous mitral annulus. Thus, I would disagree that it is impossible to freeze the subendocardium on the beating heart. My approach is somewhat different. Unlike Guiraudon, I use CPB with caval tapes and right heart venting. This removes the majority of the flowing blood from the left atrium (only the bronchial return remains, and I think I can use one of several strategies to finally divert that flow as well). In addition, the ATS probe is Argon which typically reaches -140 F. This is much colder than the pioneering work by Guiraudon on WPW. Since I am including the coronary sinus and surrounding fatty tissue in the ablation, I freeze for 3 to 4 minutes in the mitral isthmus lesion. But, as you know, only time will tell. Also, I had the honor and privilege of viewing one of your robotic endocardial left sided ablations when I visited your center last year. It is true that you can directly view the ice ball on the endocardial surface but you cannot see the epicardial ice ball for the left pulmonary vein lesions through your approach, so technically speaking, you also don't know if you are transmural. Its just that you assume there is no blood in the heart so there is no heat sink. However, in your robotic technique, transmurality is also assumed rather than verified for every single lesion. So, we are both dependent on the energy source, the thickness of the tissue (which can vary considerably from the tip of the probe to the base even within a single lesion), and the manner in which the energy is applied. I am sure you are aware of the epicardial technique reported by Eva Berglin using the same Argon instrument. In her paper, she performed a *partial* Maze (left sided lesions only!) on the fully loaded normothermic beating heart prior to establishing CPB for mitral surgery. She reported 77% freedom from a-fib at 6 months, so it does work. But, personally, I feel the heart should be completely decompressed and entire Maze lesion set performed to improve the potential for cure rates of 90+%, but only time will tell.. > It also doesn't sound like you are doing a full set of lesions on > the right side. Actually, all lesions seen in Cox's papers are being done, including the SVC-IVC line, the RA appendage to medial tricuspid valve, vertical line from RA appendage to mid RA body, and the inverted T line across the low RA to the tricuspid annulus, etc. I think it would help to get a movie of all the lesions, but that may take me a few more cases to accumulate all the video shots. > In addition, no conclusions should be drawn on the basis of 1 > chronic and 1 PAF case. Well, no electrophysiologic conclusions yet. But the surgical technique is neither impossible or beyond the reach of the average surgeon. The subxiphoid exposure is better than you would think, and having confirmed that each lesion can be done as described, I feel my operation is more complete than those reported by Eva Berglin, and others using epicardial cryosurgery. This opens the door to more lone a-fib cases and only time (and close follow-up) will tell if the approach is superior or inferior. Thanks, Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From mmlevinson at hsforum.com Tue Jan 6 01:49:06 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Tue Jan 6 02:49:36 2009 Subject: [HSF] subxiphoid approach for CABG In-Reply-To: <002d01c96f9b$2506dab0$2e9512be@LIBERTAD> References: <002d01c96f9b$2506dab0$2e9512be@LIBERTAD> Message-ID: <48734950-5E81-4B09-B656-5BB2C695F2AB@hsforum.com> On Jan 5, 2009, at 7:07 PM, gustavo abuin wrote: > Dr. Levinson: > 1)do you perform this approach with standard surgical instruments > and if you don?t can you tell us where we can buy them? When I started, I did not have a standard instrument set. It has taken me several years to weed out the ones that did not work and find the ones that work. Now there are about 6 specialty instruments for microvascular anastomosis, plus a table-mounted low profile stabilizer and the double Rultract lifter. I have not put together a formal instrument list, but I need to do that. Each one of the instruments was acquired for a specific purpose and thus they are all from different vendors. However, the entire set is based on reusable instruments, including the stabilizer. The only disposable is the Medtronic Starfish suction positioner, the mister-blower, and sutures (of course). > > 2) Do you have try to dissect the gastroepiploic artery from this > approach ant put the vessel in the lad, pda or elsewhere? The story of the RGEA is interesting. The RGEA is located in the perfect place for harvesting and grafting using the subxiphoid incision. I have done 6 such cases and my average harvest time is 15 minutes. However, my cardiologists absolutely disapprove of this conduit. Something about their past experience (with other surgeons) makes them leary of the RGEA and they tell me in no uncertain terms to avoid it. However, my mind and my experience are different. If you want to use it, please do. I have used the harmonic scalpel or the Starion to dissect the RGEA and it is easy to do through the subxiphoid incision. I prefer to use it for the RCA. I believe the LAD should always be grafted with an IMA conduit because of the proven longevity. > > 3) What about the posoperative pain. Less, equal, more pain? Much less... > > 4) Do you have noted a reduction in mediastinal infections doing > this approach? The sternum is not divided, so it is impossible to get a sternal bone infection. We have had some epigastric fascial hernias, and I am still trying to figure out why, but I think it is trauma to the linea alba fibers from the retraction. However, these are easily fixed if they occur. The only infection was a lady who was being treated preop for Hep C with Interferon. She developed a subcutaneous infection which then spread to the pleural spaces. This responded to local wound debridement, chest tubes, and antibiotics. But there was no sternal bone infection because we never see the sternum, except the tip exposed by resecting the xiphoid. For pictures and a movie, visit http:// www.newoptionsinheartsurgery.com and click the Subxiphoid links.. Thanks. Mark > > > Thanks in advance. > Gustavo Abuin > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From robertobattellini at hotmail.com Tue Jan 6 11:14:10 2009 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Tue Jan 6 05:14:58 2009 Subject: [HSF] decalcifying the aortic annulus: opinions In-Reply-To: <932261.79815.qm@web81607.mail.mud.yahoo.com> References: <932261.79815.qm@web81607.mail.mud.yahoo.com> Message-ID: Thanks, I wonder why is not widely used for mitrals, as for aortic with classic instruments it gets very fast. Roberto> Date: Mon, 5 Jan 2009 13:38:59 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> To: OpenHeart-L@lists.hsforum.com> CC: > > I don't what it stands for. It is like a blunt harmonic scapel that was used initially for liver (and brain?) resection. It vibrates out the parenchemal cells but leaves the collagen to secure closure of the residual resection. It also melts the calcium and leaves the annulus on mitral surgery.> Tea> Sent from my iPhone> > On Jan 5, 2009, at 1:08 PM, Roberto Battellini wrote:> > > Again, you, friends of Verk?rzungen, (abbreviations) (Vita brevis) we do not understand them> CUSA is a Verk?rzung, Bob said we should promote comprehension....> > What is a CUSA? an ultrashall decalzificator????> > Roberto> Date: Mon, 5 Jan 2009 10:16:41 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> To: OpenHeart-L@lists.hsforum.com> CC: > > I agree. However, at least until I am reeducated I find it unnecessary in the aortic position but more useful in the mitral where calification so redundant.> > tea> > > > > ________________________________> From: "Goldman, Scott" > To: OpenHeart-L@lists.hsforum.com; OpenHeart-L@lists.hsforum.com> Sent: Monday, January 5, 2009 10:59:00 AM> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> > Try using a CUSA. Takes only the calcium and leaves all normal tissue behind.> > Scott > > -----Original Message-----> > From: "Tea Acuff" > Subj: Re: [HSF] decalcifying the aortic annulus: opinions> Date: Mon Jan 5, 2009 9:00 am> Size: 4K> To: "OpenHeart-L@lists.hsforum.com" > > The Goldilocks Effect. Is that> literature a German report, Roberto? > Tea > > Sent from my iPhone > > On Jan 4, 2009, at 11:16 AM, Roberto Battellini wrote: > > > Tea, > We agree in Germany that the annulus should be completely decalcified but without going into the annulus.May be Cooley saw some disasters? > Too much is an error, too less also.Exactly is better.We operate the valves with loupes. > > May be bob should write THAT "lecture" > Roberto> Date: Sun, 4 Jan 2009 07:03:52 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] Request for SJM data from Prasanna> To: OpenHeart-L@lists.hsforum.com> CC: > > Could you elaborate on failure to decalcify especially since Cooley is quoted as saying too much is the worst error?> Obviously your point that in vivo " sizes" are different and one would "assume" the gradient is the market for the heart, but should not the surgeon not fit what will easily go or enlarge to fit what will easily go instead of rt21 vs> pq23 vs xz22?> Tea> > Sent from my iPhone> > On Jan 4, 2009, at 7:01 AM, Rwmfglycar@aol.com wrote:> > > In a message dated 1/3/2009 11:11:40 A.M. Eastern Standard Time, > tacuff@swbell.net writes:> > Yes. It was kind of a fun puzzle. But what does the data mean vis a vis the > implanting surgeon? That is, is this not a statement of the obvious: some > valves have bigger holes but the biggest variable ("no thing") is the surgeon?> Tea > > > > > You are absolutely right, the size of the hole of a mechanical valve is the > most important determinant of forward flow performance. Remember first the > importance of the relationship between mounting size and internal orifice, and > then that the size of the hole is not determined just by the internal > diameter of the housing. The shape of the orifice can make a difference and the > occluder must be factored in. Different occluders produce different effects on > transvalvular flow, with varying degrees of> turbulence. Then there is the > obligatory closing volume (i.e. the flow back through the orifice that is > necessary to close it; done so much better by nature) and the leakage during closure > which can be zero or a definitely measurable amount. Engineers like to put > all this together, into what they call Energy Loss. In vitro performance can > be very precisely measured. and differences between two designs clearly shown. > Clinically the > noninvasive measurements are far less precise. You have > suggested that surgeons have an effect on valve performance.> The great majority of surgeons handle aortic valve replacement very > well but you are right; the surgeon can interfere with the hemodynamic result in > a number of ways which if I were to describe them would be a lecture. In the > aortic position the single most common error in performance is failure to > decalcify the annulus completely. I would add only that this longheld opinion > has been> confirmed during the last nine years of consulting for a valve > company.> Bob> **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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@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@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@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@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@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@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> ----------------------------------------- From robertobattellini at hotmail.com Tue Jan 6 11:20:12 2009 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Tue Jan 6 05:21:01 2009 Subject: [HSF] De Bakey caged disk valve In-Reply-To: <921E5461-9D3A-4DE4-A2F7-45377C8E332C@shaw.ca> References: <921E5461-9D3A-4DE4-A2F7-45377C8E332C@shaw.ca> Message-ID: Victor, can you send me the sutureless valve to my email? robertobattellini@hotmail.com battr@medizin.uni-leipzig.de Do you know the follow up of these sutureless valves? Roberto > From: valdretemd@shaw.ca> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] De Bakey caged disk valve> Date: Mon, 5 Jan 2009 14:27:18 -0800> CC: > > I am sending these pictures again, for those of you that did not see > them. The first one is the Beall-Edwards Valve , second the McGovern > sutureless valve and last the McGovern-Crombie valve. I also have > pictures of the DeBakey-Surgitool, Harken, Hufnagel and Kalke plus > many of the more modern valves, should you want to see them please let > me know, for it is best to send them directly to your inboxes, as the > quality of the old pictures gets very bad as the files are shrunk to > fit the HSF list.> > Cheers,> > Victor From robertobattellini at hotmail.com Tue Jan 6 11:29:57 2009 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Tue Jan 6 05:30:25 2009 Subject: [HSF] Image of the week Aotic root abscess In-Reply-To: <89c4ed2d0901051826j298211fn9f945d23dddee7bf@mail.gmail.com> References: <89c4ed2d0901051826j298211fn9f945d23dddee7bf@mail.gmail.com> Message-ID: Man, born 1937, he got in Juni 2008 an AVR and aortic ascending replacement, supracoronary. Came with sepsis and the abscess seen in the echo posted by Prasanna. Reoperation on the 31 of December ...I wanted to go home, and got this case as the 2nd of the day... Well, after 3 hours of clamping under ante-retrograde blood cardioplegia I could manage it. Operation: Of course, femorofemoral cannulation and go on bypass, and the open the chest.Very easy to do, bleeds less as there are no injuries. Then, clamping, resection of all infected tissue, after which there was no more annulus.I coul suture a freestyle valve in the ventricle for the left and right coronary cusps, and in a patch for the non coronary cusp.Thios patch was sutured in the "free" anterior sail of the mitral valve.A little of bioglue on the sutures, and that was all. Prophilactic IABP as I had 3 hours of clamping. Of course, platelets, etc. Bleeding PO 500.He is now without IABP, intubated, at ICU. Roberto> Date: Tue, 6 Jan 2009 07:56:57 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> CC: > Subject: [HSF] Image of the week Aotic root abscess> > Image sent by Roberto.> He will discuss the case.