From alsadd at KSU.EDU.SA Mon Feb 1 08:56:54 2010 From: alsadd at KSU.EDU.SA (Ahmed Alsaddique) Date: Mon Feb 1 01:02:06 2010 Subject: [HSF] Blood transfusion for the postop heart In-Reply-To: References: <781462.16284.qm@web24703.mail.ird.yahoo.com> <001701caa034$fd2ae1f0$b28ca20a@tjumst.jefferson.edu> <759057.79616.qm@web81604.mail.mud.yahoo.com>, Message-ID: <0DB0EC72E0C57B4E8A40AD93AB7C605203FECFD3EA0C@KSUVMB02.KSU.LOCAL> Tony: I am the one who started this thread but I became too busy to log in. I find that a HCT of 15 as your threshold is interesting and will implement it ( being your student) with the same provisions you made. We were more liberal than that but not any more. Thank you Ahmed ________________________________________ From: openheart-l-bounces@lists.hsforum.com [openheart-l-bounces@lists.hsforum.com] On Behalf Of Anthony P Furnary MD [tfurnary@starrwood.com] Sent: Monday, February 01, 2010 8:39 AM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Blood transfusion for the postop heart Tea -- I totally agree. BTW -- I un-trapped my historical learnings. 15 is my threshold, (unless a vital complication exists that threatens the life of the patient and is related to the low Hct..) Tony On Jan 28, 2010, at 8:42 PM, Tea Acuff wrote: > I know we seem finished with this topic, but the same themes keep on > appearing be it transfusion or MICS or the next focus. > > We all agree that use of femoral cannula is not the same as MICS, > but do we realize that whether blood transfusion is a marker for > result (good or bad) is a completely different discussion or slice > of reality than whether to transfuse all patients at a Hct of 24 or > 30. > > When you look at a number or mark like HCT, glucose, or MICS or > femoral cannula it is as if you hold a set of cards in poker. What > you need is determined by where you currently are. If you already > have a ten, a ten is better than an ace which is otherwise ideally > best. > Picking a number to transfuse or case to femorally cannulate before > the number or event happens is like betting before the cards are > dealt. We are all going to bet if we play, but when is the best time? > > I talked about planning. Should we place our bet before we get our > first cards or second cards. Should we choose to transfuse everyone > on a standard order sheet? > > How do we decide how to decide? > > Of course the interesting thing is not so much the actual number or > HCT at all. > It does not matter whether we find out about in the morning or the > totally stupid late night call stating only that "the HCT is 23". It > is not about the reams of EBM that correlate transfusion this and > level of that. It is about everything else. What is the BP? Are we > bleeding? any drips? Oh the Jehovah witness patient! Etc. > > It of course is hardest to allow a vital threshhold to drop as it > requires more data and education than the simple transfuse at "x". > That does not mean it is best, but it is harder. > > I personally try as much as possible to empower these realtional > choices to those at the bedside and minimize the standing orders. > This of course flies in the face of the thinking that I constantly > rag on and on which is mostly how eveyone else organizes things, > that is, hierarchical: the hct. Nursing can be designed differently > (relationally perhaps)as can medicine, but we are trapped by our > historical ideas. > > Surely you, doctor, know when to transfuse, so when? If we can't > pick we can always vote right? > > tea > > > > ________________________________ > From: Scott Silvestry > To: OpenHeart-L@lists.hsforum.com > Sent: Thu, January 28, 2010 10:14:37 AM > Subject: RE: [HSF] Blood transfusion for the postop heart > > Guiseppe: > > I don't think Tony is saying we should fight it per se, just be > intellectually honest in assessing the effects of transfusion. > > > These articles are real eye openers- and suggest the effects we hope > to see, > may not be there. > > http://www.pnas.org/content/104/43/17063.full.pdf > > Evolution of adverse changes in stored RBCs > Elliott Bennett-Guerrero > > Recent studies have underscored questions about the balance of risk > and > benefit of RBC transfusion. A better understanding of the nature and > timing > of molecular and functional changes in stored RBCs may provide > strategies to > improve the balance of benefit and risk of RBC transfusion. We > analyzed > changes occurring during RBC storage focusing on RBC deformability, > RBC-dependent vasoregulatory function, and S-nitrosohemoglobin (SNO- > Hb), > through which hemoglobin(Hb) O2 desaturation is coupled to regional > increases in blood flow in vivo (hypoxic vasodilation). Five hundred > ml of > blood from each of 15 healthy volunteers was processed into > leukofiltered, > additive solution 3-exposed RBCs and stored at 1?6?C according to AABB > standards. Blood was subjected to 26 assays at 0, 3, 8, 24 and 96 h, > and at > 1, 2, 3, 4, and 6 weeks. RBC SNO-Hb decreased rapidly (1.2 104 at 3 > h vs. > 6.5 104 (fresh) mol S-nitrosothiol (SNO)/mol Hb tetramer (P 0.032, > mercuric-displaced photolysis chemiluminescence assay), and remained > low > over the 42-day period. The decline was corroborated by using the > carbon > monoxide-saturated copper-cysteine assay [3.0 105 at 3 h vs. 9.0 105 > (fresh) mol SNO/mol Hb]. In parallel, vasodilation by stored RBCs was > significantly depressed. RBC deformability assayed at a > physiological shear > stress decreased gradually over the 42-day period (P < 0.001). Time > courses > vary for several storage-induced defects that might account for recent > observations linking blood transfusion with adverse outcomes. Of > clinical > concern is that SNO levels, and their physiological correlate, RBC- > dependent > vasodilation, become depressed soon after collection, suggesting > that even > ??fresh?? blood may have developed adverse biological characteristics. > > > > http://www.pnas.org/content/104/43/17058.full.pdf > > S-nitrosohemoglobin deficiency: A mechanism for > loss of physiological activity in banked blood > James D. Reynolds* > RBCs distribute oxygen to tissues, but, paradoxically, blood > transfusion > does not always improve oxygen delivery and is associated with > ischemic > events. We hypothesized that storage of blood would result in loss > of NO > bioactivity, impairing RBC vasodilation and thus compromising blood > flow, > and that repleting NO bioactivity would restore RBC function. We > report that > S-nitrosohemoglobin (SNO-Hb) concentrations declined rapidly after > storage > of fresh venous blood and that hypoxic vasodilation by banked RBCs > correlated strongly with the amounts of SNO-Hb (r2 0.90; P < 0.0005). > Renitrosylation of banked blood during storage increased the SNO-Hb > content > and restored its vasodilatory activity. In addition, canine coronary > blood > flow was greater during infusion of renitrosylated RBCs than during > infusion > of S-nitrosothiol-depleted RBCs, and this > difference in coronary flow was accentuated by hypoxemia (P < > 0.001). Our > findings indicate that NO bioactivity is depleted in banked blood, > impairing > the vasodilatory response to hypoxia, and they suggest that SNO-Hb > repletion > may improve transfusion efficacy. > > > > > > > Scott C. Silvestry, MD > Associate Professor of Surgery > Division of Cardiac Surgery > Thomas Jefferson University Hospital > 1025 Walnut Street > 607 College > Philadelphia, PA 19107 > Phone (215)955-6996 > Fax (215) 955-6010 > Email: scott.silvestry@jefferson.edu > > The information contained in this email is confidential, privileged, > or > otherwise protected from disclosure. It is intended only for the > use of the > authorized individual as indicated in the e-mail. Any unauthorized > disclosure, copying, distribution or taking of any action based on the > contents of this material is strictly prohibited. Review by any > individual > other than the intended recipient does not waive or give up the > physician-patient privilege. > > If you received this e-mail in error, please delete it immediately. > > > > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com > [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Giuseppe > Rescigno > Sent: Thursday, January 28, 2010 5:34 AM > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] Blood transfusion for the postop heart > > David, > > I completely agree. Our population is actually so sick, elerly and > with multiple comorbidities that fighting a fundamentalist battle > against blood transfusion is not my first priority. In my center we > have the 8 grams of Hb as threshold. Moreover, and this is not an > excuse but just reality, in case of any unrelated problem, the judge > will surely consider the anemic state as a possible collateral cause. > > Giuseppe > > > > Il giorno 28/gen/10, alle ore 07:03, David Harris ha scritto: > >> I just think that's a reflection of a sicker patient who has had >> more acute blood loss, thus organ malperfusion. Not blood >> transfusion per se. I have never seen a prob$em with a patient who >> gets 1 or 2 units a few days down the line for Hb that's drifted >> below 9. In fact recovery and wound healing is better. Patients >> also feel instantly better and start to mobilise faster, especially >> if heart failure. I see more benefit than harm aiming for HKT 30. >> Dfave >> >> On Thu, 28 Jan 2010 02:07 EET Anthony P Furnary Md wrote: >> >>> YIKES!!! >>> >>> Speaking of education.... Here are some of the data: >>> >>> Multiple studies have shown that more perioperative blood (as in >>> transfused PRBCs) = >>> >>> More acute renal failure >>> More infections >>> More acute heart failure and low cardiac output syndrome >>> And most importantly, in CABG patients: >>> Significantly worse long term survival. >>> >>> I think, for my patients at least, that is Certainly worth >>> fighting for, no matter how much sleep is lost. Actually I loose >>> less, because the nurses and PAs know not to call me for a low >>> Hct, as I will not transfuse, unless the patient requests it and >>> completely understands the implications of even a single unit of >>> PRBC. >>> >>> Would never put my own interests (sleep, fighting a battle for a >>> patient benefit, etc) above a patients' best interest. >>> >>> Sorry, >>> Tony >>> Sent from my iPhone >>> >>> On Jan 27, 2010, at 8:15 AM, Michael Firstenberg >>> wrote: >>> >>>> yeah - what prasanna said. >>>> I have a very very low threshold for transfusing people up to >>>> close to 30. >>>> 1) Old patients with bad hearts "feel better" and contrary to >>>> all of the data - their organs and hemodynamics like it >>>> 2) Anyone leaving on coumadin (yuck, rat poison) - who might bleed >>>> 3) Anyone going to a nursing home/etc in which someone might >>>> check their levels "just because" (and then send them back to the >>>> hospital for a bleeding work-up when the numbers are low) >>>> 4) Anyone who might need another procedure soon - like a pacer/icd >>>> >>>> 5) Education is key - but it is not worth fighting over or >>>> losing sleep. Some of my partners get called in the middle of >>>> the night when the morning labs come back and the hcts are in the >>>> 8's asking about giving blood....... I like to sleep! I trust >>>> the night team to use their judgement...... there are larger >>>> battles to fight. >>>> >>>> >>>> now - we can discuss whether it is a scarce and/or expensive >>>> resource...... >>>> >>>> >>>> >>>> On Jan 27, 2010, at 6:57 AM, Prasanna Simha M wrote: >>>> >>>>> An example of cases where oxygen delivery and extraction is >>>>> important >>>>> is incomplete comgenital corrections where a higher Hb has to be >>>>> achieved to allow oxygen deklivery in deasturated patients. >>>>> Prasanna >>>>> >>>>> On Wed, Jan 27, 2010 at 5:18 PM, Prasanna Simha M >>>>> wrote: >>>>>> This has lead to a lot of hot blood ! >>>>>> Strictly there is no real transfusion trigger ever >>>>>> demonstrated. A >>>>>> large multicentric study showed that a Hb of > 7 Gm is enough for >>>>>> noninfants and less than 65 years and a higher Hb of 8 may be >>>>>> needed >>>>>> for elderly and infants. I am extremely stingy and will not >>>>>> transfuse >>>>>> unless the oxygen extraction or hemodynamics are impaired by an >>>>>> objective criterion. More importantly I try to conserve blood and >>>>>> prevent blood loss on the first place. >>>>>> Prasanna. >>>>>> Prasanna >>>>>> >>>>>> On Wed, Jan 27, 2010 at 1:14 PM, Ahmed Alsaddique >>>>>> wrote: >>>>>>> It would be interesting to get a feel from the Forum about the >>>>>>> transfusion policy in the post op heart. >>>>>>> I am interested in getting the members threshold for >>>>>>> transfusion? I am labeled as stingy when it comes to >>>>>>> transfusion >>>>>>> Thank you >>>>>>> >>>>>>> Ahmed >>>>>>> _______________________________________________ >>>>>>> OpenHeart-L mailing list >>>>>>> >>>>>>> Send postings to: >>>>>>> OpenHeart-L@lists.hsforum.com >>>>>>> >>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>>>> http://mmp.cjp.com/mailman/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 >>>>> _______________________________________________ >>>>> OpenHeart-L mailing list >>>>> >>>>> Send postings to: >>>>> OpenHeart-L@lists.hsforum.com >>>>> >>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>> http://mmp.cjp.com/mailman/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 anddisclaimers 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 hgrmd at aol.com Mon Feb 1 09:52:28 2010 From: hgrmd at aol.com (hgrmd@aol.com) Date: Mon Feb 1 04:52:10 2010 Subject: [HSF] Blood transfusion for the postop heart In-Reply-To: <0DB0EC72E0C57B4E8A40AD93AB7C605203FECFD3EA0C@KSUVMB02.KSU.LOCAL> References: <781462.16284.qm@web24703.mail.ird.yahoo.com><001701caa034$fd2ae1f0$b28ca20a@tjumst.jefferson.edu><759057.79616.qm@web81604.mail.mud.yahoo.com>, <0DB0EC72E0C57B4E8A40AD93AB7C605203FECFD3EA0C@KSUVMB02.KSU.LOCAL> Message-ID: <298065774-1265017898-cardhu_decombobulator_blackberry.rim.net-104298272-@bda730.bisx.prod.on.blackberry> So, do you plan to send these patients home on Levophed? A HCT of 15 may be tolerated in a young person, but I've not seen many patients who will have a decent BP with such severe anemia. Also, what about the CPB data says HCT's below 20 during a pump run are associated with higher mortality, presumably due to impaired oxygen delivery? Hal Sent from my Verizon Wireless BlackBerry -----Original Message----- From: Ahmed Alsaddique Date: Mon, 1 Feb 2010 08:56:54 To: OpenHeart-L@lists.hsforum.com Subject: RE: [HSF] Blood transfusion for the postop heart Tony: I am the one who started this thread but I became too busy to log in. I find that a HCT of 15 as your threshold is interesting and will implement it ( being your student) with the same provisions you made. We were more liberal than that but not any more. Thank you Ahmed ________________________________________ From: openheart-l-bounces@lists.hsforum.com [openheart-l-bounces@lists.hsforum.com] On Behalf Of Anthony P Furnary MD [tfurnary@starrwood.com] Sent: Monday, February 01, 2010 8:39 AM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Blood transfusion for the postop heart Tea -- I totally agree. BTW -- I un-trapped my historical learnings. 15 is my threshold, (unless a vital complication exists that threatens the life of the patient and is related to the low Hct..) Tony On Jan 28, 2010, at 8:42 PM, Tea Acuff wrote: > I know we seem finished with this topic, but the same themes keep on > appearing be it transfusion or MICS or the next focus. > > We all agree that use of femoral cannula is not the same as MICS, > but do we realize that whether blood transfusion is a marker for > result (good or bad) is a completely different discussion or slice > of reality than whether to transfuse all patients at a Hct of 24 or > 30. > > When you look at a number or mark like HCT, glucose, or MICS or > femoral cannula it is as if you hold a set of cards in poker. What > you need is determined by where you currently are. If you already > have a ten, a ten is better than an ace which is otherwise ideally > best. > Picking a number to transfuse or case to femorally cannulate before > the number or event happens is like betting before the cards are > dealt. We are all going to bet if we play, but when is the best time? > > I talked about planning. Should we place our bet before we get our > first cards or second cards. Should we choose to transfuse everyone > on a standard order sheet? > > How do we decide how to decide? > > Of course the interesting thing is not so much the actual number or > HCT at all. > It does not matter whether we find out about in the morning or the > totally stupid late night call stating only that "the HCT is 23". It > is not about the reams of EBM that correlate transfusion this and > level of that. It is about everything else. What is the BP? Are we > bleeding? any drips? Oh the Jehovah witness patient! Etc. > > It of course is hardest to allow a vital threshhold to drop as it > requires more data and education than the simple transfuse at "x". > That does not mean it is best, but it is harder. > > I personally try as much as possible to empower these realtional > choices to those at the bedside and minimize the standing orders. > This of course flies in the face of the thinking that I constantly > rag on and on which is mostly how eveyone else organizes things, > that is, hierarchical: the hct. Nursing can be designed differently > (relationally perhaps)as can medicine, but we are trapped by our > historical ideas. > > Surely you, doctor, know when to transfuse, so when? If we can't > pick we can always vote right? > > tea > > > >________________________________ > From: Scott Silvestry > To: OpenHeart-L@lists.hsforum.com > Sent: Thu, January 28, 2010 10:14:37 AM > Subject: RE: [HSF] Blood transfusion for the postop heart > > Guiseppe: > > I don't think Tony is saying we should fight it per se, just be > intellectually honest in assessing the effects of transfusion. > > > These articles are real eye openers- and suggest the effects we hope > to see, > may not be there. > > http://www.pnas.org/content/104/43/17063.full.pdf > > Evolution of adverse changes in stored RBCs > Elliott Bennett-Guerrero > > Recent studies have underscored questions about the balance of risk > and > benefit of RBC transfusion. A better understanding of the nature and > timing > of molecular and functional changes in stored RBCs may provide > strategies to > improve the balance of benefit and risk of RBC transfusion. We > analyzed > changes occurring during RBC storage focusing on RBC deformability, > RBC-dependent vasoregulatory function, and S-nitrosohemoglobin (SNO- > Hb), > through which hemoglobin(Hb) O2 desaturation is coupled to regional > increases in blood flow in vivo (hypoxic vasodilation). Five hundred > ml of > blood from each of 15 healthy volunteers was processed into > leukofiltered, > additive solution 3-exposed RBCs and stored at 1?6?C according to AABB > standards. Blood was subjected to 26 assays at 0, 3, 8, 24 and 96 h, > and at > 1, 2, 3, 4, and 6 weeks. RBC SNO-Hb decreased rapidly (1.2 104 at 3 > h vs. > 6.5 104 (fresh) mol S-nitrosothiol (SNO)/mol Hb tetramer (P 0.032, > mercuric-displaced photolysis chemiluminescence assay), and remained > low > over the 42-day period. The decline was corroborated by using the > carbon > monoxide-saturated copper-cysteine assay [3.0 105 at 3 h vs. 9.0 105 > (fresh) mol SNO/mol Hb]. In parallel, vasodilation by stored RBCs was > significantly depressed. RBC deformability assayed at a > physiological shear > stress decreased gradually over the 42-day period (P < 0.001). Time > courses > vary for several storage-induced defects that might account for recent > observations linking blood transfusion with adverse outcomes. Of > clinical > concern is that SNO levels, and their physiological correlate, RBC- > dependent > vasodilation, become depressed soon after collection, suggesting > that even > ??fresh?? blood may have developed adverse biological characteristics. > > > > http://www.pnas.org/content/104/43/17058.full.pdf > > S-nitrosohemoglobin deficiency: A mechanism for > loss of physiological activity in banked blood > James D. Reynolds* > RBCs distribute oxygen to tissues, but, paradoxically, blood > transfusion > does not always improve oxygen delivery and is associated with > ischemic > events. We hypothesized that storage of blood would result in loss > of NO > bioactivity, impairing RBC vasodilation and thus compromising blood > flow, > and that repleting NO bioactivity would restore RBC function. We > report that > S-nitrosohemoglobin (SNO-Hb) concentrations declined rapidly after > storage > of fresh venous blood and that hypoxic vasodilation by banked RBCs > correlated strongly with the amounts of SNO-Hb (r2 0.90; P < 0.0005). > Renitrosylation of banked blood during storage increased the SNO-Hb > content > and restored its vasodilatory activity. In addition, canine coronary > blood > flow was greater during infusion of renitrosylated RBCs than during > infusion > of S-nitrosothiol-depleted RBCs, and this > difference in coronary flow was accentuated by hypoxemia (P < > 0.001). Our > findings indicate that NO bioactivity is depleted in banked blood, > impairing > the vasodilatory response to hypoxia, and they suggest that SNO-Hb > repletion > may improve transfusion efficacy. > > > > > > > Scott C. Silvestry, MD > Associate Professor of Surgery > Division of Cardiac Surgery > Thomas Jefferson University Hospital > 1025 Walnut Street > 607 College > Philadelphia, PA 19107 > Phone (215)955-6996 > Fax (215) 955-6010 > Email: scott.silvestry@jefferson.edu > > The information contained in this email is confidential, privileged, > or > otherwise protected from disclosure. It is intended only for the > use of the > authorized individual as indicated in the e-mail. Any unauthorized > disclosure, copying, distribution or taking of any action based on the > contents of this material is strictly prohibited. Review by any > individual > other than the intended recipient does not waive or give up the > physician-patient privilege. > > If you received this e-mail in error, please delete it immediately. > > > > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com > [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Giuseppe > Rescigno > Sent: Thursday, January 28, 2010 5:34 AM > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] Blood transfusion for the postop heart > > David, > > I completely agree. Our population is actually so sick, elerly and > with multiple comorbidities that fighting a fundamentalist battle > against blood transfusion is not my first priority. In my center we > have the 8 grams of Hb as threshold. Moreover, and this is not an > excuse but just reality, in case of any unrelated problem, the judge > will surely consider the anemic state as a possible collateral cause. > > Giuseppe > > > > Il giorno 28/gen/10, alle ore 07:03, David Harris ha scritto: > >> I just think that's a reflection of a sicker patient who has had >> more acute blood loss, thus organ malperfusion. Not blood >> transfusion per se. I have never seen a prob$em with a patient who >> gets 1 or 2 units a few days down the line for Hb that's drifted >> below 9. In fact recovery and wound healing is better. Patients >> also feel instantly better and start to mobilise faster, especially >> if heart failure. I see more benefit than harm aiming for HKT 30. >> Dfave >> >> On Thu, 28 Jan 2010 02:07 EET Anthony P Furnary Md wrote: >> >>> YIKES!!! >>> >>> Speaking of education.... Here are some of the data: >>> >>> Multiple studies have shown that more perioperative blood (as in >>> transfused PRBCs) = >>> >>> More acute renal failure >>> More infections >>> More acute heart failure and low cardiac output syndrome >>> And most importantly, in CABG patients: >>> Significantly worse long term survival. >>> >>> I think, for my patients at least, that is Certainly worth >>> fighting for, no matter how much sleep is lost. Actually I loose >>> less, because the nurses and PAs know not to call me for a low >>> Hct, as I will not transfuse, unless the patient requests it and >>> completely understands the implications of even a single unit of >>> PRBC. >>> >>> Would never put my own interests (sleep, fighting a battle for a >>> patient benefit, etc) above a patients' best interest. >>> >>> Sorry, >>> Tony >>> Sent from my iPhone >>> >>> On Jan 27, 2010, at 8:15 AM, Michael Firstenberg >>> wrote: >>> >>>> yeah - what prasanna said. >>>> I have a very very low threshold for transfusing people up to >>>> close to 30. >>>> 1) Old patients with bad hearts "feel better" and contrary to >>>> all of the data - their organs and hemodynamics like it >>>> 2) Anyone leaving on coumadin (yuck, rat poison) - who might bleed >>>> 3) Anyone going to a nursing home/etc in which someone might >>>> check their levels "just because" (and then send them back to the >>>> hospital for a bleeding work-up when the numbers are low) >>>> 4) Anyone who might need another procedure soon - like a pacer/icd >>>> >>>> 5) Education is key - but it is not worth fighting over or >>>> losing sleep. Some of my partners get called in the middle of >>>> the night when the morning labs come back and the hcts are in the >>>> 8's asking about giving blood....... I like to sleep! I trust >>>> the night team to use their judgement...... there are larger >>>> battles to fight. >>>> >>>> >>>> now - we can discuss whether it is a scarce and/or expensive >>>> resource...... >>>> >>>> >>>> >>>> On Jan 27, 2010, at 6:57 AM, Prasanna Simha M wrote: >>>> >>>>> An example of cases where oxygen delivery and extraction is >>>>> important >>>>> is incomplete comgenital corrections where a higher Hb has to be >>>>> achieved to allow oxygen deklivery in deasturated patients. >>>>> Prasanna >>>>> >>>>> On Wed, Jan 27, 2010 at 5:18 PM, Prasanna Simha M >>>>> wrote: >>>>>> This has lead to a lot of hot blood ! >>>>>> Strictly there is no real transfusion trigger ever >>>>>> demonstrated. A >>>>>> large multicentric study showed that a Hb of > 7 Gm is enough for >>>>>> noninfants and less than 65 years and a higher Hb of 8 may be >>>>>> needed >>>>>> for elderly and infants. I am extremely stingy and will not >>>>>> transfuse >>>>>> unless the oxygen extraction or hemodynamics are impaired by an >>>>>> objective criterion. More importantly I try to conserve blood and >>>>>> prevent blood loss on the first place. >>>>>> Prasanna. >>>>>> Prasanna >>>>>> >>>>>> On Wed, Jan 27, 2010 at 1:14 PM, Ahmed Alsaddique >>>>>> wrote: >>>>>>> It would be interesting to get a feel from the Forum about the >>>>>>> transfusion policy in the post op heart. >>>>>>> I am interested in getting the members threshold for >>>>>>> transfusion? I am labeled as stingy when it comes to >>>>>>> transfusion >>>>>>> Thank you >>>>>>> >>>>>>> Ahmed >>>>>>>_______________________________________________ >>>>>>> OpenHeart-L mailing list >>>>>>> >>>>>>> Send postings to: >>>>>>> OpenHeart-L@lists.hsforum.com >>>>>>> >>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>>>> http://mmp.cjp.com/mailman/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 >>>>>_______________________________________________ >>>>> OpenHeart-L mailing list >>>>> >>>>> Send postings to: >>>>> OpenHeart-L@lists.hsforum.com >>>>> >>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>> http://mmp.cjp.com/mailman/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 anddisclaimers 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 wftjrtyler at aol.com Mon Feb 1 06:28:54 2010 From: wftjrtyler at aol.com (wftjrtyler@aol.com) Date: Mon Feb 1 06:30:04 2010 Subject: [HSF] Blood transfusion for the postop heart Message-ID: <1189.a976a13.389814f6@aol.com> In a message dated 1/31/2010 11:32:07 PM Central Standard Time, tfurnary@starrwood.com writes: My transfusion "threshold" is Hct of 15. Tony, How did you determine 15 to be the threshold? bill From grescigno at mac.com Mon Feb 1 14:38:10 2010 From: grescigno at mac.com (Giuseppe Rescigno) Date: Mon Feb 1 08:47:08 2010 Subject: [HSF] Blood transfusion for the postop heart In-Reply-To: References: <781462.16284.qm@web24703.mail.ird.yahoo.com> Message-ID: <23914C0D-8C40-472E-AA5A-F779606AEAE0@mac.com> Tony, have you ever published your results with such a low threshold? I am quite surprised as for the populations I deal with it is difficult to achieve. Giuseppe Il giorno 01/feb/10, alle ore 06:29, Anthony P Furnary MD ha scritto: > Dave -- It's not a reflection of anything of the sort. > > Even one unit of blood in an elective CABG patient decreases > survival and increases the likelihood of ARF. > > Widely supported in the literature. Not anecdotal -- that's where > we never seem to remember the causal associations of complications > we've "seen".. and thus have "never seen " them. Not due to > "sicker" patient population. Multiple publications implicating > transfusions in worsening heart failure. > > My transfusion "threshold" is Hct of 15. > > Tony > On Jan 27, 2010, at 10:03 PM, David Harris wrote: > >> I just think that's a reflection of a sicker patient who has had >> more acute blood loss, thus organ malperfusion. Not blood >> transfusion per se. I have never seen a prob$em with a patient who >> gets 1 or 2 units a few days down the line for Hb that's drifted >> below 9. In fact recovery and wound healing is better. Patients >> also feel instantly better and start to mobilise faster, >> especially if heart failure. I see more benefit than harm aiming >> for HKT 30. Dfave >> >> On Thu, 28 Jan 2010 02:07 EET Anthony P Furnary Md wrote: >> >>> YIKES!!! >>> >>> Speaking of education.... Here are some of the data: >>> >>> Multiple studies have shown that more perioperative blood (as in >>> transfused PRBCs) = >>> >>> More acute renal failure >>> More infections >>> More acute heart failure and low cardiac output syndrome >>> And most importantly, in CABG patients: >>> Significantly worse long term survival. >>> >>> I think, for my patients at least, that is Certainly worth >>> fighting for, no matter how much sleep is lost. Actually I loose >>> less, because the nurses and PAs know not to call me for a low >>> Hct, as I will not transfuse, unless the patient requests it and >>> completely understands the implications of even a single unit of >>> PRBC. >>> >>> Would never put my own interests (sleep, fighting a battle for a >>> patient benefit, etc) above a patients' best interest. >>> >>> Sorry, >>> Tony >>> Sent from my iPhone >>> >>> On Jan 27, 2010, at 8:15 AM, Michael Firstenberg >>> wrote: >>> >>>> yeah - what prasanna said. >>>> I have a very very low threshold for transfusing people up to >>>> close to 30. >>>> 1) Old patients with bad hearts "feel better" and contrary to >>>> all of the data - their organs and hemodynamics like it >>>> 2) Anyone leaving on coumadin (yuck, rat poison) - who might bleed >>>> 3) Anyone going to a nursing home/etc in which someone might >>>> check their levels "just because" (and then send them back to >>>> the hospital for a bleeding work-up when the numbers are low) >>>> 4) Anyone who might need another procedure soon - like a pacer/icd >>>> >>>> 5) Education is key - but it is not worth fighting over or >>>> losing sleep. Some of my partners get called in the middle of >>>> the night when the morning labs come back and the hcts are in >>>> the 8's asking about giving blood....... I like to sleep! I >>>> trust the night team to use their judgement...... there are >>>> larger battles to fight. >>>> >>>> >>>> now - we can discuss whether it is a scarce and/or expensive >>>> resource...... >>>> >>>> >>>> >>>> On Jan 27, 2010, at 6:57 AM, Prasanna Simha M wrote: >>>> >>>>> An example of cases where oxygen delivery and extraction is >>>>> important >>>>> is incomplete comgenital corrections where a higher Hb has to be >>>>> achieved to allow oxygen deklivery in deasturated patients. >>>>> Prasanna >>>>> >>>>> On Wed, Jan 27, 2010 at 5:18 PM, Prasanna Simha M >>>>> wrote: >>>>>> This has lead to a lot of hot blood ! >>>>>> Strictly there is no real transfusion trigger ever >>>>>> demonstrated. A >>>>>> large multicentric study showed that a Hb of > 7 Gm is enough for >>>>>> noninfants and less than 65 years and a higher Hb of 8 may be >>>>>> needed >>>>>> for elderly and infants. I am extremely stingy and will not >>>>>> transfuse >>>>>> unless the oxygen extraction or hemodynamics are impaired by an >>>>>> objective criterion. More importantly I try to conserve blood and >>>>>> prevent blood loss on the first