[HSF] Tea philosophy

Sun Mar 8 21:45:32 EDT 2009

Perhaps it is fair that I feel his pain, since no one seems to make much use of what I say. The obvious question that your comment begs is that fifty years later do you think Vineberg
was correct in both his assertions: that he was right and only he was right?

tea

________________________________
From: "Salerno, Tomas" <TSalerno at med.miami.edu>
To: "OpenHeart-L at lists.hsforum.com" <OpenHeart-L at lists.hsforum.com>
Sent: Sunday, March 8, 2009 12:53:36 PM
Subject: Re: [HSF] Tea philosophy

As a student of Vineberg, he used to tell me over and over again that the reason why surgeons could not duplicate his results is because they did not do what he described. But rather, surgeons had modified their technique of performing the vineberg operation

Tomas

----- Original Message -----
From: openheart-l-bounces at lists.hsforum.com <openheart-l-bounces at lists.hsforum.com>
To: lists HSF <openheart-l at lists.hsforum.com>
Sent: Sun Mar 08 13:45:09 2009
Subject: RE: [HSF] Tea philosophy

Tea, I am waiting a brainstorming book from your thoughts!

Roberto

> Date: Sun, 8 Mar 2009 08:24:22 -0700
> From: tacuff at swbell.net
> Subject: Re: [HSF] &quot;Internal Sleeve&quot;
> To: OpenHeart-L at lists.hsforum.com
> CC:
>
> Ani says:
>
> "Anyone who wants to take on a new technique should emulate that of the originators - the entire package to the small print - for you do not know the component of the technique that yields efficacy and that that yields safety. A lot of animal and clinical work has gotten them (originators) to their settled technique; to sit down one day in our own offices and decide - without experimentation or logic - how to recreate their operation is potentially dangerous for our patients" (Italics mine...)
>
>
>
> I call this the "black box" theory of cardiac surgery. There is a fundamental truth in this idea and a whole lot of crap. As a general surgeon who was learning cardiac surgery knowing little about cardiac surgery or even cardiology for that matter, I came to both see and treat cardiac surgery in that light.
>
> However, the rest of my career is largely an antithesis of that concept. Those that study systems theory know that a discussion of this idea, the black box, would take several chapters just to start. The long and short of it is that while we can never know in a complex system all the pieces in the black box (life is indeed a black box), a peak inside can change everything. That is, the more we know about the behavior or character of the function(s) inside, the more closely we can guess the actual output from the black box.
>
> Of course it is also true that we can never know the pieces of the black box left in the head of the surgeon that described the black box for the rest of us to use. And this is part of my next "philosophic" topic as if we don't talk philosophy in medicine or find it dished out to us in the hospital in the form of decrees and obligations.
>
>
> tea
>
>
>
>
>
> ________________________________
> From: Ani Anyanwu <anianyanwu at hotmail.com>
> To: open heart list <openheart-l at lists.hsforum.com>
> Sent: Sunday, March 8, 2009 7:56:29 AM
> Subject: RE: [HSF] "Internal Sleeve"
>
>
> > I did a patient the way Hal mentioned and he died from gut ischaemia. The most >experienced aortic surgeons use cold so why should we differ. We should do what they do >. Dave
> >
>
>
> Dave
>
>
>
> I think this is the most important take away message of this discussion. "We should do what they do and let them do the research". Several contributors have just picked on 26 degrees or more and say it is okay to do because the likes of Mohr and Kazui say so. Unfortunately, they are not replicating what the experts in asia and europe do and therein comes the problem.
>
>
>
> Anyone who wants to take on a new technique should emmulate that of the originators - the entire package to the small print - for you do not know the component of the technique that yields efficacy and that that yields safety. A lot of animal and clinical work has gotten them (originators) to their settled technique; to sit down one day in our own offices and decide - without experimentation or logic - how to recreate their operation is potentially dangerous for our patients.
>
>
>