> > -- > Prasanna Simha M From Hgrmd at aol.com Tue Jan 6 06:07:51 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Tue Jan 6 06:08:58 2009 Subject: [HSF] Subxiphoid CryoMaze Message-ID: Mark, Thanks for your detailed response. Undoubtedly, we will all be interested to see how the long term results as you accumulate more cases. BTW, if you already aren't doing it, I would suggest you determine success with a 7 day Cardionet. For those not familiar, this is a device worn by the patient for 7 days. The company comes to the patient's house and installs it, so it's very easy for physician and patient. The harder you look for AF, the more likely you are to find it. Hal In a message dated 1/6/2009 12:53:30 A.M. Eastern Standard Time, mmlevinson@hsforum.com writes: On Jan 5, 2009, at 6:54 AM, Hgrmd@aol.com wrote: > Mark, > Sorry, but I don't believe you can reliably create a transmural > mitral isthmus lesion from an epicardial approach. The heat sink > effect, particularly in thick atria, will prevent the endocardium > from freezing. Hal: Thanks for your thoughtful response. I had the advantage of spending 1 month in London, Ontario in 1987 with Gerard Guiraudon. Gerard was a marvelous anatomist and I spent many days in the autopsy lab dissecting hearts with him. As you know, Gerard reported a lifetime experience of 300+ WPW ablations on the beating heart using cryosurgical lesions in the AV groove. I watched several of these cases. He would sublux the apex (a maneuver that is now routine in OPCAB) and dissect the AV groove and then map the position of the earliest activation. The ablation was performed epicardially along the mitral or tricuspid annulus with a liquid nitrogen probe that, at best, could reach -70 F. The heart was full and thus there was always an active endocardial heat sink from the flowing blood. Despite this, he could document ablation of the WPW pathways in every case, and did not leave the OR until pre-excitation disappeared and pacing proved the pathway was ablated. His recurrance rate was very low (but I don't have the papers here with me right now). Anatomically these accessory pathways were small bands of residual conductive muscle in the subendocardium crossing the (otherwise) fibrous mitral annulus. Thus, I would disagree that it is impossible to freeze the subendocardium on the beating heart. My approach is somewhat different. Unlike Guiraudon, I use CPB with caval tapes and right heart venting. This removes the majority of the flowing blood from the left atrium (only the bronchial return remains, and I think I can use one of several strategies to finally divert that flow as well). In addition, the ATS probe is Argon which typically reaches -140 F. This is much colder than the pioneering work by Guiraudon on WPW. Since I am including the coronary sinus and surrounding fatty tissue in the ablation, I freeze for 3 to 4 minutes in the mitral isthmus lesion. But, as you know, only time will tell. Also, I had the honor and privilege of viewing one of your robotic endocardial left sided ablations when I visited your center last year. It is true that you can directly view the ice ball on the endocardial surface but you cannot see the epicardial ice ball for the left pulmonary vein lesions through your approach, so technically speaking, you also don't know if you are transmural. Its just that you assume there is no blood in the heart so there is no heat sink. However, in your robotic technique, transmurality is also assumed rather than verified for every single lesion. So, we are both dependent on the energy source, the thickness of the tissue (which can vary considerably from the tip of the probe to the base even within a single lesion), and the manner in which the energy is applied. I am sure you are aware of the epicardial technique reported by Eva Berglin using the same Argon instrument. In her paper, she performed a *partial* Maze (left sided lesions only!) on the fully loaded normothermic beating heart prior to establishing CPB for mitral surgery. She reported 77% freedom from a-fib at 6 months, so it does work. But, personally, I feel the heart should be completely decompressed and entire Maze lesion set performed to improve the potential for cure rates of 90+%, but only time will tell.. > It also doesn't sound like you are doing a full set of lesions on > the right side. Actually, all lesions seen in Cox's papers are being done, including the SVC-IVC line, the RA appendage to medial tricuspid valve, vertical line from RA appendage to mid RA body, and the inverted T line across the low RA to the tricuspid annulus, etc. I think it would help to get a movie of all the lesions, but that may take me a few more cases to accumulate all the video shots. > In addition, no conclusions should be drawn on the basis of 1 > chronic and 1 PAF case. Well, no electrophysiologic conclusions yet. But the surgical technique is neither impossible or beyond the reach of the average surgeon. The subxiphoid exposure is better than you would think, and having confirmed that each lesion can be done as described, I feel my operation is more complete than those reported by Eva Berglin, and others using epicardial cryosurgery. This opens the door to more lone a-fib cases and only time (and close follow-up) will tell if the approach is superior or inferior. Thanks, Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- **************New year...new news. Be the first to know what is making headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026) From gabuin at intramed.net Tue Jan 6 12:55:14 2009 From: gabuin at intramed.net (gustavo abuin) Date: Tue Jan 6 09:58:01 2009 Subject: [HSF] subxiphoid approach for CABG References: <002d01c96f9b$2506dab0$2e9512be@LIBERTAD> <48734950-5E81-4B09-B656-5BB2C695F2AB@hsforum.com> Message-ID: <009c01c97017$2c860870$3c9d12be@LIBERTAD> Thanks a lot. I will try very soon the approach and with the gastroepiploic artery. I agree of course the "lima-lad complex" is a must in our surgical heritage. I hope show some results wiht this approach. Gustavo abuin ----- Original Message ----- From: "Mark Levinson" To: Sent: Tuesday, January 06, 2009 4:49 AM Subject: Re: [HSF] subxiphoid approach for CABG On Jan 5, 2009, at 7:07 PM, gustavo abuin wrote: > Dr. Levinson: > 1)do you perform this approach with standard surgical instruments and if > you don?t can you tell us where we can buy them? When I started, I did not have a standard instrument set. It has taken me several years to weed out the ones that did not work and find the ones that work. Now there are about 6 specialty instruments for microvascular anastomosis, plus a table-mounted low profile stabilizer and the double Rultract lifter. I have not put together a formal instrument list, but I need to do that. Each one of the instruments was acquired for a specific purpose and thus they are all from different vendors. However, the entire set is based on reusable instruments, including the stabilizer. The only disposable is the Medtronic Starfish suction positioner, the mister-blower, and sutures (of course). > > 2) Do you have try to dissect the gastroepiploic artery from this > approach ant put the vessel in the lad, pda or elsewhere? The story of the RGEA is interesting. The RGEA is located in the perfect place for harvesting and grafting using the subxiphoid incision. I have done 6 such cases and my average harvest time is 15 minutes. However, my cardiologists absolutely disapprove of this conduit. Something about their past experience (with other surgeons) makes them leary of the RGEA and they tell me in no uncertain terms to avoid it. However, my mind and my experience are different. If you want to use it, please do. I have used the harmonic scalpel or the Starion to dissect the RGEA and it is easy to do through the subxiphoid incision. I prefer to use it for the RCA. I believe the LAD should always be grafted with an IMA conduit because of the proven longevity. > > 3) What about the posoperative pain. Less, equal, more pain? Much less... > > 4) Do you have noted a reduction in mediastinal infections doing this > approach? The sternum is not divided, so it is impossible to get a sternal bone infection. We have had some epigastric fascial hernias, and I am still trying to figure out why, but I think it is trauma to the linea alba fibers from the retraction. However, these are easily fixed if they occur. The only infection was a lady who was being treated preop for Hep C with Interferon. She developed a subcutaneous infection which then spread to the pleural spaces. This responded to local wound debridement, chest tubes, and antibiotics. But there was no sternal bone infection because we never see the sternum, except the tip exposed by resecting the xiphoid. For pictures and a movie, visit http:// www.newoptionsinheartsurgery.com and click the Subxiphoid links.. Thanks. Mark > > > Thanks in advance. > Gustavo Abuin > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- -- No virus found in this incoming message. Checked by AVG. Version: 7.5.552 / Virus Database: 270.10.3/1878 - Release Date: 1/6/2009 7:56 AM From nfaabouseada at gmail.com Tue Jan 6 09:49:25 2009 From: nfaabouseada at gmail.com (Nasser F Abou'Seada) Date: Tue Jan 6 10:49:57 2009 Subject: [HSF] subxiphoid approach for CABG In-Reply-To: <009c01c97017$2c860870$3c9d12be@LIBERTAD> References: <002d01c96f9b$2506dab0$2e9512be@LIBERTAD><48734950-5E81-4B09-B656-5BB2C695F2AB@hsforum.com> <009c01c97017$2c860870$3c9d12be@LIBERTAD> Message-ID: Dr. Levinson That certainly is a distinguished approach. The Movies were just excellent. NFA ----- Original Message ----- From: "Mark Levinson" To: Sent: Tuesday, January 06, 2009 4:49 AM Subject: Re: [HSF] subxiphoid approach for CABG On Jan 5, 2009, at 7:07 PM, gustavo abuin wrote: > Dr. Levinson: > 1)do you perform this approach with standard surgical instruments and if > you don?t can you tell us where we can buy them? When I started, I did not have a standard instrument set. It has taken me several years to weed out the ones that did not work and find the ones that work. Now there are about 6 specialty instruments for microvascular anastomosis, plus a table-mounted low profile stabilizer and the double Rultract lifter. I have not put together a formal instrument list, but I need to do that. Each one of the instruments was acquired for a specific purpose and thus they are all from different vendors. However, the entire set is based on reusable instruments, including the stabilizer. The only disposable is the Medtronic Starfish suction positioner, the mister-blower, and sutures (of course). > > 2) Do you have try to dissect the gastroepiploic artery from this > approach ant put the vessel in the lad, pda or elsewhere? The story of the RGEA is interesting. The RGEA is located in the perfect place for harvesting and grafting using the subxiphoid incision. I have done 6 such cases and my average harvest time is 15 minutes. However, my cardiologists absolutely disapprove of this conduit. Something about their past experience (with other surgeons) makes them leary of the RGEA and they tell me in no uncertain terms to avoid it. However, my mind and my experience are different. If you want to use it, please do. I have used the harmonic scalpel or the Starion to dissect the RGEA and it is easy to do through the subxiphoid incision. I prefer to use it for the RCA. I believe the LAD should always be grafted with an IMA conduit because of the proven longevity. > > 3) What about the posoperative pain. Less, equal, more pain? Much less... > > 4) Do you have noted a reduction in mediastinal infections doing this > approach? The sternum is not divided, so it is impossible to get a sternal bone infection. We have had some epigastric fascial hernias, and I am still trying to figure out why, but I think it is trauma to the linea alba fibers from the retraction. However, these are easily fixed if they occur. The only infection was a lady who was being treated preop for Hep C with Interferon. She developed a subcutaneous infection which then spread to the pleural spaces. This responded to local wound debridement, chest tubes, and antibiotics. But there was no sternal bone infection because we never see the sternum, except the tip exposed by resecting the xiphoid. For pictures and a movie, visit http:// www.newoptionsinheartsurgery.com and click the Subxiphoid links.. Thanks. Mark > > > Thanks in advance. > Gustavo Abuin > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- -- No virus found in this incoming message. Checked by AVG. Version: 7.5.552 / Virus Database: 270.10.3/1878 - Release Date: 1/6/2009 7:56 AM _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From mmlevinson at hsforum.com Tue Jan 6 11:59:46 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Tue Jan 6 13:00:20 2009 Subject: [HSF] subxiphoid approach for CABG In-Reply-To: <009c01c97017$2c860870$3c9d12be@LIBERTAD> References: <002d01c96f9b$2506dab0$2e9512be@LIBERTAD> <48734950-5E81-4B09-B656-5BB2C695F2AB@hsforum.com> <009c01c97017$2c860870$3c9d12be@LIBERTAD> Message-ID: <8ACADF13-DA58-463B-A450-DE3AACEA7876@hsforum.com> On Jan 6, 2009, at 9:55 AM, gustavo abuin wrote: > Thanks a lot. > I will try very soon the approach and with the gastroepiploic artery. > I agree of course the "lima-lad complex" is a must in our surgical > heritage. > I hope show some results wiht this approach. >> Start with LIMA-LAD cases, where the anatomy is favorable and the rewards are easiest to reach. Contact me off-list for other details as to the instruments and technical refinements. Thanks. Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From tacuff at swbell.net Tue Jan 6 11:50:57 2009 From: tacuff at swbell.net (Tea Acuff) Date: Tue Jan 6 14:52:27 2009 Subject: [HSF] decalcifying the aortic annulus: opinions Message-ID: <66705.2530.qm@web81603.mail.mud.yahoo.com> It is fairly slow but allows you to maserate as much of calcium as you need for suturing. Some recommend separating the AV junction and then rebuild it, but characteristically I would only do what I needed to do for what I came for Tea Sent from my iPhone On Jan 6, 2009, at 4:14 AM, Roberto Battellini wrote: Thanks, I wonder why is not widely used for mitrals, as for aortic with classic instruments it gets very fast. Roberto> Date: Mon, 5 Jan 2009 13:38:59 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> To: OpenHeart-L@lists.hsforum.com> CC: > > I don't what it stands for. It is like a blunt harmonic scapel that was used initially for liver (and brain?) resection. It vibrates out the parenchemal cells but leaves the collagen to secure closure of the residual resection. It also melts the calcium and leaves the annulus on mitral surgery.> Tea> Sent from my iPhone> > On Jan 5, 2009, at 1:08 PM, Roberto Battellini wrote:> > > Again, you, friends of Verk?rzungen, (abbreviations) (Vita brevis) we do not understand them> CUSA is a Verk?rzung, Bob said we should promote comprehension....> > What is a CUSA? an ultrashall decalzificator????> > Roberto> Date: Mon, 5 Jan 2009 10:16:41 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> To: OpenHeart-L@lists.hsforum.com> CC: > > I agree. However, at least until I am reeducated I find it unnecessary in the aortic position but more useful in the mitral where calification so redundant.> > tea> > > > > ________________________________> From: "Goldman, Scott" > To: OpenHeart-L@lists.hsforum.com; OpenHeart-L@lists.hsforum.com> Sent: Monday, January 5, 2009 10:59:00 AM> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> > Try using a CUSA. Takes only the calcium and leaves all normal tissue behind.