place. >>>>>> Prasanna. >>>>>> Prasanna >>>>>> >>>>>> On Wed, Jan 27, 2010 at 1:14 PM, Ahmed Alsaddique >>>>>> wrote: >>>>>>> It would be interesting to get a feel from the Forum about >>>>>>> the transfusion policy in the post op heart. >>>>>>> I am interested in getting the members threshold for >>>>>>> transfusion? I am labeled as stingy when it comes to >>>>>>> transfusion >>>>>>> Thank you >>>>>>> >>>>>>> Ahmed >>>>>>> _______________________________________________ >>>>>>> OpenHeart-L mailing list >>>>>>> >>>>>>> Send postings to: >>>>>>> OpenHeart-L@lists.hsforum.com >>>>>>> >>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>>>> http://mmp.cjp.com/mailman/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 >>>>> _______________________________________________ >>>>> OpenHeart-L mailing list >>>>> >>>>> Send postings to: >>>>> OpenHeart-L@lists.hsforum.com >>>>> >>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>> http://mmp.cjp.com/mailman/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 anddisclaimers 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 anddisclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- From prasannasimha at gmail.com Mon Feb 1 19:35:53 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Mon Feb 1 09:12:53 2010 Subject: [HSF] Who should manage the cardiac surgery ICU Message-ID: <89c4ed2d1002010605v7e030bffi29073851bd98f02a@mail.gmail.com> Interventional/Surgery Looking after their own: Surgeons may provide better care than intensivists in ICU January 28, 2010 | Reed Miller Download slides *Fort Lauderdale,* *FL* *-* Thoracic surgeons can provide better care to critical cardiac patients in the ICU than intensivists not board-certified in thoracic surgery, a new study suggests [*1*]. Researchers say there are multiple possible explanations for the differences between specialists' outcomes beyond their different medical skills. Here at the *Society* *for* *Thoracic* *Surgeons* (STS) *2010* *Annual* * Meeting*, *Dr* *Glenn* *Whitman* (Jefferson Medical College, Philadelphia) presented data from his institution's investigation conducted to determine whether the quality of ICU care provided by thoracic surgeons was different from that given by intensivists not board-certified in thoracic surgery. Whitman cited research by the *Institute* *for* *Healthcare* *Improvement*showing that if all ICU patients in the US were cared for by trained intensivists, more than 200 000 lives per year would be saved. Given the potential of high-quality ICU care to save lives, this study was intended to determine whether "all intensivists are created equal," Whitman explained. "By virtue of their operative and nonoperative training, specifically concentrating on cardiac surgical diseases, we speculate that thoracic surgeons may be uniquely qualified to provide critical care to postoperative cardiac-surgery patients." The study found that, in populations with similar postoperative risks, thoracic surgeons provided postoperative critical care that shortened patients' hospital stays and decreased drug costs, compared with the care provided by nonsurgeon intensivists, without sacrificing quality. The study retrospectively compared outcomes of similar patients treated in the ICU during two different periods. The populations were matched for STS operative risk scores. In the first period, which lasted about nine months, cardiac intensive care for 168 patients was overseen by nonthoracic intensivists without specific credentials in cardiac surgery. These intensivists were trained in either pulmonary critical care or trauma critical care. During the second period, which lasted about 16 months, care for 272 patients was managed by board-certified thoracic surgeons who were totally committed to the ICU for that period and who had no other surgical or consulting responsibilities. The variables measured included mortality, central-line infections, ventilator-acquired pneumonias per 1000 device-days, percentage of patients with red blood cell exposure (PRBC), percentage of patients with low blood sugar one and two days after cardiac surgery, postoperative and total length of hospital stay, and ICU pharmacy costs per patient. *Comparison of outcomes for ICU care by intensivists and surgeons* *Measurement* *Intensivist** care* *(**168 patients**)* *Surgeon care* *272 patients**)* *p* *Mortality rate** (%)* 3.1 2.5 0.15 *C**entral-**line infection** (n)* 1.3 1.6 0.81 *V**entilator**-acquired pneumonias** per 1000 device-**days** (n)* 7.6 4.2 0.19 *PRBC exposure** (%)* 46 57 0.28 *Blood sugar compliance** (%)* 83 88 0.19 *Av**era**g**e post**operative length of stay (d**)* 9.8 8.3 0.04 *Av**era**g**e **time from admission to discharge (d)* 13.4 11.2 0.01 *Av**era**g**e **ICU drug costs** ($**)* 4300 1800 0.001 To download table as a slide, click on slide logo above The reduction in patients' time in the hospital created an additional "600 opportunity days" for the hospital, which could potentially allow the hospital to admit an additional 100 patients and increase its revenues by $750 000. The direct cost savings from decreased ICU pharmacy expenditures was $680 000. What caused the improvements? While the hospital was shifting the care of cardiac critical-care patients from nonsurgeon intensivists to intensivists trained as surgeons, it implemented a new ICU quality-improvement initiative, which included the creation of multidisciplinary committees to provide input into ICU patient-care decisions. The initiative also created a list of quality metrics that were tracked and reported back to the caregivers every month. Also, every bedside nurse was given a checklist of steps to take every morning to improve on the quality measures. At the STS meeting, *Dr* *Jonathan* *Haft* (University of Michigan, Ann Arbor) suggested that the improvements in efficiency seen during the period when surgeons were managing the patients could have been the result of the quality-improvement initiative and not the difference in the training of the physicians. Whitman responded that it is impossible to know how many of the improvements were due to the change in physicians and how many were due to the quality-improvement initiative, but he believes that the difference in the intensivists' training did make a difference, because the surgeon-intensivists were better able to work closely with the surgeons who operated on the patients than the nonsurgeon intensivists. "It's tempting to speculate that, by virtue of specific operative and nonoperative training, cardiothoracic surgeons may be uniquely qualified to provide postoperative cardiac critical care. The improvements may have been facilitated by a 'sense of team' that enabled implementation of an array of quality and performance improvements," Whitman suggested. "The improved efficiency of care may not have been solely due to the expertise of the caring physicians but may have also been facilitated by the comfort level of the [surgeon-intensivist] and the [operating surgeon.] He pointed out that surgeons managing the postoperative care usually had an easier time than their nonsurgeon colleagues in getting the surgeon who operated on the patient to go along with suggested changes in medication. "I don't think the kind of changes that we made, in terms of the way we cared for the patients, would have gone over well with the surgeons if those who were asking for the changes were not also thoracic surgeons," he said. "It's a very sociology-related issue. I don't know how to address that scientifically, but having worked in a few ICUs, I know it's certainly palpable." Citing test-score data that showed that surgical residents often score below average on subjects specific to intensive care, Whitman agreed that "if we would like to have cardiac surgeons take care of their own patients in the intensive care unit, we are going to have to do a better job training our residents in critical care. "Nevertheless, I think the commonality associated with having thoracic surgeons care for their own patients and working with the surgeons who operate on them is an extremely important aspect of cardiac critical care. We should take it into consideration and, in many respects, not abrogate the responsibility of the care of our patients to nonthoracic intensivists," he concluded. ? Previous heartwire article Beta blockers: Less effect on pulse pressure than diuretics Jan 28, 2010 13:30 EST Next heartwire article ? The atrial septal pouch?a new source of thrombus? Jan 29, 2010 11:30 EST *Source* Whitman G, Haddad M, Hirose H, et al. Thoracic surgeons providing cardiac critical care improve patient management and decrease costs. Society of Thoracic Surgeons 2010 Annual Meeting; January 26, 2010; Fort Lauderdale, FL -- Prasanna Simha M From GoldmanS at MLHS.ORG Mon Feb 1 09:14:42 2010 From: GoldmanS at MLHS.ORG (Goldman, Scott) Date: Mon Feb 1 09:15:15 2010 Subject: [HSF] Blood transfusion for the postop heart Message-ID: <6FF71BF92ACC044F80A522679DCF118503A2DA6D72@MLHMB2.ad.mlhs.org> I agree with Hal Scott Goldman MD ----- Original Message ----- From: openheart-l-bounces@lists.hsforum.com To: OpenHeart-L@lists.hsforum.com Sent: Mon Feb 01 04:52:28 2010 Subject: Re: [HSF] Blood transfusion for the postop heart So, do you plan to send these patients home on Levophed? A HCT of 15 may be tolerated in a young person, but I've not seen many patients who will have a decent BP with such severe anemia. Also, what about the CPB data says HCT's below 20 during a pump run are associated with higher mortality, presumably due to impaired oxygen delivery? Hal Sent from my Verizon Wireless BlackBerry -----Original Message----- From: Ahmed Alsaddique Date: Mon, 1 Feb 2010 08:56:54 To: OpenHeart-L@lists.hsforum.com Subject: RE: [HSF] Blood transfusion for the postop heart Tony: I am the one who started this thread but I became too busy to log in. I find that a HCT of 15 as your threshold is interesting and will implement it ( being your student) with the same provisions you made. We were more liberal than that but not any more. Thank you Ahmed ________________________________________ From: openheart-l-bounces@lists.hsforum.com [openheart-l-bounces@lists.hsforum.com] On Behalf Of Anthony P Furnary MD [tfurnary@starrwood.com] Sent: Monday, February 01, 2010 8:39 AM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Blood transfusion for the postop heart Tea -- I totally agree. BTW -- I un-trapped my historical learnings. 15 is my threshold, (unless a vital complication exists that threatens the life of the patient and is related to the low Hct..) Tony On Jan 28, 2010, at 8:42 PM, Tea Acuff wrote: > I know we seem finished with this topic, but the same themes keep on > appearing be it transfusion or MICS or the next focus. > > We all agree that use of femoral cannula is not the same as MICS, > but do we realize that whether blood transfusion is a marker for > result (good or bad) is a completely different discussion or slice > of reality than whether to transfuse all patients at a Hct of 24 or > 30. > > When you look at a number or mark like HCT, glucose, or MICS or > femoral cannula it is as if you hold a set of cards in poker. What > you need is determined by where you currently are. If you already > have a ten, a ten is better than an ace which is otherwise ideally > best. > Picking a number to transfuse or case to femorally cannulate before > the number or event happens is like betting before the cards are > dealt. We are all going to bet if we play, but when is the best time? > > I talked about planning. Should we place our bet before we get our > first cards or second cards. Should we choose to transfuse everyone > on a standard order sheet? > > How do we decide how to decide? > > Of course the interesting thing is not so much the actual number or > HCT at all. > It does not matter whether we find out about in the morning or the > totally stupid late night call stating only that "the HCT is 23". It > is not about the reams of EBM that correlate transfusion this and > level of that. It is about everything else. What is the BP? Are we > bleeding? any drips? Oh the Jehovah witness patient! Etc. > > It of course is hardest to allow a vital threshhold to drop as it > requires more data and education than the simple transfuse at "x". > That does not mean it is best, but it is harder. > > I personally try as much as possible to empower these realtional > choices to those at the bedside and minimize the standing orders. > This of course flies in the face of the thinking that I constantly > rag on and on which is mostly how eveyone else organizes things, > that is, hierarchical: the hct. Nursing can be designed differently > (relationally perhaps)as can medicine, but we are trapped by our > historical ideas. > > Surely you, doctor, know when to transfuse, so when? If we can't > pick we can always vote right? > > tea > > > >________________________________ > From: Scott Silvestry > To: OpenHeart-L@lists.hsforum.com > Sent: Thu, January 28, 2010 10:14:37 AM > Subject: RE: [HSF] Blood transfusion for the postop heart > > Guiseppe: > > I don't think Tony is saying we should fight it per se, just be > intellectually honest in assessing the effects of transfusion. > > > These articles are real eye openers- and suggest the effects we hope > to see, > may not be there. > > http://www.pnas.org/content/104/43/17063.full.pdf > > Evolution of adverse changes in stored RBCs > Elliott Bennett-Guerrero > > Recent studies have underscored questions about the balance of risk > and > benefit of RBC transfusion. A better understanding of the nature and > timing > of molecular and functional changes in stored RBCs may provide > strategies to > improve the balance of benefit and risk of RBC transfusion. We > analyzed > changes occurring during RBC storage focusing on RBC deformability, > RBC-dependent vasoregulatory function, and S-nitrosohemoglobin (SNO- > Hb), > through which hemoglobin(Hb) O2 desaturation is coupled to regional > increases in blood flow in vivo (hypoxic vasodilation). Five hundred > ml of > blood from each of 15 healthy volunteers was processed into > leukofiltered, > additive solution 3-exposed RBCs and stored at 1?6?C according to AABB > standards. Blood was subjected to 26 assays at 0, 3, 8, 24 and 96 h, > and at > 1, 2, 3, 4, and 6 weeks. RBC SNO-Hb decreased rapidly (1.2 104 at 3 > h vs. > 6.5 104 (fresh) mol S-nitrosothiol (SNO)/mol Hb tetramer (P 0.032, > mercuric-displaced photolysis chemiluminescence assay), and remained > low > over the 42-day period. The decline was corroborated by using the > carbon > monoxide-saturated copper-cysteine assay [3.0 105 at 3 h vs. 9.0 105 > (fresh) mol SNO/mol Hb]. In parallel, vasodilation by stored RBCs was > significantly depressed. RBC deformability assayed at a > physiological shear > stress decreased gradually over the 42-day period (P < 0.001). Time > courses > vary for several storage-induced defects that might account for recent > observations linking blood transfusion with adverse outcomes. Of > clinical > concern is that SNO levels, and their physiological correlate, RBC- > dependent > vasodilation, become depressed soon after collection, suggesting > that even > ??fresh?? blood may have developed adverse biological characteristics. > > > > http://www.pnas.org/content/104/43/17058.full.pdf > > S-nitrosohemoglobin deficiency: A mechanism for > loss of physiological activity in banked blood > James D. Reynolds* > RBCs distribute oxygen to tissues, but, paradoxically, blood > transfusion > does not always improve oxygen delivery and is associated with > ischemic > events. We hypothesized that storage of blood would result in loss > of NO > bioactivity, impairing RBC vasodilation and thus compromising blood > flow, > and that repleting NO bioactivity would restore RBC function. We > report that > S-nitrosohemoglobin (SNO-Hb) concentrations declined rapidly after > storage > of fresh venous blood and that hypoxic vasodilation by banked RBCs > correlated strongly with the amounts of SNO-Hb (r2 0.90; P < 0.0005). > Renitrosylation of banked blood during storage increased the SNO-Hb > content > and restored its vasodilatory activity. In addition, canine coronary > blood > flow was greater during infusion of renitrosylated RBCs than during > infusion > of S-nitrosothiol-depleted RBCs, and this > difference in coronary flow was accentuated by hypoxemia (P < > 0.001). Our > findings indicate that NO bioactivity is depleted in banked blood, > impairing > the vasodilatory response to hypoxia, and they suggest that SNO-Hb > repletion > may improve transfusion efficacy. > > > > > > > Scott C. Silvestry, MD > Associate Professor of Surgery > Division of Cardiac Surgery > Thomas Jefferson University Hospital > 1025 Walnut Street > 607 College > Philadelphia, PA 19107 > Phone (215)955-6996 > Fax (215) 955-6010 > Email: scott.silvestry@jefferson.edu > > The information contained in this email is confidential, privileged, > or > otherwise protected from disclosure. It is intended only for the > use of the > authorized individual as indicated in the e-mail. Any unauthorized > disclosure, copying, distribution or taking of any action based on the > contents of this material is strictly prohibited. Review by any > individual > other than the intended recipient does not waive or give up the > physician-patient privilege. > > If you received this e-mail in error, please delete it immediately. > > > > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com > [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Giuseppe > Rescigno > Sent: Thursday, January 28, 2010 5:34 AM > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] Blood transfusion for the postop heart > > David, > > I completely agree. Our population is actually so sick, elerly and > with multiple comorbidities that fighting a fundamentalist battle > against blood transfusion is not my first priority. In my center we > have the 8 grams of Hb as threshold. Moreover, and this is not an > excuse but just reality, in case of any unrelated problem, the judge > will surely consider the anemic state as a possible collateral cause. > > Giuseppe > > > > Il giorno 28/gen/10, alle ore 07:03, David Harris ha scritto: > >> I just think that's a reflection of a sicker patient who has had >> more acute blood loss, thus organ malperfusion. Not blood >> transfusion per se. I have never seen a prob$em with a patient who >> gets 1 or 2 units a few days down the line for Hb that's drifted >> below 9. In fact recovery and wound healing is better. Patients >> also feel instantly better and start to mobilise faster, especially >> if heart failure. I see more benefit than harm aiming for HKT 30. >> Dfave >> >> On Thu, 28 Jan 2010 02:07 EET Anthony P Furnary Md wrote: >> >>> YIKES!!! >>> >>> Speaking of education.... Here are some of the data: >>> >>> Multiple studies have shown that more perioperative blood (as in >>> transfused PRBCs) = >>> >>> More acute renal failure >>> More infections >>> More acute heart failure and low cardiac output syndrome >>> And most importantly, in CABG patients: >>> Significantly worse long term survival. >>> >>> I think, for my patients at least, that is Certainly worth >>> fighting for, no matter how much sleep is lost. Actually I loose >>> less, because the nurses and PAs know not to call me for a low >>> Hct, as I will not transfuse, unless the patient requests it and >>> completely understands the implications of even a single unit of >>> PRBC. >>> >>> Would never put my own interests (sleep, fighting a battle for a >>> patient benefit, etc) above a patients' best interest. >>> >>> Sorry, >>> Tony >>> Sent from my iPhone >>> >>> On Jan 27, 2010, at 8:15 AM, Michael Firstenberg >>> wrote: >>> >>>> yeah - what prasanna said. >>>> I have a very very low threshold for transfusing people up to >>>> close to 30. >>>> 1) Old patients with bad hearts "feel better" and contrary to >>>> all of the data - their organs and hemodynamics like it >>>> 2) Anyone leaving on coumadin (yuck, rat poison) - who might bleed >>>> 3) Anyone going to a nursing home/etc in which someone might >>>> check their levels "just because" (and then send them back to the >>>> hospital for a bleeding work-up when the numbers are low) >>>> 4) Anyone who might need another procedure soon - like a pacer/icd >>>> >>>> 5) Education is key - but it is not worth fighting over or >>>> losing sleep. Some of my partners get called in the middle of >>>> the night when the morning labs come back and the hcts are in the >>>> 8's asking about giving blood....... I like to sleep! I trust >>>> the night team to use their judgement...... there are larger >>>> battles to fight. >>>> >>>> >>>> now - we can discuss whether it is a scarce and/or expensive >>>> resource...... >>>> >>>> >>>> >>>> On Jan 27, 2010, at 6:57 AM, Prasanna Simha M wrote: >>>> >>>>> An example of cases where oxygen delivery and extraction is >>>>> important >>>>> is incomplete comgenital corrections where a higher Hb has to be >>>>> achieved to allow oxygen deklivery in deasturated patients. >>>>> Prasanna >>>>> >>>>> On Wed, Jan 27, 2010 at 5:18 PM, Prasanna Simha M >>>>> wrote: >>>>>> This has lead to a lot of hot blood ! >>>>>> Strictly there is no real transfusion trigger ever >>>>>> demonstrated. A >>>>>> large multicentric study showed that a Hb of > 7 Gm is enough for >>>>>> noninfants and less than 65 years and a higher Hb of 8 may be >>>>>> needed >>>>>> for elderly and infants. I am extremely stingy and will not >>>>>> transfuse >>>>>> unless the oxygen extraction or hemodynamics are impaired by an >>>>>> objective criterion. More importantly I try to conserve blood and >>>>>> prevent blood loss on the first place. >>>>>> Prasanna. >>>>>> Prasanna >>>>>> >>>>>> On Wed, Jan 27, 2010 at 1:14 PM, Ahmed Alsaddique >>>>>> wrote: >>>>>>> It would be interesting to get a feel from the Forum about the >>>>>>> transfusion policy in the post op heart. >>>>>>> I am interested in getting the members threshold for >>>>>>> transfusion? I am labeled as stingy when it comes to >>>>>>> transfusion >>>>>>> Thank you >>>>>>> >>>>>>> Ahmed >>>>>>>_______________________________________________ >>>>>>> OpenHeart-L mailing list >>>>>>> >>>>>>> Send postings to: >>>>>>> OpenHeart-L@lists.hsforum.com >>>>>>> >>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>>>> http://mmp.cjp.com/mailman/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 >>>>>_______________________________________________ >>>>> OpenHeart-L mailing list >>>>> >>>>> Send postings to: >>>>> OpenHeart-L@lists.hsforum.com >>>>> >>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>> http://mmp.cjp.com/mailman/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 anddisclaimers 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 prasannasimha at gmail.com Mon Feb 1 19:45:47 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Mon Feb 1 09:16:38 2010 Subject: [HSF] Blood transfusion for the postop heart In-Reply-To: <23914C0D-8C40-472E-AA5A-F779606AEAE0@mac.com> References: <781462.16284.qm@web24703.mail.ird.yahoo.com> <23914C0D-8C40-472E-AA5A-F779606AEAE0@mac.com> Message-ID: <89c4ed2d1002010615s1f085c75ha8960744a9cd1578@mail.gmail.com> Interventional/Surgery Blood products should be used conservatively in heart-surgery patients, trial shows October 27, 2009 | Reed Miller Download slides *Edmonton, AB* - Perioperative blood product transfusions for stable cardiac-surgery patients increases the risk of death, renal failure, and sepsis or infection, results of a new study released at the *Canadian Cardiovascular Congress 2009* show [*1*]. The study, presented by medical student *Robert Riddell* (Dalhousie University, Halifax, NS), was conducted at the Maritime Heart Center in Halifax, NS in 3842 consecutive patients undergoing all types of cardiac surgery. The patients were sorted into four groups: the first received no blood product transfusions; the second received blood products during their surgery; the third group received blood products within the first 48 hours; and the fourth received blood products 48 hours or later after surgery. After adjustment for baseline differences including preoperative renal failure, gender, left ventricular ejection fraction, age, and procedure type, a logistic regression found that the administration of blood products dramatically increased morbidity and mortality of patients compared with those who received no blood products. Furthermore, the study suggests patients are worse off the later they receive the blood transfusion. *Risk ratios (95% CI) compared with patients receiving no blood products by timing of administration* *Outcome* *Intraoperative* *Within 48 h** post**op* *After 48 h postop* *In-hospital mortality* 7.71 (4.44-13.38) 7.09 (3.95-12.72) 10.37 (5.21-20.63) *Acute renal failure* 3.98 (2.77-5.74) 4.12 (2.82-6.03) 10.78 (7.03-16.52) *Sepsis/**DSWI* 3.74 (1.85-7.57) 4.11 (1.99-8.48) 11.84 (5.56-25.23) DSWI=Deep sternal wound infection To download table as a slide, click on slide logo above Maritime Heart Center's director of research in the division of cardiac surgery, *Dr Jean-Francois L**?**gar**?* (Dalhousie Medical School), explained the motivation for the study to *heart**wire**.* "If you're bleeding to death, you need blood, but once you are stable and anemic?it is less clear," he explained. Previous research, reported by heartwire *,* has shown a trend toward harm from blood transfusions in some surgery patients, but the Halifax study was the first to focus exclusively on stable patients who are not at risk of bleeding to death, L?gar? said. L?gar? said that although there are guidelines for administration of blood products in Canada, the amount of blood products given stable surgery patients varies greatly from center to center. "The perception is that someone who is anemic should be given blood, [but the study shows] that we need to be more aggressive in not giving blood" and reinforces the need for blood conservation strategies and the development of more stringent criteria for the administration of blood products to stable surgery patients. He also suggests that centers should reevaluate their processes for taking blood from patients for diagnostic tests so there will be less need for replacement blood products. For example, a patient in an ICU will often give up to two units of blood per week for various diagnostics. L?gar? suggested centers consider adopting new methods and technologies that require smaller blood samples. On Mon, Feb 1, 2010 at 7:08 PM, Giuseppe Rescigno wrote: > Tony, > > have you ever published your results with such a low threshold? I am quite > surprised as for the populations I deal with it is difficult to achieve. > > Giuseppe > > > Il giorno 01/feb/10, alle ore 06:29, Anthony P Furnary MD ha scritto: > > > Dave -- It's not a reflection of anything of the sort. >> >> Even one unit of blood in an elective CABG patient decreases survival and >> increases the likelihood of ARF. >> >> Widely supported in the literature. Not anecdotal -- that's where we never >> seem to remember the causal associations of complications we've "seen".. and >> thus have "never seen " them. Not due to "sicker" patient population. >> Multiple publications implicating transfusions in worsening heart failure. >> >> My transfusion "threshold" is Hct of 15. >> >> Tony >> On Jan 27, 2010, at 10:03 PM, David Harris wrote: >> >> I just think that's a reflection of a sicker patient who has had more >>> acute blood loss, thus organ malperfusion. Not blood transfusion per se. I >>> have never seen a prob$em with a patient who gets 1 or 2 units a few days >>> down the line for Hb that's drifted below 9. In fact recovery and wound >>> healing is better. Patients also feel instantly better and start to mobilise >>> faster, especially if heart failure. I see more benefit than harm aiming for >>> HKT 30. Dfave >>> >>> On Thu, 28 Jan 2010 02:07 EET Anthony P Furnary Md wrote: >>> >>> YIKES!!! >>>> >>>> Speaking of education.... Here are some of the data: >>>> >>>> Multiple studies have shown that more perioperative blood (as in >>>> transfused PRBCs) = >>>> >>>> More acute renal failure >>>> More infections >>>> More acute heart failure and low cardiac output syndrome >>>> And most importantly, in CABG patients: >>>> Significantly worse long term survival. >>>> >>>> I think, for my patients at least, that is Certainly worth fighting for, >>>> no matter how much sleep is lost. Actually I loose less, because the nurses >>>> and PAs know not to call me for a low Hct, as I will not transfuse, unless >>>> the patient requests it and completely understands the implications of even >>>> a single unit of PRBC. >>>> >>>> Would never put my own interests (sleep, fighting a battle for a patient >>>> benefit, etc) above a patients' best interest. >>>> >>>> Sorry, >>>> Tony >>>> Sent from my iPhone >>>> >>>> On Jan 27, 2010, at 8:15 AM, Michael Firstenberg >>>> wrote: >>>> >>>> yeah - what prasanna said. >>>>> I have a very very low threshold for transfusing people up to close to >>>>> 30. >>>>> 1) Old patients with bad hearts "feel better" and contrary to all of >>>>> the data - their organs and hemodynamics like it >>>>> 2) Anyone leaving on coumadin (yuck, rat poison) - who might bleed >>>>> 3) Anyone going to a nursing home/etc in which someone might check >>>>> their levels "just because" (and then send them back to the hospital for a >>>>> bleeding work-up when the numbers are low) >>>>> 4) Anyone who might need another procedure soon - like a pacer/icd >>>>> >>>>> 5) Education is key - but it is not worth fighting over or losing >>>>> sleep. Some of my partners get called in the middle of the night when the >>>>> morning labs come back and the hcts are in the 8's asking about giving >>>>> blood....... I like to sleep! I trust the night team to use their >>>>> judgement...... there are larger battles to fight. >>>>> >>>>> >>>>> now - we can discuss whether it is a scarce and/or expensive >>>>> resource...... >>>>> >>>>> >>>>> >>>>> On Jan 27, 2010, at 6:57 AM, Prasanna Simha M wrote: >>>>> >>>>> An example of cases where oxygen delivery and extraction is important >>>>>> is incomplete comgenital corrections where a higher Hb has to be >>>>>> achieved to allow oxygen deklivery in deasturated patients. >>>>>> Prasanna >>>>>> >>>>>> On Wed, Jan 27, 2010 at 5:18 PM, Prasanna Simha M >>>>>> wrote: >>>>>> >>>>>>> This has lead to a lot of hot blood ! >>>>>>> Strictly there is no real transfusion trigger ever demonstrated. A >>>>>>> large multicentric study showed that a Hb of > 7 Gm is enough for >>>>>>> noninfants and less than 65 years and a higher Hb of 8 may be needed >>>>>>> for elderly and infants. I am extremely stingy and will not transfuse >>>>>>> unless the oxygen extraction or hemodynamics are impaired by an >>>>>>> objective criterion. More importantly I try to conserve blood and >>>>>>> prevent blood loss on the first place. >>>>>>> Prasanna. >>>>>>> Prasanna >>>>>>> >>>>>>> On Wed, Jan 27, 2010 at 1:14 PM, Ahmed Alsaddique >>>>>>> wrote: >>>>>>> >>>>>>>> It would be interesting to get a feel from the Forum about the >>>>>>>> transfusion policy in the post op heart. >>>>>>>> I am interested in getting the members threshold for transfusion? I >>>>>>>> am labeled as stingy when it comes to transfusion >>>>>>>> Thank you >>>>>>>> >>>>>>>> Ahmed >>>>>>>> _______________________________________________ >>>>>>>> OpenHeart-L mailing list >>>>>>>> >>>>>>>> Send postings to: >>>>>>>> OpenHeart-L@lists.hsforum.com >>>>>>>> >>>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>>>>> http://mmp.cjp.com/mailman/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 >>>>>> _______________________________________________ >>>>>> OpenHeart-L mailing list >>>>>> >>>>>> Send postings to: >>>>>> OpenHeart-L@lists.hsforum.com >>>>>> >>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>>> http://mmp.cjp.com/mailman/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 >>>> anddisclaimers 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 >> anddisclaimers 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 > ----------------------------------------- > -- Prasanna Simha M From msfirst at gmail.com Mon Feb 1 10:13:34 2010 From: msfirst at gmail.com (Michael Firstenberg) Date: Mon Feb 1 10:14:02 2010 Subject: [HSF] Blood transfusion for the postop heart In-Reply-To: <89c4ed2d1002010615s1f085c75ha8960744a9cd1578@mail.gmail.com> References: <781462.16284.qm@web24703.mail.ird.yahoo.com> <23914C0D-8C40-472E-AA5A-F779606AEAE0@mac.com> <89c4ed2d1002010615s1f085c75ha8960744a9cd1578@mail.gmail.com> Message-ID: 15? On Mon, Feb 1, 2010 at 9:15 AM, Prasanna Simha M wrote: > Interventional/Surgery > Blood products should be used conservatively in heart-surgery patients, > trial shows > October 27, 2009 | Reed > Miller > Download slides > > > > *Edmonton, AB* - Perioperative blood product transfusions for stable > cardiac-surgery patients increases the risk of death, renal failure, and > sepsis or infection, results of a new study released at the *Canadian > Cardiovascular Congress 2009* show > [*1*]. > > > The study, presented by medical student *Robert Riddell* (Dalhousie > University, Halifax, NS), was conducted at the Maritime Heart Center in > Halifax, NS in 3842 consecutive patients undergoing all types of cardiac > surgery. The patients were sorted into four groups: the first received no > blood product transfusions; the second received blood products during their > surgery; the third group received blood products within the first 48 hours; > and the fourth received blood products 48 hours or later after surgery. > > After adjustment for baseline differences including preoperative renal > failure, gender, left ventricular ejection fraction, age, and procedure > type, a logistic regression found that the administration of blood products > dramatically increased morbidity and mortality of patients compared with > those who received no blood products. Furthermore, the study suggests > patients are worse off the later they receive the blood transfusion. > *Risk ratios (95% CI) compared with patients receiving no blood products by > timing of administration* > > *Outcome* > *Intraoperative* > *Within 48 h** post**op* > *After 48 h postop* > *In-hospital mortality* > 7.71 (4.44-13.38) > 7.09 (3.95-12.72) > 10.37 (5.21-20.63) > *Acute renal failure* > 3.98 (2.77-5.74) > 4.12 (2.82-6.03) > 10.78 (7.03-16.52) > *Sepsis/**DSWI* > 3.74 (1.85-7.57) > 4.11 (1.99-8.48) > 11.84 (5.56-25.23) > DSWI=Deep sternal wound infection > To download table as a slide, click on slide logo above > > Maritime Heart Center's director of research in the division of cardiac > surgery, *Dr Jean-Francois L**?