> Several of the variants being described here - such as perfusing only the innominate and clamping Left Carotid, perfusing the innominate and left carotid and leaving left subclavian bleeding, perfusing innominate and left carotid and clamping left subclavian - all done without brain monitoring negates some of the essential principles of the antegrade cerebral perfusion/moderate hypothermia approach. For example, the above variants assume a complete circle of willis (sometimes not the case), assumes cerebral circulation free of atherosclerosis (often not the case), negates the contributions of the vertebral arteries to the posterior brain circulation, negates the importance of spinal cord perfusion, ignores the contribution of collaterals from left subclavian to lower body perfusion. Fine if all one is doing is an open distal anastomosis - that can be done safely at 28 degrees even without cerebral perfusion as will take 10 to 15 minutes which most
> viscera can cope with, as shown experimentally, but if circulatory arrest is longer, one must give thought to protection of every organ in the body.
>
>
>
> Many of the 'experts' would cringe at what is being done or proposed in their name in this thread, as they (experts) would never do it that way and would not support uncontrolled and unstudied changes to a well worked out operation. Undertaking arch operations at 26 degrees without brain monitoring and without left subclavian perfusion amounts to playing Russian Roulette with other human being's brain, intestines, and spinal cord. Most of the times you will get away with it but occasionally disaster will occur.
>
>
>
> Ani
>
>
>
>
>
> > Date: Fri, 6 Mar 2009 08:01:48 -0800
> > From: drdharris at yahoo.co.uk
> > Subject: Re: [HSF] &quot;Internal Sleeve&quot;
> > To: benjamin.bidstrup at bigpond.com; OpenHeart-L at lists.hsforum.com
> > CC:
> >
> >
> > I have been using innominate, and it works well. I use a straight DLP aortic and it works well. I did a patient the way Hal mentioned and he died from gut ischaemia. The most experienced aortic surgeons use cold so why should we differ. We should do what they do and let them do the research. Dave
> >
> > Ben Bidstrup wrote:
> > > This all sounds better than digging out the axillary artery. How often is the innominate diseased in your opinion as to cause concern re distal embolism?
> > > Also over time with some organisation, you could get total arrest time down to a few minutes only. I take it you mean distal body arrest whilst you do the distal arch anastomosis.
> > > I have made some of those grafts with 3/0 prolene and Gelseal and they work well no need to spend a fortune on the premade ones.
> > > Ben Bidstrup FRACS FRCSEd FEBCTS
> > > Cardiothoracic Surgeon
> > > On 06/03/2009, at 11:23 AM, Hgrmd at aol.com wrote:
> > >> Roberto,
> > >> A week ago, I did a hemiarch replacement on an 84 yo man at 26 degrees. I
> > >> directly cannulated the innominate. During selective perfusion, I clamped
> > >> the take off of the innominate and gave half the flow down the arterial
> > >> cannula. The other half went down an autoinflating regrograde cannula placed in
> > >> the left common. I just let the left subclavian backbleed. The arrest time
> > >> was 27 minutes. The patient did fine. My question is whether it is necessary
> > >> to block or perfuse the left subclavian. Other than preventing steal from
> > >> the left vertebral, I don't really see the advantage.
> > >>
> > >> Hal
> > >>
> > >>
> > >> In a message dated 3/5/2009 5:21:30 A.M. Eastern Standard Time,
> > >> robertobattellini at hotmail.com writes:
> > >>
> > >>
> > >> Prasanna,
> > >>
> > >>
> > >>
> > >> Look at Strauch et al EJCTS 2004, he studied the spinal cord of pigs under
> > >> normothermia and 32 degrees, a reduction of 5 degrees centigrades helped to
> > >> prolongue the ischemia tolerance up to 50 minutes.
> > >>
> > >> If you extrapolate this to the arch surgery, and you DO perfuse the
> > >> innominate artery and the left carotid and block or perfuse the left subclavia, you
> > >> can perform your operation at 26 degrees as Giuseppe says, providing you do
> > >> the distal in less than 30 minutes (for security).And if you need distal aortic
> > >> perfusion, use the Dalla Torre technique of using a tracheal cannula and
> > >> perfuse distally.You need a second arterial line in Y and that´s all.
> > >>
> > >> Of course, we have a little extra heat exchanger for that line, so if the
> > >> core temperature is 26, we can perfuse the brain at 20°C.
> > >>
> > >> We do all that surgery at 25-26 degrees, axillary cannulation.