> > Scott > > -----Original Message-----> > From: "Tea Acuff" > Subj: Re: [HSF] decalcifying the aortic annulus: opinions> Date: Mon Jan 5, 2009 9:00 am> Size: 4K> To: "OpenHeart-L@lists.hsforum.com" > > The Goldilocks Effect. Is that> literature a German report, Roberto? > Tea > > Sent from my iPhone > > On Jan 4, 2009, at 11:16 AM, Roberto Battellini wrote: > > > Tea, > We agree in Germany that the annulus should be completely decalcified but without going into the annulus.May be Cooley saw some disasters? > Too much is an error, too less also.Exactly is better.We operate the valves with loupes. > > May be bob should write THAT "lecture" > Roberto> Date: Sun, 4 Jan 2009 07:03:52 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] Request for SJM data from Prasanna> To: OpenHeart-L@lists.hsforum.com> CC: > > Could you elaborate on failure to decalcify especially since Cooley is quoted as saying too much is the worst error?> Obviously your point that in vivo " sizes" are different and one would "assume" the gradient is the market for the heart, but should not the surgeon not fit what will easily go or enlarge to fit what will easily go instead of rt21 vs> pq23 vs xz22?> Tea> > Sent from my iPhone> > On Jan 4, 2009, at 7:01 AM, Rwmfglycar@aol.com wrote:> > > In a message dated 1/3/2009 11:11:40 A.M. Eastern Standard Time, > tacuff@swbell.net writes:> > Yes. It was kind of a fun puzzle. But what does the data mean vis a vis the > implanting surgeon? That is, is this not a statement of the obvious: some > valves have bigger holes but the biggest variable ("no thing") is the surgeon?> Tea > > > > > You are absolutely right, the size of the hole of a mechanical valve is the > most important determinant of forward flow performance. Remember first the > importance of the relationship between mounting size and internal orifice, and > then that the size of the hole is not determined just by the internal > diameter of the housing. The shape of the orifice can make a difference and the > occluder must be factored in. Different occluders produce different effects on > transvalvular flow, with varying degrees of> turbulence. Then there is the > obligatory closing volume (i.e. the flow back through the orifice that is > necessary to close it; done so much better by nature) and the leakage during closure > which can be zero or a definitely measurable amount. Engineers like to put > all this together, into what they call Energy Loss. In vitro performance can > be very precisely measured. and differences between two designs clearly shown. > Clinically the > noninvasive measurements are far less precise. You have > suggested that surgeons have an effect on valve performance.> The great majority of surgeons handle aortic valve replacement very > well but you are right; the surgeon can interfere with the hemodynamic result in > a number of ways which if I were to describe them would be a lecture. In the > aortic position the single most common error in performance is failure to > decalcify the annulus completely. I would add only that this longheld opinion > has been> confirmed during the last nine years of consulting for a valve > company.> Bob> **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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@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@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@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@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@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@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@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 ----------------------------------------- From tacuff at swbell.net Tue Jan 6 11:56:38 2009 From: tacuff at swbell.net (Tea Acuff) Date: Tue Jan 6 14:58:08 2009 Subject: [HSF] decalcifying the aortic annulus: opinions Message-ID: <598841.86887.qm@web81606.mail.mud.yahoo.com> I have not used it on the aortic valve (annulus, Bob) Tea Sent from my iPhone On Jan 6, 2009, at 4:14 AM, Roberto Battellini wrote: Thanks, I wonder why is not widely used for mitrals, as for aortic with classic instruments it gets very fast. Roberto> Date: Mon, 5 Jan 2009 13:38:59 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> To: OpenHeart-L@lists.hsforum.com> CC: > > I don't what it stands for. It is like a blunt harmonic scapel that was used initially for liver (and brain?) resection. It vibrates out the parenchemal cells but leaves the collagen to secure closure of the residual resection. It also melts the calcium and leaves the annulus on mitral surgery.> Tea> Sent from my iPhone> > On Jan 5, 2009, at 1:08 PM, Roberto Battellini wrote:> > > Again, you, friends of Verk?rzungen, (abbreviations) (Vita brevis) we do not understand them> CUSA is a Verk?rzung, Bob said we should promote comprehension....> > What is a CUSA? an ultrashall decalzificator????> > Roberto> Date: Mon, 5 Jan 2009 10:16:41 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> To: OpenHeart-L@lists.hsforum.com> CC: > > I agree. However, at least until I am reeducated I find it unnecessary in the aortic position but more useful in the mitral where calification so redundant.> > tea> > > > > ________________________________> From: "Goldman, Scott" > To: OpenHeart-L@lists.hsforum.com; OpenHeart-L@lists.hsforum.com> Sent: Monday, January 5, 2009 10:59:00 AM> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> > Try using a CUSA. Takes only the calcium and leaves all normal tissue behind.> > Scott > > -----Original Message-----> > From: "Tea Acuff" > Subj: Re: [HSF] decalcifying the aortic annulus: opinions> Date: Mon Jan 5, 2009 9:00 am> Size: 4K> To: "OpenHeart-L@lists.hsforum.com" > > The Goldilocks Effect. Is that> literature a German report, Roberto? > Tea > > Sent from my iPhone > > On Jan 4, 2009, at 11:16 AM, Roberto Battellini wrote: > > > Tea, > We agree in Germany that the annulus should be completely decalcified but without going into the annulus.May be Cooley saw some disasters? > Too much is an error, too less also.Exactly is better.We operate the valves with loupes. > > May be bob should write THAT "lecture" > Roberto> Date: Sun, 4 Jan 2009 07:03:52 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] Request for SJM data from Prasanna> To: OpenHeart-L@lists.hsforum.com> CC: > > Could you elaborate on failure to decalcify especially since Cooley is quoted as saying too much is the worst error?> Obviously your point that in vivo " sizes" are different and one would "assume" the gradient is the market for the heart, but should not the surgeon not fit what will easily go or enlarge to fit what will easily go instead of rt21 vs> pq23 vs xz22?> Tea> > Sent from my iPhone> > On Jan 4, 2009, at 7:01 AM, Rwmfglycar@aol.com wrote:> > > In a message dated 1/3/2009 11:11:40 A.M. Eastern Standard Time, > tacuff@swbell.net writes:> > Yes. It was kind of a fun puzzle. But what does the data mean vis a vis the > implanting surgeon? That is, is this not a statement of the obvious: some > valves have bigger holes but the biggest variable ("no thing") is the surgeon?> Tea > > > > > You are absolutely right, the size of the hole of a mechanical valve is the > most important determinant of forward flow performance. Remember first the > importance of the relationship between mounting size and internal orifice, and > then that the size of the hole is not determined just by the internal > diameter of the housing. The shape of the orifice can make a difference and the > occluder must be factored in. Different occluders produce different effects on > transvalvular flow, with varying degrees of> turbulence. Then there is the > obligatory closing volume (i.e. the flow back through the orifice that is > necessary to close it; done so much better by nature) and the leakage during closure > which can be zero or a definitely measurable amount. Engineers like to put > all this together, into what they call Energy Loss. In vitro performance can > be very precisely measured. and differences between two designs clearly shown. > Clinically the > noninvasive measurements are far less precise. You have > suggested that surgeons have an effect on valve performance.> The great majority of surgeons handle aortic valve replacement very > well but you are right; the surgeon can interfere with the hemodynamic result in > a number of ways which if I were to describe them would be a lecture. In the > aortic position the single most common error in performance is failure to > decalcify the annulus completely. I would add only that this longheld opinion > has been> confirmed during the last nine years of consulting for a valve > company.> Bob> **************New year...new news. Be the first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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@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@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@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@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@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@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@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 ----------------------------------------- From robertobattellini at hotmail.com Tue Jan 6 22:25:59 2009 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Tue Jan 6 16:26:26 2009 Subject: [HSF] decalcifying the aortic annulus: opinions In-Reply-To: <66705.2530.qm@web81603.mail.mud.yahoo.com> References: <66705.2530.qm@web81603.mail.mud.yahoo.com> Message-ID: We put the device in a list for next year "Musts" Thanks to you all, Roberto and Fred Mohr> Date: Tue, 6 Jan 2009 11:50:57 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> To: OpenHeart-L@lists.hsforum.com> CC: > > It is fairly slow but allows you to maserate as much of calcium as you need for suturing. Some recommend separating the AV junction and then rebuild it, but characteristically I would only do what I needed to do for what I came for> Tea> > Sent from my iPhone> > On Jan 6, 2009, at 4:14 AM, Roberto Battellini wrote:> > > Thanks, I wonder why is not widely used for mitrals, as for aortic with classic instruments it gets very fast.> Roberto> Date: Mon, 5 Jan 2009 13:38:59 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> To: OpenHeart-L@lists.hsforum.com> CC: > > I don't what it stands for. It is like a blunt harmonic scapel that was used initially for liver (and brain?) resection. It vibrates out the parenchemal cells but leaves the collagen to secure closure of the residual resection. It also melts the calcium and leaves the annulus on mitral surgery.> Tea> Sent from my iPhone> > On Jan 5, 2009, at 1:08 PM, Roberto Battellini wrote:> > > Again, you, friends of Verk?rzungen, (abbreviations) (Vita brevis) we do not understand them> CUSA is a Verk?rzung, Bob said we should promote comprehension....> > What is a CUSA? an ultrashall decalzificator????> > Roberto> Date: Mon, 5 Jan 2009 10:16:41 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> To:> OpenHeart-L@lists.hsforum.com> CC: > > I agree. However, at least until I am reeducated I find it unnecessary in the aortic position but more useful in the mitral where calification so redundant.> > tea> > > > > ________________________________> From: "Goldman, Scott" > To: OpenHeart-L@lists.hsforum.com; OpenHeart-L@lists.hsforum.com> Sent: Monday, January 5, 2009 10:59:00 AM> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> > Try using a CUSA. Takes only the calcium and leaves all normal tissue behind.> > Scott > > -----Original Message-----> > From: "Tea Acuff" > Subj: Re: [HSF] decalcifying the aortic annulus: opinions> Date: Mon Jan 5, 2009 9:00 am> Size: 4K> To: "OpenHeart-L@lists.hsforum.com" > > The Goldilocks Effect. Is that> literature a German report, Roberto? > Tea > > Sent from my iPhone > > On Jan 4, 2009, at 11:16 AM, Roberto Battellini> wrote: > > > Tea, > We agree in Germany that the annulus should be completely decalcified but without going into the annulus.May be Cooley saw some disasters? > Too much is an error, too less also.Exactly is better.We operate the valves with loupes. > > May be bob should write THAT "lecture" > Roberto> Date: Sun, 4 Jan 2009 07:03:52 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] Request for SJM data from Prasanna> To: OpenHeart-L@lists.hsforum.com> CC: > > Could you elaborate on failure to decalcify especially since Cooley is quoted as saying too much is the worst error?> Obviously your point that in vivo " sizes" are different and one would "assume" the gradient is the market for the heart, but should not the surgeon not fit what will easily go or enlarge to fit what will easily go instead of rt21 vs> pq23 vs xz22?> Tea> > Sent from my iPhone> > On Jan 4, 2009, at 7:01 AM, Rwmfglycar@aol.com wrote:> > > In a message> dated 1/3/2009 11:11:40 A.M. Eastern Standard Time, > tacuff@swbell.net writes:> > Yes. It was kind of a fun puzzle. But what does the data mean vis a vis the > implanting surgeon? That is, is this not a statement of the obvious: some > valves have bigger holes but the biggest variable ("no thing") is the surgeon?> Tea > > > > > You are absolutely right, the size of the hole of a mechanical valve is the > most important determinant of forward flow performance. Remember first the > importance of the relationship between mounting size and internal orifice, and > then that the size of the hole is not determined just by the internal > diameter of the housing. The shape of the orifice can make a difference and the > occluder must be factored in. Different occluders produce different effects on > transvalvular flow, with varying degrees of> turbulence. Then there is the > obligatory closing volume (i.e. the flow back through the orifice that is > necessary to> close it; done so much better by nature) and the leakage during closure > which can be zero or a definitely measurable amount. Engineers like to put > all this together, into what they call Energy Loss. In vitro performance can > be very precisely measured. and differences between two designs clearly shown. > Clinically the > noninvasive measurements are far less precise. You have > suggested that surgeons have an effect on valve performance.> The great majority of surgeons handle aortic valve replacement very > well but you are right; the surgeon can interfere with the hemodynamic result in > a number of ways which if I were to describe them would be a lecture. In the > aortic position the single most common error in performance is failure to > decalcify the annulus completely. I would add only that this longheld opinion > has been> confirmed during the last nine years of consulting for a valve > company.