**gar**?* (Dalhousie Medical School), > explained the motivation for the study to *heart**wire**.* "If you're > bleeding to death, you need blood, but once you are stable and anemic?it is > less clear," he explained. > > Previous research, reported by > heartwire > *,* has shown a trend toward harm from blood transfusions in some surgery > patients, but the Halifax study was the first to focus exclusively on > stable > patients who are not at risk of bleeding to death, L?gar? said. > > L?gar? said that although there are guidelines for administration of blood > products in Canada, the amount of blood products given stable surgery > patients varies greatly from center to center. > > "The perception is that someone who is anemic should be given blood, [but > the study shows] that we need to be more aggressive in not giving blood" > and > reinforces the need for blood conservation strategies and the development > of > more stringent criteria for the administration of blood products to stable > surgery patients. > > He also suggests that centers should reevaluate their processes for taking > blood from patients for diagnostic tests so there will be less need for > replacement blood products. For example, a patient in an ICU will often > give > up to two units of blood per week for various diagnostics. L?gar? suggested > centers consider adopting new methods and technologies that require smaller > blood samples. > > > On Mon, Feb 1, 2010 at 7:08 PM, Giuseppe Rescigno > wrote: > > > Tony, > > > > have you ever published your results with such a low threshold? I am > quite > > surprised as for the populations I deal with it is difficult to achieve. > > > > Giuseppe > > > > > > Il giorno 01/feb/10, alle ore 06:29, Anthony P Furnary MD ha scritto: > > > > > > Dave -- It's not a reflection of anything of the sort. > >> > >> Even one unit of blood in an elective CABG patient decreases survival > and > >> increases the likelihood of ARF. > >> > >> Widely supported in the literature. Not anecdotal -- that's where we > never > >> seem to remember the causal associations of complications we've "seen".. > and > >> thus have "never seen " them. Not due to "sicker" patient population. > >> Multiple publications implicating transfusions in worsening heart > failure. > >> > >> My transfusion "threshold" is Hct of 15. > >> > >> Tony > >> On Jan 27, 2010, at 10:03 PM, David Harris wrote: > >> > >> I just think that's a reflection of a sicker patient who has had more > >>> acute blood loss, thus organ malperfusion. Not blood transfusion per > se. I > >>> have never seen a prob$em with a patient who gets 1 or 2 units a few > days > >>> down the line for Hb that's drifted below 9. In fact recovery and wound > >>> healing is better. Patients also feel instantly better and start to > mobilise > >>> faster, especially if heart failure. I see more benefit than harm > aiming for > >>> HKT 30. Dfave > >>> > >>> On Thu, 28 Jan 2010 02:07 EET Anthony P Furnary Md wrote: > >>> > >>> YIKES!!! > >>>> > >>>> Speaking of education.... Here are some of the data: > >>>> > >>>> Multiple studies have shown that more perioperative blood (as in > >>>> transfused PRBCs) = > >>>> > >>>> More acute renal failure > >>>> More infections > >>>> More acute heart failure and low cardiac output syndrome > >>>> And most importantly, in CABG patients: > >>>> Significantly worse long term survival. > >>>> > >>>> I think, for my patients at least, that is Certainly worth fighting > for, > >>>> no matter how much sleep is lost. Actually I loose less, because the > nurses > >>>> and PAs know not to call me for a low Hct, as I will not transfuse, > unless > >>>> the patient requests it and completely understands the implications of > even > >>>> a single unit of PRBC. > >>>> > >>>> Would never put my own interests (sleep, fighting a battle for a > patient > >>>> benefit, etc) above a patients' best interest. > >>>> > >>>> Sorry, > >>>> Tony > >>>> Sent from my iPhone > >>>> > >>>> On Jan 27, 2010, at 8:15 AM, Michael Firstenberg > >>>> wrote: > >>>> > >>>> yeah - what prasanna said. > >>>>> I have a very very low threshold for transfusing people up to close > to > >>>>> 30. > >>>>> 1) Old patients with bad hearts "feel better" and contrary to all of > >>>>> the data - their organs and hemodynamics like it > >>>>> 2) Anyone leaving on coumadin (yuck, rat poison) - who might bleed > >>>>> 3) Anyone going to a nursing home/etc in which someone might check > >>>>> their levels "just because" (and then send them back to the hospital > for a > >>>>> bleeding work-up when the numbers are low) > >>>>> 4) Anyone who might need another procedure soon - like a pacer/icd > >>>>> > >>>>> 5) Education is key - but it is not worth fighting over or losing > >>>>> sleep. Some of my partners get called in the middle of the night > when the > >>>>> morning labs come back and the hcts are in the 8's asking about > giving > >>>>> blood....... I like to sleep! I trust the night team to use their > >>>>> judgement...... there are larger battles to fight. > >>>>> > >>>>> > >>>>> now - we can discuss whether it is a scarce and/or expensive > >>>>> resource...... > >>>>> > >>>>> > >>>>> > >>>>> On Jan 27, 2010, at 6:57 AM, Prasanna Simha M wrote: > >>>>> > >>>>> An example of cases where oxygen delivery and extraction is > important > >>>>>> is incomplete comgenital corrections where a higher Hb has to be > >>>>>> achieved to allow oxygen deklivery in deasturated patients. > >>>>>> Prasanna > >>>>>> > >>>>>> On Wed, Jan 27, 2010 at 5:18 PM, Prasanna Simha M > >>>>>> wrote: > >>>>>> > >>>>>>> This has lead to a lot of hot blood ! > >>>>>>> Strictly there is no real transfusion trigger ever demonstrated. A > >>>>>>> large multicentric study showed that a Hb of > 7 Gm is enough for > >>>>>>> noninfants and less than 65 years and a higher Hb of 8 may be > needed > >>>>>>> for elderly and infants. I am extremely stingy and will not > transfuse > >>>>>>> unless the oxygen extraction or hemodynamics are impaired by an > >>>>>>> objective criterion. More importantly I try to conserve blood and > >>>>>>> prevent blood loss on the first place. > >>>>>>> Prasanna. > >>>>>>> Prasanna > >>>>>>> > >>>>>>> On Wed, Jan 27, 2010 at 1:14 PM, Ahmed Alsaddique < > alsadd@ksu.edu.sa> > >>>>>>> wrote: > >>>>>>> > >>>>>>>> It would be interesting to get a feel from the Forum about the > >>>>>>>> transfusion policy in the post op heart. > >>>>>>>> I am interested in getting the members threshold for transfusion? > I > >>>>>>>> am labeled as stingy when it comes to transfusion > >>>>>>>> Thank you > >>>>>>>> > >>>>>>>> Ahmed > >>>>>>>> _______________________________________________ > >>>>>>>> OpenHeart-L mailing list > >>>>>>>> > >>>>>>>> Send postings to: > >>>>>>>> OpenHeart-L@lists.hsforum.com > >>>>>>>> > >>>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: > >>>>>>>> http://mmp.cjp.com/mailman/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 > >>>>>> _______________________________________________ > >>>>>> OpenHeart-L mailing list > >>>>>> > >>>>>> Send postings to: > >>>>>> OpenHeart-L@lists.hsforum.com > >>>>>> > >>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: > >>>>>> http://mmp.cjp.com/mailman/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 > >>>> anddisclaimers 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 > >> anddisclaimers 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 > > ----------------------------------------- > > > > > > -- > 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 drdharris at yahoo.co.uk Mon Feb 1 16:05:37 2010 From: drdharris at yahoo.co.uk (David Harris) Date: Mon Feb 1 11:07:07 2010 Subject: [HSF] Blood transfusion for the postop heart Message-ID: <987758.38185.qm@web24703.mail.ird.yahoo.com> Many thanks for stressing this! We all need to be aware of this and thanks for HSF which is the best way to keep up to date with the literature. Dave On Mon, 01 Feb 2010 16:15 EET Prasanna Simha M wrote: > Interventional/Surgery >Blood products should be used conservatively in heart-surgery patients, >trial shows >October 27, 2009 | Reed >Miller > Download slides > > > > *Edmonton, AB* - Perioperative blood product transfusions for stable >cardiac-surgery patients increases the risk of death, renal failure, and >sepsis or infection, results of a new study released at the *Canadian >Cardiovascular Congress 2009* show >[*1*]. > > >The study, presented by medical student *Robert Riddell* (Dalhousie >University, Halifax, NS), was conducted at the Maritime Heart Center in >Halifax, NS in 3842 consecutive patients undergoing all types of cardiac >surgery. The patients were sorted into four groups: the first received no >blood product transfusions; the second received blood products during their >surgery; the third group received blood products within the first 48 hours; >and the fourth received blood products 48 hours or later after surgery. > >After adjustment for baseline differences including preoperative renal >failure, gender, left ventricular ejection fraction, age, and procedure >type, a logistic regression found that the administration of blood products >dramatically increased morbidity and mortality of patients compared with >those who received no blood products. Furthermore, the study suggests >patients are worse off the later they receive the blood transfusion. >*Risk ratios (95% CI) compared with patients receiving no blood products by >timing of administration* > > *Outcome* > *Intraoperative* > *Within 48 h** post**op* > *After 48 h postop* > *In-hospital mortality* > 7.71 (4.44-13.38) > 7.09 (3.95-12.72) > 10.37 (5.21-20.63) > *Acute renal failure* > 3.98 (2.77-5.74) > 4.12 (2.82-6.03) > 10.78 (7.03-16.52) > *Sepsis/**DSWI* > 3.74 (1.85-7.57) > 4.11 (1.99-8.48) > 11.84 (5.56-25.23) > DSWI=Deep sternal wound infection > To download table as a slide, click on slide logo above > >Maritime Heart Center's director of research in the division of cardiac >surgery, *Dr Jean-Francois L**?**gar**?* (Dalhousie Medical School), >explained the motivation for the study to *heart**wire**.* "If you're >bleeding to death, you need blood, but once you are stable and anemic?it is >less clear," he explained. > >Previous research, reported by >heartwire >*,* has shown a trend toward harm from blood transfusions in some surgery >patients, but the Halifax study was the first to focus exclusively on stable >patients who are not at risk of bleeding to death, L?gar? said. > >L?gar? said that although there are guidelines for administration of blood >products in Canada, the amount of blood products given stable surgery >patients varies greatly from center to center. > >"The perception is that someone who is anemic should be given blood, [but >the study shows] that we need to be more aggressive in not giving blood" and >reinforces the need for blood conservation strategies and the development of >more stringent criteria for the administration of blood products to stable >surgery patients. > >He also suggests that centers should reevaluate their processes for taking >blood from patients for diagnostic tests so there will be less need for >replacement blood products. For example, a patient in an ICU will often give >up to two units of blood per week for various diagnostics. L?gar? suggested >centers consider adopting new methods and technologies that require smaller >blood samples. > > >On Mon, Feb 1, 2010 at 7:08 PM, Giuseppe Rescigno wrote: > >> Tony, >> >> have you ever published your results with such a low threshold? I am quite >> surprised as for the populations I deal with it is difficult to achieve. >> >> Giuseppe >> >> >> Il giorno 01/feb/10, alle ore 06:29, Anthony P Furnary MD ha scritto: >> >> >> Dave -- It's not a reflection of anything of the sort. >>> >>> Even one unit of blood in an elective CABG patient decreases survival and >>> increases the likelihood of ARF. >>> >>> Widely supported in the literature. Not anecdotal -- that's where we never >>> seem to remember the causal associations of complications we've "seen".. and >>> thus have "never seen " them. Not due to "sicker" patient population. >>> Multiple publications implicating transfusions in worsening heart failure. >>> >>> My transfusion "threshold" is Hct of 15. >>> >>> Tony >>> On Jan 27, 2010, at 10:03 PM, David Harris wrote: >>> >>> I just think that's a reflection of a sicker patient who has had more >>>> acute blood loss, thus organ malperfusion. Not blood transfusion per se. I >>>> have never seen a prob$em with a patient who gets 1 or 2 units a few days >>>> down the line for Hb that's drifted below 9. In fact recovery and wound >>>> healing is better. Patients also feel instantly better and start to mobilise >>>> faster, especially if heart failure. I see more benefit than harm aiming for >>>> HKT 30. Dfave >>>> >>>> On Thu, 28 Jan 2010 02:07 EET Anthony P Furnary Md wrote: >>>> >>>> YIKES!!! >>>>> >>>>> Speaking of education.... Here are some of the data: >>>>> >>>>> Multiple studies have shown that more perioperative blood (as in >>>>> transfused PRBCs) = >>>>> >>>>> More acute renal failure >>>>> More infections >>>>> More acute heart failure and low cardiac output syndrome >>>>> And most importantly, in CABG patients: >>>>> Significantly worse long term survival. >>>>> >>>>> I think, for my patients at least, that is Certainly worth fighting for, >>>>> no matter how much sleep is lost. Actually I loose less, because the nurses >>>>> and PAs know not to call me for a low Hct, as I will not transfuse, unless >>>>> the patient requests it and completely understands the implications of even >>>>> a single unit of PRBC. >>>>> >>>>> Would never put my own interests (sleep, fighting a battle for a patient >>>>> benefit, etc) above a patients' best interest. >>>>> >>>>> Sorry, >>>>> Tony >>>>> Sent from my iPhone >>>>> >>>>> On Jan 27, 2010, at 8:15 AM, Michael Firstenberg >>>>> wrote: >>>>> >>>>> yeah - what prasanna said. >>>>>> I have a very very low threshold for transfusing people up to close to >>>>>> 30. >>>>>> 1) Old patients with bad hearts "feel better" and contrary to all of >>>>>> the data - their organs and hemodynamics like it >>>>>> 2) Anyone leaving on coumadin (yuck, rat poison) - who might bleed >>>>>> 3) Anyone going to a nursing home/etc in which someone might check >>>>>> their levels "just because" (and then send them back to the hospital for a >>>>>> bleeding work-up when the numbers are low) >>>>>> 4) Anyone who might need another procedure soon - like a pacer/icd >>>>>> >>>>>> 5) Education is key - but it is not worth fighting over or losing >>>>>> sleep. Some of my partners get called in the middle of the night when the >>>>>> morning labs come back and the hcts are in the 8's asking about giving >>>>>> blood....... I like to sleep! I trust the night team to use their >>>>>> judgement...... there are larger battles to fight. >>>>>> >>>>>> >>>>>> now - we can discuss whether it is a scarce and/or expensive >>>>>> resource...... >>>>>> >>>>>> >>>>>> >>>>>> On Jan 27, 2010, at 6:57 AM, Prasanna Simha M wrote: >>>>>> >>>>>> An example of cases where oxygen delivery and extraction is important >>>>>>> is incomplete comgenital corrections where a higher Hb has to be >>>>>>> achieved to allow oxygen deklivery in deasturated patients. >>>>>>> Prasanna >>>>>>> >>>>>>> On Wed, Jan 27, 2010 at 5:18 PM, Prasanna Simha M >>>>>>> wrote: >>>>>>> >>>>>>>> This has lead to a lot of hot blood ! >>>>>>>> Strictly there is no real transfusion trigger ever demonstrated. A >>>>>>>> large multicentric study showed that a Hb of > 7 Gm is enough for >>>>>>>> noninfants and less than 65 years and a higher Hb of 8 may be needed >>>>>>>> for elderly and infants. I am extremely stingy and will not transfuse >>>>>>>> unless the oxygen extraction or hemodynamics are impaired by an >>>>>>>> objective criterion. More importantly I try to conserve blood and >>>>>>>> prevent blood loss on the first place. >>>>>>>> Prasanna. >>>>>>>> Prasanna >>>>>>>> >>>>>>>> On Wed, Jan 27, 2010 at 1:14 PM, Ahmed Alsaddique >>>>>>>> wrote: >>>>>>>> >>>>>>>>> It would be interesting to get a feel from the Forum about the >>>>>>>>> transfusion policy in the post op heart. >>>>>>>>> I am interested in getting the members threshold for transfusion? I >>>>>>>>> am labeled as stingy when it comes to transfusion >>>>>>>>> Thank you >>>>>>>>> >>>>>>>>> Ahmed >>>>>>>>> _______________________________________________ >>>>>>>>> OpenHeart-L mailing list >>>>>>>>> >>>>>>>>> Send postings to: >>>>>>>>> OpenHeart-L@lists.hsforum.com >>>>>>>>> >>>>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>>>>>> http://mmp.cjp.com/mailman/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 >>>>>>> _______________________________________________ >>>>>>> OpenHeart-L mailing list >>>>>>> >>>>>>> Send postings to: >>>>>>> OpenHeart-L@lists.hsforum.com >>>>>>> >>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>>>> http://mmp.cjp.com/mailman/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 >>>>> anddisclaimers 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 >>> anddisclaimers 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 >> ----------------------------------------- >> > > > >-- >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 tacuff at swbell.net Mon Feb 1 08:07:13 2010 From: tacuff at swbell.net (Tea Acuff) Date: Mon Feb 1 11:07:41 2010 Subject: [HSF] Who should manage the cardiac surgery ICU In-Reply-To: <89c4ed2d1002010605v7e030bffi29073851bd98f02a@mail.gmail.com> References: <89c4ed2d1002010605v7e030bffi29073851bd98f02a@mail.gmail.com> Message-ID: <445240.51861.qm@web81605.mail.mud.yahoo.com> We can all see ourselves as we like in this mirror. But I can't resist being so good looking...ha! From my bias (or theory) as a nonuniversalist we would expect those trained to do the same thing as fits that population would do better than comparable practioners trained in other populations, critical care or pulmonary or whatever in a single population. We would better match the intent or expectation of the surgeon who played the first card. Also data mining apparently adding drugs to this population from evidence from other popultions is both more expensive and more dangerous. Either less is more or one cook is better (assuming the cutting surgeon already cut the goose for a particular dish). tea ________________________________ From: Prasanna Simha M To: OpenHeart-L ; CCM-L Users Group Sent: Mon, February 1, 2010 8:05:53 AM Subject: [HSF] Who should manage the cardiac surgery ICU Interventional/Surgery Looking after their own: Surgeons may provide better care than intensivists in ICU January 28, 2010 | Reed Miller Download slides *Fort Lauderdale,* *FL* *-* Thoracic surgeons can provide better care to critical cardiac patients in the ICU than intensivists not board-certified in thoracic surgery, a new study suggests [*1*]. Researchers say there are multiple possible explanations for the differences between specialists' outcomes beyond their different medical skills. Here at the *Society* *for* *Thoracic* *Surgeons* (STS) *2010* *Annual* * Meeting*, *Dr* *Glenn* *Whitman* (Jefferson Medical College, Philadelphia) presented data from his institution's investigation conducted to determine whether the quality of ICU care provided by thoracic surgeons was different from that given by intensivists not board-certified in thoracic surgery. Whitman cited research by the *Institute* *for* *Healthcare* *Improvement*showing that if all ICU patients in the US were cared for by trained intensivists, more than 200 000 lives per year would be saved. Given the potential of high-quality ICU care to save lives, this study was intended to determine whether "all intensivists are created equal," Whitman explained. "By virtue of their operative and nonoperative training, specifically concentrating on cardiac surgical diseases, we speculate that thoracic surgeons may be uniquely qualified to provide critical care to postoperative cardiac-surgery patients." The study found that, in populations with similar postoperative risks, thoracic surgeons provided postoperative critical care that shortened patients' hospital stays and decreased drug costs, compared with the care provided by nonsurgeon intensivists, without sacrificing quality. The study retrospectively compared outcomes of similar patients treated in the ICU during two different periods. The populations were matched for STS operative risk scores. In the first period, which lasted about nine months, cardiac intensive care for 168 patients was overseen by nonthoracic intensivists without specific credentials in cardiac surgery. These intensivists were trained in either pulmonary critical care or trauma critical care. During the second period, which lasted about 16 months, care for 272 patients was managed by board-certified thoracic surgeons who were totally committed to the ICU for that period and who had no other surgical or consulting responsibilities. The variables measured included mortality, central-line infections, ventilator-acquired pneumonias per 1000 device-days, percentage of patients with red blood cell exposure (PRBC), percentage of patients with low blood sugar one and two days after cardiac surgery, postoperative and total length of hospital stay, and ICU pharmacy costs per patient. *Comparison of outcomes for ICU care by intensivists and surgeons* ? *Measurement* *Intensivist** care* *(**168 patients**)* *Surgeon care* *272 patients**)* *p* ? *Mortality rate** (%)* 3.1 2.5 0.15 ? *C**entral-**line infection** (n)* 1.3 1.6 0.81 ? *V**entilator**-acquired pneumonias** per 1000 device-**days** (n)* 7.6 4.2 0.19 ? *PRBC exposure** (%)* 46 57 0.28 ? *Blood sugar compliance** (%)* 83 88 0.19 ? *Av**era**g**e post**operative length of stay (d**)* 9.8 8.3 0.04 ? *Av**era**g**e **time from admission to discharge (d)* 13.4 11.2 0.01 ? *Av**era**g**e **ICU drug costs** ($**)* 4300 1800 0.001 ? To download table as a slide, click on slide logo above The reduction in patients' time in the hospital created an additional "600 opportunity days" for the hospital, which could potentially allow the hospital to admit an additional 100 patients and increase its revenues by $750 000. The direct cost savings from decreased ICU pharmacy expenditures was $680 000. What caused the improvements? While the hospital was shifting the care of cardiac critical-care patients from nonsurgeon intensivists to intensivists trained as surgeons, it implemented a new ICU quality-improvement initiative, which included the creation of multidisciplinary committees to provide input into ICU patient-care decisions. The initiative also created a list of quality metrics that were tracked and reported back to the caregivers every month. Also, every bedside nurse was given a checklist of steps to take every morning to improve on the quality measures. At the STS meeting, *Dr* *Jonathan* *Haft* (University of Michigan, Ann Arbor) suggested that the improvements in efficiency seen during the period when surgeons were managing the patients could have been the result of the quality-improvement initiative and not the difference in the training of the physicians. Whitman responded that it is impossible to know how many of the improvements were due to the change in physicians and how many were due to the quality-improvement initiative, but he believes that the difference in the intensivists' training did make a difference, because the surgeon-intensivists were better able to work closely with the surgeons who operated on the patients than the nonsurgeon intensivists. "It's tempting to speculate that, by virtue of specific operative and nonoperative training, cardiothoracic surgeons may be uniquely qualified to provide postoperative cardiac critical care. The improvements may have been facilitated by a 'sense of team' that enabled implementation of an array of quality and performance improvements," Whitman suggested. "The improved efficiency of care may not have been solely due to the expertise of the caring physicians but may have also been facilitated by the comfort level of the [surgeon-intensivist] and the [operating surgeon.] He pointed out that surgeons managing the postoperative care usually had an easier time than their nonsurgeon colleagues in getting the surgeon who operated on the patient to go along with suggested changes in medication. "I don't think the kind of changes that we made, in terms of the way we cared for the patients, would have gone over well with the surgeons if those who were asking for the changes were not also thoracic surgeons," he said. "It's a very sociology-related issue. I don't know how to address that scientifically, but having worked in a few ICUs, I know it's certainly palpable." Citing test-score data that showed that surgical residents often score below average on subjects specific to intensive care, Whitman agreed that "if we would like to have cardiac surgeons take care of their own patients in the intensive care unit, we are going to have to do a better job training our residents in critical care. "Nevertheless, I think the commonality associated with having thoracic surgeons care for their own patients and working with the surgeons who operate on them is an extremely important aspect of cardiac critical care. We should take it into consideration and, in many respects, not abrogate the responsibility of the care of our patients to nonthoracic intensivists," he concluded. ? ? Previous heartwire article Beta blockers: Less effect on pulse pressure than diuretics Jan 28, 2010 13:30 EST? Next heartwire article ? The atrial septal pouch?a new source of thrombus? Jan 29, 2010 11:30 EST? *Source* Whitman G, Haddad M, Hirose H, et al. Thoracic surgeons providing cardiac critical care improve patient management and decrease costs. Society of Thoracic Surgeons 2010 Annual Meeting; January 26, 2010; Fort Lauderdale, FL -- 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 tacuff at swbell.net Mon Feb 1 08:52:25 2010 From: tacuff at swbell.net (Tea Acuff) Date: Mon Feb 1 11:53:57 2010 Subject: [HSF] Blood transfusion for the postop heart In-Reply-To: <987758.38185.qm@web24703.mail.ird.yahoo.com> References: <987758.38185.qm@web24703.mail.ird.yahoo.com> Message-ID: <732175.92523.qm@web81603.mail.mud.yahoo.com> Let me just suggest that while this is a scary way of cutting the data, it does not prove your bias wrong, Dave. If Tony is correct in his bias or that of this report, then a Hct of 15 or something extreme is the correct default position. However if tony really completely agrees with my analysis than for the time being both you and he might be right...or one of you wrong including himself. Is transfusion a marker or a harm? Both would give the same result as this report. The usual stratifiers as not likely to sort out a new SNP, or bad operation, or fragile red cell popualtion or new (unaccounted by definition) effect. Even it Tony is exactly right in that there is harm in transfusion it just sets a tone or bias. It is?not a controlling (as default of 15 would suggest) piece of data. If we actually did an experiment to?ONLY transfuse for a certain level, there would be huge amounts of noise. If we repeated it in a small cardiac unit of the Hospital for GI Bleeds we likely would get a different number than Tony's based not on the bulk?in the means but the effect of the lashing tails of each population. If it is strictly a transfusion effect (a default effect) it would be smooth across the population if and only if it was universal (no SNPs, GI bleeds etc.) Even if smooth other conditions impact mortality from blood loss. If we studied shots to the head with a .45 that would likely be defalt type data, but there are already numerous historical trials of this effect. Which world (population) do you practice in? Is that due to the world or to you? tea ________________________________ From: David Harris To: openheart-l@lists.hsforum.com Sent: Mon, February 1, 2010 10:05:37 AM Subject: Re: [HSF] Blood transfusion for the postop heart Many thanks for stressing this! We all need to be aware of this and thanks for HSF which is the best way to keep up to date with the literature. Dave On Mon, 01 Feb 2010 16:15 EET Prasanna Simha M wrote: > Interventional/Surgery >Blood products should be used conservatively in heart-surgery patients, >trial shows >October 27, 2009 | Reed >Miller > Download slides > > > > *Edmonton, AB* - Perioperative blood product transfusions for stable >cardiac-surgery patients increases the risk of death, renal failure, and >sepsis or infection, results of a new study released at the *Canadian >Cardiovascular Congress 2009* show >[*1*]. > > >The study, presented by medical student *Robert Riddell* (Dalhousie >University, Halifax, NS), was conducted at the Maritime Heart Center in >Halifax, NS in 3842 consecutive patients undergoing all types of cardiac >surgery. The patients were sorted into four groups: the first received no >blood product transfusions; the second received blood products during their >surgery; the third group received blood products within the first 48 hours; >and the fourth received blood products 48 hours or later after surgery. > >After adjustment for baseline differences including preoperative renal >failure, gender, left ventricular ejection fraction, age, and procedure >type, a logistic regression found that the administration of blood products >dramatically increased morbidity and mortality of patients compared with >those who received no blood products. Furthermore, the study suggests >patients are worse off the later they receive the blood transfusion. >*Risk ratios (95% CI) compared with patients receiving no blood products by >timing of administration* > >? *Outcome* > *Intraoperative* > *Within 48 h** post**op* > *After 48 h postop* >? *In-hospital mortality* > 7.71 (4.44-13.38) > 7.09 (3.95-12.72) > 10.37 (5.21-20.63) >? *Acute renal failure* > 3.98 (2.77-5.74) > 4.12 (2.82-6.03) > 10.78 (7.03-16.52) >? *Sepsis/**DSWI* > 3.74 (1.85-7.57) > 4.11 (1.99-8.48) > 11.84 (5.56-25.23) >? DSWI=Deep sternal wound infection > To download table as a slide, click on slide logo above > >Maritime Heart Center's director of research in the division of cardiac >surgery, *Dr Jean-Francois L**?**gar**?* (Dalhousie Medical School), >explained the motivation for the study to *heart**wire**.