> > >>
> > >> Roberto
> > >>
> > >>> Date: Wed, 4 Mar 2009 23:53:43 +0100
> > >>> From: grescigno at mac.com
> > >>> To: OpenHeart-L at lists.hsforum.com
> > >>> Subject: Re: [HSF] "Internal Sleeve"
> > >>> CC:
> > >>>
> > >>> Prasanna,
> > >>>
> > >>> very nice case. I have just 2 comments: 1. I think that you should switch
> > >> to 26 °C, at least for an end to end anastomosis. 2. I am not using the
> > >> innominate trunk (even if I think that is a very good idea, as 90% of my
> > >> circulatory arrests are for aortic dissections and I am too worried about an
> > >> involvement of the innominate artery.
> > >>>
> > >>> Giuseppe
> > >>>
> > >>>
> > >>> Giuseppe Rescigno M.D.
> > >>> Cardiothoracic Surgeon
> > >>>
> > >>> Lancisi Hospital
> > >>> Torrette - Ancona
> > >>> Italy
> > >>>
> > >>>
> > >>>
> > >>> On Wednesday, March 04, 2009, at 07:45PM, "Prasanna Simha M"
> > >> <prasannasimha at gmail.com> wrote:
> > >>>> 26 year old lady , Marfanoid presented with an ascending aortic aneurysm +
> > >>>> severe AR. Leaflets looked normal and mechanism of AR appeared due to ST
> > >>>> junction dilatation. She was AB positive and there was cncerns regarding
> > >>>> adequate supply of blood products as there was a bleeder case which had
> > >>>> reduced AB +ve donor pool in the city.(We had blood but not a very large
> > >>>> donor pool)
> > >>>> I planned to see the leaflets and if normal considered her for valve
> > >>>> sparing ascending aortic replacement with root reconstruction.
> > >>>> On table the aneurysm was up to the innominate and I cannulated the
> > >>>> innominate artery for systemic perfusion and also for innominate artery
> > >>>> perfusion.
> > >>>> On opening the aorta there was thickened wall (Not marfanoid) which was
> > >> sent
> > >>>> for biopsy (Histopath awaited) .The leaflets looked normal and well
> > >>>> preserved. I decided to use a technique described in Interactive journal
> > >> of
> > >>>> CT surgery (Original plan was for a Florida sleeve) and used an annular
> > >>>> stabilizing suture as described by Lars Svensson (The LV aortic junction
> > >> was
> > >>>> not actually dilated) and then placed 3 tear drop patches fixed
> > >> subannularly
> > >>>> with pledgeted sutures in each sinus with fenestrations for the coronaries
> > >>>> with the ostia fixed to the fenstrations. (The RCA ostium was painfully
> > >>>> small !!). This allowed good coaptation. Under ACP at 18 Deg C (I am still
> > >>>> not confident of doing it at higher temperatures) I did an intraluminal
> > >>>> hemiarch placement.The tube was then attached to the teardrop patches
> > >> which
> > >>>> had been fixed at the ST junction.I then placed a prophylactic cabrol
> > >> patch
> > >>>> fistula as soon as I came off CPB as I was worried about blood and blood
> > >>>> product usage (As you can see there wasnt much bleeding and the fistula
> > >> hood
> > >>>> is not distended so its use may be questioned).
> > >>>> Intraop Echo showed Mild AR and was accepted. Total blood loss in the ICU
> > >>>> was a worrisome 20 ml !!
> > >>>> Patient was extubated within 6 hours and is doing well and will be
> > >>>> discharged tomorrow when the HPE report comes.The postop transthoracic
> > >> echo
> > >>>> shows the Cabrol patch fistula has closed.
> > >>>> Questions are how many of the members use innominate cannulation versus
> > >>>> axillary cannulation and reasons for the preerence.What are the problems
> > >>>> that the members have occurred with each strategy.
> > >>>> What are the tips and tricks that people who do aortic sparing surgery use
> > >>>> to judge aortic competence during intraop testing .(Not echocardiographic
> > >>>> which requires going off CPB ) as I find my judgement with aortic repairs
> > >>>> still hazy. Apart from holding water and visual inspection I also use the
> > >>>> method of El Khoury of placing a sucker in the LVOT and allowing the
> > >>>> leaflets to oppose and pull it (the sucker) out but somehow I am not able
> > >> to
> > >>>> get the leaflets to stay put as I feel that the negative suction gets lost
> > >>>> by the time I pull the sucker out (Maybe It may be becuase I am using the
> > >>>> big Yankauer sucker which may be part of the problem and am planning to
> > >> use
> > >>>> a dentist irrigation sucker for the same.
> > >>>>
> > >>>>
> > >>>> --Prasanna Simha M
> > >>>>
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