> Bob> **************New year...new news. Be the> first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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@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@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@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@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@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@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@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@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> ----------------------------------------- From tacuff at swbell.net Tue Jan 6 14:48:48 2009 From: tacuff at swbell.net (Tea Acuff) Date: Tue Jan 6 17:49:17 2009 Subject: [HSF] Subxiphoid CryoMaze Message-ID: <417488.67365.qm@web81608.mail.mud.yahoo.com> A very nice discussion, Mark. I particularly liked the part where you pulled out your own light saber (authority, Dr Guiraudon) to wack away at the powers of darkness and senatorial power. tea ________________________________ From: Mark Levinson To: OpenHeart-L@lists.hsforum.com Sent: Monday, January 5, 2009 11:51:13 PM Subject: Re: [HSF] Subxiphoid CryoMaze On Jan 5, 2009, at 6:54 AM, Hgrmd@aol.com wrote: > Mark, >? Sorry, but I don't believe you can reliably create a transmural? > mitral isthmus lesion from an epicardial approach.? The heat sink? > effect, particularly in thick atria, will prevent the endocardium? > from freezing. Hal: Thanks for your thoughtful response. I had the advantage of spending 1 month in London, Ontario in 1987? with Gerard Guiraudon.? Gerard was a marvelous anatomist and I spent? many days in the autopsy lab dissecting hearts with him.? As you know, Gerard reported a lifetime? experience of 300+ WPW ablations on the beating heart using? cryosurgical lesions in the AV groove.? ? I watched several of these? cases.? He would sublux the apex (a maneuver that is now routine in? OPCAB) and dissect the AV groove and then map the position of the? earliest activation.? ? The ablation was performed epicardially along? the mitral or tricuspid annulus with a liquid nitrogen probe that, at? best, could reach -70 F.? ? The heart was full and thus there was? always an active endocardial heat sink from the flowing blood.? Despite this, he could document ablation of the WPW pathways in every? case, and did not leave the OR until pre-excitation disappeared and? pacing proved the pathway was ablated.? His recurrance rate was very? low (but I don't have the papers here with me right now). Anatomically these accessory pathways were small bands of residual? conductive muscle in the subendocardium crossing the (otherwise)? fibrous mitral annulus.? ? Thus, I would disagree that it is? impossible to freeze the subendocardium on the beating heart. My approach is somewhat different.? ? Unlike Guiraudon, I use CPB with? caval tapes and right heart venting.? This removes the majority of? the flowing blood from the left atrium (only the bronchial return remains, and I think I can use one of several? strategies to finally divert that flow as well).? In addition, the? ATS probe is Argon which typically reaches -140 F.? This is much? colder than the pioneering work by Guiraudon on WPW.? ? Since I am? including the coronary sinus and surrounding fatty tissue in the? ablation, I freeze for 3 to 4 minutes in the mitral isthmus lesion.? ? But, as you know, only time will tell. Also, I had the honor and privilege of viewing one of your robotic? endocardial left sided ablations when I visited your center last? year.? ? It is true that you can directly view the ice ball on the? endocardial surface but you cannot see the epicardial ice ball for the? left pulmonary vein lesions through your approach, so technically? speaking, you also don't know if you are transmural.? Its just that? you assume there is no blood in the heart so there is no heat sink.? ? However, in your robotic technique, transmurality is also assumed? rather than verified for every single lesion.? So, we are both? dependent on the energy source, the thickness of the tissue (which can? vary considerably from the tip of the probe to the base even within a? single lesion), and the manner in which the energy is applied. I am sure you are aware of the epicardial technique reported by Eva? Berglin using the same Argon instrument.? In her paper, she performed? a *partial* Maze (left sided lesions only!) on the fully loaded? normothermic beating heart prior to establishing CPB for mitral? surgery.? ? She reported 77% freedom from a-fib at 6 months, so it? does work.? ? But, personally,? I feel the heart should be completely? decompressed and entire Maze lesion set performed to improve the? potential for cure rates of 90+%, but only time will tell.. > It also doesn't sound like you are doing a full set of lesions on? > the right side. Actually, all lesions seen in Cox's papers are being done, including? the SVC-IVC line, the RA appendage to medial tricuspid valve, vertical? line from RA appendage to mid RA body, and the inverted T line across? the low RA to the tricuspid annulus, etc.? ? I think it would help to? get a movie of all the lesions, but that may take me a few more cases? to accumulate all the video shots. > In addition, no conclusions should be drawn on the basis of 1? > chronic and 1 PAF case. Well, no electrophysiologic conclusions yet.? But the surgical? technique is neither impossible or beyond the reach of the average? surgeon.? ? The subxiphoid exposure is better than you would think,? and having confirmed that each lesion can be done as described, I feel? my operation is more complete than those reported by Eva Berglin, and? others using epicardial cryosurgery.? This opens the door to more? lone a-fib cases and only time (and close follow-up) will tell if the? approach is superior or inferior. Thanks, Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali:? mmlevinson@hsforum.com _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From tacuff at swbell.net Tue Jan 6 15:14:10 2009 From: tacuff at swbell.net (Tea Acuff) Date: Tue Jan 6 18:15:44 2009 Subject: [HSF] decalcifying the aortic annulus: opinions Message-ID: <843199.772.qm@web81601.mail.mud.yahoo.com> Interesting. I presume I missed most of the story. And you call CUSA an abbreviation! tea ________________________________ From: Roberto Battellini To: lists HSF Sent: Tuesday, January 6, 2009 3:25:59 PM Subject: RE: [HSF] decalcifying the aortic annulus: opinions We put the device in a list for next year "Musts" Thanks to you all, Roberto and Fred Mohr> Date: Tue, 6 Jan 2009 11:50:57 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> To: OpenHeart-L@lists.hsforum.com> CC: > > It is fairly slow but allows you to maserate as much of calcium as you need for suturing. Some recommend separating the AV junction and then rebuild it, but characteristically I would only do what I needed to do for what I came for> Tea> > Sent from my iPhone> > On Jan 6, 2009, at 4:14 AM, Roberto Battellini wrote:> > > Thanks, I wonder why is not widely used for mitrals, as for aortic with classic instruments it gets very fast.> Roberto> Date: Mon, 5 Jan 2009 13:38:59 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> To: OpenHeart-L@lists.hsforum.com> CC: > > I don't what it stands for. It is like a blunt harmonic scapel that was used initially for liver (and brain?) resection. It vibrates out the parenchemal cells but leaves the collagen to secure closure of the residual resection. It also melts the calcium and leaves the annulus on mitral surgery.> Tea> Sent from my iPhone> > On Jan 5, 2009, at 1:08 PM, Roberto Battellini wrote:> > > Again, you, friends of Verk?rzungen, (abbreviations) (Vita brevis) we do not understand them> CUSA is a Verk?rzung, Bob said we should promote comprehension....> > What is a CUSA? an ultrashall decalzificator????> > Roberto> Date: Mon, 5 Jan 2009 10:16:41 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> To:> OpenHeart-L@lists.hsforum.com> CC: > > I agree. However, at least until I am reeducated I find it unnecessary in the aortic position but more useful in the mitral where calification so redundant.> > tea> > > > > ________________________________> From: "Goldman, Scott" > To: OpenHeart-L@lists.hsforum.com; OpenHeart-L@lists.hsforum.com> Sent: Monday, January 5, 2009 10:59:00 AM> Subject: Re: [HSF] decalcifying the aortic annulus: opinions> > Try using a CUSA. Takes only the calcium and leaves all normal tissue behind.> > Scott > > -----Original Message-----> > From: "Tea Acuff" > Subj: Re: [HSF] decalcifying the aortic annulus: opinions> Date: Mon Jan 5, 2009 9:00 am> Size: 4K> To: "OpenHeart-L@lists.hsforum.com" > > The Goldilocks Effect. Is that> literature a German report, Roberto? > Tea > > Sent from my iPhone > > On Jan 4, 2009, at 11:16 AM, Roberto Battellini> wrote: > > > Tea, > We agree in Germany that the annulus should be completely decalcified but without going into the annulus.May be Cooley saw some disasters? > Too much is an error, too less also.Exactly is better.We operate the valves with loupes. > > May be bob should write THAT "lecture" > Roberto> Date: Sun, 4 Jan 2009 07:03:52 -0800> From: tacuff@swbell.net> Subject: Re: [HSF] Request for SJM data from Prasanna> To: OpenHeart-L@lists.hsforum.com> CC: > > Could you elaborate on failure to decalcify especially since Cooley is quoted as saying too much is the worst error?> Obviously your point that in vivo " sizes" are different and one would "assume" the gradient is the market for the heart, but should not the surgeon not fit what will easily go or enlarge to fit what will easily go instead of rt21 vs> pq23 vs xz22?> Tea> > Sent from my iPhone> > On Jan 4, 2009, at 7:01 AM, Rwmfglycar@aol.com wrote:> > > In a message> dated 1/3/2009 11:11:40 A.M. Eastern Standard Time, > tacuff@swbell.net writes:> > Yes. It was kind of a fun puzzle. But what does the data mean vis a vis the > implanting surgeon? That is, is this not a statement of the obvious: some > valves have bigger holes but the biggest variable ("no thing") is the surgeon?> Tea > > > > > You are absolutely right, the size of the hole of a mechanical valve is the > most important determinant of forward flow performance. Remember first the > importance of the relationship between mounting size and internal orifice, and > then that the size of the hole is not determined just by the internal > diameter of the housing. The shape of the orifice can make a difference and the > occluder must be factored in. Different occluders produce different effects on > transvalvular flow, with varying degrees of> turbulence. Then there is the > obligatory closing volume (i.e. the flow back through the orifice that is > necessary to> close it; done so much better by nature) and the leakage during closure > which can be zero or a definitely measurable amount. Engineers like to put > all this together, into what they call Energy Loss. In vitro performance can > be very precisely measured. and differences between two designs clearly shown. > Clinically the > noninvasive measurements are far less precise. You have > suggested that surgeons have an effect on valve performance.> The great majority of surgeons handle aortic valve replacement very > well but you are right; the surgeon can interfere with the hemodynamic result in > a number of ways which if I were to describe them would be a lecture. In the > aortic position the single most common error in performance is failure to > decalcify the annulus completely. I would add only that this longheld opinion > has been> confirmed during the last nine years of consulting for a valve > company.> Bob> **************New year...new news. Be the> first to know what is making > headlines. (http://www.aol.com/?ncid=emlcntaolcom00000026)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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@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@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@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@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@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@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@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@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@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 ----------------------------------------- From damle at cableone.net Wed Jan 7 08:06:52 2009 From: damle at cableone.net (Ajit Damle) Date: Wed Jan 7 09:13:39 2009 Subject: [HSF] Subxiphoid CryoMaze In-Reply-To: <417488.67365.qm@web81608.mail.mud.yahoo.com> Message-ID: <6BD7DB7C78C640EC8747F4C26E43FF30@yourg8he5gjrox> Couldn't have said better myself!! Ajit -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Tea Acuff Sent: Tuesday, January 06, 2009 4:49 PM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Subxiphoid CryoMaze A very nice discussion, Mark. I particularly liked the part where you pulled out your own light saber (authority, Dr Guiraudon) to wack away at the powers of darkness and senatorial power. tea ________________________________ From: Mark Levinson To: OpenHeart-L@lists.hsforum.com Sent: Monday, January 5, 2009 11:51:13 PM Subject: Re: [HSF] Subxiphoid CryoMaze On Jan 5, 2009, at 6:54 AM, Hgrmd@aol.com wrote: > Mark, >? Sorry, but I don't believe you can reliably create a transmural? > mitral isthmus lesion from an epicardial approach.? The heat sink? > effect, particularly in thick atria, will prevent the endocardium? > from freezing. Hal: Thanks for your thoughtful response. I had the advantage of spending 1 month in London, Ontario in 1987? with Gerard Guiraudon.? Gerard was a marvelous anatomist and I spent? many days in the autopsy lab dissecting hearts with him.? As you know, Gerard reported a lifetime? experience of 300+ WPW ablations on the beating heart using? cryosurgical lesions in the AV groove.? ? I watched several of these? cases.? He would sublux the apex (a maneuver that is now routine in? OPCAB) and dissect the AV groove and then map the position of the? earliest activation.? ? The ablation was performed epicardially along? the mitral or tricuspid annulus with a liquid nitrogen probe that, at? best, could reach -70 F.? ? The heart was full and thus there was? always an active endocardial heat sink from the flowing blood.? Despite this, he could document ablation of the WPW pathways in every? case, and did not leave the OR until pre-excitation disappeared and? pacing proved the pathway was ablated.? His recurrance rate was very? low (but I don't have the papers here with me right now). Anatomically these accessory pathways were small bands of residual? conductive muscle in the subendocardium crossing the (otherwise)? fibrous mitral annulus.? ? Thus, I would disagree that it is? impossible to freeze the subendocardium on the beating heart. My approach is somewhat different.? ? Unlike Guiraudon, I use CPB with? caval tapes and right heart venting.? This removes the majority of? the flowing blood from the left atrium (only the bronchial return remains, and I think I can use one of several? strategies to finally divert that flow as well).? In addition, the? ATS probe is Argon which typically reaches -140 F.? This is much? colder than the pioneering work by Guiraudon on WPW.? ? Since I am? including the coronary sinus and surrounding fatty tissue in the? ablation, I freeze for 3 to 4 minutes in the mitral isthmus lesion.? ? But, as you know, only time will tell. Also, I had the honor and privilege of viewing one of your robotic? endocardial left sided ablations when I visited your center last? year.? ? It is true that you can directly view the ice ball on the? endocardial surface but you cannot see the epicardial ice ball for the? left pulmonary vein lesions through your approach, so technically? speaking, you also don't know if you are transmural.? Its just that? you assume there is no blood in the heart so there is no heat sink.? ? However, in