* "If you're >bleeding to death, you need blood, but once you are stable and anemic?it is >less clear," he explained. > >Previous research, reported by >heartwire >*,* has shown a trend toward harm from blood transfusions in some surgery >patients, but the Halifax study was the first to focus exclusively on stable >patients who are not at risk of bleeding to death, L?gar? said. > >L?gar? said that although there are guidelines for administration of blood >products in Canada, the amount of blood products given stable surgery >patients varies greatly from center to center. > >"The perception is that someone who is anemic should be given blood, [but >the study shows] that we need to be more aggressive in not giving blood" and >reinforces the need for blood conservation strategies and the development of >more stringent criteria for the administration of blood products to stable >surgery patients. > >He also suggests that centers should reevaluate their processes for taking >blood from patients for diagnostic tests so there will be less need for >replacement blood products. For example, a patient in an ICU will often give >up to two units of blood per week for various diagnostics. L?gar? suggested >centers consider adopting new methods and technologies that require smaller >blood samples. > > >On Mon, Feb 1, 2010 at 7:08 PM, Giuseppe Rescigno wrote: > >> Tony, >> >> have you ever published your results with such a low threshold? I am quite >> surprised as for the populations I deal with it is difficult to achieve. >> >> Giuseppe >> >> >> Il giorno 01/feb/10, alle ore 06:29, Anthony P Furnary MD ha scritto: >> >> >>? Dave -- It's not a reflection of anything of the sort. >>> >>> Even one unit of blood in an elective CABG patient decreases survival and >>> increases the likelihood of ARF. >>> >>> Widely supported in the literature. Not anecdotal -- that's where we never >>> seem to remember the causal associations of complications we've "seen".. and >>> thus have "never seen " them.? Not due to "sicker" patient population. >>>? Multiple publications implicating transfusions in worsening heart failure. >>> >>> My transfusion "threshold" is Hct of 15. >>> >>> Tony >>> On Jan 27, 2010, at 10:03 PM, David Harris wrote: >>> >>>? I just think that's a reflection of a sicker patient who has had more >>>> acute blood loss, thus organ malperfusion. Not blood transfusion per se. I >>>> have never seen a prob$em with a patient who gets 1 or 2 units a few days >>>> down the line for Hb that's drifted below 9. In fact recovery and wound >>>> healing is better. Patients also feel instantly better and start to mobilise >>>> faster, especially if heart failure. I see more benefit than harm aiming for >>>> HKT 30. Dfave >>>> >>>> On Thu, 28 Jan 2010 02:07 EET Anthony P Furnary Md wrote: >>>> >>>>? YIKES!!! >>>>> >>>>> Speaking of education.... Here are some of the data: >>>>> >>>>> Multiple studies have shown that more perioperative blood (as in >>>>> transfused PRBCs) = >>>>> >>>>> More acute renal failure >>>>> More infections >>>>> More acute heart failure and low cardiac output syndrome >>>>> And most importantly, in CABG patients: >>>>> Significantly worse long term survival. >>>>> >>>>> I think, for my patients at least, that is Certainly worth fighting for, >>>>> no matter how much sleep is lost.? Actually I loose less, because the nurses >>>>> and PAs know not to call me for a low Hct, as I will not transfuse, unless >>>>> the patient requests it and completely understands the implications of even >>>>> a single unit of PRBC. >>>>> >>>>> Would never put my own interests (sleep, fighting a battle for a patient >>>>> benefit, etc) above a patients' best interest. >>>>> >>>>> Sorry, >>>>> Tony >>>>> Sent from my iPhone >>>>> >>>>> On Jan 27, 2010, at 8:15 AM, Michael Firstenberg >>>>> wrote: >>>>> >>>>>? yeah - what prasanna said. >>>>>> I have a very very low threshold for transfusing people up to close to >>>>>> 30. >>>>>> 1)? Old patients with bad hearts "feel better" and contrary to all of >>>>>> the data - their organs and hemodynamics like it >>>>>> 2) Anyone leaving on coumadin (yuck, rat poison) - who might bleed >>>>>> 3) Anyone going to a nursing home/etc in which someone might check >>>>>> their levels "just because" (and then send them back to the hospital for a >>>>>> bleeding work-up when the numbers are low) >>>>>> 4)? Anyone who might need another procedure soon - like a pacer/icd >>>>>> >>>>>> 5)? Education is key - but it is not worth fighting over or losing >>>>>> sleep.? Some of my partners get called in the middle of the night when the >>>>>> morning labs come back and the hcts are in the 8's asking about giving >>>>>> blood....... I like to sleep!? I trust the night team to use their >>>>>> judgement...... there are larger battles to fight. >>>>>> >>>>>> >>>>>> now - we can discuss whether it is a scarce and/or expensive >>>>>> resource...... >>>>>> >>>>>> >>>>>> >>>>>> On Jan 27, 2010, at 6:57 AM, Prasanna Simha M wrote: >>>>>> >>>>>>? An example of? cases where oxygen delivery and extraction is important >>>>>>> is incomplete comgenital corrections where a higher Hb has to be >>>>>>> achieved to allow oxygen deklivery in deasturated patients. >>>>>>> Prasanna >>>>>>> >>>>>>> On Wed, Jan 27, 2010 at 5:18 PM, Prasanna Simha M >>>>>>> wrote: >>>>>>> >>>>>>>> This has lead to a lot of hot blood ! >>>>>>>> Strictly there is no real transfusion trigger ever demonstrated. A >>>>>>>> large multicentric study showed that a Hb of > 7 Gm is enough for >>>>>>>> noninfants and less than 65 years and a higher Hb of 8 may be needed >>>>>>>> for elderly and infants. I am extremely stingy and will not transfuse >>>>>>>> unless the oxygen extraction or hemodynamics are impaired by an >>>>>>>> objective criterion. More importantly I try to conserve blood and >>>>>>>> prevent blood loss on the first place. >>>>>>>> Prasanna. >>>>>>>> Prasanna >>>>>>>> >>>>>>>> On Wed, Jan 27, 2010 at 1:14 PM, Ahmed Alsaddique >>>>>>>> wrote: >>>>>>>> >>>>>>>>> It would be interesting to get a feel from the Forum about the >>>>>>>>> transfusion policy in the post op heart. >>>>>>>>> I am interested in getting the members threshold for transfusion?? I >>>>>>>>> am labeled as stingy when it comes to transfusion >>>>>>>>> Thank? you >>>>>>>>> >>>>>>>>> Ahmed >>>>>>>>> _______________________________________________ >>>>>>>>> OpenHeart-L mailing list >>>>>>>>> >>>>>>>>> Send postings to: >>>>>>>>> OpenHeart-L@lists.hsforum.com >>>>>>>>> >>>>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>>>>>> http://mmp.cjp.com/mailman/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 >>>>>>> _______________________________________________ >>>>>>> OpenHeart-L mailing list >>>>>>> >>>>>>> Send postings to: >>>>>>> OpenHeart-L@lists.hsforum.com >>>>>>> >>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>>>> http://mmp.cjp.com/mailman/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 >>>>> anddisclaimers 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 >>> anddisclaimers 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 >> ----------------------------------------- >> > > > >-- >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 ----------------------------------------- From robertobattellini at hotmail.com Mon Feb 1 21:33:02 2010 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Mon Feb 1 15:33:29 2010 Subject: [HSF] STS Meeting - MICS Vs Conventional MV surgery In-Reply-To: References: , , , Message-ID: Ani, Have you ever done Mitral Mics to talk like that? The view is Superb with cameras, if you have doubts just go to leipzig and look at Mohr doing it. may be the higher stroke problems are with deairing the heart if the surgeon is not very strict and does not uses TEE. For MICS, camera and TEE are obligatory. Roberto > From: anianyanwu@hotmail.com > To: openheart-l@lists.hsforum.com > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > Date: Wed, 27 Jan 2010 02:13:54 +0000 > > > MICS was a risk factor independent of age and endoclamp use was not a predictor of stroke if I recall correctly. > > > > I doubt it is all retrograde perfusion as the MICS cohort were largely younger patients with minimal risk factors so should have clean aorta. > > > I think poor debris management due to the limited surgical view is certainly a possibility. Dr Gammie mentioned this in passing and I believe could well be the reason why a higher stroke rate in MICS persists regardless of age and risk factors. In MICS especially port access or robotic variety the surgeon's eye is by definition just on a limited area of the surgical field, and the assistant often sees less. Whereas via big incision the surgeon sees most of field and assistant sees areas surgeon doesnt. Jim postulated that maybe small bits of fat or valve, annular or ventricular tissue or surgical material could fall into the atrium or pulmonary veins unnoticed and go on to cause stroke. Whereas in sternotomy, the surgeon or assistant is more likely to spot that particle of fat or calcium on the atrial wall; with a robot, one would not see it as can see only the valve (i presume). This explantion, rather than air, could also tie up the observation of higher strokes with no-clamp methods as with the heart beating and blood in the field you are probably even less likely to see loose bits of tissue in the ventricle and around the annulus or leaflets. > > > > Ani > > > > > > Date: Tue, 26 Jan 2010 19:30:40 -0600 > > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > From: ebender001@me.com > > To: OpenHeart-L@lists.hsforum.com > > CC: > > > > Besides operating without a cross-clamp and air embolus (which obviously > > must be prevented no matter what approach), I assume the increased stroke > > risk was due to retrograde perfusion and athero emboli from the aorta, plus > > a small number due to malpositioned endo clamp or poor debris management > > through a small incision or port approach. Obviously these are concerning > > numbers, and stresses the need for a pre-op study of the aorta (most use CTA > > through the femorals) Did Jim break down the age groups? I guess one could > > use age as a surrogate for plaque build up in the aorta. > > > > Thanks for the feedback. > > > > Ed Bender, MD > > > > > > On 1/26/10 6:31 PM, "Ani Anyanwu" wrote: > > > > > > > > redos were excluded from this analysis > > > > > >> Date: Tue, 26 Jan 2010 18:28:44 -0600 > > >> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > >> From: ebender001@me.com > > >> To: OpenHeart-L@lists.hsforum.com > > >> CC: > > >> > > >> Very interesting. I would, as you stated, be cautious in using peripheral > > >> cannulation as a proxy for MICS. I use it liberally for redo approaches with > > >> a full sternotomy (as at least one other person on this forum does). Could > > >> it be that the reop rate might reflect a redo staus rather than a MICS? > > >> > > >> Ed Bender, MD > > >> > > >> > > >> On 1/26/10 6:04 PM, "Ani Anyanwu" wrote: > > >> > > >>> > > >>> I was at the STS for just a day. Only one paper caught my interest. Dr > > >>> Gammie > > >>> presented an excellent analysis of mitral valve surgery reported to the STS > > >>> database to compare analysis of conventional mitral valve surgery vs > > >>> minimally > > >>> invasive cardiac surgery. Becausesurgical incision is not collected by STS, > > >>> Gammie and colleagues used cannulation strategy as surrogate for > > >>> invasiveness. > > >>> If patient was cannulated centrally (aorta, right atrium) was assumed a > > >>> conventional appproach, if cannulated femoro-femoral, then was assumed to be > > >>> minimally invasive approach. Other permutations of cannulation were excluded > > >>> from analysis. Isolated MV only (?). They reviewed over 20,000 operations > > >>> performed in US between 2004-2008. > > >>> > > >>> > > >>> > > >>> Summary of findings > > >>> > > >>> . > > >>> > > >>> About 15% of all mitral operations were done with MICS as defined. Frequency > > >>> increased from 10% in 2004 to 20% in 2008. > > >>> > > >>> 35% of MICS robot assisted. > > >>> > > >>> Median number of MICS cases per center was 3. Over 75% of procedures in US > > >>> were done by institutions doing less than 5 procedures a year. > > >>> > > >>> Endoaortic balloon used in 35%. > > >>> > > >>> More valve repair in MICS group (85% Vs 67%) > > >>> > > >>> Clamp and bypass times 20 and 27 min longer in MICS group. > > >>> > > >>> 41% transfusion rate in MICS (51% conventional). > > >>> > > >>> More (yes - more) reoperations for bleeding with MICS (Odds ratio 1.22). > > >>> > > >>> Shorter length of saty and ventilation with MICS. > > >>> > > >>> Mortality same. > > >>> > > >>> > > >>> > > >>> KEY FINDING: Twice more strokes with MICS (Odds Ratio 1.96). Strokes defined > > >>> as stroke with permanent deficit. Higher stroke rate with MICS seen in all > > >>> groups examined, regardless of risk factors, center case volume, use of > > >>> endocclamp, use of clamp. However, highest rate of stroke was seen in those > > >>> cases done without a cross clamp (beating or fibrillation) associated with > > >>> odds ratio of 3. > > >>> > > >>> > > >>> > > >>> Limitations: Definition of MICS based on cannulaation strategy likely > > >>> misscalssified some patients. While very likely almost all femorofemoral > > >>> approachs were truly MICS procedures, a lot of MICS would have been called > > >>> conventional if centrally cannulated. Of importance because some high volume > > >>> MICS centers like NYU, Cleveland, BWH I believe use central cannulation > > >>> liberally for thoracotomy or hemisternotomy approach. Also hybrids eg > > >>> femoral > > >>> artery and central venous cannulation, used by some, were excluded. > > >>> > > >>> Patients in MICS were less sick, younger etc and more likely repairable > > >>> hence > > >>> introducing bias - of concern though is despite lower risk there was still > > >>> double stroke incidence. > > >>> > > >>> No data on true outcomes of surgery such as results of repair, reoperation, > > >>> 12 > > >>> month symptoms or survival. > > >>> > > >>> No data on mitral pathology and disease treated. > > >>> > > >>> > > >>> > > >>> Response from disscussants (most MICS enthusiasts) largely ignored or > > >>> dismissed the stroke risk and felt the data were sufficient to show that > > >>> MICS > > >>> 1) is valid approach for MV surgery 2) Does not compromise repair 3) Is safe > > >>> 4) Has better 'outcomes' but 5) other explanations likely exist for higher > > >>> stroke and 6) MV surgery without a clamp should be strongly discouraged. One > > >>> discussant cautioned that the stroke risk cannot be ignored as this is the > > >>> second mega-analysis of a database presented at STS in recent years showing > > >>> higher stroke risk with MICS (the other being a paper by Mehmet Oz group 5 > > >>> years or so ago I think presented by our Dr Cheema which also found doubling > > >>> of incidence of stroke in NY State). > > >>> > > >>> > > >>> > > >>> > > >>> > > >>> Ani > > >>> > > >>> > > >>> > > >>> > > >>> > > >>> > > >>> > > >>> > > >>> > > >>>> From: msfirst@gmail.com > > >>>> To: OpenHeart-L@lists.hsforum.com > > >>>> Subject: Re: [HSF] STS Meeting > > >>>> Date: Tue, 26 Jan 2010 18:23:52 -0500 > > >>>> CC: > > >>>> > > >>>> Guess not > > >>>> > > >>>> -michael/iPhone > > >>>> > > >>>> On Jan 26, 2010, at 4:50 PM, Edward Bender wrote: > > >>>> > > >>>>> Anything new and/or interesting coming out of the STS meeting? > > >>>>> > > >>>>> 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 > > >>>> ----------------------------------------- > > >>> > > >>> _________________________________________________________________ > > >>> Got a cool Hotmail story? Tell us now > > >>> http://clk.atdmt.com/UKM/go/195013117/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 > > >> ----------------------------------------- > > > > > > _________________________________________________________________ > > > We want to hear all your funny, exciting and crazy Hotmail stories. Tell us > > > now > > > http://clk.atdmt.com/UKM/go/195013117/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 > > ----------------------------------------- > > _________________________________________________________________ > We want to hear all your funny, exciting and crazy Hotmail stories. Tell us now > http://clk.atdmt.com/UKM/go/195013117/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 drmitch at cox.net Mon Feb 1 20:48:36 2010 From: drmitch at cox.net (Mitch Lirtzman) Date: Mon Feb 1 21:49:09 2010 Subject: [HSF] Fwd: Myxoma-n Follow up. Message-ID: <6.2.1.2.2.20100201202801.05552fe0@pop.east.cox.net> Sorry for the poor quality photo. Nurse had a tough time focusing. Not quite tall enough to see well over the retractor. I think next time I'll reglove and take it myself. Prasanna, any photographic tips? Be all that as it may. I did go through the ASD. As soon as I made my initial cut on the lower border of the defect, it bulged through like a wad of grape jelly gone bad. Always surprising that the thing didn't float off into the ether a long time ago. The stalk was on the posterior- inferior septum. Between the Rt inf PV and the valve. Right over the coronary sinus. Thanks to all. Mitch >X-VR-Score: 0.00 >X-Authority-Analysis: v=1.1 cv=mu+wxrgCBz+cTL0c2lRuwJM8TptuAecZNp/84wrWurE= > c=1 sm=1 a=66aYUnUyC0pl1KwasmjPfA==:17 a=PgvuvCAnhrTknUi7u3YA:9 > a=J87I6PvSsGiRj0YJ2t-AnHyn8V8A:4 a=KQqxNPgzF0kA:10 a=1dvLGVSKd1vjbQPF:18 > a=--_8wY0C-EiUZUvWQiEA:9 a=UrfPK9zIYjyIKoXfAlntJiq8ysYA:4 > a=66aYUnUyC0pl1KwasmjPfA==:117 >X-CM-Score: 0.00 >From: Lirtzman Mitchell >To: "drmitch@cox.net" >Date: Mon, 1 Feb 2010 20:25:45 -0600 >Subject: Myxoma >Thread-Topic: Myxoma >Thread-Index: AcqjrwuP2m20z3DsRPqpTbe6D5CsrQ== >Accept-Language: en-US >X-MS-Has-Attach: yes >X-MS-TNEF-Correlator: >acceptlanguage: en-US >X-Proofpoint-Spam-Details: rule=notspam policy=default score=0 spamscore=0 >ipscore=0 phishscore=0 bulkscore=0 adultscore=0 classifier=spam adjust=0 >reason=mlx engine=5.0.0-0908210000 definitions=main-1002010259 > > > > > -------------- next part -------------- A non-text attachment was scrubbed... Name: photo27.jpg Type: image/jpeg Size: 126131 bytes Desc: not available Url : http://mmp.cjp.com/pipermail/openheart-l/attachments/20100201/5847c77e/photo27-0001.jpg -------------- next part -------------- Sent from my iPhone From drmitch at cox.net Mon Feb 1 20:53:19 2010 From: drmitch at cox.net (Mitch Lirtzman) Date: Mon Feb 1 21:53:49 2010 Subject: [HSF] Fwd: Myxoma-n Follow up. In-Reply-To: <6.2.1.2.2.20100201202801.05552fe0@pop.east.cox.net> References: <6.2.1.2.2.20100201202801.05552fe0@pop.east.cox.net> Message-ID: <6.2.1.2.2.20100201205254.05596e20@pop.east.cox.net> Oh yeah, it's just to the left of the pump sucker.At 08:48 PM 2/1/2010, you wrote: >Sorry for the poor quality photo. Nurse had a tough time focusing. Not >quite tall enough to see well over the retractor. I think next time I'll >reglove and take it myself. Prasanna, any photographic tips? >Be all that as it may. I did go through the ASD. As soon as I made my >initial cut on the lower border of the defect, it bulged through like a >wad of grape jelly gone bad. Always surprising that the thing didn't float >off into the ether a long time ago. The stalk was on the posterior- >inferior septum. Between the Rt inf PV and the valve. Right over the >coronary sinus. >Thanks to all. > >Mitch >>X-VR-Score: 0.00 >>X-Authority-Analysis: v=1.1 cv=mu+wxrgCBz+cTL0c2lRuwJM8TptuAecZNp/84wrWurE= >> c=1 sm=1 a=66aYUnUyC0pl1KwasmjPfA==:17 a=PgvuvCAnhrTknUi7u3YA:9 >> a=J87I6PvSsGiRj0YJ2t-AnHyn8V8A:4 a=KQqxNPgzF0kA:10 a=1dvLGVSKd1vjbQPF:18 >> a=--_8wY0C-EiUZUvWQiEA:9 a=UrfPK9zIYjyIKoXfAlntJiq8ysYA:4 >> a=66aYUnUyC0pl1KwasmjPfA==:117 >>X-CM-Score: 0.00 >>From: Lirtzman Mitchell >>To: "drmitch@cox.net" >>Date: Mon, 1 Feb 2010 20:25:45 -0600 >>Subject: Myxoma >>Thread-Topic: Myxoma >>Thread-Index: AcqjrwuP2m20z3DsRPqpTbe6D5CsrQ== >>Accept-Language: en-US >>X-MS-Has-Attach: yes >>X-MS-TNEF-Correlator: >>acceptlanguage: en-US >>X-Proofpoint-Spam-Details: rule=notspam policy=default score=0 >>spamscore=0 ipscore=0 phishscore=0 bulkscore=0 adultscore=0 >>classifier=spam adjust=0 reason=mlx engine=5.0.0-0908210000 >>definitions=main-1002010259 >> >> >> >> > > > > >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: > OpenHeart-L@lists.hsforum.com > >To UNSUBSCRIBE, to CHANGE email address, or to view archives: >http://mmp.cjp.com/mailman/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 Feb 2 08:31:18 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Mon Feb 1 22:06:41 2010 Subject: [HSF] Re: Removal of a Myxoma In-Reply-To: <466EA3C6.7050604@gmail.com> References: <466EA3C6.7050604@gmail.com> Message-ID: <89c4ed2d1002011901o7e5b2f28tfbc2a9968022d87@mail.gmail.com> Old panorama showing steps of a Myxoma removal (originally sent on Jun 12 2007) Prasanna On Tue, Jun 12, 2007 at 7:16 PM, prasannasimha wrote: > Picture of Myxoma being removed trans right atrially. > CCMLers this is the same patient I sent the mp4's > Prasanna > -- Prasanna Simha M From prasannasimha at gmail.com Tue Feb 2 08:26:40 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Mon Feb 1 22:53:33 2010 Subject: [HSF] Fwd: Myxoma-n Follow up. In-Reply-To: <6.2.1.2.2.20100201202801.05552fe0@pop.east.cox.net> References: <6.2.1.2.2.20100201202801.05552fe0@pop.east.cox.net> Message-ID: <89c4ed2d1002011856o4983731boda0b6a859e35a1d9@mail.gmail.com> Two options mount (I had posted how to make one before) and another option is to wear double gloves, use the camera and peel off the glove. Prasanna On Tue, Feb 2, 2010 at 8:18 AM, Mitch Lirtzman wrote: > Sorry for the poor quality photo. Nurse had a tough time focusing. Not > quite tall enough to see well over the retractor. I think next time I'll > reglove and take it myself. Prasanna, any photographic tips? > Be all that as it may. I did go through the ASD. As soon as I made my > initial cut on the lower border of the defect, it bulged through like a wad > of grape jelly gone bad. Always surprising that the thing didn't float off > into the ether a long time ago. The stalk was on the posterior- inferior > septum. Between the Rt inf PV and the valve. Right over the coronary sinus. > Thanks to all. > > Mitch > >> X-VR-Score: 0.00 >> X-Authority-Analysis: v=1.1 >> cv=mu+wxrgCBz+cTL0c2lRuwJM8TptuAecZNp/84wrWurE= >> c=1 sm=1 a=66aYUnUyC0pl1KwasmjPfA==:17 a=PgvuvCAnhrTknUi7u3YA:9 >> a=J87I6PvSsGiRj0YJ2t-AnHyn8V8A:4 a=KQqxNPgzF0kA:10 a=1dvLGVSKd1vjbQPF:18 >> a=--_8wY0C-EiUZUvWQiEA:9 a=UrfPK9zIYjyIKoXfAlntJiq8ysYA:4 >> a=66aYUnUyC0pl1KwasmjPfA==:117 >> X-CM-Score: 0.00 >> From: Lirtzman Mitchell >> To: "drmitch@cox.net" >> Date: Mon, 1 Feb 2010 20:25:45 -0600 >> Subject: Myxoma >> Thread-Topic: Myxoma >> Thread-Index: AcqjrwuP2m20z3DsRPqpTbe6D5CsrQ== >> Accept-Language: en-US >> X-MS-Has-Attach: yes >> X-MS-TNEF-Correlator: >> acceptlanguage: en-US >> X-Proofpoint-Spam-Details: rule=notspam policy=default score=0 spamscore=0 >> ipscore=0 phishscore=0 bulkscore=0 adultscore=0 classifier=spam adjust=0 >> reason=mlx engine=5.0.0-0908210000 definitions=main-1002010259 >> >> >> >> >> >> > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 ebender001 at me.com Mon Feb 1 22:14:05 2010 From: ebender001 at me.com (Edward Bender) Date: Mon Feb 1 23:14:37 2010 Subject: [HSF] Fwd: Myxoma-n Follow up. In-Reply-To: <6.2.1.2.2.20100201202801.05552fe0@pop.east.cox.net> Message-ID: Mitch: One other trick I use is to mount or hold a thoracoscope so that you can capture video. Then you can have video or frame capture for an isolated still. Ed Bender, MD On 2/1/10 8:48 PM, "Mitch Lirtzman" wrote: > Sorry for the poor quality photo. Nurse had a tough time focusing. Not > quite tall enough to see well over the retractor. I think next time I'll > reglove and take it myself. Prasanna, any photographic tips? > Be all that as it may. I did go through the ASD. As soon as I made my > initial cut on the lower border of the defect, it bulged through like a wad > of grape jelly gone bad. Always surprising that the thing didn't float off > into the ether a long time ago. The stalk was on the posterior- inferior > septum. Between the Rt inf PV and the valve. Right over the coronary sinus. > Thanks to all. > > Mitch >> X-VR-Score: 0.00 >> X-Authority-Analysis: v=1.1 cv=mu+wxrgCBz+cTL0c2lRuwJM8TptuAecZNp/84wrWurE= >> c=1 sm=1 a=66aYUnUyC0pl1KwasmjPfA==:17 a=PgvuvCAnhrTknUi7u3YA:9 >> a=J87I6PvSsGiRj0YJ2t-AnHyn8V8A:4 a=KQqxNPgzF0kA:10 a=1dvLGVSKd1vjbQPF:18 >> a=--_8wY0C-EiUZUvWQiEA:9 a=UrfPK9zIYjyIKoXfAlntJiq8ysYA:4 >> a=66aYUnUyC0pl1KwasmjPfA==:117 >> X-CM-Score: 0.00 >> From: Lirtzman Mitchell >> To: "drmitch@cox.net" >> Date: Mon, 1 Feb 2010 20:25:45 -0600 >> Subject: Myxoma >> Thread-Topic: Myxoma >> Thread-Index: AcqjrwuP2m20z3DsRPqpTbe6D5CsrQ== >> Accept-Language: en-US >> X-MS-Has-Attach: yes >> X-MS-TNEF-Correlator: >> acceptlanguage: en-US >> X-Proofpoint-Spam-Details: rule=notspam policy=default score=0 spamscore=0 >> ipscore=0 phishscore=0 bulkscore=0 adultscore=0 classifier=spam adjust=0 >> reason=mlx engine=5.0.0-0908210000 definitions=main-1002010259 >> >> >> >> >> > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 Tue Feb 2 05:22:07 2010 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Tue Feb 2 00:22:35 2010 Subject: [HSF] STS Meeting - MICS Vs Conventional MV surgery In-Reply-To: References: , , , , , , Message-ID: Roberto Yes I have done mitral MICS. What I say about view from camera's is from personal observation where I have sometimes seen debris (under direct vision) in the atrium in an area that was not in camera's view (which is focused on the valve). I think valve repair without TEE is rarely, if ever practiced. I found it strange at STS all discussants (Mohr included ) seemed to give *impression* strokes were no longer seen in MICS and the problem had been 'solved' with CO2, deairing, changes to perfusion and clamping etc. Heck we see stroke with sternotomy - indeed in 2008 you may recall I posted for advice on the forum after having two patients in a month with devastating strokes after mitral repair via sternotomy - so what is strange about saying strokes occur after MICS? Any surgeon who says he has not seen strokes in mitral repair needs to do more and sooner or later willl have a stroke come to visit. Those who do MICS will have those visits a bit more frequently. I personally have my doubts as to whether air is a predominant cause of stroke with permanent deficit - the definition used in STS. When I worked with Yacoub in early days of routine TEE (and no CO2) there was often a snowstorm on echo just before coming of bypass - he just put a needle in aorta - like he had in 30 years of practice without TEE tellling him what to do - and came off bypass ignoring the echo (unless big pockets of air). Maybe there were neuro changes we could not measure, but rarely did the patients wake up with an STS defined stroke. I think we can blame air for global changes like delirium, cognitive dysfunction etc, but when a patient is hemiplegic I think we need to first look for, and exclude, other causes before we blame air. Ani > From: robertobattellini@hotmail.com > To: openheart-l@lists.hsforum.com > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > Date: Mon, 1 Feb 2010 21:33:02 +0100 > > > Ani, > > Have you ever done Mitral Mics to talk like that? > > The view is Superb with cameras, if you have doubts just go to leipzig and look at Mohr doing it. > > may be the higher stroke problems are with deairing the heart if the surgeon is not very strict and does > > not uses TEE. > > For MICS, camera and TEE are obligatory. > > Roberto > > > From: anianyanwu@hotmail.com > > To: openheart-l@lists.hsforum.com > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > Date: Wed, 27 Jan 2010 02:13:54 +0000 > > > > > > MICS was a risk factor independent of age and endoclamp use was not a predictor of stroke if I recall correctly. > > > > > > > > I doubt it is all retrograde perfusion as the MICS cohort were largely younger patients with minimal risk factors so should have clean aorta. > > > > > > I think poor debris management due to the limited surgical view is certainly a possibility. Dr Gammie mentioned this in passing and I believe could well be the reason why a higher stroke rate in MICS persists regardless of age and risk factors. In MICS especially port access or robotic variety the surgeon's eye is by definition just on a limited area of the surgical field, and the assistant often sees less. Whereas via big incision the surgeon sees most of field and assistant sees areas surgeon doesnt. Jim postulated that maybe small bits of fat or valve, annular or ventricular tissue or surgical material could fall into the atrium or pulmonary veins unnoticed and go on to cause stroke. Whereas in sternotomy, the surgeon or assistant is more likely to spot that particle of fat or calcium on the atrial wall; with a robot, one would not see it as can see only the valve (i presume). This explantion, rather than air, could also tie up the observation of higher strokes with no-clamp methods as with the heart beating and blood in the field you are probably even less likely to see loose bits of tissue in the ventricle and around the annulus or leaflets. > > > > > > > > Ani > > > > > > > > > > > Date: Tue, 26 Jan 2010 19:30:40 -0600 > > > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > From: ebender001@me.com > > > To: OpenHeart-L@lists.hsforum.com > > > CC: > > > > > > Besides operating without a cross-clamp and air embolus (which obviously > > > must be prevented no matter what approach), I assume the increased stroke > > > risk was due to retrograde perfusion and athero emboli from the aorta, plus > > > a small number due to malpositioned endo clamp or poor debris management > > > through a small incision or port approach. Obviously these are concerning > > > numbers, and stresses the need for a pre-op study of the aorta (most use CTA > > > through the femorals) Did Jim break down the age groups? I guess one could > > > use age as a surrogate for plaque build up in the aorta. > > > > > > Thanks for the feedback. > > > > > > Ed Bender, MD > > > > > > > > > On 1/26/10 6:31 PM, "Ani Anyanwu" wrote: > > > > > > > > > > > redos were excluded from this analysis > > > > > > > >> Date: Tue, 26 Jan 2010 18:28:44 -0600 > > > >> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > >> From: ebender001@me.com > > > >> To: OpenHeart-L@lists.hsforum.com > > > >> CC: > > > >> > > > >> Very interesting. I would, as you stated, be cautious in using peripheral > > > >> cannulation as a proxy for MICS. I use it liberally for redo approaches with > > > >> a full sternotomy (as at least one other person on this forum does). Could > > > >> it be that the reop rate might reflect a redo staus rather than a MICS? > > > >> > > > >> Ed Bender, MD > > > >> > > > >> > > > >> On 1/26/10 6:04 PM, "Ani Anyanwu" wrote: > > > >> > > > >>> > > > >>> I was at the STS for just a day. Only one paper caught my interest. Dr > > > >>> Gammie > > > >>> presented an excellent analysis of mitral valve surgery reported to the STS > > > >>> database to compare analysis of conventional mitral valve surgery vs > > > >>> minimally > > > >>> invasive cardiac surgery. Becausesurgical incision is not collected by STS, > > > >>> Gammie and colleagues used cannulation strategy as surrogate for > > > >>> invasiveness. > > > >>> If patient was cannulated centrally (aorta, right atrium) was assumed a > > > >>> conventional appproach, if cannulated femoro-femoral, then was assumed to be > > > >>> minimally invasive approach. Other permutations of cannulation were excluded > > > >>> from analysis. Isolated MV only (?). They reviewed over 20,000 operations > > > >>> performed in US between 2004-2008. > > > >>> > > > >>> > > > >>> > > > >>> Summary of findings > > > >>> > > > >>> . > > > >>> > > > >>> About 15% of all mitral operations were done with MICS as defined. Frequency > > > >>> increased from 10% in 2004 to 20% in 2008. > > > >>> > > > >>> 35% of MICS robot assisted. > > > >>> > > > >>> Median number of MICS cases per center was 3. Over 75% of procedures in US > > > >>> were done by institutions doing less than 5 procedures a year. > > > >>> > > > >>> Endoaortic balloon used in 35%. > > > >>> > > > >>> More valve repair in MICS group (85% Vs 67%) > > > >>> > > > >>> Clamp and bypass times 20 and 27 min longer in MICS group. > > > >>> > > > >>> 41% transfusion rate in MICS (51% conventional). > > > >>> > > > >>> More (yes - more) reoperations for bleeding with MICS (Odds ratio 1.22). > > > >>> > > > >>> Shorter length of saty and ventilation with MICS. > > > >>> > > > >>> Mortality same. > > > >>> > > > >>> > > > >>> > > > >>> KEY FINDING: Twice more strokes with MICS (Odds Ratio 1.96). Strokes defined > > > >>> as stroke with permanent deficit. Higher stroke rate with MICS seen in all > > > >>> groups examined, regardless of risk factors, center case volume, use of > > > >>> endocclamp, use of clamp. However, highest rate of stroke was seen in those > > > >>> cases done without a cross clamp (beating or fibrillation) associated with > > > >>> odds ratio of 3. > > > >>> > > > >>> > > > >>> > > > >>> Limitations: Definition of MICS based on cannulaation strategy likely > > > >>> misscalssified some patients. While very likely almost all femorofemoral > > > >>> approachs were truly MICS procedures, a lot of MICS would have been called > > > >>> conventional if centrally cannulated. Of importance because some high volume > > > >>> MICS centers like NYU, Cleveland, BWH I believe use central cannulation > > > >>> liberally for thoracotomy or hemisternotomy approach. Also hybrids eg > > > >>> femoral > > > >>> artery and central venous cannulation, used by some, were excluded. > > > >>> > > > >>> Patients in MICS were less sick, younger etc and more likely repairable > > > >>> hence > > > >>> introducing bias - of concern though is despite lower risk there was still > > > >>> double stroke incidence. > > > >>> > > > >>> No data on true outcomes of surgery such as results of repair, reoperation, > > > >>> 12 > > > >>> month symptoms or survival. > > > >>> > > > >>> No data on mitral pathology and disease treated. > > > >>> > > > >>> > > > >>> > > > >>> Response from disscussants (most MICS enthusiasts) largely ignored or > > > >>> dismissed the stroke risk and felt the data were sufficient to show that > > > >>> MICS > > > >>> 1) is valid approach for MV surgery 2) Does not compromise repair 3) Is safe > > > >>> 4) Has better 'outcomes' but 5) other explanations likely exist for higher > > > >>> stroke and 6) MV surgery without a clamp should be strongly discouraged. One > > > >>> discussant cautioned that the stroke risk cannot be ignored as this is the > > > >>> second mega-analysis of a database presented at STS in recent years showing > > > >>> higher stroke risk with MICS (the other being a paper by Mehmet Oz group 5 > > > >>> years or so ago I think presented by our Dr Cheema which also found doubling > > > >>> of incidence of stroke in NY State). > > > >>> > > > >>> > > > >>> > > > >>> > > > >>> > > > >>> Ani > > > >>> > > > >>> > > > >>> > > > >>> > > > >>> > > > >>> > > > >>> > > > >>> > > > >>> > > > >>>> From: msfirst@gmail.com > > > >>>> To: OpenHeart-L@lists.hsforum.com > > > >>>> Subject: Re: [HSF] STS Meeting > > > >>>> Date: Tue, 26 Jan 2010 18:23:52 -0500 > > > >>>> CC: > > > >>>> > > > >>>> Guess not > > > >>>> > > > >>>> -michael/iPhone > > > >>>> > > > >>>> On Jan 26, 2010, at 4:50 PM, Edward Bender wrote: > > > >>>> > > > >>>>> Anything new and/or interesting coming out of the STS meeting? > > > >>>>> > > > >>>>> 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 > > > >>>> ----------------------------------------- > > > >>> > > > >>> _________________________________________________________________ > > > >>> Got a cool Hotmail story? Tell us now > > > >>> http://clk.atdmt.com/UKM/go/195013117/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 > > > >> ----------------------------------------- > > > > > > > > _________________________________________________________________ > > > > We want to hear all your funny, exciting and crazy Hotmail stories. 