[HSF] Afib Procedures and Conduction Disease

Tea Acuff tacuff at swbell.net
Sat Jan 3 08:12:53 EST 2009 

So you also predict that the world is round?
Tea

Sent from my iPhone

On Jan 3, 2009, at 7:30 AM, Ben Bidstrup <benjamin.bidstrup at bigpond.com> 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 at 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 at 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 at hsforum.com

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