your robotic technique, transmurality is also assumed? rather than verified for every single lesion.? So, we are both? dependent on the energy source, the thickness of the tissue (which can? vary considerably from the tip of the probe to the base even within a? single lesion), and the manner in which the energy is applied. I am sure you are aware of the epicardial technique reported by Eva? Berglin using the same Argon instrument.? In her paper, she performed? a *partial* Maze (left sided lesions only!) on the fully loaded? normothermic beating heart prior to establishing CPB for mitral? surgery.? ? She reported 77% freedom from a-fib at 6 months, so it? does work.? ? But, personally,? I feel the heart should be completely? decompressed and entire Maze lesion set performed to improve the? potential for cure rates of 90+%, but only time will tell.. > It also doesn't sound like you are doing a full set of lesions on? > the right side. Actually, all lesions seen in Cox's papers are being done, including? the SVC-IVC line, the RA appendage to medial tricuspid valve, vertical? line from RA appendage to mid RA body, and the inverted T line across? the low RA to the tricuspid annulus, etc.? ? I think it would help to? get a movie of all the lesions, but that may take me a few more cases? to accumulate all the video shots. > In addition, no conclusions should be drawn on the basis of 1? > chronic and 1 PAF case. Well, no electrophysiologic conclusions yet.? But the surgical? technique is neither impossible or beyond the reach of the average? surgeon.? ? The subxiphoid exposure is better than you would think,? and having confirmed that each lesion can be done as described, I feel? my operation is more complete than those reported by Eva Berglin, and? others using epicardial cryosurgery.? This opens the door to more? lone a-fib cases and only time (and close follow-up) will tell if the? approach is superior or inferior. Thanks, Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali:? mmlevinson@hsforum.com _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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@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 ----------------------------------------- From tacuff at swbell.net Wed Jan 7 07:58:01 2009 From: tacuff at swbell.net (Tea Acuff) Date: Wed Jan 7 10:58:30 2009 Subject: [HSF] two surgeons Message-ID: <255257.43365.qm@web81604.mail.mud.yahoo.com> I was reading the literature, in this case a book that was discussing aviation disasters, and thinking about what this had to do with heart surgery. We have talked about aviation lessons for heart surgery, but there were several ideas that we did not sort though in this context. Interestingly, if you can believe the writer since he did not give the data,?there?is much less likely hood?of an accident if the junior pilot is in the "captain" seat. I think this can only be properly understood in the context of the discussion that commerial planes are made to be flown by two pilot cooperating and that accidents are less likely with cooperation than with two pilots as a pilot with a back up. I have a few questions. Is there evidence that surgey is better with two surgeons than one (with or without backup)? California requires two surgeons but does not require "cooperation". Would the California verses STS data or other data shed any light on this issue?? As a different query can anyone tell me the? pilot factor, eg IQ, seniority, gender, etc that most?correlated with?clusters of accidents? hint: It is politically incorrect.? tea From TSalerno at med.miami.edu Wed Jan 7 11:06:06 2009 From: TSalerno at med.miami.edu (Salerno, Tomas) Date: Wed Jan 7 11:06:36 2009 Subject: [HSF] two surgeons Message-ID: Pilots retire at age 65 which is the peak of their career and experience Ts ----- Original Message ----- From: openheart-l-bounces@lists.hsforum.com To: OpenHeart-L Sent: Wed Jan 07 10:58:01 2009 Subject: [HSF] two surgeons I was reading the literature, in this case a book that was discussing aviation disasters, and thinking about what this had to do with heart surgery. We have talked about aviation lessons for heart surgery, but there were several ideas that we did not sort though in this context. Interestingly, if you can believe the writer since he did not give the data,?there?is much less likely hood?of an accident if the junior pilot is in the "captain" seat. I think this can only be properly understood in the context of the discussion that commerial planes are made to be flown by two pilot cooperating and that accidents are less likely with cooperation than with two pilots as a pilot with a back up. I have a few questions. Is there evidence that surgey is better with two surgeons than one (with or without backup)? California requires two surgeons but does not require "cooperation". Would the California verses STS data or other data shed any light on this issue?? As a different query can anyone tell me the? pilot factor, eg IQ, seniority, gender, etc that most?correlated with?clusters of accidents? hint: It is politically incorrect.? tea _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From tacuff at swbell.net Wed Jan 7 09:21:42 2009 From: tacuff at swbell.net (Tea Acuff) Date: Wed Jan 7 12:22:10 2009 Subject: [HSF] two surgeons Message-ID: <714437.5486.qm@web81607.mail.mud.yahoo.com> And that means? Tea Sent from my iPhone On Jan 7, 2009, at 10:06 AM, "Salerno, Tomas" wrote: Pilots retire at age 65 which is the peak of their career and experience Ts ----- Original Message ----- From: openheart-l-bounces@lists.hsforum.com To: OpenHeart-L Sent: Wed Jan 07 10:58:01 2009 Subject: [HSF] two surgeons I was reading the literature, in this case a book that was discussing aviation disasters, and thinking about what this had to do with heart surgery. We have talked about aviation lessons for heart surgery, but there were several ideas that we did not sort though in this context. Interestingly, if you can believe the writer since he did not give the data, there is much less likely hood of an accident if the junior pilot is in the "captain" seat. I think this can only be properly understood in the context of the discussion that commerial planes are made to be flown by two pilot cooperating and that accidents are less likely with cooperation than with two pilots as a pilot with a back up. I have a few questions. Is there evidence that surgey is better with two surgeons than one (with or without backup)? California requires two surgeons but does not require "cooperation". Would the California verses STS data or other data shed any light on this issue? As a different query can anyone tell me the pilot factor, eg IQ, seniority, gender, etc that most correlated with clusters of accidents? hint: It is politically incorrect. tea _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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@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 ----------------------------------------- From cardiacnse at aol.com Wed Jan 7 13:02:29 2009 From: cardiacnse at aol.com (cardiacnse@aol.com) Date: Wed Jan 7 13:03:37 2009 Subject: [HSF] two surgeons In-Reply-To: <714437.5486.qm@web81607.mail.mud.yahoo.com> References: <714437.5486.qm@web81607.mail.mud.yahoo.com> Message-ID: <8CB3F093D9F7368-104-287@WEBMAIL-MB15.sysops.aol.com> Being a huge proponent of the IHI and VA NCPS, my take on this issue is more about the "cockpit" communication and leveling of hierarchy than it is about whether or not 2 pilots or surgeons are better than 1. Lessons learned from the aviation industry highlight open communication, errors caused by systems and not by people, and stopping the line methodology. But that's just me. I'm just coming in on the tailend of this thread so I may have missed pertinent exchange of ideas. Becky (the nurse) -----Original Message----- From: Tea Acuff To: OpenHeart-L@lists.hsforum.com Sent: Wed, 7 Jan 2009 9:21 am Subject: Re: [HSF] two surgeons And that means? Tea Sent from my iPhone On Jan 7, 2009, at 10:06 AM, "Salerno, Tomas" wrote: Pilots retire at age 65 which is the peak of their career and experience Ts ----- Original Message ----- From: openheart-l-bounces@lists.hsforum.com To: OpenHeart-L Sent: Wed Jan 07 10:58:01 2009 Subject: [HSF] two surgeons I was reading the literature, in this case a book that was discussing aviation disasters, and thinking about what this had to do with heart surgery. We have talked about aviation lessons for heart surgery, but there were several ideas that we did not sort though in this context. Interestingly, if you can believe the writer since he did not give the data, there is much less likely hood of an accident if the junior pilot is in the "captain" seat. I think this can only be properly understood in the context of the discussion that commerial planes are made to be flown by two pilot cooperating and that accidents are less likely with cooperation than with two pilots as a pilot with a back up. I have a few questions. Is there evidence that surgey is better with two surgeons than one (with or without backup)? California requires two surgeons but does not require "cooperation". Would the California verses STS data or other data shed any light on this issue? As a different query can anyone tell me the pilot factor, eg IQ, seniority, gender, etc that most correlated with clusters of accidents? hint: It is politically incorrect. tea _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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@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@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 ----------------------------------------- From tacuff at swbell.net Wed Jan 7 12:36:09 2009 From: tacuff at swbell.net (Tea Acuff) Date: Wed Jan 7 15:37:40 2009 Subject: [HSF] two surgeons Message-ID: <46732.75919.qm@web81607.mail.mud.yahoo.com> You are correct that the focus was on communication and the linguistic "patterns" that underlie the information being being "shared". That said, is there something to the pattern of working together by design even at the level of surgeon. What makes a good surgeon? And if the answer is her/ his results, how does one get there. Tea Sent from my iPhone On Jan 7, 2009, at 12:02 PM, cardiacnse@aol.com wrote: Being a huge proponent of the IHI and VA NCPS, my take on this issue is more about the "cockpit" communication and leveling of hierarchy than it is about whether or not 2 pilots or surgeons are better than 1. Lessons learned from the aviation industry highlight open communication, errors caused by systems and not by people, and stopping the line methodology. But that's just me. I'm just coming in on the tailend of this thread so I may have missed pertinent exchange of ideas. Becky (the nurse) -----Original Message----- From: Tea Acuff To: OpenHeart-L@lists.hsforum.com Sent: Wed, 7 Jan 2009 9:21 am Subject: Re: [HSF] two surgeons And that means? Tea Sent from my iPhone On Jan 7, 2009, at 10:06 AM, "Salerno, Tomas" wrote: Pilots retire at age 65 which is the peak of their career and experience Ts ----- Original Message ----- From: openheart-l-bounces@lists.hsforum.com To: OpenHeart-L Sent: Wed Jan 07 10:58:01 2009 Subject: [HSF] two surgeons I was reading the literature, in this case a book that was discussing aviation disasters, and thinking about what this had to do with heart surgery. We have talked about aviation lessons for heart surgery, but there were several ideas that we did not sort though in this context. Interestingly, if you can believe the writer since he did not give the data, there is much less likely hood of an accident if the junior pilot is in the "captain" seat. I think this can only be properly understood in the context of the discussion that commerial planes are made to be flown by two pilot cooperating and that accidents are less likely with cooperation than with two pilots as a pilot with a back up. I have a few questions. Is there evidence that surgey is better with two surgeons than one (with or without backup)? California requires two surgeons but does not require "cooperation". Would the California verses STS data or other data shed any light on this issue? As a different query can anyone tell me the pilot factor, eg IQ, seniority, gender, etc that most correlated with clusters of accidents? hint: It is politically incorrect. tea _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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@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@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@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 ----------------------------------------- From drdharris at yahoo.co.uk Wed Jan 7 23:06:06 2009 From: drdharris at yahoo.co.uk (David Harris) Date: Wed Jan 7 18:07:35 2009 Subject: [HSF] Image of the week Aotic root abscess In-Reply-To: Message-ID: <539991.64343.qm@web26703.mail.ukl.yahoo.com> Good one! The freestyle is a very good idea. Have`nt done one like that for a while. The large one I remember putting in a massive piece of pericardium. ? Regards, ? Dave Harris --- On Tue, 6/1/09, Roberto Battellini wrote: From: Roberto Battellini Subject: RE: [HSF] Image of the week Aotic root abscess To: "lists HSF" Date: Tuesday, 6 January, 2009, 12:29 PM Man, born 1937, he got in Juni 2008 an AVR and aortic ascending replacement, supracoronary. Came with sepsis and the abscess seen in the echo posted by Prasanna. Reoperation on the 31 of December ...I wanted to go home, and got this case as the 2nd of the day... Well, after 3 hours of clamping under ante-retrograde blood cardioplegia I could manage it. Operation: Of course, femorofemoral cannulation and go on bypass, and the open the chest.Very easy to do, bleeds less as there are no injuries. Then, clamping, resection of all infected tissue, after which there was no more annulus.I coul suture a freestyle valve in the ventricle for the left and right coronary cusps, and in a patch for the non coronary cusp.Thios patch was sutured in the "free" anterior sail of the mitral valve.A little of bioglue on the sutures, and that was all. Prophilactic IABP as I had 3 hours of clamping. Of course, platelets, etc. Bleeding PO 500.He is now without IABP, intubated, at ICU. Roberto> Date: Tue, 6 Jan 2009 07:56:57 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> CC: > Subject: [HSF] Image of the week Aotic root abscess> > Image sent by Roberto.> He will discuss the case.