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Tell us now > > http://clk.atdmt.com/UKM/go/195013117/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 > ----------------------------------------- _________________________________________________________________ Got a cool Hotmail story? Tell us now http://clk.atdmt.com/UKM/go/195013117/direct/01/ From msfirst at gmail.com Tue Feb 2 06:39:46 2010 From: msfirst at gmail.com (Michael Firstenberg) Date: Tue Feb 2 06:40:05 2010 Subject: [HSF] Aortic guru's - Where to stop? Message-ID: I recently saw a lady in clinic (smoker, hypertension) with an ascending aortic aneurysm. She is not very large and a MRA showed the following: The entire thoracic and supra renal abdominal aorta is aneurysmal. The aortic sinuses measure 3.8 x 3.9cm, STJ 3.8 x 3.5cm, AscAo 5.5 x 5.3cm, mid transverse arch 3.5 x 3.2cm, proximal DescAo 3.6 x 3.5cm. Her aortic valve is normal with only trace/mild AI Clearly her ascending needs to be replaced - but do you just do a hemi-arch and follow her or do you replace the arch as well with an Elephant trunk now (obviously a much larger operation)? (or some other strange endovascular thing). She had a relatively normal cath in 2007 (getting repeated) but otherwise appears to be a reasonable operative candidate. thanks -michael From Hgrmd at aol.com Tue Feb 2 06:42:54 2010 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Tue Feb 2 06:43:41 2010 Subject: [HSF] STS Meeting - MICS Vs Conventional MV surgery Message-ID: <133f.125d0014.389969be@aol.com> Ani, I wish I could have heard Gammie's talk, and I look forward to scrutinizing the paper when it is published. However, the problem is that it looks at the incidence of strokes for all MICS. As we know, MICS is not a uniform procedure, so these results are really a mish mash. I agree with Fred Mohr that the incidence of strokes in experienced MICS centers is probably as low or lower when compared to sternotomy. From my conversations with other MICS surgeons, fat emboli from the cut sternal edge is eliminated. In addition, in the closed chest filled with CO2, you rarely see ANY bubbles on TEE. Hal In a message dated 2/2/2010 12:24:17 A.M. Eastern Standard Time, anianyanwu@hotmail.com writes: Roberto Yes I have done mitral MICS. What I say about view from camera's is from personal observation where I have sometimes seen debris (under direct vision) in the atrium in an area that was not in camera's view (which is focused on the valve). I think valve repair without TEE is rarely, if ever practiced. I found it strange at STS all discussants (Mohr included ) seemed to give *impression* strokes were no longer seen in MICS and the problem had been 'solved' with CO2, deairing, changes to perfusion and clamping etc. Heck we see stroke with sternotomy - indeed in 2008 you may recall I posted for advice on the forum after having two patients in a month with devastating strokes after mitral repair via sternotomy - so what is strange about saying strokes occur after MICS? Any surgeon who says he has not seen strokes in mitral repair needs to do more and sooner or later willl have a stroke come to visit. Those who do MICS will have those visits a bit more frequently. I personally have my doubts as to whether air is a predominant cause of stroke with permanent deficit - the definition used in STS. When I worked with Yacoub in early days of routine TEE (and no CO2) there was often a snowstorm on echo just before coming of bypass - he just put a needle in aorta - like he had in 30 years of practice without TEE tellling him what to do - and came off bypass ignoring the echo (unless big pockets of air). Maybe there were neuro changes we could not measure, but rarely did the patients wake up with an STS defined stroke. I think we can blame air for global changes like delirium, cognitive dysfunction etc, but when a patient is hemiplegic I think we need to first look for, and exclude, other causes before we blame air. Ani > From: robertobattellini@hotmail.com > To: openheart-l@lists.hsforum.com > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > Date: Mon, 1 Feb 2010 21:33:02 +0100 > > > Ani, > > Have you ever done Mitral Mics to talk like that? > > The view is Superb with cameras, if you have doubts just go to leipzig and look at Mohr doing it. > > may be the higher stroke problems are with deairing the heart if the surgeon is not very strict and does > > not uses TEE. > > For MICS, camera and TEE are obligatory. > > Roberto > > > From: anianyanwu@hotmail.com > > To: openheart-l@lists.hsforum.com > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > Date: Wed, 27 Jan 2010 02:13:54 +0000 > > > > > > MICS was a risk factor independent of age and endoclamp use was not a predictor of stroke if I recall correctly. > > > > > > > > I doubt it is all retrograde perfusion as the MICS cohort were largely younger patients with minimal risk factors so should have clean aorta. > > > > > > I think poor debris management due to the limited surgical view is certainly a possibility. Dr Gammie mentioned this in passing and I believe could well be the reason why a higher stroke rate in MICS persists regardless of age and risk factors. In MICS especially port access or robotic variety the surgeon's eye is by definition just on a limited area of the surgical field, and the assistant often sees less. Whereas via big incision the surgeon sees most of field and assistant sees areas surgeon doesnt. Jim postulated that maybe small bits of fat or valve, annular or ventricular tissue or surgical material could fall into the atrium or pulmonary veins unnoticed and go on to cause stroke. Whereas in sternotomy, the surgeon or assistant is more likely to spot that particle of fat or calcium on the atrial wall; with a robot, one would not see it as can see only the valve (i presume). This explantion, rather than air, could also tie up the observation of higher strokes with no-clamp methods as with the heart beating and blood in the field you are probably even less likely to see loose bits of tissue in the ventricle and around the annulus or leaflets. > > > > > > > > Ani > > > > > > > > > > > Date: Tue, 26 Jan 2010 19:30:40 -0600 > > > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > From: ebender001@me.com > > > To: OpenHeart-L@lists.hsforum.com > > > CC: > > > > > > Besides operating without a cross-clamp and air embolus (which obviously > > > must be prevented no matter what approach), I assume the increased stroke > > > risk was due to retrograde perfusion and athero emboli from the aorta, plus > > > a small number due to malpositioned endo clamp or poor debris management > > > through a small incision or port approach. Obviously these are concerning > > > numbers, and stresses the need for a pre-op study of the aorta (most use CTA > > > through the femorals) Did Jim break down the age groups? I guess one could > > > use age as a surrogate for plaque build up in the aorta. > > > > > > Thanks for the feedback. > > > > > > Ed Bender, MD > > > > > > > > > On 1/26/10 6:31 PM, "Ani Anyanwu" wrote: > > > > > > > > > > > redos were excluded from this analysis > > > > > > > >> Date: Tue, 26 Jan 2010 18:28:44 -0600 > > > >> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > >> From: ebender001@me.com > > > >> To: OpenHeart-L@lists.hsforum.com > > > >> CC: > > > >> > > > >> Very interesting. I would, as you stated, be cautious in using peripheral > > > >> cannulation as a proxy for MICS. I use it liberally for redo approaches with > > > >> a full sternotomy (as at least one other person on this forum does). Could > > > >> it be that the reop rate might reflect a redo staus rather than a MICS? > > > >> > > > >> Ed Bender, MD > > > >> > > > >> > > > >> On 1/26/10 6:04 PM, "Ani Anyanwu" wrote: > > > >> > > > >>> > > > >>> I was at the STS for just a day. Only one paper caught my interest. Dr > > > >>> Gammie > > > >>> presented an excellent analysis of mitral valve surgery reported to the STS > > > >>> database to compare analysis of conventional mitral valve surgery vs > > > >>> minimally > > > >>> invasive cardiac surgery. Becausesurgical incision is not collected by STS, > > > >>> Gammie and colleagues used cannulation strategy as surrogate for > > > >>> invasiveness. > > > >>> If patient was cannulated centrally (aorta, right atrium) was assumed a > > > >>> conventional appproach, if cannulated femoro-femoral, then was assumed to be > > > >>> minimally invasive approach. Other permutations of cannulation were excluded > > > >>> from analysis. Isolated MV only (?). They reviewed over 20,000 operations > > > >>> performed in US between 2004-2008. > > > >>> > > > >>> > > > >>> > > > >>> Summary of findings > > > >>> > > > >>> . > > > >>> > > > >>> About 15% of all mitral operations were done with MICS as defined. Frequency > > > >>> increased from 10% in 2004 to 20% in 2008. > > > >>> > > > >>> 35% of MICS robot assisted. > > > >>> > > > >>> Median number of MICS cases per center was 3. Over 75% of procedures in US > > > >>> were done by institutions doing less than 5 procedures a year. > > > >>> > > > >>> Endoaortic balloon used in 35%. > > > >>> > > > >>> More valve repair in MICS group (85% Vs 67%) > > > >>> > > > >>> Clamp and bypass times 20 and 27 min longer in MICS group. > > > >>> > > > >>> 41% transfusion rate in MICS (51% conventional). > > > >>> > > > >>> More (yes - more) reoperations for bleeding with MICS (Odds ratio 1.22). > > > >>> > > > >>> Shorter length of saty and ventilation with MICS. > > > >>> > > > >>> Mortality same. > > > >>> > > > >>> > > > >>> > > > >>> KEY FINDING: Twice more strokes with MICS (Odds Ratio 1.96). Strokes defined > > > >>> as stroke with permanent deficit. Higher stroke rate with MICS seen in all > > > >>> groups examined, regardless of risk factors, center case volume, use of > > > >>> endocclamp, use of clamp. However, highest rate of stroke was seen in those > > > >>> cases done without a cross clamp (beating or fibrillation) associated with > > > >>> odds ratio of 3. > > > >>> > > > >>> > > > >>> > > > >>> Limitations: Definition of MICS based on cannulaation strategy likely > > > >>> misscalssified some patients. While very likely almost all femorofemoral > > > >>> approachs were truly MICS procedures, a lot of MICS would have been called > > > >>> conventional if centrally cannulated. Of importance because some high volume > > > >>> MICS centers like NYU, Cleveland, BWH I believe use central cannulation > > > >>> liberally for thoracotomy or hemisternotomy approach. Also hybrids eg > > > >>> femoral > > > >>> artery and central venous cannulation, used by some, were excluded. > > > >>> > > > >>> Patients in MICS were less sick, younger etc and more likely repairable > > > >>> hence > > > >>> introducing bias - of concern though is despite lower risk there was still > > > >>> double stroke incidence. > > > >>> > > > >>> No data on true outcomes of surgery such as results of repair, reoperation, > > > >>> 12 > > > >>> month symptoms or survival. > > > >>> > > > >>> No data on mitral pathology and disease treated. > > > >>> > > > >>> > > > >>> > > > >>> Response from disscussants (most MICS enthusiasts) largely ignored or > > > >>> dismissed the stroke risk and felt the data were sufficient to show that > > > >>> MICS > > > >>> 1) is valid approach for MV surgery 2) Does not compromise repair 3) Is safe > > > >>> 4) Has better 'outcomes' but 5) other explanations likely exist for higher > > > >>> stroke and 6) MV surgery without a clamp should be strongly discouraged. One > > > >>> discussant cautioned that the stroke risk cannot be ignored as this is the > > > >>> second mega-analysis of a database presented at STS in recent years showing > > > >>> higher stroke risk with MICS (the other being a paper by Mehmet Oz group 5 > > > >>> years or so ago I think presented by our Dr Cheema which also found doubling > > > >>> of incidence of stroke in NY State). > > > >>> > > > >>> > > > >>> > > > >>> > > > >>> > > > >>> Ani > > > >>> > > > >>> > > > >>> > > > >>> > > > >>> > > > >>> > > > >>> > > > >>> > > > >>> > > > >>>> From: msfirst@gmail.com > > > >>>> To: OpenHeart-L@lists.hsforum.com > > > >>>> Subject: Re: [HSF] STS Meeting > > > >>>> Date: Tue, 26 Jan 2010 18:23:52 -0500 > > > >>>> CC: > > > >>>> > > > >>>> Guess not > > > >>>> > > > >>>> -michael/iPhone > > > >>>> > > > >>>> On Jan 26, 2010, at 4:50 PM, Edward Bender wrote: > > > >>>> > > > >>>>> Anything new and/or interesting coming out of the STS meeting? > > > >>>>> > > > >>>>> 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 > > > >>>> ----------------------------------------- > > > >>> > > > >>> _________________________________________________________________ > > > >>> Got a cool Hotmail story? Tell us now > > > >>> http://clk.atdmt.com/UKM/go/195013117/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 > > > >> ----------------------------------------- > > > > > > > > _________________________________________________________________ > > > > We want to hear all your funny, exciting and crazy Hotmail stories. Tell us > > > > now > > > > http://clk.atdmt.com/UKM/go/195013117/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 > > > ----------------------------------------- > > > > _________________________________________________________________ > > We want to hear all your funny, exciting and crazy Hotmail stories. Tell us now > > http://clk.atdmt.com/UKM/go/195013117/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 > ----------------------------------------- _________________________________________________________________ Got a cool Hotmail story? Tell us now http://clk.atdmt.com/UKM/go/195013117/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 jbflegejr at aol.com Tue Feb 2 07:31:36 2010 From: jbflegejr at aol.com (John Flege) Date: Tue Feb 2 07:32:10 2010 Subject: [HSF] Fwd: Myxoma-n Follow up. In-Reply-To: <6.2.1.2.2.20100201202801.05552fe0@pop.east.cox.net> References: <6.2.1.2.2.20100201202801.05552fe0@pop.east.cox.net> Message-ID: <6A6E3853-A330-4506-9EFB-8743E4600F97@aol.com> You could keep a sterile camera on the shelf. John Flege On Feb 1, 2010, at 9:48 PM, Mitch Lirtzman wrote: > Sorry for the poor quality photo. Nurse had a tough time focusing. Not quite tall enough to see well over the retractor. I think next time I'll reglove and take it myself. Prasanna, any photographic tips? > Be all that as it may. I did go through the ASD. As soon as I made my initial cut on the lower border of the defect, it bulged through like a wad of grape jelly gone bad. Always surprising that the thing didn't float off into the ether a long time ago. The stalk was on the posterior- inferior septum. Between the Rt inf PV and the valve. Right over the coronary sinus. > Thanks to all. > > Mitch >> X-VR-Score: 0.00 >> X-Authority-Analysis: v=1.1 cv=mu+wxrgCBz+cTL0c2lRuwJM8TptuAecZNp/84wrWurE= >> c=1 sm=1 a=66aYUnUyC0pl1KwasmjPfA==:17 a=PgvuvCAnhrTknUi7u3YA:9 >> a=J87I6PvSsGiRj0YJ2t-AnHyn8V8A:4 a=KQqxNPgzF0kA:10 a=1dvLGVSKd1vjbQPF:18 >> a=--_8wY0C-EiUZUvWQiEA:9 a=UrfPK9zIYjyIKoXfAlntJiq8ysYA:4 >> a=66aYUnUyC0pl1KwasmjPfA==:117 >> X-CM-Score: 0.00 >> From: Lirtzman Mitchell >> To: "drmitch@cox.net" >> Date: Mon, 1 Feb 2010 20:25:45 -0600 >> Subject: Myxoma >> Thread-Topic: Myxoma >> Thread-Index: AcqjrwuP2m20z3DsRPqpTbe6D5CsrQ== >> Accept-Language: en-US >> X-MS-Has-Attach: yes >> X-MS-TNEF-Correlator: >> acceptlanguage: en-US >> X-Proofpoint-Spam-Details: rule=notspam policy=default score=0 spamscore=0 ipscore=0 phishscore=0 bulkscore=0 adultscore=0 classifier=spam adjust=0 reason=mlx engine=5.0.0-0908210000 definitions=main-1002010259 >> >> >> >> >> > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 jbflegejr at aol.com Tue Feb 2 07:35:12 2010 From: jbflegejr at aol.com (John Flege) Date: Tue Feb 2 07:36:25 2010 Subject: [HSF] STS Meeting - MICS Vs Conventional MV surgery In-Reply-To: References: , , , , , , Message-ID: <918994A1-479B-4A52-A19D-A026EEEE1D6E@aol.com> Fat embolism can be associated with long bone fractures. A sternotomy is something like a long bone fracture. John Flege On Feb 2, 2010, at 12:22 AM, Ani Anyanwu wrote: > > Roberto > > > > Yes I have done mitral MICS. What I say about view from camera's is from personal observation where I have sometimes seen debris (under direct vision) in the atrium in an area that was not in camera's view (which is focused on the valve). I think valve repair without TEE is rarely, if ever practiced. > > > > I found it strange at STS all discussants (Mohr included ) seemed to give *impression* strokes were no longer seen in MICS and the problem had been 'solved' with CO2, deairing, changes to perfusion and clamping etc. Heck we see stroke with sternotomy - indeed in 2008 you may recall I posted for advice on the forum after having two patients in a month with devastating strokes after mitral repair via sternotomy - so what is strange about saying strokes occur after MICS? Any surgeon who says he has not seen strokes in mitral repair needs to do more and sooner or later willl have a stroke come to visit. Those who do MICS will have those visits a bit more frequently. > > > > I personally have my doubts as to whether air is a predominant cause of stroke with permanent deficit - the definition used in STS. When I worked with Yacoub in early days of routine TEE (and no CO2) there was often a snowstorm on echo just before coming of bypass - he just put a needle in aorta - like he had in 30 years of practice without TEE tellling him what to do - and came off bypass ignoring the echo (unless big pockets of air). Maybe there were neuro changes we could not measure, but rarely did the patients wake up with an STS defined stroke. I think we can blame air for global changes like delirium, cognitive dysfunction etc, but when a patient is hemiplegic I think we need to first look for, and exclude, other causes before we blame air. > > > > Ani > >> From: robertobattellini@hotmail.com >> To: openheart-l@lists.hsforum.com >> Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery >> Date: Mon, 1 Feb 2010 21:33:02 +0100 >> >> >> Ani, >> >> Have you ever done Mitral Mics to talk like that? >> >> The view is Superb with cameras, if you have doubts just go to leipzig and look at Mohr doing it. >> >> may be the higher stroke problems are with deairing the heart if the surgeon is not very strict and does >> >> not uses TEE. >> >> For MICS, camera and TEE are obligatory. >> >> Roberto >> >>> From: anianyanwu@hotmail.com >>> To: openheart-l@lists.hsforum.com >>> Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery >>> Date: Wed, 27 Jan 2010 02:13:54 +0000 >>> >>> >>> MICS was a risk factor independent of age and endoclamp use was not a predictor of stroke if I recall correctly. >>> >>> >>> >>> I doubt it is all retrograde perfusion as the MICS cohort were largely younger patients with minimal risk factors so should have clean aorta. >>> >>> >>> I think poor debris management due to the limited surgical view is certainly a possibility. Dr Gammie mentioned this in passing and I believe could well be the reason why a higher stroke rate in MICS persists regardless of age and risk factors. In MICS especially port access or robotic variety the surgeon's eye is by definition just on a limited area of the surgical field, and the assistant often sees less. Whereas via big incision the surgeon sees most of field and assistant sees areas surgeon doesnt. Jim postulated that maybe small bits of fat or valve, annular or ventricular tissue or surgical material could fall into the atrium or pulmonary veins unnoticed and go on to cause stroke. Whereas in sternotomy, the surgeon or assistant is more likely to spot that particle of fat or calcium on the atrial wall; with a robot, one would not see it as can see only the valve (i presume). This explantion, rather than air, could also tie up the observation of higher strokes with no-clamp methods as with the heart beating and blood in the field you are probably even less likely to see loose bits of tissue in the ventricle and around the annulus or leaflets. >>> >>> >>> >>> Ani >>> >>> >>> >>> >>>> Date: Tue, 26 Jan 2010 19:30:40 -0600 >>>> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery >>>> From: ebender001@me.com >>>> To: OpenHeart-L@lists.hsforum.com >>>> CC: >>>> >>>> Besides operating without a cross-clamp and air embolus (which obviously >>>> must be prevented no matter what approach), I assume the increased stroke >>>> risk was due to retrograde perfusion and athero emboli from the aorta, plus >>>> a small number due to malpositioned endo clamp or poor debris management >>>> through a small incision or port approach. Obviously these are concerning >>>> numbers, and stresses the need for a pre-op study of the aorta (most use CTA >>>> through the femorals) Did Jim break down the age groups? I guess one could >>>> use age as a surrogate for plaque build up in the aorta. >>>> >>>> Thanks for the feedback. >>>> >>>> Ed Bender, MD >>>> >>>> >>>> On 1/26/10 6:31 PM, "Ani Anyanwu" wrote: >>>> >>>>> >>>>> redos were excluded from this analysis >>>>> >>>>>> Date: Tue, 26 Jan 2010 18:28:44 -0600 >>>>>> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery >>>>>> From: ebender001@me.com >>>>>> To: OpenHeart-L@lists.hsforum.com >>>>>> CC: >>>>>> >>>>>> Very interesting. I would, as you stated, be cautious in using peripheral >>>>>> cannulation as a proxy for MICS. I use it liberally for redo approaches with >>>>>> a full sternotomy (as at least one other person on this forum does). Could >>>>>> it be that the reop rate might reflect a redo staus rather than a MICS? >>>>>> >>>>>> Ed Bender, MD >>>>>> >>>>>> >>>>>> On 1/26/10 6:04 PM, "Ani Anyanwu" wrote: >>>>>> >>>>>>> >>>>>>> I was at the STS for just a day. Only one paper caught my interest. Dr >>>>>>> Gammie >>>>>>> presented an excellent analysis of mitral valve surgery reported to the STS >>>>>>> database to compare analysis of conventional mitral valve surgery vs >>>>>>> minimally >>>>>>> invasive cardiac surgery. Becausesurgical incision is not collected by STS, >>>>>>> Gammie and colleagues used cannulation strategy as surrogate for >>>>>>> invasiveness. >>>>>>> If patient was cannulated centrally (aorta, right atrium) was assumed a >>>>>>> conventional appproach, if cannulated femoro-femoral, then was assumed to be >>>>>>> minimally invasive approach. Other permutations of cannulation were excluded >>>>>>> from analysis. Isolated MV only (?). They reviewed over 20,000 operations >>>>>>> performed in US between 2004-2008. >>>>>>> >>>>>>> >>>>>>> >>>>>>> Summary of findings >>>>>>> >>>>>>> . >>>>>>> >>>>>>> About 15% of all mitral operations were done with MICS as defined. Frequency >>>>>>> increased from 10% in 2004 to 20% in 2008. >>>>>>> >>>>>>> 35% of MICS robot assisted. >>>>>>> >>>>>>> Median number of MICS cases per center was 3. Over 75% of procedures in US >>>>>>> were done by institutions doing less than 5 procedures a year. >>>>>>> >>>>>>> Endoaortic balloon used in 35%. >>>>>>> >>>>>>> More valve repair in MICS group (85% Vs 67%) >>>>>>> >>>>>>> Clamp and bypass times 20 and 27 min longer in MICS group. >>>>>>> >>>>>>> 41% transfusion rate in MICS (51% conventional). >>>>>>> >>>>>>> More (yes - more) reoperations for bleeding with MICS (Odds ratio 1.22). >>>>>>> >>>>>>> Shorter length of saty and ventilation with MICS. >>>>>>> >>>>>>> Mortality same. >>>>>>> >>>>>>> >>>>>>> >>>>>>> KEY FINDING: Twice more strokes with MICS (Odds Ratio 1.96). Strokes defined >>>>>>> as stroke with permanent deficit. Higher stroke rate with MICS seen in all >>>>>>> groups examined, regardless of risk factors, center case volume, use of >>>>>>> endocclamp, use of clamp. However, highest rate of stroke was seen in those >>>>>>> cases done without a cross clamp (beating or fibrillation) associated with >>>>>>> odds ratio of 3. >>>>>>> >>>>>>> >>>>>>> >>>>>>> Limitations: Definition of MICS based on cannulaation strategy likely >>>>>>> misscalssified some patients. While very likely almost all femorofemoral >>>>>>> approachs were truly MICS procedures, a lot of MICS would have been called >>>>>>> conventional if centrally cannulated. Of importance because some high volume >>>>>>> MICS centers like NYU, Cleveland, BWH I believe use central cannulation >>>>>>> liberally for thoracotomy or hemisternotomy approach. Also hybrids eg >>>>>>> femoral >>>>>>> artery and central venous cannulation, used by some, were excluded. >>>>>>> >>>>>>> Patients in MICS were less sick, younger etc and more likely repairable >>>>>>> hence >>>>>>> introducing bias - of concern though is despite lower risk there was still >>>>>>> double stroke incidence. >>>>>>> >>>>>>> No data on true outcomes of surgery such as results of repair, reoperation, >>>>>>> 12 >>>>>>> month symptoms or survival. >>>>>>> >>>>>>> No data on mitral pathology and disease treated. >>>>>>> >>>>>>> >>>>>>> >>>>>>> Response from disscussants (most MICS enthusiasts) largely ignored or >>>>>>> dismissed the stroke risk and felt the data were sufficient to show that >>>>>>> MICS >>>>>>> 1) is valid approach for MV surgery 2) Does not compromise repair 3) Is safe >>>>>>> 4) Has better 'outcomes' but 5) other explanations likely exist for higher >>>>>>> stroke and 6) MV surgery without a clamp should be strongly discouraged. One >>>>>>> discussant cautioned that the stroke risk cannot be ignored as this is the >>>>>>> second mega-analysis of a database presented at STS in recent years showing >>>>>>> higher stroke risk with MICS (the other being a paper by Mehmet Oz group 5 >>>>>>> years or so ago I think presented by our Dr Cheema which also found doubling >>>>>>> of incidence of stroke in NY State). >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>> Ani >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>>> From: msfirst@gmail.com >>>>>>>> To: OpenHeart-L@lists.hsforum.com >>>>>>>> Subject: Re: [HSF] STS Meeting >>>>>>>> Date: Tue, 26 Jan 2010 18:23:52 -0500 >>>>>>>> CC: >>>>>>>> >>>>>>>> Guess not >>>>>>>> >>>>>>>> -michael/iPhone >>>>>>>> >>>>>>>> On Jan 26, 2010, at 4:50 PM, Edward Bender wrote: >>>>>>>> >>>>>>>>> Anything new and/or interesting coming out of the STS meeting? >>>>>>>>> >>>>>>>>> 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 >>>>>>>> ----------------------------------------- >>>>>>> >>>>>>> _________________________________________________________________ >>>>>>> Got a cool Hotmail story? Tell us now >>>>>>> http://clk.atdmt.com/UKM/go/195013117/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 >>>>>> ----------------------------------------- >>>>> >>>>> _________________________________________________________________ >>>>> We want to hear all your funny, exciting and crazy Hotmail stories. Tell us >>>>> now >>>>> http://clk.atdmt.com/UKM/go/195013117/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 >>>> ----------------------------------------- >>> >>> _________________________________________________________________ >>> We want to hear all your funny, exciting and crazy Hotmail stories. Tell us now >>> http://clk.atdmt.com/UKM/go/195013117/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 >> ----------------------------------------- > > _________________________________________________________________ > Got a cool Hotmail story? Tell us now > http://clk.atdmt.com/UKM/go/195013117/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 jbflegejr at aol.com Tue Feb 2 07:38:30 2010 From: jbflegejr at aol.com (John Flege) Date: Tue Feb 2 07:39:40 2010 Subject: [HSF] Aortic guru's - Where to stop? In-Reply-To: References: Message-ID: <71153BD6-BBB9-4E59-9F1D-59F573A882CA@aol.com> Replace her ascending aorta or hemiarch, treat her hypertension and stop her smoking. How old is she. John On Feb 2, 2010, at 6:39 AM, Michael Firstenberg wrote: > I recently saw a lady in clinic (smoker, hypertension) with an ascending > aortic aneurysm. > She is not very large and a MRA showed the following: > > The entire thoracic and supra renal abdominal aorta is aneurysmal. > The aortic sinuses measure 3.8 x 3.9cm, STJ 3.8 x 3.5cm, AscAo 5.5 x 5.3cm, > mid transverse > arch 3.5 x 3.2cm, proximal DescAo 3.6 x 3.5cm. > > Her aortic valve is normal with only trace/mild AI > > Clearly her ascending needs to be replaced - but do you just do a hemi-arch > and follow her or do you replace the arch as well with an Elephant trunk now > (obviously a much larger operation)? (or some other strange endovascular > thing). > > She had a relatively normal cath in 2007 (getting repeated) but otherwise > appears to be a reasonable operative candidate. > > thanks > > -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 robertobattellini at hotmail.com Tue Feb 2 13:43:17 2010 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Tue Feb 2 07:44:05 2010 Subject: [HSF] STS Meeting - MICS Vs Conventional MV surgery In-Reply-To: References: ,,, , , , , , , , Message-ID: Ani, I was the consultant in B4, Mohr?s private Station for MICS.The results were excellent.I agree that if the mics were done as redo (previous bypass-sternotomy or AVR), and fibrilating, if needle vent was not used, may be the stroke incidence was higher.We deaired all clamped mics with