> > -- > Prasanna Simha M_______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From mmlevinson at hsforum.com Wed Jan 7 22:32:23 2009 From: mmlevinson at hsforum.com (Mark Levinson) Date: Wed Jan 7 23:32:53 2009 Subject: [HSF] Subxiphoid CryoMaze In-Reply-To: <1113788687-1231160046-cardhu_decombobulator_blackberry.rim.net-1760673732-@bxe016.bisx.prod.on.blackberry> References: <1113788687-1231160046-cardhu_decombobulator_blackberry.rim.net-1760673732-@bxe016.bisx.prod.on.blackberry> Message-ID: On Jan 5, 2009, at 6:54 AM, Hgrmd@aol.com wrote: > Mark, > Sorry, but I don't believe you can reliably create a transmural > mitral isthmus lesion from an epicardial approach. The heat sink > effect, particularly in thick atria, will prevent the endocardium > from freezing. Hal: I remembered another aspect of this case that may help confirm that the mitral isthmus lesion is possible from an epicardial approach. The patient presented with a-fib but after D/C cardioversion, he was in sinus with frequent PAC's. At anesth induction and during the right sided lesions, he still had frequent PACs. However, when I did the freeze on the mitral isthmus and coronary sinus, the PACs suddenly stopped and did not return. I think this area was his primary arrythmogenic focus and we got it ablated epicardially. Thanks Mark Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From robertobattellini at hotmail.com Thu Jan 8 08:21:19 2009 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Thu Jan 8 02:21:49 2009 Subject: [HSF] two surgeons and Becky (OT) In-Reply-To: <8CB3F093D9F7368-104-287@WEBMAIL-MB15.sysops.aol.com> References: <714437.5486.qm@web81607.mail.mud.yahoo.com> <8CB3F093D9F7368-104-287@WEBMAIL-MB15.sysops.aol.com> Message-ID: Becky, if we are on the cockpit and you talk me with IHI and VA NCPS our plain will fall down.... Roberto> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] two surgeons> Date: Wed, 7 Jan 2009 13:02:29 -0500> From: cardiacnse@aol.com> CC: > > Being a huge proponent of the IHI and VA NCPS, my take on this issue is more about the "cockpit" communication and leveling of hierarchy than it is about whether or not 2 pilots or surgeons are better than 1. Lessons learned from the aviation industry highlight open communication, errors caused by systems and not by people, and stopping the line methodology. But that's just me.> > I'm just coming in on the tailend of this thread so I may have missed pertinent exchange of ideas.> > Becky (the nurse)> > > > > -----Original Message-----> From: Tea Acuff > To: OpenHeart-L@lists.hsforum.com > Sent: Wed, 7 Jan 2009 9:21 am> Subject: Re: [HSF] two surgeons> > > > > And that means?> Tea> > Sent from my iPhone> > On Jan 7, 2009, at 10:06 AM, "Salerno, Tomas" wrote:> > Pilots retire at age 65 which is the peak of their career and experience> > Ts> > ----- Original Message -----> From: openheart-l-bounces@lists.hsforum.com > To: OpenHeart-L > Sent: Wed Jan 07 10:58:01 2009> Subject: [HSF] two surgeons> > I was reading the literature, in this case a book that was discussing aviation > disasters, and thinking about what this had to do with heart surgery. We have > talked about aviation lessons for heart surgery, but there were several ideas > that we did not sort though in this context.> Interestingly, if you can believe the writer since he did not give the data, > there is much less likely hood of an accident if the junior pilot is in the > "captain" seat. I think this can only be properly understood in the context of > the discussion that commerial planes are made to be flown by two pilot > cooperating and that accidents are less likely with cooperation than with two > pilots as a pilot with a back up. > I have a few questions. Is there evidence that surgey is better with two > surgeons than one (with or without backup)? California requires two surgeons but > does not require "cooperation". Would the California verses STS data or other > data shed any light on this issue? As a different query can anyone tell me the > pilot factor, eg IQ, seniority, gender, etc that most correlated with clusters > of accidents? hint: It is politically incorrect. > > tea> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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@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@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> ----------------------------------------- From prasannasimha at gmail.com Thu Jan 8 15:12:02 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Thu Jan 8 04:42:31 2009 Subject: [HSF] two surgeons and Becky (OT) In-Reply-To: References: <714437.5486.qm@web81607.mail.mud.yahoo.com> <8CB3F093D9F7368-104-287@WEBMAIL-MB15.sysops.aol.com> Message-ID: <89c4ed2d0901080142n43cc2e02xbf965225ba2c1bba@mail.gmail.com> Whats IHI and VA NCPS ? Prasanna On Thu, Jan 8, 2009 at 12:51 PM, Roberto Battellini < robertobattellini@hotmail.com> wrote: > > Becky, > > if we are on the cockpit and you talk me with IHI and VA NCPS our plain > will fall down.... > Roberto> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] two > surgeons> Date: Wed, 7 Jan 2009 13:02:29 -0500> From: cardiacnse@aol.com> > CC: > > Being a huge proponent of the IHI and VA NCPS, my take on this issue > is more about the "cockpit" communication and leveling of hierarchy than it > is about whether or not 2 pilots or surgeons are better than 1. Lessons > learned from the aviation industry highlight open communication, errors > caused by systems and not by people, and stopping the line methodology. But > that's just me.> > I'm just coming in on the tailend of this thread so I may > have missed pertinent exchange of ideas.> > Becky (the nurse)> > > > > > -----Original Message-----> From: Tea Acuff > To: > OpenHeart-L@lists.hsforum.com > Sent: Wed, > 7 Jan 2009 9:21 am> Subject: Re: [HSF] two surgeons> > > > > And that > means?> Tea> > Sent from my iPhone> > On Jan 7, 2009, at 10:06 AM, "Salerno, > Tomas" wrote:> > Pilots retire at age 65 which is > the peak of their career and experience> > Ts> > ----- Original Message > -----> From: openheart-l-bounces@lists.hsforum.com < > openheart-l-bounces@lists.hsforum.com>> To: OpenHeart-L < > OpenHeart-L@lists.hsforum.com>> Sent: Wed Jan 07 10:58:01 2009> Subject: > [HSF] two surgeons> > I was reading the literature, in this case a book that > was discussing aviation > disasters, and thinking about what this had to do > with heart surgery. We have > talked about aviation lessons for heart > surgery, but there were several ideas > that we did not sort though in this > context.> Interestingly, if you can believe the writer since he did not give > the data, > there is much less likely hood of an accident if the junior > pilot is in the > "captain" seat. I think this can only be properly > understood in the context of > the discussion that commerial planes are made > to be flown by two pilot > cooperating and that accidents are less likely > with cooperation than with two > pilots as a pilot with a back up. > I have > a few questions. Is there evidence that surgey is better with two > surgeons > than one (with or without backup)? California requires two surgeons but > > does not require "cooperation". Would the California verses STS data or > other > data shed any light on this issue? As a different query can anyone > tell me the > pilot factor, eg IQ, seniority, gender, etc that most > correlated with clusters > of accidents? hint: It is politically incorrect. > > > tea> _______________________________________________> OpenHeart-L > mailing list> > Send postings to:> OpenHeart-L@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@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@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@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@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 > ----------------------------------------- > -- Prasanna Simha M From benjamin.bidstrup at bigpond.com Thu Jan 8 20:39:49 2009 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Thu Jan 8 05:40:33 2009 Subject: [HSF] two surgeons and Becky (OT) In-Reply-To: <89c4ed2d0901080142n43cc2e02xbf965225ba2c1bba@mail.gmail.com> References: <714437.5486.qm@web81607.mail.mud.yahoo.com> <8CB3F093D9F7368-104-287@WEBMAIL-MB15.sysops.aol.com> <89c4ed2d0901080142n43cc2e02xbf965225ba2c1bba@mail.gmail.com> Message-ID: IHI is the Institute for Healthcare Improvement. VA Veterans Affairs. NCPS National Centre for Patient Safety. (Google them to get to their websites.) Ben Bidstrup FRACS FRCSEd FEBCTS Cardiothoracic Surgeon On 08/01/2009, at 7:42 PM, Prasanna Simha M wrote: > Whats IHI and VA NCPS ? > Prasanna > > On Thu, Jan 8, 2009 at 12:51 PM, Roberto Battellini < > robertobattellini@hotmail.com> wrote: > >> >> Becky, >> >> if we are on the cockpit and you talk me with IHI and VA NCPS our >> plain >> will fall down.... >> Roberto> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] two >> surgeons> Date: Wed, 7 Jan 2009 13:02:29 -0500> From: cardiacnse@aol.com >> > >> CC: > > Being a huge proponent of the IHI and VA NCPS, my take on >> this issue >> is more about the "cockpit" communication and leveling of hierarchy >> than it >> is about whether or not 2 pilots or surgeons are better than 1. >> Lessons >> learned from the aviation industry highlight open communication, >> errors >> caused by systems and not by people, and stopping the line >> methodology. But >> that's just me.> > I'm just coming in on the tailend of this thread >> so I may >> have missed pertinent exchange of ideas.> > Becky (the nurse)> > > >> > > >> -----Original Message-----> From: Tea Acuff > To: >> OpenHeart-L@lists.hsforum.com > >> Sent: Wed, >> 7 Jan 2009 9:21 am> Subject: Re: [HSF] two surgeons> > > > > And that >> means?> Tea> > Sent from my iPhone> > On Jan 7, 2009, at 10:06 AM, >> "Salerno, >> Tomas" wrote:> > Pilots retire at age 65 >> which is >> the peak of their career and experience> > Ts> > ----- Original >> Message >> -----> From: openheart-l-bounces@lists.hsforum.com < >> openheart-l-bounces@lists.hsforum.com>> To: OpenHeart-L < >> OpenHeart-L@lists.hsforum.com>> Sent: Wed Jan 07 10:58:01 2009> >> Subject: >> [HSF] two surgeons> > I was reading the literature, in this case a >> book that >> was discussing aviation > disasters, and thinking about what this >> had to do >> with heart surgery. We have > talked about aviation lessons for heart >> surgery, but there were several ideas > that we did not sort though >> in this >> context.> Interestingly, if you can believe the writer since he did >> not give >> the data, > there is much less likely hood of an accident if the >> junior >> pilot is in the > "captain" seat. I think this can only be properly >> understood in the context of > the discussion that commerial planes >> are made >> to be flown by two pilot > cooperating and that accidents are less >> likely >> with cooperation than with two > pilots as a pilot with a back up. >> > I have >> a few questions. Is there evidence that surgey is better with two > >> surgeons >> than one (with or without backup)? California requires two surgeons >> but > >> does not require "cooperation". Would the California verses STS >> data or >> other > data shed any light on this issue? As a different query can >> anyone >> tell me the > pilot factor, eg IQ, seniority, gender, etc that most >> correlated with clusters > of accidents? hint: It is politically >> incorrect. >>>> tea> _______________________________________________> OpenHeart-L >> mailing list> > Send postings to:> OpenHeart-L@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@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@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@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@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 >> ----------------------------------------- >> > > > > -- > Prasanna Simha M > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From hgrmd at aol.com Thu Jan 8 12:20:04 2009 From: hgrmd at aol.com (hgrmd@aol.com) Date: Thu Jan 8 07:21:29 2009 Subject: [HSF] Subxiphoid CryoMaze Message-ID: <1399661543-1231417200-cardhu_decombobulator_blackberry.rim.net-1531904701-@bxe016.bisx.prod.on.blackberry> I've seen similar when I made the cavo tricuspid isthmus lesion on the beating heart. Please keep us informed of your results as your experience grows. I know of no purely epicardial approaches that have a high success rate with chronic AF. Hal ------Original Message------ From: Mark Levinson Sender: openheart-l-bounces@lists.hsforum.com To: OpenHeart-L@lists.hsforum.com ReplyTo: OpenHeart-L@lists.hsforum.com Sent: Jan 7, 2009 11:32 PM Subject: Re: [HSF] Subxiphoid CryoMaze On Jan 5, 2009, at 6:54 AM, Hgrmd@aol.com wrote: > Mark, > Sorry, but I don't believe you can reliably create a transmural > mitral isthmus lesion from an epicardial approach. The heat sink > effect, particularly in thick atria, will prevent the endocardium > from freezing. Hal: I remembered another aspect of this case that may help confirm that the mitral isthmus lesion is possible from an epicardial approach. The patient presented with a-fib but after D/C cardioversion, he was in sinus with frequent PAC's. At anesth induction and during the right sided lesions, he still had frequent PACs. However, when I did the freeze on the mitral isthmus and coronary sinus, the PACs suddenly stopped and did not return. I think this area was his primary arrythmogenic focus and we got it ablated epicardially. Thanks Mark Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- Sent from my Verizon Wireless BlackBerry From prasannasimha at gmail.com Thu Jan 8 17:57:26 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Thu Jan 8 07:27:54 2009 Subject: [HSF] Subxiphoid CryoMaze In-Reply-To: <1399661543-1231417200-cardhu_decombobulator_blackberry.rim.net-1531904701-@bxe016.bisx.prod.on.blackberry> References: <1399661543-1231417200-cardhu_decombobulator_blackberry.rim.net-1531904701-@bxe016.bisx.prod.on.blackberry> Message-ID: <89c4ed2d0901080427v464a1e20t2fd6addb4bf2a866@mail.gmail.com> I have encountered this quite a few times since I do the right lesions on a nonpleged beating heart at normothermia. Ther are often right and left "trigger" foci and interruption of these can decrease the afib substrate. Prasanna On Thu, Jan 8, 2009 at 5:50 PM, wrote: > I've seen similar when I made the cavo tricuspid isthmus lesion on the > beating heart. Please keep us informed of your results as your experience > grows. I know of no purely epicardial approaches that have a high success > rate with chronic AF. > > Hal > ------Original Message------ > From: Mark Levinson > Sender: openheart-l-bounces@lists.hsforum.com > To: OpenHeart-L@lists.hsforum.com > ReplyTo: OpenHeart-L@lists.hsforum.com > Sent: Jan 7, 2009 11:32 PM > Subject: Re: [HSF] Subxiphoid CryoMaze > > > On Jan 5, 2009, at 6:54 AM, Hgrmd@aol.com wrote: > > > Mark, > > Sorry, but I don't believe you can reliably create a transmural > > mitral isthmus lesion from an epicardial approach. The heat sink > > effect, particularly in thick atria, will prevent the endocardium > > from freezing. > > Hal: > > I remembered another aspect of this case that may help confirm that > the mitral isthmus lesion is possible from an epicardial approach. > The patient presented with a-fib but after D/C cardioversion, he was > in sinus with frequent PAC's. At anesth induction and during the > right sided lesions, he still had frequent PACs. However, when I > did the freeze on the mitral isthmus and coronary sinus, the PACs > suddenly stopped and did not return. I think this area was his > primary arrythmogenic focus and we got it ablated epicardially. > > Thanks > > Mark > > Mark Levinson, MD. > Founder, Editor-in-Chief > The Heart Surgery Forum(R) > Multimedia Cardiothoracic Journal > URL: http://www.hsforum.com > URL: http://newoptionsinheartsurgery.com > Emali: mmlevinson@hsforum.com > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > > Sent from my Verizon Wireless BlackBerry > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > -- Prasanna Simha M From robertobattellini at hotmail.com Thu Jan 8 13:56:26 2009 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Thu Jan 8 07:57:15 2009 Subject: [HSF] two surgeons and Becky and Prasanna(OT) In-Reply-To: <89c4ed2d0901080142n43cc2e02xbf965225ba2c1bba@mail.gmail.com> References: <714437.5486.qm@web81607.mail.mud.yahoo.com> <8CB3F093D9F7368-104-287@WEBMAIL-MB15.sysops.aol.com> <89c4ed2d0901080142n43cc2e02xbf965225ba2c1bba@mail.gmail.com> Message-ID: Prasanna, Becky is teaching us the new language of the Marcian inhabitants...