needlevent, Co2 , etc. I agree the first times were not so perfect. Roberto > From: anianyanwu@hotmail.com > To: openheart-l@lists.hsforum.com > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > Date: Tue, 2 Feb 2010 05:22:07 +0000 > > > Roberto > > > > Yes I have done mitral MICS. What I say about view from camera's is from personal observation where I have sometimes seen debris (under direct vision) in the atrium in an area that was not in camera's view (which is focused on the valve). I think valve repair without TEE is rarely, if ever practiced. > > > > I found it strange at STS all discussants (Mohr included ) seemed to give *impression* strokes were no longer seen in MICS and the problem had been 'solved' with CO2, deairing, changes to perfusion and clamping etc. Heck we see stroke with sternotomy - indeed in 2008 you may recall I posted for advice on the forum after having two patients in a month with devastating strokes after mitral repair via sternotomy - so what is strange about saying strokes occur after MICS? Any surgeon who says he has not seen strokes in mitral repair needs to do more and sooner or later willl have a stroke come to visit. Those who do MICS will have those visits a bit more frequently. > > > > I personally have my doubts as to whether air is a predominant cause of stroke with permanent deficit - the definition used in STS. When I worked with Yacoub in early days of routine TEE (and no CO2) there was often a snowstorm on echo just before coming of bypass - he just put a needle in aorta - like he had in 30 years of practice without TEE tellling him what to do - and came off bypass ignoring the echo (unless big pockets of air). Maybe there were neuro changes we could not measure, but rarely did the patients wake up with an STS defined stroke. I think we can blame air for global changes like delirium, cognitive dysfunction etc, but when a patient is hemiplegic I think we need to first look for, and exclude, other causes before we blame air. > > > > Ani > > > From: robertobattellini@hotmail.com > > To: openheart-l@lists.hsforum.com > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > Date: Mon, 1 Feb 2010 21:33:02 +0100 > > > > > > Ani, > > > > Have you ever done Mitral Mics to talk like that? > > > > The view is Superb with cameras, if you have doubts just go to leipzig and look at Mohr doing it. > > > > may be the higher stroke problems are with deairing the heart if the surgeon is not very strict and does > > > > not uses TEE. > > > > For MICS, camera and TEE are obligatory. > > > > Roberto > > > > > From: anianyanwu@hotmail.com > > > To: openheart-l@lists.hsforum.com > > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > Date: Wed, 27 Jan 2010 02:13:54 +0000 > > > > > > > > > MICS was a risk factor independent of age and endoclamp use was not a predictor of stroke if I recall correctly. > > > > > > > > > > > > I doubt it is all retrograde perfusion as the MICS cohort were largely younger patients with minimal risk factors so should have clean aorta. > > > > > > > > > I think poor debris management due to the limited surgical view is certainly a possibility. Dr Gammie mentioned this in passing and I believe could well be the reason why a higher stroke rate in MICS persists regardless of age and risk factors. In MICS especially port access or robotic variety the surgeon's eye is by definition just on a limited area of the surgical field, and the assistant often sees less. Whereas via big incision the surgeon sees most of field and assistant sees areas surgeon doesnt. Jim postulated that maybe small bits of fat or valve, annular or ventricular tissue or surgical material could fall into the atrium or pulmonary veins unnoticed and go on to cause stroke. Whereas in sternotomy, the surgeon or assistant is more likely to spot that particle of fat or calcium on the atrial wall; with a robot, one would not see it as can see only the valve (i presume). This explantion, rather than air, could also tie up the observation of higher strokes with no-clamp methods as with the heart beating and blood in the field you are probably even less likely to see loose bits of tissue in the ventricle and around the annulus or leaflets. > > > > > > > > > > > > Ani > > > > > > > > > > > > > > > > Date: Tue, 26 Jan 2010 19:30:40 -0600 > > > > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > From: ebender001@me.com > > > > To: OpenHeart-L@lists.hsforum.com > > > > CC: > > > > > > > > Besides operating without a cross-clamp and air embolus (which obviously > > > > must be prevented no matter what approach), I assume the increased stroke > > > > risk was due to retrograde perfusion and athero emboli from the aorta, plus > > > > a small number due to malpositioned endo clamp or poor debris management > > > > through a small incision or port approach. Obviously these are concerning > > > > numbers, and stresses the need for a pre-op study of the aorta (most use CTA > > > > through the femorals) Did Jim break down the age groups? I guess one could > > > > use age as a surrogate for plaque build up in the aorta. > > > > > > > > Thanks for the feedback. > > > > > > > > Ed Bender, MD > > > > > > > > > > > > On 1/26/10 6:31 PM, "Ani Anyanwu" wrote: > > > > > > > > > > > > > > redos were excluded from this analysis > > > > > > > > > >> Date: Tue, 26 Jan 2010 18:28:44 -0600 > > > > >> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > >> From: ebender001@me.com > > > > >> To: OpenHeart-L@lists.hsforum.com > > > > >> CC: > > > > >> > > > > >> Very interesting. I would, as you stated, be cautious in using peripheral > > > > >> cannulation as a proxy for MICS. I use it liberally for redo approaches with > > > > >> a full sternotomy (as at least one other person on this forum does). Could > > > > >> it be that the reop rate might reflect a redo staus rather than a MICS? > > > > >> > > > > >> Ed Bender, MD > > > > >> > > > > >> > > > > >> On 1/26/10 6:04 PM, "Ani Anyanwu" wrote: > > > > >> > > > > >>> > > > > >>> I was at the STS for just a day. Only one paper caught my interest. Dr > > > > >>> Gammie > > > > >>> presented an excellent analysis of mitral valve surgery reported to the STS > > > > >>> database to compare analysis of conventional mitral valve surgery vs > > > > >>> minimally > > > > >>> invasive cardiac surgery. Becausesurgical incision is not collected by STS, > > > > >>> Gammie and colleagues used cannulation strategy as surrogate for > > > > >>> invasiveness. > > > > >>> If patient was cannulated centrally (aorta, right atrium) was assumed a > > > > >>> conventional appproach, if cannulated femoro-femoral, then was assumed to be > > > > >>> minimally invasive approach. Other permutations of cannulation were excluded > > > > >>> from analysis. Isolated MV only (?). They reviewed over 20,000 operations > > > > >>> performed in US between 2004-2008. > > > > >>> > > > > >>> > > > > >>> > > > > >>> Summary of findings > > > > >>> > > > > >>> . > > > > >>> > > > > >>> About 15% of all mitral operations were done with MICS as defined. Frequency > > > > >>> increased from 10% in 2004 to 20% in 2008. > > > > >>> > > > > >>> 35% of MICS robot assisted. > > > > >>> > > > > >>> Median number of MICS cases per center was 3. Over 75% of procedures in US > > > > >>> were done by institutions doing less than 5 procedures a year. > > > > >>> > > > > >>> Endoaortic balloon used in 35%. > > > > >>> > > > > >>> More valve repair in MICS group (85% Vs 67%) > > > > >>> > > > > >>> Clamp and bypass times 20 and 27 min longer in MICS group. > > > > >>> > > > > >>> 41% transfusion rate in MICS (51% conventional). > > > > >>> > > > > >>> More (yes - more) reoperations for bleeding with MICS (Odds ratio 1.22). > > > > >>> > > > > >>> Shorter length of saty and ventilation with MICS. > > > > >>> > > > > >>> Mortality same. > > > > >>> > > > > >>> > > > > >>> > > > > >>> KEY FINDING: Twice more strokes with MICS (Odds Ratio 1.96). Strokes defined > > > > >>> as stroke with permanent deficit. Higher stroke rate with MICS seen in all > > > > >>> groups examined, regardless of risk factors, center case volume, use of > > > > >>> endocclamp, use of clamp. However, highest rate of stroke was seen in those > > > > >>> cases done without a cross clamp (beating or fibrillation) associated with > > > > >>> odds ratio of 3. > > > > >>> > > > > >>> > > > > >>> > > > > >>> Limitations: Definition of MICS based on cannulaation strategy likely > > > > >>> misscalssified some patients. While very likely almost all femorofemoral > > > > >>> approachs were truly MICS procedures, a lot of MICS would have been called > > > > >>> conventional if centrally cannulated. Of importance because some high volume > > > > >>> MICS centers like NYU, Cleveland, BWH I believe use central cannulation > > > > >>> liberally for thoracotomy or hemisternotomy approach. Also hybrids eg > > > > >>> femoral > > > > >>> artery and central venous cannulation, used by some, were excluded. > > > > >>> > > > > >>> Patients in MICS were less sick, younger etc and more likely repairable > > > > >>> hence > > > > >>> introducing bias - of concern though is despite lower risk there was still > > > > >>> double stroke incidence. > > > > >>> > > > > >>> No data on true outcomes of surgery such as results of repair, reoperation, > > > > >>> 12 > > > > >>> month symptoms or survival. > > > > >>> > > > > >>> No data on mitral pathology and disease treated. > > > > >>> > > > > >>> > > > > >>> > > > > >>> Response from disscussants (most MICS enthusiasts) largely ignored or > > > > >>> dismissed the stroke risk and felt the data were sufficient to show that > > > > >>> MICS > > > > >>> 1) is valid approach for MV surgery 2) Does not compromise repair 3) Is safe > > > > >>> 4) Has better 'outcomes' but 5) other explanations likely exist for higher > > > > >>> stroke and 6) MV surgery without a clamp should be strongly discouraged. One > > > > >>> discussant cautioned that the stroke risk cannot be ignored as this is the > > > > >>> second mega-analysis of a database presented at STS in recent years showing > > > > >>> higher stroke risk with MICS (the other being a paper by Mehmet Oz group 5 > > > > >>> years or so ago I think presented by our Dr Cheema which also found doubling > > > > >>> of incidence of stroke in NY State). > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> Ani > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>>> From: msfirst@gmail.com > > > > >>>> To: OpenHeart-L@lists.hsforum.com > > > > >>>> Subject: Re: [HSF] STS Meeting > > > > >>>> Date: Tue, 26 Jan 2010 18:23:52 -0500 > > > > >>>> CC: > > > > >>>> > > > > >>>> Guess not > > > > >>>> > > > > >>>> -michael/iPhone > > > > >>>> > > > > >>>> On Jan 26, 2010, at 4:50 PM, Edward Bender wrote: > > > > >>>> > > > > >>>>> Anything new and/or interesting coming out of the STS meeting? > > > > >>>>> > > > > >>>>> 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 > > > > >>>> ----------------------------------------- > > > > >>> > > > > >>> _________________________________________________________________ > > > > >>> Got a cool Hotmail story? Tell us now > > > > >>> http://clk.atdmt.com/UKM/go/195013117/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 > > > > >> ----------------------------------------- > > > > > > > > > > _________________________________________________________________ > > > > > We want to hear all your funny, exciting and crazy Hotmail stories. Tell us > > > > > now > > > > > http://clk.atdmt.com/UKM/go/195013117/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 > > > > ----------------------------------------- > > > > > > _________________________________________________________________ > > > We want to hear all your funny, exciting and crazy Hotmail stories. Tell us now > > > http://clk.atdmt.com/UKM/go/195013117/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 > > ----------------------------------------- > > _________________________________________________________________ > Got a cool Hotmail story? Tell us now > http://clk.atdmt.com/UKM/go/195013117/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 grescigno at mac.com Tue Feb 2 13:45:03 2010 From: grescigno at mac.com (Giuseppe Rescigno) Date: Tue Feb 2 07:50:19 2010 Subject: [HSF] Aortic guru's - Where to stop? In-Reply-To: References: Message-ID: Michael, this is a nice case where to replace the ascending aorta and reimplant, by means of a 10 mm graft the innominate trunk more proximally. This will allow, in case of evolution into the arch, to do an extraanatomic bypass (left to right carotid plus minus left subclavian) and put an endovascular something into the arch with a very nice landing zone onto the prosthesis. BTW I am not an aortic guru but I like this surgery very much Giuseppe Il giorno 02/feb/10, alle ore 12:39, Michael Firstenberg ha scritto: > I recently saw a lady in clinic (smoker, hypertension) with an > ascending > aortic aneurysm. > She is not very large and a MRA showed the following: > > The entire thoracic and supra renal abdominal aorta is aneurysmal. > The aortic sinuses measure 3.8 x 3.9cm, STJ 3.8 x 3.5cm, AscAo 5.5 > x 5.3cm, > mid transverse > arch 3.5 x 3.2cm, proximal DescAo 3.6 x 3.5cm. > > Her aortic valve is normal with only trace/mild AI > > Clearly her ascending needs to be replaced - but do you just do a > hemi-arch > and follow her or do you replace the arch as well with an Elephant > trunk now > (obviously a much larger operation)? (or some other strange > endovascular > thing). > > She had a relatively normal cath in 2007 (getting repeated) but > otherwise > appears to be a reasonable operative candidate. > > thanks > > -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 anianyanwu at hotmail.com Tue Feb 2 13:56:44 2010 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Tue Feb 2 08:57:34 2010 Subject: [HSF] STS Meeting - MICS Vs Conventional MV surgery In-Reply-To: <133f.125d0014.389969be@aol.com> References: <133f.125d0014.389969be@aol.com> Message-ID: > From my conversations with other MICS surgeons, fat emboli from the cut sternal edge is eliminated. > Hal> >Fat embolism can be associated with long bone fractures. A sternotomy is something like a long >bone fracture. John Flege Are we saying the sternotomy is implicated in etiology of stroke after cardiac surgery? Must say not something I have read about previously. To my knowledge non-bypass cases done via sternotomy, principally thymectomy, mediastinal mass excision and anortic OBCAB had not been associated with higher rate of stroke? And all large datasets available show lower stroke rates with sternotomy than non-sternotomy approaches to heart surgery. Is this a real phenomenom or a theoretical justification used by enthusiasts to promote their (non-sternotomy) approach? Hal - from gammies paper, even looking at high-volume centers there has higher incidence of stroke in MICS so not sure it is true that experienced centers necessarily have less stroke. We do about 300 mitrals a year and certainly do see a few strokes a year, maybe at least 3 with major deficit. A surgeon may not see it because he does say 100 MICS mitrals a year (therefore expect only one, two or none most years) but when you pool 20 centers each doing 100, you will find the strokes (for some unlucky surgeons would have had a bad run with four of five in the year another had none). If a center is doing a few hundred MICS mitrals a year and telling me they have had no strokes in last few years (like some discussants seemed to imply at STS) then either they are not looking, dont recollect or are not being truthful. The other thing we need to talk about one day is vascular complications - I have started reading between the lines in the emerging literature and discussions on the subject, and although often carefully hidden or brushed over, it seems the number of patients requiring vascular intervention or fasciotomy after MICS is not insignificant. Last week a surgeon mentioned he was an expert witness on two robotic cases with vascular complications, one of which ended in a below knee amputation, so peripheral arterial access is also something we need to focus on (i personally take chand's approach of sewing a side-graft to femoral artery, and I think you mentioned you place a distal cathether - maybe overkill but at least one does not have to worry about the leg). Ani > From: Hgrmd@aol.com > Date: Tue, 2 Feb 2010 06:42:54 -0500 > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > To: OpenHeart-L@lists.hsforum.com > CC: > > Ani, > I wish I could have heard Gammie's talk, and I look forward to > scrutinizing the paper when it is published. However, the problem is that it looks > at the incidence of strokes for all MICS. As we know, MICS is not a > uniform procedure, so these results are really a mish mash. I agree with Fred > Mohr that the incidence of strokes in experienced MICS centers is probably as > low or lower when compared to sternotomy. From my conversations with > other MICS surgeons, fat emboli from the cut sternal edge is eliminated. In > addition, in the closed chest filled with CO2, you rarely see ANY bubbles on > TEE. > > Hal > > > In a message dated 2/2/2010 12:24:17 A.M. Eastern Standard Time, > anianyanwu@hotmail.com writes: > > > Roberto > > > > Yes I have done mitral MICS. What I say about view from camera's is from > personal observation where I have sometimes seen debris (under direct > vision) in the atrium in an area that was not in camera's view (which is focused > on the valve). I think valve repair without TEE is rarely, if ever > practiced. > > > > I found it strange at STS all discussants (Mohr included ) seemed to give > *impression* strokes were no longer seen in MICS and the problem had been > 'solved' with CO2, deairing, changes to perfusion and clamping etc. Heck we > see stroke with sternotomy - indeed in 2008 you may recall I posted for > advice on the forum after having two patients in a month with devastating > strokes after mitral repair via sternotomy - so what is strange about saying > strokes occur after MICS? Any surgeon who says he has not seen strokes in > mitral repair needs to do more and sooner or later willl have a stroke come > to visit. Those who do MICS will have those visits a bit more frequently. > > > > I personally have my doubts as to whether air is a predominant cause of > stroke with permanent deficit - the definition used in STS. When I worked > with Yacoub in early days of routine TEE (and no CO2) there was often a > snowstorm on echo just before coming of bypass - he just put a needle in aorta - > like he had in 30 years of practice without TEE tellling him what to do - > and came off bypass ignoring the echo (unless big pockets of air). Maybe > there were neuro changes we could not measure, but rarely did the patients > wake up with an STS defined stroke. I think we can blame air for global > changes like delirium, cognitive dysfunction etc, but when a patient is > hemiplegic I think we need to first look for, and exclude, other causes before we > blame air. > > > > Ani > > > From: robertobattellini@hotmail.com > > To: openheart-l@lists.hsforum.com > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > Date: Mon, 1 Feb 2010 21:33:02 +0100 > > > > > > Ani, > > > > Have you ever done Mitral Mics to talk like that? > > > > The view is Superb with cameras, if you have doubts just go to leipzig > and look at Mohr doing it. > > > > may be the higher stroke problems are with deairing the heart if the > surgeon is not very strict and does > > > > not uses TEE. > > > > For MICS, camera and TEE are obligatory. > > > > Roberto > > > > > From: anianyanwu@hotmail.com > > > To: openheart-l@lists.hsforum.com > > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > Date: Wed, 27 Jan 2010 02:13:54 +0000 > > > > > > > > > MICS was a risk factor independent of age and endoclamp use was not a > predictor of stroke if I recall correctly. > > > > > > > > > > > > I doubt it is all retrograde perfusion as the MICS cohort were largely > younger patients with minimal risk factors so should have clean aorta. > > > > > > > > > I think poor debris management due to the limited surgical view is > certainly a possibility. Dr Gammie mentioned this in passing and I believe > could well be the reason why a higher stroke rate in MICS persists regardless > of age and risk factors. In MICS especially port access or robotic variety > the surgeon's eye is by definition just on a limited area of the surgical > field, and the assistant often sees less. Whereas via big incision the > surgeon sees most of field and assistant sees areas surgeon doesnt. Jim > postulated that maybe small bits of fat or valve, annular or ventricular tissue or > surgical material could fall into the atrium or pulmonary veins unnoticed > and go on to cause stroke. Whereas in sternotomy, the surgeon or assistant > is more likely to spot that particle of fat or calcium on the atrial wall; > with a robot, one would not see it as can see only the valve (i presume). > This explantion, rather than air, could also tie up the observation of higher > strokes with no-clamp methods as with the heart beating and blood in the > field you are probably even less likely to see loose bits of tissue in the > ventricle and around the annulus or leaflets. > > > > > > > > > > > > Ani > > > > > > > > > > > > > > > > Date: Tue, 26 Jan 2010 19:30:40 -0600 > > > > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > From: ebender001@me.com > > > > To: OpenHeart-L@lists.hsforum.com > > > > CC: > > > > > > > > Besides operating without a cross-clamp and air embolus (which > obviously > > > > must be prevented no matter what approach), I assume the increased > stroke > > > > risk was due to retrograde perfusion and athero emboli from the > aorta, plus > > > > a small number due to malpositioned endo clamp or poor debris > management > > > > through a small incision or port approach. Obviously these are > concerning > > > > numbers, and stresses the need for a pre-op study of the aorta (most > use CTA > > > > through the femorals) Did Jim break down the age groups? I guess one > could > > > > use age as a surrogate for plaque build up in the aorta. > > > > > > > > Thanks for the feedback. > > > > > > > > Ed Bender, MD > > > > > > > > > > > > On 1/26/10 6:31 PM, "Ani Anyanwu" wrote: > > > > > > > > > > > > > > redos were excluded from this analysis > > > > > > > > > >> Date: Tue, 26 Jan 2010 18:28:44 -0600 > > > > >> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > >> From: ebender001@me.com > > > > >> To: OpenHeart-L@lists.hsforum.com > > > > >> CC: > > > > >> > > > > >> Very interesting. I would, as you stated, be cautious in using > peripheral > > > > >> cannulation as a proxy for MICS. I use it liberally for redo > approaches with > > > > >> a full sternotomy (as at least one other person on this forum > does). Could > > > > >> it be that the reop rate might reflect a redo staus rather than a > MICS? > > > > >> > > > > >> Ed Bender, MD > > > > >> > > > > >> > > > > >> On 1/26/10 6:04 PM, "Ani Anyanwu" wrote: > > > > >> > > > > >>> > > > > >>> I was at the STS for just a day. Only one paper caught my > interest. Dr > > > > >>> Gammie > > > > >>> presented an excellent analysis of mitral valve surgery reported > to the STS > > > > >>> database to compare analysis of conventional mitral valve > surgery vs > > > > >>> minimally > > > > >>> invasive cardiac surgery. Becausesurgical incision is not > collected by STS, > > > > >>> Gammie and colleagues used cannulation strategy as surrogate for > > > > >>> invasiveness. > > > > >>> If patient was cannulated centrally (aorta, right atrium) was > assumed a > > > > >>> conventional appproach, if cannulated femoro-femoral, then was > assumed to be > > > > >>> minimally invasive approach. Other permutations of cannulation > were excluded > > > > >>> from analysis. Isolated MV only (?). They reviewed over 20,000 > operations > > > > >>> performed in US between 2004-2008. > > > > >>> > > > > >>> > > > > >>> > > > > >>> Summary of findings > > > > >>> > > > > >>> . > > > > >>> > > > > >>> About 15% of all mitral operations were done with MICS as > defined. Frequency > > > > >>> increased from 10% in 2004 to 20% in 2008. > > > > >>> > > > > >>> 35% of MICS robot assisted. > > > > >>> > > > > >>> Median number of MICS cases per center was 3. Over 75% of > procedures in US > > > > >>> were done by institutions doing less than 5 procedures a year. > > > > >>> > > > > >>> Endoaortic balloon used in 35%. > > > > >>> > > > > >>> More valve repair in MICS group (85% Vs 67%) > > > > >>> > > > > >>> Clamp and bypass times 20 and 27 min longer in MICS group. > > > > >>> > > > > >>> 41% transfusion rate in MICS (51% conventional). > > > > >>> > > > > >>> More (yes - more) reoperations for bleeding with MICS (Odds > ratio 1.22). > > > > >>> > > > > >>> Shorter length of saty and ventilation with MICS. > > > > >>> > > > > >>> Mortality same. > > > > >>> > > > > >>> > > > > >>> > > > > >>> KEY FINDING: Twice more strokes with MICS (Odds Ratio 1.96). > Strokes defined > > > > >>> as stroke with permanent deficit. Higher stroke rate with MICS > seen in all > > > > >>> groups examined, regardless of risk factors, center case volume, > use of > > > > >>> endocclamp, use of clamp. However, highest rate of stroke was > seen in those > > > > >>> cases done without a cross clamp (beating or fibrillation) > associated with > > > > >>> odds ratio of 3. > > > > >>> > > > > >>> > > > > >>> > > > > >>> Limitations: Definition of MICS based on cannulaation strategy > likely > > > > >>> misscalssified some patients. While very likely almost all > femorofemoral > > > > >>> approachs were truly MICS procedures, a lot of MICS would have > been called > > > > >>> conventional if centrally cannulated. Of importance because some > high volume > > > > >>> MICS centers like NYU, Cleveland, BWH I believe use central > cannulation > > > > >>> liberally for thoracotomy or hemisternotomy approach. Also > hybrids eg > > > > >>> femoral > > > > >>> artery and central venous cannulation, used by some, were > excluded. > > > > >>> > > > > >>> Patients in MICS were less sick, younger etc and more likely > repairable > > > > >>> hence > > > > >>> introducing bias - of concern though is despite lower risk there > was still > > > > >>> double stroke incidence. > > > > >>> > > > > >>> No data on true outcomes of surgery such as results of repair, > reoperation, > > > > >>> 12 > > > > >>> month symptoms or survival. > > > > >>> > > > > >>> No data on mitral pathology and disease treated. > > > > >>> > > > > >>> > > > > >>> > > > > >>> Response from disscussants (most MICS enthusiasts) largely > ignored or > > > > >>> dismissed the stroke risk and felt the data were sufficient to > show that > > > > >>> MICS > > > > >>> 1) is valid approach for MV surgery 2) Does not compromise > repair 3) Is safe > > > > >>> 4) Has better 'outcomes' but 5) other explanations likely exist > for higher > > > > >>> stroke and 6) MV surgery without a clamp should be strongly > discouraged. One > > > > >>> discussant cautioned that the stroke risk cannot be ignored as > this is the > > > > >>> second mega-analysis of a database presented at STS in recent > years showing > > > > >>> higher stroke risk with MICS (the other being a paper by Mehmet > Oz group 5 > > > > >>> years or so ago I think presented by our Dr Cheema which also > found doubling > > > > >>> of incidence of stroke in NY State). > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> Ani > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>>> From: msfirst@gmail.com > > > > >>>> To: OpenHeart-L@lists.hsforum.com > > > > >>>> Subject: Re: [HSF] STS Meeting > > > > >>>> Date: Tue, 26 Jan 2010 18:23:52 -0500 > > > > >>>> CC: > > > > >>>> > > > > >>>> Guess not > > > > >>>> > > > > >>>> -michael/iPhone > > > > >>>> > > > > >>>> On Jan 26, 2010, at 4:50 PM, Edward Bender > wrote: > > > > >>>> > > > > >>>>> Anything new and/or interesting coming out of the STS meeting? > > > > >>>>> > > > > >>>>> 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 > > > > >>>> ----------------------------------------- > > > > >>> > > > > >>> _________________________________________________________________ > > > > >>> Got a cool Hotmail story? 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Tell us now > http://clk.atdmt.com/UKM/go/195013117/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 > ----------------------------------------- _________________________________________________________________ Got a cool Hotmail story? Tell us now http://clk.atdmt.com/UKM/go/195013117/direct/01/ From prasannasimha at gmail.com Tue Feb 2 19:20:50 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Tue Feb 2 08:58:35 2010 Subject: [HSF] Aortic guru's - Where to stop? In-Reply-To: References: Message-ID: <89c4ed2d1002020550l7c427362sda3b182d1a5865db@mail.gmail.com> You cant keep going indefinitely. The standard thing would be just to replace the ascendcing aorta. At the most you may do a hemiarch or debranch the innominate to ease any future surgery/stent grafting. Prasanna On Tue, Feb 2, 2010 at 5:09 PM, Michael Firstenberg wrote: > I recently saw a lady in clinic (smoker, hypertension) with an ascending > aortic aneurysm. > She is not very large and a MRA showed the following: > > The entire thoracic and supra renal abdominal aorta is aneurysmal. > The aortic sinuses measure 3.8 x 3.9cm, STJ 3.8 x 3.5cm, AscAo 5.5 x > 5.3cm, > mid transverse > arch 3.5 x 3.2cm, proximal DescAo 3.6 x 3.5cm. > > Her aortic valve is normal with only trace/mild AI > > Clearly her ascending needs to be replaced - but do you just do a hemi-arch > and follow her or do you replace the arch as well with an Elephant trunk > now > (obviously a much larger operation)? (or some other strange endovascular > thing). > > She had a relatively normal cath in 2007 (getting repeated) but otherwise > appears to be a reasonable operative candidate. > > thanks > > -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 > ----------------------------------------- > -- Prasanna Simha M From msfirst at gmail.com Tue Feb 2 08:51:18 2010 From: msfirst at gmail.com (Michael Firstenberg) Date: Tue Feb 2 08:58:43 2010 Subject: [HSF] Aortic guru's - Where to stop? In-Reply-To: References: Message-ID: 65 year/old so, sew her head vessels to a separate graft to the ascending? an Elephant sounds easier? (given her aortic sizes?) -michael On Tue, Feb 2, 2010 at 7:45 AM, Giuseppe Rescigno wrote: > Michael, > > this is a nice case where to replace the ascending aorta and reimplant, by > means of a 10 mm graft the innominate trunk more proximally. This will > allow, in case of evolution into the arch, to do an extraanatomic bypass > (left to right carotid plus minus left subclavian) and put an endovascular > something into the arch with a very nice landing zone onto the prosthesis. > BTW I am not an aortic guru but I like this surgery very much > > > Giuseppe > > > Il giorno 02/feb/10, alle ore 12:39, Michael Firstenberg ha scritto: > > I recently saw a lady in clinic (smoker, hypertension) with an ascending >> aortic aneurysm. >> She is not very large and a MRA showed the following: >> >> The entire thoracic and supra renal abdominal aorta is aneurysmal. >> The aortic sinuses measure 3.8 x 3.9cm, STJ 3.8 x 3.5cm, AscAo 5.5 x >> 5.3cm, >> mid transverse >> arch 3.5 x 3.2cm, proximal DescAo 3.6 x 3.5cm. >> >> Her aortic valve is normal with only trace/mild AI >> >> Clearly her ascending needs to be replaced - but do you just do a >> hemi-arch >> and follow her or do you replace the arch as well with an Elephant trunk >> now >> (obviously a much larger operation)? (or some other strange endovascular >> thing). >> >> She had a relatively normal cath in 2007 (getting repeated) but otherwise >> appears to be a reasonable operative candidate. >> >> thanks >> >> -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 > anddisclaimers posted at: > > http://www.hsforum.com/listdisclaim > ----------------------------------------- > From hgrmd at aol.com Tue Feb 2 14:01:07 2010 From: hgrmd at aol.com (hgrmd@aol.com) Date: Tue Feb 2 09:01:42 2010 Subject: [HSF] STS Meeting - MICS Vs Conventional MV surgery In-Reply-To: References: <133f.125d0014.389969be@aol.com> Message-ID: <1758616812-1265119214-cardhu_decombobulator_blackberry.rim.net-776307233-@bda730.bisx.prod.on.blackberry> Tm8sIEFuaSwgYnV0IHRoZSBmYXQgZHJvcGxldHMgeW91IHNlZSBpbiB0aGUgcGVyaWNhcmRpYWwg d2VsbCBjb21lIGZyb20gc29tZSB3aGVyZS4NCg0KSGFsDQoNClNlbnQgZnJvbSBteSBWZXJpem9u IFdpcmVsZXNzIEJsYWNrQmVycnkNCg0KLS0tLS1PcmlnaW5hbCBNZXNzYWdlLS0tLS0NCkZyb206 IEFuaSBBbnlhbnd1IDxhbmlhbnlhbnd1QGhvdG1haWwuY29tPg0KRGF0ZTogVHVlLCAyIEZlYiAy MDEwIDEzOjU2OjQ0IA0KVG86IG9wZW4gaGVhcnQgbGlzdDxvcGVuaGVhcnQtbEBsaXN0cy5oc2Zv cnVtLmNvbT4NClN1YmplY3Q6IFJFOiBbSFNGXSBTVFMgTWVldGluZyAtIE1JQ1MgVnMgQ29udmVu dGlvbmFsIE1WIHN1cmdlcnkNCg0KDQo+IEZyb20gbXkgY29udmVyc2F0aW9ucyB3aXRoICBvdGhl 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SGVhcnQtTEBsaXN0cy5oc2ZvcnVtLmNvbQ0KDQpUbyBVTlNVQlNDUklCRSwgdG8gQ0hBTkdFIGVt YWlsIGFkZHJlc3MsIG9yIHRvIHZpZXcgYXJjaGl2ZXM6DQpodHRwOi8vbW1wLmNqcC5jb20vbWFp bG1hbi9saXN0aW5mby9vcGVuaGVhcnQtbA0KDQpBbGwgbWVzc2FnZXMgdHJhbnNtaXR0ZWQgYnkg dGhlIE9wZW5IZWFydC1MIGFyZSBzdWJqZWN0IHRvIHRoZSBwb2xpY2llcyBhbmQgDQpkaXNjbGFp bWVycyBwb3N0ZWQgYXQ6DQpodHRwOi8vd3d3LmhzZm9ydW0uY29tL2xpc3RkaXNjbGFpbQ0KLS0t LS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0NCg== From grescigno at mac.com Tue Feb 2 15:11:23 2010 From: grescigno at mac.com (Giuseppe Rescigno) Date: Tue Feb 2 09:23:20 2010 Subject: [HSF] Aortic guru's - Where to stop? In-Reply-To: References: Message-ID: <11C9A1F2-D272-44FB-B466-C4182BA96470@mac.com> Not all the vessels, just the innominate trunk; if you cannulate the right subclavian artery circulatory arrest may be very short: clamp the innominate while reducing the flow to cerebral protection value then remove the clamp and open the aneurysm. Transect just the innominate and do the distal anastomosis just proximal to the left carotid with an tube graft with a side-branch; therefore purge the prosthesis while connecting a second arterial line to the side branch. Restore systemic perfusion through the side-branch by clamping the graft and in the meantime continues your "hemiKazui" through the innominate. Finally do the proximal and anastomosis and do a T-T anastomosis of a dacron 10 mm graft to the innominate stump, that you have previously anastomosed to the aortic tube graft. Giuseppe Il giorno 02/feb/10, alle ore 14:51, Michael Firstenberg ha scritto: > 65 year/old > > so, sew her head vessels to a separate graft to the ascending? > an Elephant sounds easier? > (given her aortic sizes?) > > -michael > > > > On Tue, Feb 2, 2010 at 7:45 AM, Giuseppe Rescigno > wrote: > >> Michael, >> >> this is a nice case where to replace the ascending aorta and >> reimplant, by >> means of a 10 mm graft the innominate trunk more proximally. This >> will >> allow, in case of evolution into the arch, to do an extraanatomic >> bypass >> (left to right carotid plus minus left subclavian) and put an >> endovascular >> something into the arch with a very nice landing zone onto the >> prosthesis. >> BTW I am not an aortic guru but I like this surgery very much >> >> >> Giuseppe >> >> >> Il giorno 02/feb/10, alle ore 12:39, Michael Firstenberg ha scritto: >> >> I recently saw a lady in clinic (smoker, hypertension) with an >> ascending >>> aortic aneurysm. >>> She is not very large and a MRA showed the following: >>> >>> The entire thoracic and supra renal abdominal aorta is aneurysmal. >>> The aortic sinuses measure 3.8 x 3.9cm, STJ 3.8 x 3.5cm, AscAo >>> 5.5 x >>> 5.3cm, >>> mid transverse >>> arch 3.5 x 3.2cm, proximal DescAo 3.6 x 3.5cm. >>> >>> Her aortic valve is normal with only trace/mild AI >>> >>> Clearly her ascending needs to be replaced - but do you just do a >>> hemi-arch >>> and follow her or do you replace the arch as well with an >>> Elephant trunk >>> now >>> (obviously a much larger operation)? (or some other strange >>> endovascular >>> thing). >>> >>> She had a relatively normal cath in 2007 (getting repeated) but >>> otherwise >>> appears to be a reasonable operative candidate. >>> >>> thanks >>> >>> -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 >> anddisclaimers 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 chand.ramaiah at uky.edu Tue Feb 2 09:22:59 2010 From: chand.ramaiah at uky.edu (Ramaiah, Chandrashekar) Date: Tue Feb 2 09:23:27 2010 Subject: [HSF] Aortic guru's - Where to stop? In-Reply-To: References: Message-ID: <3ACC54310BF13645A0D12496D7CA94E501BD4237DD@EX7FM04.ad.uky.edu> Michael, Replace only the ascending, more than likely you do not need to circ arrest. Chand -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Michael Firstenberg Sent: Tuesday, February 02, 2010 6:40 AM To: openheart-l Subject: [HSF] Aortic guru's - Where to stop? I recently saw a lady in clinic (smoker, hypertension) with an ascending aortic aneurysm. She is not very large and a MRA showed the following: The entire thoracic and supra renal abdominal aorta is aneurysmal. The aortic sinuses measure 3.8 x 3.9cm, STJ 3.8 x 3.5cm, AscAo 5.5 x 5.3cm, mid transverse arch 3.5 x 3.2cm, proximal DescAo 3.6 x 3.5cm. Her aortic valve is normal with only trace/mild AI Clearly her ascending needs to be replaced - but do you just do a hemi-arch and follow her or do you replace the arch as well with an Elephant trunk now (obviously a much larger operation)? (or some other strange endovascular thing). She had a relatively normal cath in 2007 (getting repeated) but otherwise appears to be a reasonable operative candidate. thanks -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 grescigno at mac.com Tue Feb 2 15:20:56 2010 From: grescigno at mac.com (Giuseppe Rescigno) Date: Tue Feb 2 09:30:19 2010 Subject: [HSF] Aortic guru's - Where to stop? In-Reply-To: References: Message-ID: Just the innominate, not all the vessels. Circ arrest time will be very short. Giuseppe Il giorno 02/feb/10, alle ore 14:51, Michael Firstenberg ha scritto: > 65 year/old > > so, sew her head vessels to a separate graft to the ascending? > an Elephant sounds easier? > (given her aortic sizes?) > > -michael > > > > On Tue, Feb 2, 2010 at 7:45 AM, Giuseppe Rescigno > wrote: > >> Michael, >> >> this is a nice case where to replace the ascending aorta and >> reimplant, by >> means of a 10 mm graft the innominate trunk more proximally. This >> will >> allow, in case of evolution into the arch, to do an extraanatomic >> bypass >> (left to right carotid plus minus left subclavian) and put an >> endovascular >> something into the arch with a very nice landing zone onto the >> prosthesis. >> BTW I am not an aortic guru but I like this surgery very much >> >> >> Giuseppe >> >> >> Il giorno 02/feb/10, alle ore 12:39, Michael Firstenberg ha scritto: >> >> I recently saw a lady in clinic (smoker, hypertension) with an >> ascending >>> aortic aneurysm. >>> She is not very large and a MRA showed the following: >>> >>> The entire thoracic and supra renal abdominal aorta is aneurysmal. >>> The aortic sinuses measure 3.8 x 3.9cm, STJ 3.8 x 3.5cm, AscAo >>> 5.5 x >>> 5.3cm, >>> mid transverse >>> arch 3.5 x 3.2cm, proximal DescAo 3.6 x 3.5cm. >>> >>> Her aortic valve is normal with only trace/mild AI >>> >>> Clearly her ascending needs to be replaced - but do you just do a >>> hemi-arch >>> and follow her or do you replace the arch as well with an >>> Elephant trunk >>> now >>> (obviously a much larger operation)? (or some other strange >>> endovascular >>> thing). >>> >>> She had a relatively normal cath in 2007 (getting repeated) but >>> otherwise >>> appears to be a reasonable operative candidate. >>> >>> thanks >>> >>> -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 >> anddisclaimers 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 Tue Feb 2 19:48:12 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Tue Feb 2 09:48:30 2010 Subject: [HSF] STS Meeting - MICS Vs Conventional MV surgery In-Reply-To: <1758616812-1265119214-cardhu_decombobulator_blackberry.rim.net-776307233-@bda730.bisx.prod.on.blackberry> References: <133f.125d0014.389969be@aol.com> <1758616812-1265119214-cardhu_decombobulator_blackberry.rim.net-776307233-@bda730.bisx.prod.on.blackberry> Message-ID: <89c4ed2d1002020618v69dbbf0ciafac7bf02df6ab12@mail.gmail.com> The source of that oil is not actually from the cut sternal edge (or else you should be seeing oil running around with say a thymectomy !! The actual source for majority of the oil is activation of lipoprotein lipase which gets activated by Heparin (obviously high dose due to CPB requirements) and which breaks triglycerides into triacyl glycerol and free fatty acids. In the days before statins I bet all of you remember the fatty butter churned up and often seen in the venous line or inthe venous reservoir filter when clamped after CPB . The pools of oil are the free fatty acids that are released. If the long bone fracture analogy was true we would be swimming with fat embolism cases. The femur has a higher fat to marrow ratio and that is one reason for fat embolism. In fact the current theory is not fat getting injected into the systemic circulation as classicaly held but an inflammatory reaction causing micellar instability in the blood leading to fat globule. formation. Prasanna On Tue, Feb 2, 2010 at 7:31 PM, wrote: > No, Ani, but the fat droplets you see in the pericardial well come from > some where. > > Hal > > Sent from my Verizon Wireless BlackBerry > > -----Original Message----- > From: Ani Anyanwu > Date: Tue, 2 Feb 2010 13:56:44 > To: open heart list > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > From my conversations with other MICS surgeons, fat emboli from the cut > sternal edge is eliminated. > Hal> > > >Fat embolism can be associated with long bone fractures. A sternotomy is > something like a long >bone fracture. John Flege > > > Are we saying the sternotomy is implicated in etiology of stroke after > cardiac surgery? > > > > Must say not something I have read about previously. To my knowledge > non-bypass cases done via sternotomy, principally thymectomy, mediastinal > mass excision and anortic OBCAB had not been associated with higher rate of > stroke? And all large datasets available show lower stroke rates with > sternotomy than non-sternotomy approaches to heart surgery. Is this a real > phenomenom or a theoretical justification used by enthusiasts to promote > their (non-sternotomy) approach? > > > > Hal - from gammies paper, even looking at high-volume centers there has > higher incidence of stroke in MICS so not sure it is true that experienced > centers necessarily have less stroke. We do about 300 mitrals a year and > certainly do see a few strokes a year, maybe at least 3 with major deficit. > A surgeon may not see it because he does say 100 MICS mitrals a year > (therefore expect only one, two or none most years) but when you pool 20 > centers each doing 100, you will find the strokes (for some unlucky surgeons > would have had a bad run with four of five in the year another had none). If > a center is doing a few hundred MICS mitrals a year and telling me they have > had no strokes in last few years (like some discussants seemed to imply at > STS) then either they are not looking, dont recollect or are not being > truthful. > > > > The other thing we need to talk about one day is vascular complications - I > have started reading between the lines in the emerging literature and > discussions on the subject, and although often carefully hidden or brushed > over, it seems the number of patients requiring vascular intervention or > fasciotomy after MICS is not insignificant. Last week a surgeon mentioned he > was an expert witness on two robotic cases with vascular complications, one > of which ended in a below knee amputation, so peripheral arterial access is > also something we need to focus on (i personally take chand's approach of > sewing a side-graft to femoral artery, and I think you mentioned you place a > distal cathether - maybe overkill but at least one does not have to worry > about the leg). > > > > Ani > > > From: Hgrmd@aol.com > > Date: Tue, 2 Feb 2010 06:42:54 -0500 > > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > To: OpenHeart-L@lists.hsforum.com > > CC: > > > > Ani, > > I wish I could have heard Gammie's talk, and I look forward to > > scrutinizing the paper when it is published. However, the problem is that > it looks > > at the incidence of strokes for all MICS. As we know, MICS is not a > > uniform procedure, so these results are really a mish mash. I agree with > Fred > > Mohr that the incidence of strokes in experienced MICS centers is > probably as > > low or lower when compared to sternotomy. From my conversations with > > other MICS surgeons, fat emboli from the cut sternal edge is eliminated. > In > > addition, in the closed chest filled with CO2, you rarely see ANY bubbles > on > > TEE. > > > > Hal > > > > > > In a message dated 2/2/2010 12:24:17 A.M. Eastern Standard Time, > > anianyanwu@hotmail.com writes: > > > > > > Roberto > > > > > > > > Yes I have done mitral MICS. What I say about view from camera's is from > > personal observation where I have sometimes seen debris (under direct > > vision) in the atrium in an area that was not in camera's view (which is > focused > > on the valve). I think valve repair without TEE is rarely, if ever > > practiced. > > > > > > > > I found it strange at STS all discussants (Mohr included ) seemed to give > > *impression* strokes were no longer seen in MICS and the problem had been > > 'solved' with CO2, deairing, changes to perfusion and clamping etc. Heck > we > > see stroke with sternotomy - indeed in 2008 you may recall I posted for > > advice on the forum after having two patients in a month with devastating > > strokes after mitral repair via sternotomy - so what is strange about > saying > > strokes occur after MICS? Any surgeon who says he has not seen strokes in > > mitral repair needs to do more and sooner or later willl have a stroke > come > > to visit. Those who do MICS will have those visits a bit more frequently. > > > > > > > > I personally have my doubts as to whether air is a predominant cause of > > stroke with permanent deficit - the definition used in STS. When I worked > > with Yacoub in early days of routine TEE (and no CO2) there was often a > > snowstorm on echo just before coming of bypass - he just put a needle in > aorta - > > like he had in 30 years of practice without TEE tellling him what to do - > > and came off bypass ignoring the echo (unless big pockets of air). Maybe > > there were neuro changes we could not measure, but rarely did the > patients > > wake up with an STS defined stroke. I think we can blame air for global > > changes like delirium, cognitive dysfunction etc, but when a patient is > > hemiplegic I think we need to first look for, and exclude, other causes > before we > > blame air. > > > > > > > > Ani > > > > > From: robertobattellini@hotmail.com > > > To: openheart-l@lists.hsforum.com > > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > Date: Mon, 1 Feb 2010 21:33:02 +0100 > > > > > > > > > Ani, > > > > > > Have you ever done Mitral Mics to talk like that? > > > > > > The view is Superb with cameras, if you have doubts just go to leipzig > > and look at Mohr doing it. > > > > > > may be the higher stroke problems are with deairing the heart if the > > surgeon is not very strict and does > > > > > > not uses TEE. > > > > > > For MICS, camera and TEE are obligatory. > > > > > > Roberto > > > > > > > From: anianyanwu@hotmail.com > > > > To: openheart-l@lists.hsforum.com > > > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > Date: Wed, 27 Jan 2010 02:13:54 +0000 > > > > > > > > > > > > MICS was a risk factor independent of age and endoclamp use was not a > > predictor of stroke if I recall correctly. > > > > > > > > > > > > > > > > I doubt it is all retrograde perfusion as the MICS cohort were > largely > > younger patients with minimal risk factors so should have clean aorta. > > > > > > > > > > > > I think poor debris management due to the limited surgical view is > > certainly a possibility. Dr Gammie mentioned this in passing and I > believe > > could well be the reason why a higher stroke rate in MICS persists > regardless > > of age and risk factors. In MICS especially port access or robotic > variety > > the surgeon's eye is by definition just on a limited area of the surgical > > field, and the assistant often sees less. Whereas via big incision the > > surgeon sees most of field and assistant sees areas surgeon doesnt. Jim > > postulated that maybe small bits of fat or valve, annular or ventricular > tissue or > > surgical material could fall into the atrium or pulmonary veins unnoticed > > and go on to cause stroke. Whereas in sternotomy, the surgeon or > assistant > > is more likely to spot that particle of fat or calcium on the atrial > wall; > > with a robot, one would not see it as can see only the valve (i presume). > > This explantion, rather than air, could also tie up the observation of > higher > > strokes with no-clamp methods as with the heart beating and blood in the > > field you are probably even less likely to see loose bits of tissue in > the > > ventricle and around the annulus or leaflets. > > > > > > > > > > > > > > > > Ani > > > > > > > > > > > > > > > > > > > > > Date: Tue, 26 Jan 2010 19:30:40 -0600 > > > > > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > > From: ebender001@me.com > > > > > To: OpenHeart-L@lists.hsforum.com > > > > > CC: > > > > > > > > > > Besides operating without a cross-clamp and air embolus (which > > obviously > > > > > must be prevented no matter what approach), I assume the increased > > stroke > > > > > risk was due to retrograde perfusion and athero emboli from the > > aorta, plus > > > > > a small number due to malpositioned endo clamp or poor debris > > management > > > > > through a small incision or port approach. Obviously these are > > concerning > > > > > numbers, and stresses the need for a pre-op study of the aorta > (most > > use CTA > > > > > through the femorals) Did Jim break down the age groups? I guess > one > > could > > > > > use age as a surrogate for plaque build up in the aorta. > > > > > > > > > > Thanks for the feedback. > > > > > > > > > > Ed Bender, MD > > > > > > > > > > > > > > > On 1/26/10 6:31 PM, "Ani Anyanwu" wrote: > > > > > > > > > > > > > > > > > redos were excluded from this analysis > > > > > > > > > > > >> Date: Tue, 26 Jan 2010 18:28:44 -0600 > > > > > >> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > > >> From: ebender001@me.com > > > > > >> To: OpenHeart-L@lists.hsforum.com > > > > > >> CC: > > > > > >> > > > > > >> Very interesting. I would, as you stated, be cautious in using > > peripheral > > > > > >> cannulation as a proxy for MICS. I use it liberally for redo > > approaches with > > > > > >> a full sternotomy (as at least one other person on this forum > > does). Could > > > > > >> it be that the reop rate might reflect a redo staus rather than > a > > MICS? > > > > > >> > > > > > >> Ed Bender, MD > > > > > >> > > > > > >> > > > > > >> On 1/26/10 6:04 PM, "Ani Anyanwu" > wrote: > > > > > >> > > > > > >>> > > > > > >>> I was at the STS for just a day. Only one paper caught my > > interest. Dr > > > > > >>> Gammie > > > > > >>> presented an excellent analysis of mitral valve surgery > reported > > to the STS > > > > > >>> database to compare analysis of conventional mitral valve > > surgery vs > > > > > >>> minimally > > > > > >>> invasive cardiac surgery. Becausesurgical incision is not > > collected by STS, > > > > > >>> Gammie and colleagues used cannulation strategy as surrogate > for > > > > > >>> invasiveness. > > > > > >>> If patient was cannulated centrally (aorta, right atrium) was > > assumed a > > > > > >>> conventional appproach, if cannulated femoro-femoral, then was > > assumed to be > > > > > >>> minimally invasive approach. Other permutations of cannulation > > were excluded > > > > > >>> from analysis. Isolated MV only (?). They reviewed over 20,000 > > operations > > > > > >>> performed in US between 2004-2008. > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> Summary of findings > > > > > >>> > > > > > >>> . > > > > > >>> > > > > > >>> About 15% of all mitral operations were done with MICS as > > defined. Frequency > > > > > >>> increased from 10% in 2004 to 20% in 2008. > > > > > >>> > > > > > >>> 35% of MICS robot assisted. > > > > > >>> > > > > > >>> Median number of MICS cases per center was 3. Over 75% of > > procedures in US > > > > > >>> were done by institutions doing less than 5 procedures a year. > > > > > >>> > > > > > >>> Endoaortic balloon used in 35%. > > > > > >>> > > > > > >>> More valve repair in MICS group (85% Vs 67%) > > > > > >>> > > > > > >>> Clamp and bypass times 20 and 27 min longer in MICS group. > > > > > >>> > > > > > >>> 41% transfusion rate in MICS (51% conventional). > > > > > >>> > > > > > >>> More (yes - more) reoperations for bleeding with MICS (Odds > > ratio 1.22). > > > > > >>> > > > > > >>> Shorter length of saty and ventilation with MICS. > > > > > >>> > > > > > >>> Mortality same. > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> KEY FINDING: Twice more strokes with MICS (Odds Ratio 1.96). > > Strokes defined > > > > > >>> as stroke with permanent deficit. Higher stroke rate with MICS > > seen in all > > > > > >>> groups examined, regardless of risk factors, center case > volume, > > use of > > > > > >>> endocclamp, use of clamp. However, highest rate of stroke was > > seen in those > > > > > >>> cases done without a cross clamp (beating or fibrillation) > > associated with > > > > > >>> odds ratio of 3. > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> Limitations: Definition of MICS based on cannulaation strategy > > likely > > > > > >>> misscalssified some patients. While very likely almost all > > femorofemoral > > > > > >>> approachs were truly MICS procedures, a lot of MICS would have > > been called > > > > > >>> conventional if centrally cannulated. Of importance because > some > > high volume > > > > > >>> MICS centers like NYU, Cleveland, BWH I believe use central > > cannulation > > > > > >>> liberally for thoracotomy or hemisternotomy approach. Also > > hybrids eg > > > > > >>> femoral > > > > > >>> artery and central venous cannulation, used by some, were > > excluded. > > > > > >>> > > > > > >>> Patients in MICS were less sick, younger etc and more likely > > repairable > > > > > >>> hence > > > > > >>> introducing bias - of concern though is despite lower risk > there > > was still > > > > > >>> double stroke incidence. > > > > > >>> > > > > > >>> No data on true outcomes of surgery such as results of repair, > > reoperation, > > > > > >>> 12 > > > > > >>> month symptoms or survival. > > > > > >>> > > > > > >>> No data on mitral pathology and disease treated. > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> Response from disscussants (most MICS enthusiasts) largely > > ignored or > > > > > >>> dismissed the stroke risk and felt the data were sufficient to > > show that > > > > > >>> MICS > > > > > >>> 1) is valid approach for MV surgery 2) Does not compromise > > repair 3) Is safe > > > > > >>> 4) Has better 'outcomes' but 5) other explanations likely exist > > for higher > > > > > >>> stroke and 6) MV surgery without a clamp should be strongly > > discouraged. One > > > > > >>> discussant cautioned that the stroke risk cannot be ignored as > > this is the > > > > > >>> second mega-analysis of a database presented at STS in recent > > years showing > > > > > >>> higher stroke risk with MICS (the other being a paper by Mehmet > > Oz group 5 > > > > > >>> years or so ago I think presented by our Dr Cheema which also > > found doubling > > > > > >>> of incidence of stroke in NY State). > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> Ani > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>>> From: msfirst@gmail.com > > > > > >>>> To: OpenHeart-L@lists.hsforum.com > > > > > >>>> Subject: Re: [HSF] STS Meeting > > > > > >>>> Date: Tue, 26 Jan 2010 18:23:52 -0500 > > > > > >>>> CC: > > > > > >>>> > > > > > >>>> Guess not > > > > > >>>> > > > > > >>>> -michael/iPhone > > > > > >>>> > > > > > >>>> On Jan 26, 2010, at 4:50 PM, Edward Bender > > > wrote: > > > > > >>>> > > > > > >>>>> Anything new and/or interesting coming out of the STS > meeting? > > > > > >>>>> > > > > > >>>>> 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 > > > > > >>>> ----------------------------------------- > > > > > >>> > > > > > > >>>_________________________________________________________________ > > > > > >>> Got a cool Hotmail story? 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Tell us > > > > > > now > > > > > > > > > http://clk.atdmt.com/UKM/go/195013117/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 > > > > > ----------------------------------------- > > > > > > > >_________________________________________________________________ > > > > We want to hear all your funny, exciting and crazy Hotmail stories. > > Tell us now > > > > > > > http://clk.atdmt.com/UKM/go/195013117/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 > > > ----------------------------------------- > > > >_________________________________________________________________ > > Got a cool Hotmail story? Tell us now > > > http://clk.atdmt.com/UKM/go/195013117/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 > > ----------------------------------------- > > _________________________________________________________________ > Got a cool Hotmail story? Tell us now > > http://clk.atdmt.com/UKM/go/195013117/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 > ----------------------------------------- > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 Tue Feb 2 15:53:13 2010 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Tue Feb 2 09:53:43 2010 Subject: [HSF] STS Meeting - MICS Vs Conventional MV surgery In-Reply-To: <133f.125d0014.389969be@aol.com> References: <133f.125d0014.389969be@aol.com> Message-ID: Without sternotomy you eliminate bone marrow, bone wax,thymus fat.We always see fat bubbles like olive oil when we suck. In MICS these are less. And you surprise me talking about thymectomies and no embolies, the heart there is not open!!! I sucked always these fat bubbles before closing the atrium. Roberto > From: Hgrmd@aol.com > Date: Tue, 2 Feb 2010 06:42:54 -0500 > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > To: OpenHeart-L@lists.hsforum.com > CC: > > Ani, > I wish I could have heard Gammie's talk, and I look forward to > scrutinizing the paper when it is published. However, the problem is that it looks > at the incidence of strokes for all MICS. As we know, MICS is not a > uniform procedure, so these results are really a mish mash. I agree with Fred > Mohr that the incidence of strokes in experienced MICS centers is probably as > low or lower when compared to sternotomy. From my conversations with > other MICS surgeons, fat emboli from the cut sternal edge is eliminated. In > addition, in the closed chest filled with CO2, you rarely see ANY bubbles on > TEE. > > Hal > > > In a message dated 2/2/2010 12:24:17 A.M. Eastern Standard Time, > anianyanwu@hotmail.com writes: > > > Roberto > > > > Yes I have done mitral MICS. What I say about view from camera's is from > personal observation where I have sometimes seen debris (under direct > vision) in the atrium in an area that was not in camera's view (which is focused > on the valve). I think valve repair without TEE is rarely, if ever > practiced. > > > > I found it strange at STS all discussants (Mohr included ) seemed to give > *impression* strokes were no longer seen in MICS and the problem had been > 'solved' with CO2, deairing, changes to perfusion and clamping etc. Heck we > see stroke with sternotomy - indeed in 2008 you may recall I posted for > advice on the forum after having two patients in a month with devastating > strokes after mitral repair via sternotomy - so what is strange about saying > strokes occur after MICS? Any surgeon who says he has not seen strokes in > mitral repair needs to do more and sooner or later willl have a stroke come > to visit. Those who do MICS will have those visits a bit more frequently. > > > > I personally have my doubts as to whether air is a predominant cause of > stroke with permanent deficit - the definition used in STS. When I worked > with Yacoub in early days of routine TEE (and no CO2) there was often a > snowstorm on echo just before coming of bypass - he just put a needle in aorta - > like he had in 30 years of practice without TEE tellling him what to do - > and came off bypass ignoring the echo (unless big pockets of air). Maybe > there were neuro changes we could not measure, but rarely did the patients > wake up with an STS defined stroke. I think we can blame air for global > changes like delirium, cognitive dysfunction etc, but when a patient is > hemiplegic I think we need to first look for, and exclude, other causes before we > blame air. > > > > Ani > > > From: robertobattellini@hotmail.com > > To: openheart-l@lists.hsforum.com > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > Date: Mon, 1 Feb 2010 21:33:02 +0100 > > > > > > Ani, > > > > Have you ever done Mitral Mics to talk like that? > > > > The view is Superb with cameras, if you have doubts just go to leipzig > and look at Mohr doing it. > > > > may be the higher stroke problems are with deairing the heart if the > surgeon is not very strict and does > > > > not uses TEE. > > > > For MICS, camera and TEE are obligatory. > > > > Roberto > > > > > From: anianyanwu@hotmail.com > > > To: openheart-l@lists.hsforum.com > > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > Date: Wed, 27 Jan 2010 02:13:54 +0000 > > > > > > > > > MICS was a risk factor independent of age and endoclamp use was not a > predictor of stroke if I recall correctly. > > > > > > > > > > > > I doubt it is all retrograde perfusion as the MICS cohort were largely > younger patients with minimal risk factors so should have clean aorta. > > > > > > > > > I think poor debris management due to the limited surgical view is > certainly a possibility. Dr Gammie mentioned this in passing and I believe > could well be the reason why a higher stroke rate in MICS persists regardless > of age and risk factors. In MICS especially port access or robotic variety > the surgeon's eye is by definition just on a limited area of the surgical > field, and the assistant often sees less. Whereas via big incision the > surgeon sees most of field and assistant sees areas surgeon doesnt. Jim > postulated that maybe small bits of fat or valve, annular or ventricular tissue or > surgical material could fall into the atrium or pulmonary veins unnoticed > and go on to cause stroke. Whereas in sternotomy, the surgeon or assistant > is more likely to spot that particle of fat or calcium on the atrial wall; > with a robot, one would not see it as can see only the valve (i presume). > This explantion, rather than air, could also tie up the observation of higher > strokes with no-clamp methods as with the heart beating and blood in the > field you are probably even less likely to see loose bits of tissue in the > ventricle and around the annulus or leaflets. > > > > > > > > > > > > Ani > > > > > > > > > > > > > > > > Date: Tue, 26 Jan 2010 19:30:40 -0600 > > > > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > From: ebender001@me.com > > > > To: OpenHeart-L@lists.hsforum.com > > > > CC: > > > > > > > > Besides operating without a cross-clamp and air embolus (which > obviously > > > > must be prevented no matter what approach), I assume the increased > stroke > > > > risk was due to retrograde perfusion and athero emboli from the > aorta, plus > > > > a small number due to malpositioned endo clamp or poor debris > management > > > > through a small incision or port approach. Obviously these are > concerning > > > > numbers, and stresses the need for a pre-op study of the aorta (most > use CTA > > > > through the femorals) Did Jim break down the age groups? I guess one > could > > > > use age as a surrogate for plaque build up in the aorta. > > > > > > > > Thanks for the feedback. > > > > > > > > Ed Bender, MD > > > > > > > > > > > > On 1/26/10 6:31 PM, "Ani Anyanwu" wrote: > > > > > > > > > > > > > > redos were excluded from this analysis > > > > > > > > > >> Date: Tue, 26 Jan 2010 18:28:44 -0600 > > > > >> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > >> From: ebender001@me.com > > > > >> To: OpenHeart-L@lists.hsforum.com > > > > >> CC: > > > > >> > > > > >> Very interesting. I would, as you stated, be cautious in using > peripheral > > > > >> cannulation as a proxy for MICS. I use it liberally for redo > approaches with > > > > >> a full sternotomy (as at least one other person on this forum > does). Could > > > > >> it be that the reop rate might reflect a redo staus rather than a > MICS? > > > > >> > > > > >> Ed Bender, MD > > > > >> > > > > >> > > > > >> On 1/26/10 6:04 PM, "Ani Anyanwu" wrote: > > > > >> > > > > >>> > > > > >>> I