> Date: Thu, 8 Jan 2009 15:12:02 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] two surgeons and Becky (OT)> CC: > > Whats IHI and VA NCPS ?> Prasanna> > On Thu, Jan 8, 2009 at 12:51 PM, Roberto Battellini <> robertobattellini@hotmail.com> wrote:> > >> > Becky,> >> > if we are on the cockpit and you talk me with IHI and VA NCPS our plain> > will fall down....> > Roberto> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] two> > surgeons> Date: Wed, 7 Jan 2009 13:02:29 -0500> From: cardiacnse@aol.com>> > CC: > > Being a huge proponent of the IHI and VA NCPS, my take on this issue> > is more about the "cockpit" communication and leveling of hierarchy than it> > is about whether or not 2 pilots or surgeons are better than 1. Lessons> > learned from the aviation industry highlight open communication, errors> > caused by systems and not by people, and stopping the line methodology. But> > that's just me.> > I'm just coming in on the tailend of this thread so I may> > have missed pertinent exchange of ideas.> > Becky (the nurse)> > > > >> > -----Original Message-----> From: Tea Acuff > To:> > OpenHeart-L@lists.hsforum.com > Sent: Wed,> > 7 Jan 2009 9:21 am> Subject: Re: [HSF] two surgeons> > > > > And that> > means?> Tea> > Sent from my iPhone> > On Jan 7, 2009, at 10:06 AM, "Salerno,> > Tomas" wrote:> > Pilots retire at age 65 which is> > the peak of their career and experience> > Ts> > ----- Original Message> > -----> From: openheart-l-bounces@lists.hsforum.com <> > openheart-l-bounces@lists.hsforum.com>> To: OpenHeart-L <> > OpenHeart-L@lists.hsforum.com>> Sent: Wed Jan 07 10:58:01 2009> Subject:> > [HSF] two surgeons> > I was reading the literature, in this case a book that> > was discussing aviation > disasters, and thinking about what this had to do> > with heart surgery. We have > talked about aviation lessons for heart> > surgery, but there were several ideas > that we did not sort though in this> > context.> Interestingly, if you can believe the writer since he did not give> > the data, > there is much less likely hood of an accident if the junior> > pilot is in the > "captain" seat. I think this can only be properly> > understood in the context of > the discussion that commerial planes are made> > to be flown by two pilot > cooperating and that accidents are less likely> > with cooperation than with two > pilots as a pilot with a back up. > I have> > a few questions. Is there evidence that surgey is better with two > surgeons> > than one (with or without backup)? California requires two surgeons but >> > does not require "cooperation". Would the California verses STS data or> > other > data shed any light on this issue? As a different query can anyone> > tell me the > pilot factor, eg IQ, seniority, gender, etc that most> > correlated with clusters > of accidents? hint: It is politically incorrect.> > > > tea> _______________________________________________> OpenHeart-L> > mailing list> > Send postings to:> OpenHeart-L@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@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@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@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@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> > -----------------------------------------> >> > > > -- > Prasanna Simha M> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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> ----------------------------------------- From zzhoumd at pol.net Thu Jan 8 08:28:44 2009 From: zzhoumd at pol.net (Zhandong Zhou) Date: Thu Jan 8 08:33:04 2009 Subject: [HSF] two surgeons and Becky (OT) Message-ID: <20090108132844.VTCS20009.atlmtaow03.cingularme.com@Inbox> Becky, I think cockpit system is completely different from our operating room. Every boeing 737 or airbus 320 is made same. Our patients are completely different from each other. Recently, new york started a long check list before the surgery, it made the surgeons get more distracted from the surgery and more agitated to perform the surgery. Zhandong Zhou, MD, PhD St. Joseph Hospital Syracuse, New York 315 423 7192 -----Original Message----- From: Roberto Battellini Sent: Thursday, January 08, 2009 2:21 AM To: lists HSF Subject: RE: [HSF] two surgeons and Becky (OT) Becky, if we are on the cockpit and you talk me with IHI and VA NCPS our plain will fall down.... Roberto> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] two surgeons> Date: Wed, 7 Jan 2009 13:02:29 -0500> From: cardiacnse@aol.com> CC: > > Being a huge proponent of the IHI and VA NCPS, my take on this issue is more about the "cockpit" communication and leveling of hierarchy than it is about whether or not 2 pilots or surgeons are better than 1. Lessons learned from the aviation industry highlight open communication, errors caused by systems and not by people, and stopping the line methodology. But that's just me.> > I'm just coming in on the tailend of this thread so I may have missed pertinent exchange of ideas.> > Becky (the nurse)> > > > > -----Original Message-----> From: Tea Acuff > To: OpenHeart-L@lists.hsforum.com > Sent: Wed, 7 Jan 2009 9:21 am> Subject: Re: [HSF] two surgeons> > > > > And that means?> Tea> > Sent from my iPhone> > On Jan 7, 2009, at 10:06 AM, "Salerno, Tomas" wrote:> > Pilots retire at age 65 which is the peak of their career and experience> > Ts> > ----- Original Message -----> From: openheart-l-bounces@lists.hsforum.com > To: OpenHeart-L > Sent: Wed Jan 07 10:58:01 2009> Subject: [HSF] two surgeons> > I was reading the literature, in this case a book that was discussing aviation > disasters, and thinking about what this had to do with heart surgery. We have > talked about aviation lessons for heart surgery, but there were several ideas > that we did not sort though in this context.> Interestingly, if you can believe the writer since he did not give the data, > there is much less likely hood of an accident if the junior pilot is in the > "captain" seat. I think this can only be properly understood in the context of > the discussion that commerial planes are made to be flown by two pilot > cooperating and that accidents are less likely with cooperation than with two > pilots as a pilot with a back up. > I have a few questions. Is there evidence that surgey is better with two > surgeons than one (with or without backup)? California requires two surgeons but > does not require "cooperation". Would the California verses STS data or other > data shed any light on this issue? As a different query can anyone tell me the > pilot factor, eg IQ, seniority, gender, etc that most correlated with clusters > of accidents? hint: It is politically incorrect. > > tea> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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@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@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@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 ----------------------------------------- From robertobattellini at hotmail.com Thu Jan 8 15:31:21 2009 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Thu Jan 8 09:31:49 2009 Subject: [HSF] two surgeons and Becky (OT) In-Reply-To: <20090108132844.VTCS20009.atlmtaow03.cingularme.com@Inbox> References: <20090108132844.VTCS20009.atlmtaow03.cingularme.com@Inbox> Message-ID: Good said, Zhandong, When we operate those terrible aortic root abscesses, Type A dissections at night, those are not "planned flights", may be "combat flights at night" Roberto> From: zzhoumd@pol.net> Subject: RE: [HSF] two surgeons and Becky (OT)> Date: Thu, 8 Jan 2009 08:28:44 -0500> To: OpenHeart-L@lists.hsforum.com> CC: > > Becky,> > I think cockpit system is completely different from our operating room. Every boeing 737 or airbus 320 is made same. Our patients are completely different from each other. > > Recently, new york started a long check list before the surgery, it made the surgeons get more distracted from the surgery and more agitated to perform the surgery. > > Zhandong Zhou, MD, PhD> St. Joseph Hospital> Syracuse, New York> 315 423 7192> > -----Original Message-----> From: Roberto Battellini > Sent: Thursday, January 08, 2009 2:21 AM> To: lists HSF > Subject: RE: [HSF] two surgeons and Becky (OT)> > > Becky,> > if we are on the cockpit and you talk me with IHI and VA NCPS our plain will fall down....> Roberto> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] two surgeons> Date: Wed, 7 Jan 2009 13:02:29 -0500> From: cardiacnse@aol.com> CC: > > Being a huge proponent of the IHI and VA NCPS, my take on this issue is more about the "cockpit" communication and leveling of hierarchy than it is about whether or not 2 pilots or surgeons are better than 1. Lessons learned from the aviation industry highlight open communication, errors caused by systems and not by people, and stopping the line methodology. But that's just me.> > I'm just coming in on the tailend of this thread so I may have missed pertinent exchange of ideas.> > Becky (the nurse)> > > > > -----Original Message-----> From: Tea Acuff > To: OpenHeart-L@lists.hsforum.com > Sent: Wed, 7 Jan 2009 9:21 am> Subject: Re: [HSF] two surgeons> > > > > And that means?> Tea> > Sent from my iPhone> > On Jan 7, 2009, at 10:06 AM, "Salerno, Tomas" wrote:> > Pilots retire at age 65 which is the peak of their career and experience> > Ts> > ----- Original Message -----> From: openheart-l-bounces@lists.hsforum.com > To: OpenHeart-L > Sent: Wed Jan 07 10:58:01 2009> Subject: [HSF] two surgeons> > I was reading the literature, in this case a book that was discussing aviation > disasters, and thinking about what this had to do with heart surgery. We have > talked about aviation lessons for heart surgery, but there were several ideas > that we did not sort though in this context.> Interestingly, if you can believe the writer since he did not give the data, > there is much less likely hood of an accident if the junior pilot is in the > "captain" seat. I think this can only be properly understood in the context of > the discussion that commerial planes are made to be flown by two pilot > cooperating and that accidents are less likely with cooperation than with two > pilots as a pilot with a back up. > I have a few questions. Is there evidence that surgey is better with two > surgeons than one (with or without backup)? California requires two surgeons but > does not require "cooperation". Would the California verses STS data or other > data shed any light on this issue? As a different query can anyone tell me the > pilot factor, eg IQ, seniority, gender, etc that most correlated with clusters > of accidents? hint: It is politically incorrect. > > tea> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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@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@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@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@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> ----------------------------------------- From cardiacnse at aol.com Thu Jan 8 09:48:18 2009 From: cardiacnse at aol.com (cardiacnse@aol.com) Date: Thu Jan 8 09:49:00 2009 Subject: [HSF] two surgeons and Becky and Prasanna(OT) In-Reply-To: References: <714437.5486.qm@web81607.mail.mud.yahoo.com><8CB3F093D9F7368-104-287@WEBMAIL-MB15.sysops.aol.com> <89c4ed2d0901080142n43cc2e02xbf965225ba2c1bba@mail.gmail.com> Message-ID: <8CB3FB747715C9E-D58-2732@FWM-M36.sysops.aol.com> Well, this could get very interesting. However having spent the majority of my professional life with surgeons and most of that with cardiac surgeons, I shall try to suffer the slings and arrows........ Trust me, I am your biggest fan. I can be a bit grouchy about some of our personal interactions, but no one and I mean no one, better say a bad word about "my surgeons." First, I must plead ignorance on the Marcian reference. What is that? It was interesting when I took the IHI Patient Safety Officer Development course that there were a few physicians who spoke to the issue of the airline industry being different from healthcare in that we are dealing with people and every scenario is or can be different. By the end of the 8 days of intense immersion into the concepts of having a patient safety culture, these few physicians were the loudest proponents of what this is all about. In other words, they "got it." It is not about "cookbook" medicine, it is about working in a safe environment where communication is open, direct, and collaborative. An example is the "time out." All members of the team are to stop what they are doing and focus on having the right patient, procedure, site or side, and required equipment and supplies (implants). While this seems frustrating, it serves a purpose. If even one wrong site surgery is prevented, is it worth the frustration? In my very simple example, the team sort of did the time out, however not everyone totally focused on the communication. So when the surgeon walked up to the patient and placed the scalpel on the WRONG side of the scrotal sac, the scrub or anesthesiologist did not say, hey, I thought we said we were doing the right not the left. Would this have been less likely to have happened if it had been a leg or a breast? Oh, and by the way, the side wasn't marked. Despite the fact that the surgeon had requested that the patient be held in the holding room until he could get there and mark the site. The MDA decided things needed to get moving and did not respect that request. The nursing staff did not feel comfortable stoping that line and saying, no we need to wait for the surgeon or wait, let me call the surgeon and let him know that you are proceeding. Now these people did not get up in the morning and figure out who they could harm that morning. This was a system that allowed people to fail because it was not applied the way it was intended. The system needs work. It is about being able to respect each other enough to recognize everyone's contribution to the care of the patient. Even if wrong, anyone should feel comfortable having a conversation and knowing that leaning is always the end result. This takes a team effort to recognize that the communication is flawed and can be improved through respect and collaboration. I know the surgical safety check list seems to cause more problems than it prevents, but it comes about because we continue operating on the wrong patient, with the wrong procedure, and on the wrong side. Although, it can "never happen to you" there are alot of practitioners who have had to eat those words and would love to rewind the clock. Sorry to belabor the point and I know, blah, blah, blah, but you pushed the button. Hopefully, you didn't just delete the email after the first or second sentances. There is something very interesting that seems to happen once a physician "crosses over to the other side." The physicians who have fostered this new approach to safe healthcare are at the top of the game in my opinion and seem to have lost credibility for some strange reason. Jim Bagian at the VA was an engineer turned astronaut turned physician. Talk about credibility. Don Berwick, James Conway, Lician Leape, Allan Frankel, Charles Denholm - google any one of these or go to the "about us" link at www.IHI.org and see who they are. Sorry to go on and on. What you all do is nothing short of amazing and wonderful and I feel very blessed to have been in this profession for over 40 years. I know the regulatory environment is and can be very aggravating and frustrating, but it has gone that way because we haven't seen fit to manage this ourselves. Sorry to be so opinionated, but it's just one person's humble opinion. Everybody has at least one. Respecfully and absolutely no offense intended. Becky -----Original Message----- From: Roberto Battellini To: lists HSF Sent: Thu, 8 Jan 2009 4:56 am Subject: RE: [HSF] two surgeons and Becky and Prasanna(OT) Prasanna, Becky is teaching us the new language of the Marcian inhabitants...> Date: Thu, 8 Jan 2009 15:12:02 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] two surgeons and Becky (OT)> CC: > > Whats IHI and VA NCPS ?> Prasanna> > On Thu, Jan 8, 2009 at 12:51 PM, Roberto Battellini <> robertobattellini@hotmail.com> wrote:> > >> > Becky,> >> > if we are on the cockpit and you talk me with IHI and VA NCPS our plain> > will fall down....> > Roberto> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] two> > surgeons> Date: Wed, 7 Jan 2009 13:02:29 -0500> From: cardiacnse@aol.com>> > CC: > > Being a huge proponent of the IHI and VA NCPS, my take on this issue> > is more about the "cockpit" communication and leveling of hierarchy than it> > is about whether or not 2 pilots or surgeons are better than 1. Lessons> > learned from the aviation industry highlight open communication, errors> > caused by systems and not by people, and stopping the line methodology. But> > that's just me.> > I'm just coming in on the tailend of this thread so I may> > have missed pertinent exchange of ideas.> > Becky (the nurse)> > > > >> > -----Original Message-----> From: Tea Acuff > To:> > OpenHeart-L@lists.hsforum.com > Sent: Wed,> > 7 Jan 2009 9:21 am> Subject: Re: [HSF] two surgeons> > > > > And that> > means?> Tea> > Sent from my iPhone> > On Jan 7, 2009, at 10:06 AM, "Salerno,> > Tomas" wrote:> > Pilots retire at age 65 which is> > the peak of their career and experience> > Ts> > ----- Original Message> > -----> From: openheart-l-bounces@lists.hsforum.com <> > openheart-l-bounces@lists.hsforum.com>> To: OpenHeart-L <> > OpenHeart-L@lists.hsforum.com>> Sent: Wed Jan 07 10:58:01 2009> Subject:> > [HSF] two surgeons> > I was reading the literature, in this case a book that> > was discussing aviation > disasters, and thinking about what this had to do> > with heart surgery. We have > talke d about aviation lessons for heart> > surgery, but there were several ideas > that we did not sort though in this> > context.> Interestingly, if you can believe the writer since he did not give> > the data, > there is much less likely hood of an accident if the junior> > pilot is in the > "captain" seat. I think this can only be properly> > understood in the context of > the discussion that commerial planes are made> > to be flown by two pilot > cooperating and that accidents are less likely> > with cooperation than with two > pilots as a pilot with a back up. > I have> > a few questions. Is there evidence that surgey is better with two > surgeons> > than one (with or without backup)? California requires two surgeons but >> > does not require "cooperation". Would the California verses STS data or> > other > data shed any light on this issue? As a different query can anyone> > tell me the > pilot factor, eg IQ, seniority, gender, etc that most> > correlated with clusters > of accidents? hint: It is politically incorrect.> > > > tea> _______________________________________________> OpenHeart-L> > mailing list> > Send postings to:> OpenHeart-L@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@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@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@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@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> > -----------------------------------------> >> > > > -- > Prasanna Simha M> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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@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 disc laimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From prasannasimha at gmail.com Thu Jan 8 21:46:30 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Thu Jan 8 11:24:33 2009 Subject: [HSF] Infective endocarditis with pseudoaneurysm Message-ID: <89c4ed2d0901080816m155846b5s447b97326e38ab52@mail.gmail.com> 14 year old girl with infective endocarditis with a pseudoaneurysm in the iliac artery. patient was undergoing antibiotic therapy with the understanding that we will go in for the pseudoaneurysm if she has worsening symptoms. Today she had severe pain and an angio showed the speudoaneurysm and femorals reformed through collaterals. On opening I saw a contained rupture and in view of friable tissues I elected to open the pseudoaneurysm and ligated the iliac artery and undersew the orifices of the common iliac artery involed in the aneurysm. I did not consider grafting as distal perfusion was OK (due to collaterals) and the tissues weree friable so I was worried that any graft in place would probably get infected. 9I had made arrangements to take a piece of residual vein from a CABG patient going on in the next OR if required and if the patients own saphenous vein was small in caliber). Patinet is doing well at present and I hope to repair /replace her mitral valve once she completes her antibiotic course and consider cross femero femeral or iliofemoral bypass at that time. Would anyone have considered an alternative ? Prasanna -- Prasanna Simha M -------------- next part -------------- A non-text attachment was scrubbed... Name: iliacpseudoaneurysm eml.jpg Type: image/jpeg Size: 107879 bytes Desc: not available Url : http://mmp.cjp.com/pipermail/openheart-l/attachments/20090108/54e26e64/iliacpseudoaneurysmeml-0001.jpg From sukumarhmehta at yahoo.com Thu Jan 8 21:57:12 2009 From: sukumarhmehta at yahoo.com (Mehta Sukumar) Date: Thu Jan 8 11:27:45 2009 Subject: [HSF] two surgeons and Becky and Prasanna(OT) In-Reply-To: <8CB3FB747715C9E-D58-2732@FWM-M36.sysops.aol.com> Message-ID: <307009.2702.qm@web94911.mail.in2.yahoo.com> Becky, I read Martian in place of Marcian and understood. Sukumar. --- On Thu, 8/1/09, cardiacnse@aol.com wrote: From: cardiacnse@aol.com Subject: Re: [HSF] two surgeons and Becky and Prasanna(OT) To: OpenHeart-L@lists.hsforum.com Date: Thursday, 8 January, 2009, 8:18 PM Well, this could get very interesting. However having spent the majority of my professional life with surgeons and most of that with cardiac surgeons, I shall try to suffer the slings and arrows........ Trust me, I am your biggest fan.. I can be a bit grouchy about some of our personal interactions, but no one and I mean no one, better say a bad word about "my surgeons." First, I must plead ignorance on the Marcian reference. What is that? Add more friends to your messenger and enjoy! Go to http://messenger.yahoo.com/invite/ From prasannasimha at gmail.com Thu Jan 8 22:06:26 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Thu Jan 8 12:00:54 2009 Subject: [HSF] two surgeons and Becky and Prasanna(OT) In-Reply-To: <307009.2702.qm@web94911.mail.in2.yahoo.com> References: <8CB3FB747715C9E-D58-2732@FWM-M36.sysops.aol.com> <307009.2702.qm@web94911.mail.in2.yahoo.com> Message-ID: <89c4ed2d0901080836q117cc9f1wceb5289dbc0b8a51@mail.gmail.com> Martian Indeed. The value of using the aeroindustry analytic methods is standardization of certain protocols especially various emergent situations which do not occur frequently but the response needs to be predictable so that everyone in the team can act. Even in the dissection case etc many of the movements done are virtually standardization helps. The CPB run is like an aeroplane takeoff , cruising and landing. In Perfusion training I run a virtual session where we simulate accidents and reponses can be pracitised and mistakes analyzed and corrected. The near miss hot concept can help understand and reduce mortality and morbidity too. Prasanna On Thu, Jan 8, 2009 at 9:57 PM, Mehta Sukumar wrote: > Becky, > I read Martian in place of Marcian and understood. > Sukumar. > > --- On Thu, 8/1/09, cardiacnse@aol.com wrote: > From: cardiacnse@aol.com > Subject: Re: [HSF] two surgeons and Becky and Prasanna(OT) > To: OpenHeart-L@lists.hsforum.com > Date: Thursday, 8 January, 2009, 8:18 PM > > Well, this could get very interesting. However having spent the majority of > my > professional life with surgeons and most of that with cardiac surgeons, I > shall > try to suffer the slings and arrows........ Trust me, I am your biggest > fan.. I > can be a bit grouchy about some of our personal interactions, but no one > and I > mean no one, better say a bad word about "my surgeons." First, I must > plead ignorance on the Marcian reference. What is that? > > > > > > Add more friends to your messenger and enjoy! Go to > http://messenger.yahoo.com/invite/ > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > -- Prasanna Simha M From anianyanwu at hotmail.com Thu Jan 8 17:10:37 2009 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Thu Jan 8 12:11:26 2009 Subject: [HSF] Infective endocarditis with pseudoaneurysm In-Reply-To: <89c4ed2d0901080816m155846b5s447b97326e38ab52@mail.gmail.com> References: <89c4ed2d0901080816m155846b5s447b97326e38ab52@mail.gmail.com> Message-ID: >I had made arrangements to take a piece of residual> vein from a CABG patient going on in the next OR if required ?> Prasanna> > -- Prasanna I am not a vascular surgeon so not area I have expertise in but I am intruiged at the above statement. What arrangements exactly did you make? Did you obtain consent from the prospective donor or were you just going to take the 'residual vein' to the next room? Are there any concerns for transfer of life human tissue between patients in this manner, for example do you do any screening for infectious diseases? Are there any regulatory committess or authorities internally, locally or nationally that have to sanction such tranplantation of tissues or can you just do it? Ani PS for prasanna - dont have the pdf, just print version > Date: Thu, 8 Jan 2009 21:46:30 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> CC: > Subject: [HSF] Infective endocarditis with pseudoaneurysm> > 14 year old girl with infective endocarditis with a pseudoaneurysm in the> iliac artery. patient was undergoing antibiotic therapy with the> understanding that we will go in for the pseudoaneurysm if she has worsening> symptoms. Today she had severe pain and an angio showed the speudoaneurysm> and femorals reformed through collaterals.> On opening I saw a contained rupture and in view of friable tissues I> elected to open the pseudoaneurysm and ligated the iliac artery and undersew> the orifices of the common iliac artery involed in the aneurysm. I did not> consider grafting as distal perfusion was OK (due to collaterals) and the> tissues weree friable so I was worried that any graft in place would> probably get infected. 9I had made arrangements to take a piece of residual> vein from a CABG patient going on in the next OR if required and if the> patients own saphenous vein was small in caliber).> Patinet is doing well at present and I hope to repair /replace her mitral> valve once she completes her antibiotic course and consider cross femero> femeral or iliofemoral bypass at that time.> Would anyone have considered an alternative ?> Prasanna> > -- > Prasanna Simha M _________________________________________________________________ Choose the perfect PC or mobile phone for you http://clk.atdmt.com/UKM/go/130777504/direct/01/ From prasannasimha at gmail.com Thu Jan 8 23:11:14 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Thu Jan 8 12:41:38 2009 Subject: [HSF] Infective endocarditis with pseudoaneurysm In-Reply-To: References: <89c4ed2d0901080816m155846b5s447b97326e38ab52@mail.gmail.com> Message-ID: <89c4ed2d0901080941j26b9dc85yf154052fff164aec@mail.gmail.com> There are multiple options for donor vein- one is to use a vein donated from a parent or from residual vein which would be discarded tissue and consent is taken for that if it is to be used.The third option is to splice the child's saphenous vein if it is small.There have been usage of such veins in the past for BT shunts etc in literature (In fact there were papers in the past of use of donor vein for BT shunts which had excellent patency). In India we screen for HIV , HbSAg, HCV and other transmissable disease in all cardiac surgery patients so that would not have been a real issue. Also the vein can be treated with glutaraldehyde too. In this case I had kept various options open including ligation, closure and cross femoro femoral grafting if there is limb ischemia. (There isnt and there are good Doppler signals and digital pulse oxymetry signals) but I was pretty confident of ligation due to the good collaterals that This was an emergent situation and all options were being considered.The consideration here was to minimize the amount of "infectable " synthetic material in an emergent situation. actually today was a Holiday in India for a Muslim festival called Moharram so it was coincidental that there was an emergency CABG also going on in the next OR or else that option couldnt also have been considered. (We do keep all residual veins after surgery in a fridge for 48 hours after surgery) but there were non remaining at that time so that possibility was not possible too.Asking for consent to use the vein from the potential donors relatives was not a big problem. Prasanna On Thu, Jan 8, 2009 at 10:40 PM, Ani Anyanwu wrote: > > >I had made arrangements to take a piece of residual> vein from a CABG > patient going on in the next OR if required ?> Prasanna> > -- > Prasanna > > I am not a vascular surgeon so not area I have expertise in but I am > intruiged at the above statement. What arrangements exactly did you make? > > Did you obtain consent from the prospective donor or were you just going to > take the 'residual vein' to the next room? Are there any concerns for > transfer of life human tissue between patients in this manner, for example > do you do any screening for infectious diseases? Are there any regulatory > committess or authorities internally, locally or nationally that have to > sanc