was at the STS for just a day. Only one paper caught my > interest. Dr > > > > >>> Gammie > > > > >>> presented an excellent analysis of mitral valve surgery reported > to the STS > > > > >>> database to compare analysis of conventional mitral valve > surgery vs > > > > >>> minimally > > > > >>> invasive cardiac surgery. Becausesurgical incision is not > collected by STS, > > > > >>> Gammie and colleagues used cannulation strategy as surrogate for > > > > >>> invasiveness. > > > > >>> If patient was cannulated centrally (aorta, right atrium) was > assumed a > > > > >>> conventional appproach, if cannulated femoro-femoral, then was > assumed to be > > > > >>> minimally invasive approach. Other permutations of cannulation > were excluded > > > > >>> from analysis. Isolated MV only (?). They reviewed over 20,000 > operations > > > > >>> performed in US between 2004-2008. > > > > >>> > > > > >>> > > > > >>> > > > > >>> Summary of findings > > > > >>> > > > > >>> . > > > > >>> > > > > >>> About 15% of all mitral operations were done with MICS as > defined. Frequency > > > > >>> increased from 10% in 2004 to 20% in 2008. > > > > >>> > > > > >>> 35% of MICS robot assisted. > > > > >>> > > > > >>> Median number of MICS cases per center was 3. Over 75% of > procedures in US > > > > >>> were done by institutions doing less than 5 procedures a year. > > > > >>> > > > > >>> Endoaortic balloon used in 35%. > > > > >>> > > > > >>> More valve repair in MICS group (85% Vs 67%) > > > > >>> > > > > >>> Clamp and bypass times 20 and 27 min longer in MICS group. > > > > >>> > > > > >>> 41% transfusion rate in MICS (51% conventional). > > > > >>> > > > > >>> More (yes - more) reoperations for bleeding with MICS (Odds > ratio 1.22). > > > > >>> > > > > >>> Shorter length of saty and ventilation with MICS. > > > > >>> > > > > >>> Mortality same. > > > > >>> > > > > >>> > > > > >>> > > > > >>> KEY FINDING: Twice more strokes with MICS (Odds Ratio 1.96). > Strokes defined > > > > >>> as stroke with permanent deficit. Higher stroke rate with MICS > seen in all > > > > >>> groups examined, regardless of risk factors, center case volume, > use of > > > > >>> endocclamp, use of clamp. However, highest rate of stroke was > seen in those > > > > >>> cases done without a cross clamp (beating or fibrillation) > associated with > > > > >>> odds ratio of 3. > > > > >>> > > > > >>> > > > > >>> > > > > >>> Limitations: Definition of MICS based on cannulaation strategy > likely > > > > >>> misscalssified some patients. While very likely almost all > femorofemoral > > > > >>> approachs were truly MICS procedures, a lot of MICS would have > been called > > > > >>> conventional if centrally cannulated. Of importance because some > high volume > > > > >>> MICS centers like NYU, Cleveland, BWH I believe use central > cannulation > > > > >>> liberally for thoracotomy or hemisternotomy approach. Also > hybrids eg > > > > >>> femoral > > > > >>> artery and central venous cannulation, used by some, were > excluded. > > > > >>> > > > > >>> Patients in MICS were less sick, younger etc and more likely > repairable > > > > >>> hence > > > > >>> introducing bias - of concern though is despite lower risk there > was still > > > > >>> double stroke incidence. > > > > >>> > > > > >>> No data on true outcomes of surgery such as results of repair, > reoperation, > > > > >>> 12 > > > > >>> month symptoms or survival. > > > > >>> > > > > >>> No data on mitral pathology and disease treated. > > > > >>> > > > > >>> > > > > >>> > > > > >>> Response from disscussants (most MICS enthusiasts) largely > ignored or > > > > >>> dismissed the stroke risk and felt the data were sufficient to > show that > > > > >>> MICS > > > > >>> 1) is valid approach for MV surgery 2) Does not compromise > repair 3) Is safe > > > > >>> 4) Has better 'outcomes' but 5) other explanations likely exist > for higher > > > > >>> stroke and 6) MV surgery without a clamp should be strongly > discouraged. One > > > > >>> discussant cautioned that the stroke risk cannot be ignored as > this is the > > > > >>> second mega-analysis of a database presented at STS in recent > years showing > > > > >>> higher stroke risk with MICS (the other being a paper by Mehmet > Oz group 5 > > > > >>> years or so ago I think presented by our Dr Cheema which also > found doubling > > > > >>> of incidence of stroke in NY State). > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> Ani > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>> > > > > >>>> From: msfirst@gmail.com > > > > >>>> To: OpenHeart-L@lists.hsforum.com > > > > >>>> Subject: Re: [HSF] STS Meeting > > > > >>>> Date: Tue, 26 Jan 2010 18:23:52 -0500 > > > > >>>> CC: > > > > >>>> > > > > >>>> Guess not > > > > >>>> > > > > >>>> -michael/iPhone > > > > >>>> > > > > >>>> On Jan 26, 2010, at 4:50 PM, Edward Bender > wrote: > > > > >>>> > > > > >>>>> Anything new and/or interesting coming out of the STS meeting? > > > > >>>>> > > > > >>>>> 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 > > > > >>>> ----------------------------------------- > > > > >>> > > > > >>> _________________________________________________________________ > > > > >>> Got a cool Hotmail story? Tell us now > > > > >>> > http://clk.atdmt.com/UKM/go/195013117/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 > > > > >> ----------------------------------------- > > > > > > > > > > _________________________________________________________________ > > > > > We want to hear all your funny, exciting and crazy Hotmail > stories. Tell us > > > > > now > > > > > > http://clk.atdmt.com/UKM/go/195013117/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 > > > > ----------------------------------------- > > > > > > _________________________________________________________________ > > > We want to hear all your funny, exciting and crazy Hotmail stories. > Tell us now > > > > http://clk.atdmt.com/UKM/go/195013117/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 > > ----------------------------------------- > > _________________________________________________________________ > Got a cool Hotmail story? Tell us now > http://clk.atdmt.com/UKM/go/195013117/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 robertobattellini at hotmail.com Tue Feb 2 15:55:28 2010 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Tue Feb 2 09:56:18 2010 Subject: [HSF] STS Meeting - MICS Vs Conventional MV surgery In-Reply-To: <89c4ed2d1002020618v69dbbf0ciafac7bf02df6ab12@mail.gmail.com> References: <133f.125d0014.389969be@aol.com>, , <1758616812-1265119214-cardhu_decombobulator_blackberry.rim.net-776307233-@bda730.bisx.prod.on.blackberry>, <89c4ed2d1002020618v69dbbf0ciafac7bf02df6ab12@mail.gmail.com> Message-ID: Professor!! did you investigated that or have bibliography? Roberto > Date: Tue, 2 Feb 2010 19:48:12 +0530 > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > From: prasannasimha@gmail.com > To: OpenHeart-L@lists.hsforum.com > CC: > > The source of that oil is not actually from the cut sternal edge (or else > you should be seeing oil running around with say a thymectomy !! The actual > source for majority of the oil is activation of lipoprotein lipase which > gets activated by Heparin (obviously high dose due to CPB requirements) and > which breaks triglycerides into triacyl glycerol and free fatty acids. In > the days before statins I bet all of you remember the fatty butter churned > up and often seen in the venous line or inthe venous reservoir filter when > clamped after CPB . The pools of oil are the free fatty acids that are > released. > If the long bone fracture analogy was true we would be swimming with fat > embolism cases. The femur has a higher fat to marrow ratio and that is one > reason for fat embolism. In fact the current theory is not fat getting > injected into the systemic circulation as classicaly held but an > inflammatory reaction causing micellar instability in the blood leading to > fat globule. formation. > Prasanna > > On Tue, Feb 2, 2010 at 7:31 PM, wrote: > > > No, Ani, but the fat droplets you see in the pericardial well come from > > some where. > > > > Hal > > > > Sent from my Verizon Wireless BlackBerry > > > > -----Original Message----- > > From: Ani Anyanwu > > Date: Tue, 2 Feb 2010 13:56:44 > > To: open heart list > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > > > > From my conversations with other MICS surgeons, fat emboli from the cut > > sternal edge is eliminated. > Hal> > > > > >Fat embolism can be associated with long bone fractures. A sternotomy is > > something like a long >bone fracture. John Flege > > > > > > Are we saying the sternotomy is implicated in etiology of stroke after > > cardiac surgery? > > > > > > > > Must say not something I have read about previously. To my knowledge > > non-bypass cases done via sternotomy, principally thymectomy, mediastinal > > mass excision and anortic OBCAB had not been associated with higher rate of > > stroke? And all large datasets available show lower stroke rates with > > sternotomy than non-sternotomy approaches to heart surgery. Is this a real > > phenomenom or a theoretical justification used by enthusiasts to promote > > their (non-sternotomy) approach? > > > > > > > > Hal - from gammies paper, even looking at high-volume centers there has > > higher incidence of stroke in MICS so not sure it is true that experienced > > centers necessarily have less stroke. We do about 300 mitrals a year and > > certainly do see a few strokes a year, maybe at least 3 with major deficit. > > A surgeon may not see it because he does say 100 MICS mitrals a year > > (therefore expect only one, two or none most years) but when you pool 20 > > centers each doing 100, you will find the strokes (for some unlucky surgeons > > would have had a bad run with four of five in the year another had none). If > > a center is doing a few hundred MICS mitrals a year and telling me they have > > had no strokes in last few years (like some discussants seemed to imply at > > STS) then either they are not looking, dont recollect or are not being > > truthful. > > > > > > > > The other thing we need to talk about one day is vascular complications - I > > have started reading between the lines in the emerging literature and > > discussions on the subject, and although often carefully hidden or brushed > > over, it seems the number of patients requiring vascular intervention or > > fasciotomy after MICS is not insignificant. Last week a surgeon mentioned he > > was an expert witness on two robotic cases with vascular complications, one > > of which ended in a below knee amputation, so peripheral arterial access is > > also something we need to focus on (i personally take chand's approach of > > sewing a side-graft to femoral artery, and I think you mentioned you place a > > distal cathether - maybe overkill but at least one does not have to worry > > about the leg). > > > > > > > > Ani > > > > > From: Hgrmd@aol.com > > > Date: Tue, 2 Feb 2010 06:42:54 -0500 > > > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > To: OpenHeart-L@lists.hsforum.com > > > CC: > > > > > > Ani, > > > I wish I could have heard Gammie's talk, and I look forward to > > > scrutinizing the paper when it is published. However, the problem is that > > it looks > > > at the incidence of strokes for all MICS. As we know, MICS is not a > > > uniform procedure, so these results are really a mish mash. I agree with > > Fred > > > Mohr that the incidence of strokes in experienced MICS centers is > > probably as > > > low or lower when compared to sternotomy. From my conversations with > > > other MICS surgeons, fat emboli from the cut sternal edge is eliminated. > > In > > > addition, in the closed chest filled with CO2, you rarely see ANY bubbles > > on > > > TEE. > > > > > > Hal > > > > > > > > > In a message dated 2/2/2010 12:24:17 A.M. Eastern Standard Time, > > > anianyanwu@hotmail.com writes: > > > > > > > > > Roberto > > > > > > > > > > > > Yes I have done mitral MICS. What I say about view from camera's is from > > > personal observation where I have sometimes seen debris (under direct > > > vision) in the atrium in an area that was not in camera's view (which is > > focused > > > on the valve). I think valve repair without TEE is rarely, if ever > > > practiced. > > > > > > > > > > > > I found it strange at STS all discussants (Mohr included ) seemed to give > > > *impression* strokes were no longer seen in MICS and the problem had been > > > 'solved' with CO2, deairing, changes to perfusion and clamping etc. Heck > > we > > > see stroke with sternotomy - indeed in 2008 you may recall I posted for > > > advice on the forum after having two patients in a month with devastating > > > strokes after mitral repair via sternotomy - so what is strange about > > saying > > > strokes occur after MICS? Any surgeon who says he has not seen strokes in > > > mitral repair needs to do more and sooner or later willl have a stroke > > come > > > to visit. Those who do MICS will have those visits a bit more frequently. > > > > > > > > > > > > I personally have my doubts as to whether air is a predominant cause of > > > stroke with permanent deficit - the definition used in STS. When I worked > > > with Yacoub in early days of routine TEE (and no CO2) there was often a > > > snowstorm on echo just before coming of bypass - he just put a needle in > > aorta - > > > like he had in 30 years of practice without TEE tellling him what to do - > > > and came off bypass ignoring the echo (unless big pockets of air). Maybe > > > there were neuro changes we could not measure, but rarely did the > > patients > > > wake up with an STS defined stroke. I think we can blame air for global > > > changes like delirium, cognitive dysfunction etc, but when a patient is > > > hemiplegic I think we need to first look for, and exclude, other causes > > before we > > > blame air. > > > > > > > > > > > > Ani > > > > > > > From: robertobattellini@hotmail.com > > > > To: openheart-l@lists.hsforum.com > > > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > Date: Mon, 1 Feb 2010 21:33:02 +0100 > > > > > > > > > > > > Ani, > > > > > > > > Have you ever done Mitral Mics to talk like that? > > > > > > > > The view is Superb with cameras, if you have doubts just go to leipzig > > > and look at Mohr doing it. > > > > > > > > may be the higher stroke problems are with deairing the heart if the > > > surgeon is not very strict and does > > > > > > > > not uses TEE. > > > > > > > > For MICS, camera and TEE are obligatory. > > > > > > > > Roberto > > > > > > > > > From: anianyanwu@hotmail.com > > > > > To: openheart-l@lists.hsforum.com > > > > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > > Date: Wed, 27 Jan 2010 02:13:54 +0000 > > > > > > > > > > > > > > > MICS was a risk factor independent of age and endoclamp use was not a > > > predictor of stroke if I recall correctly. > > > > > > > > > > > > > > > > > > > > I doubt it is all retrograde perfusion as the MICS cohort were > > largely > > > younger patients with minimal risk factors so should have clean aorta. > > > > > > > > > > > > > > > I think poor debris management due to the limited surgical view is > > > certainly a possibility. Dr Gammie mentioned this in passing and I > > believe > > > could well be the reason why a higher stroke rate in MICS persists > > regardless > > > of age and risk factors. In MICS especially port access or robotic > > variety > > > the surgeon's eye is by definition just on a limited area of the surgical > > > field, and the assistant often sees less. Whereas via big incision the > > > surgeon sees most of field and assistant sees areas surgeon doesnt. Jim > > > postulated that maybe small bits of fat or valve, annular or ventricular > > tissue or > > > surgical material could fall into the atrium or pulmonary veins unnoticed > > > and go on to cause stroke. Whereas in sternotomy, the surgeon or > > assistant > > > is more likely to spot that particle of fat or calcium on the atrial > > wall; > > > with a robot, one would not see it as can see only the valve (i presume). > > > This explantion, rather than air, could also tie up the observation of > > higher > > > strokes with no-clamp methods as with the heart beating and blood in the > > > field you are probably even less likely to see loose bits of tissue in > > the > > > ventricle and around the annulus or leaflets. > > > > > > > > > > > > > > > > > > > > Ani > > > > > > > > > > > > > > > > > > > > > > > > > > Date: Tue, 26 Jan 2010 19:30:40 -0600 > > > > > > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > > > From: ebender001@me.com > > > > > > To: OpenHeart-L@lists.hsforum.com > > > > > > CC: > > > > > > > > > > > > Besides operating without a cross-clamp and air embolus (which > > > obviously > > > > > > must be prevented no matter what approach), I assume the increased > > > stroke > > > > > > risk was due to retrograde perfusion and athero emboli from the > > > aorta, plus > > > > > > a small number due to malpositioned endo clamp or poor debris > > > management > > > > > > through a small incision or port approach. Obviously these are > > > concerning > > > > > > numbers, and stresses the need for a pre-op study of the aorta > > (most > > > use CTA > > > > > > through the femorals) Did Jim break down the age groups? I guess > > one > > > could > > > > > > use age as a surrogate for plaque build up in the aorta. > > > > > > > > > > > > Thanks for the feedback. > > > > > > > > > > > > Ed Bender, MD > > > > > > > > > > > > > > > > > > On 1/26/10 6:31 PM, "Ani Anyanwu" wrote: > > > > > > > > > > > > > > > > > > > > redos were excluded from this analysis > > > > > > > > > > > > > >> Date: Tue, 26 Jan 2010 18:28:44 -0600 > > > > > > >> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > > > >> From: ebender001@me.com > > > > > > >> To: OpenHeart-L@lists.hsforum.com > > > > > > >> CC: > > > > > > >> > > > > > > >> Very interesting. I would, as you stated, be cautious in using > > > peripheral > > > > > > >> cannulation as a proxy for MICS. I use it liberally for redo > > > approaches with > > > > > > >> a full sternotomy (as at least one other person on this forum > > > does). Could > > > > > > >> it be that the reop rate might reflect a redo staus rather than > > a > > > MICS? > > > > > > >> > > > > > > >> Ed Bender, MD > > > > > > >> > > > > > > >> > > > > > > >> On 1/26/10 6:04 PM, "Ani Anyanwu" > > wrote: > > > > > > >> > > > > > > >>> > > > > > > >>> I was at the STS for just a day. Only one paper caught my > > > interest. Dr > > > > > > >>> Gammie > > > > > > >>> presented an excellent analysis of mitral valve surgery > > reported > > > to the STS > > > > > > >>> database to compare analysis of conventional mitral valve > > > surgery vs > > > > > > >>> minimally > > > > > > >>> invasive cardiac surgery. Becausesurgical incision is not > > > collected by STS, > > > > > > >>> Gammie and colleagues used cannulation strategy as surrogate > > for > > > > > > >>> invasiveness. > > > > > > >>> If patient was cannulated centrally (aorta, right atrium) was > > > assumed a > > > > > > >>> conventional appproach, if cannulated femoro-femoral, then was > > > assumed to be > > > > > > >>> minimally invasive approach. Other permutations of cannulation > > > were excluded > > > > > > >>> from analysis. Isolated MV only (?). They reviewed over 20,000 > > > operations > > > > > > >>> performed in US between 2004-2008. > > > > > > >>> > > > > > > >>> > > > > > > >>> > > > > > > >>> Summary of findings > > > > > > >>> > > > > > > >>> . > > > > > > >>> > > > > > > >>> About 15% of all mitral operations were done with MICS as > > > defined. Frequency > > > > > > >>> increased from 10% in 2004 to 20% in 2008. > > > > > > >>> > > > > > > >>> 35% of MICS robot assisted. > > > > > > >>> > > > > > > >>> Median number of MICS cases per center was 3. Over 75% of > > > procedures in US > > > > > > >>> were done by institutions doing less than 5 procedures a year. > > > > > > >>> > > > > > > >>> Endoaortic balloon used in 35%. > > > > > > >>> > > > > > > >>> More valve repair in MICS group (85% Vs 67%) > > > > > > >>> > > > > > > >>> Clamp and bypass times 20 and 27 min longer in MICS group. > > > > > > >>> > > > > > > >>> 41% transfusion rate in MICS (51% conventional). > > > > > > >>> > > > > > > >>> More (yes - more) reoperations for bleeding with MICS (Odds > > > ratio 1.22). > > > > > > >>> > > > > > > >>> Shorter length of saty and ventilation with MICS. > > > > > > >>> > > > > > > >>> Mortality same. > > > > > > >>> > > > > > > >>> > > > > > > >>> > > > > > > >>> KEY FINDING: Twice more strokes with MICS (Odds Ratio 1.96). > > > Strokes defined > > > > > > >>> as stroke with permanent deficit. Higher stroke rate with MICS > > > seen in all > > > > > > >>> groups examined, regardless of risk factors, center case > > volume, > > > use of > > > > > > >>> endocclamp, use of clamp. However, highest rate of stroke was > > > seen in those > > > > > > >>> cases done without a cross clamp (beating or fibrillation) > > > associated with > > > > > > >>> odds ratio of 3. > > > > > > >>> > > > > > > >>> > > > > > > >>> > > > > > > >>> Limitations: Definition of MICS based on cannulaation strategy > > > likely > > > > > > >>> misscalssified some patients. While very likely almost all > > > femorofemoral > > > > > > >>> approachs were truly MICS procedures, a lot of MICS would have > > > been called > > > > > > >>> conventional if centrally cannulated. Of importance because > > some > > > high volume > > > > > > >>> MICS centers like NYU, Cleveland, BWH I believe use central > > > cannulation > > > > > > >>> liberally for thoracotomy or hemisternotomy approach. Also > > > hybrids eg > > > > > > >>> femoral > > > > > > >>> artery and central venous cannulation, used by some, were > > > excluded. > > > > > > >>> > > > > > > >>> Patients in MICS were less sick, younger etc and more likely > > > repairable > > > > > > >>> hence > > > > > > >>> introducing bias - of concern though is despite lower risk > > there > > > was still > > > > > > >>> double stroke incidence. > > > > > > >>> > > > > > > >>> No data on true outcomes of surgery such as results of repair, > > > reoperation, > > > > > > >>> 12 > > > > > > >>> month symptoms or survival. > > > > > > >>> > > > > > > >>> No data on mitral pathology and disease treated. > > > > > > >>> > > > > > > >>> > > > > > > >>> > > > > > > >>> Response from disscussants (most MICS enthusiasts) largely > > > ignored or > > > > > > >>> dismissed the stroke risk and felt the data were sufficient to > > > show that > > > > > > >>> MICS > > > > > > >>> 1) is valid approach for MV surgery 2) Does not compromise > > > repair 3) Is safe > > > > > > >>> 4) Has better 'outcomes' but 5) other explanations likely exist > > > for higher > > > > > > >>> stroke and 6) MV surgery without a clamp should be strongly > > > discouraged. One > > > > > > >>> discussant cautioned that the stroke risk cannot be ignored as > > > this is the > > > > > > >>> second mega-analysis of a database presented at STS in recent > > > years showing > > > > > > >>> higher stroke risk with MICS (the other being a paper by Mehmet > > > Oz group 5 > > > > > > >>> years or so ago I think presented by our Dr Cheema which also > > > found doubling > > > > > > >>> of incidence of stroke in NY State). > > > > > > >>> > > > > > > >>> > > > > > > >>> > > > > > > >>> > > > > > > >>> > > > > > > >>> Ani > > > > > > >>> > > > > > > >>> > > > > > > >>> > > > > > > >>> > > > > > > >>> > > > > > > >>> > > > > > > >>> > > > > > > >>> > > > > > > >>> > > > > > > >>>> From: msfirst@gmail.com > > > > > > >>>> To: OpenHeart-L@lists.hsforum.com > > > > > > >>>> Subject: Re: [HSF] STS Meeting > > > > > > >>>> Date: Tue, 26 Jan 2010 18:23:52 -0500 > > > > > > >>>> CC: > > > > > > >>>> > > > > > > >>>> Guess not > > > > > > >>>> > > > > > > >>>> -michael/iPhone > > > > > > >>>> > > > > > > >>>> On Jan 26, 2010, at 4:50 PM, Edward Bender > > > > > wrote: > > > > > > >>>> > > > > > > >>>>> Anything new and/or interesting coming out of the STS > > meeting? > > > > > > >>>>> > > > > > > >>>>> 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 > > > > > > >>>> ----------------------------------------- > > > > > > >>> > > > > > > > > >>>_________________________________________________________________ > > > > > > >>> Got a cool Hotmail story? 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Tell us > > > > > > > now > > > > > > > > > > > > http://clk.atdmt.com/UKM/go/195013117/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 > > > > > > ----------------------------------------- > > > > > > > > > >_________________________________________________________________ > > > > > We want to hear all your funny, exciting and crazy Hotmail stories. > > > Tell us now > > > > > > > > > > http://clk.atdmt.com/UKM/go/195013117/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 > > > > ----------------------------------------- > > > > > >_________________________________________________________________ > > > Got a cool Hotmail story? Tell us now > > > > > http://clk.atdmt.com/UKM/go/195013117/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 > > > ----------------------------------------- > > > > _________________________________________________________________ > > Got a cool Hotmail story? Tell us now > > > > http://clk.atdmt.com/UKM/go/195013117/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 > > ----------------------------------------- > > > > _______________________________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@lists.hsforum.com > > > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > > http://mmp.cjp.com/mailman/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 prasannasimha at gmail.com Tue Feb 2 20:28:46 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Tue Feb 2 09:59:13 2010 Subject: [HSF] STS Meeting - MICS Vs Conventional MV surgery In-Reply-To: References: <133f.125d0014.389969be@aol.com> Message-ID: <89c4ed2d1002020658mabc1a49q6a0b29a9b3c25308@mail.gmail.com> I was replying to the statement tht the source of majority of that fat was from the sternum Prasanna On Tue, Feb 2, 2010 at 8:23 PM, Roberto Battellini < robertobattellini@hotmail.com> wrote: > > Without sternotomy you eliminate bone marrow, bone wax,thymus fat.We always > see fat bubbles like olive oil when we suck. > > In MICS these are less. > > And you surprise me talking about thymectomies and no embolies, the heart > there is not open!!! > > I sucked always these fat bubbles before closing the atrium. > > Roberto > > > From: Hgrmd@aol.com > > Date: Tue, 2 Feb 2010 06:42:54 -0500 > > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > To: OpenHeart-L@lists.hsforum.com > > CC: > > > > Ani, > > I wish I could have heard Gammie's talk, and I look forward to > > scrutinizing the paper when it is published. However, the problem is that > it looks > > at the incidence of strokes for all MICS. As we know, MICS is not a > > uniform procedure, so these results are really a mish mash. I agree with > Fred > > Mohr that the incidence of strokes in experienced MICS centers is > probably as > > low or lower when compared to sternotomy. From my conversations with > > other MICS surgeons, fat emboli from the cut sternal edge is eliminated. > In > > addition, in the closed chest filled with CO2, you rarely see ANY bubbles > on > > TEE. > > > > Hal > > > > > > In a message dated 2/2/2010 12:24:17 A.M. Eastern Standard Time, > > anianyanwu@hotmail.com writes: > > > > > > Roberto > > > > > > > > Yes I have done mitral MICS. What I say about view from camera's is from > > personal observation where I have sometimes seen debris (under direct > > vision) in the atrium in an area that was not in camera's view (which is > focused > > on the valve). I think valve repair without TEE is rarely, if ever > > practiced. > > > > > > > > I found it strange at STS all discussants (Mohr included ) seemed to give > > *impression* strokes were no longer seen in MICS and the problem had been > > 'solved' with CO2, deairing, changes to perfusion and clamping etc. Heck > we > > see stroke with sternotomy - indeed in 2008 you may recall I posted for > > advice on the forum after having two patients in a month with devastating > > strokes after mitral repair via sternotomy - so what is strange about > saying > > strokes occur after MICS? Any surgeon who says he has not seen strokes in > > mitral repair needs to do more and sooner or later willl have a stroke > come > > to visit. Those who do MICS will have those visits a bit more frequently. > > > > > > > > I personally have my doubts as to whether air is a predominant cause of > > stroke with permanent deficit - the definition used in STS. When I worked > > with Yacoub in early days of routine TEE (and no CO2) there was often a > > snowstorm on echo just before coming of bypass - he just put a needle in > aorta - > > like he had in 30 years of practice without TEE tellling him what to do - > > and came off bypass ignoring the echo (unless big pockets of air). Maybe > > there were neuro changes we could not measure, but rarely did the > patients > > wake up with an STS defined stroke. I think we can blame air for global > > changes like delirium, cognitive dysfunction etc, but when a patient is > > hemiplegic I think we need to first look for, and exclude, other causes > before we > > blame air. > > > > > > > > Ani > > > > > From: robertobattellini@hotmail.com > > > To: openheart-l@lists.hsforum.com > > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > Date: Mon, 1 Feb 2010 21:33:02 +0100 > > > > > > > > > Ani, > > > > > > Have you ever done Mitral Mics to talk like that? > > > > > > The view is Superb with cameras, if you have doubts just go to leipzig > > and look at Mohr doing it. > > > > > > may be the higher stroke problems are with deairing the heart if the > > surgeon is not very strict and does > > > > > > not uses TEE. > > > > > > For MICS, camera and TEE are obligatory. > > > > > > Roberto > > > > > > > From: anianyanwu@hotmail.com > > > > To: openheart-l@lists.hsforum.com > > > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > Date: Wed, 27 Jan 2010 02:13:54 +0000 > > > > > > > > > > > > MICS was a risk factor independent of age and endoclamp use was not a > > predictor of stroke if I recall correctly. > > > > > > > > > > > > > > > > I doubt it is all retrograde perfusion as the MICS cohort were > largely > > younger patients with minimal risk factors so should have clean aorta. > > > > > > > > > > > > I think poor debris management due to the limited surgical view is > > certainly a possibility. Dr Gammie mentioned this in passing and I > believe > > could well be the reason why a higher stroke rate in MICS persists > regardless > > of age and risk factors. In MICS especially port access or robotic > variety > > the surgeon's eye is by definition just on a limited area of the surgical > > field, and the assistant often sees less. Whereas via big incision the > > surgeon sees most of field and assistant sees areas surgeon doesnt. Jim > > postulated that maybe small bits of fat or valve, annular or ventricular > tissue or > > surgical material could fall into the atrium or pulmonary veins unnoticed > > and go on to cause stroke. Whereas in sternotomy, the surgeon or > assistant > > is more likely to spot that particle of fat or calcium on the atrial > wall; > > with a robot, one would not see it as can see only the valve (i presume). > > This explantion, rather than air, could also tie up the observation of > higher > > strokes with no-clamp methods as with the heart beating and blood in the > > field you are probably even less likely to see loose bits of tissue in > the > > ventricle and around the annulus or leaflets. > > > > > > > > > > > > > > > > Ani > > > > > > > > > > > > > > > > > > > > > Date: Tue, 26 Jan 2010 19:30:40 -0600 > > > > > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > > From: ebender001@me.com > > > > > To: OpenHeart-L@lists.hsforum.com > > > > > CC: > > > > > > > > > > Besides operating without a cross-clamp and air embolus (which > > obviously > > > > > must be prevented no matter what approach), I assume the increased > > stroke > > > > > risk was due to retrograde perfusion and athero emboli from the > > aorta, plus > > > > > a small number due to malpositioned endo clamp or poor debris > > management > > > > > through a small incision or port approach. Obviously these are > > concerning > > > > > numbers, and stresses the need for a pre-op study of the aorta > (most > > use CTA > > > > > through the femorals) Did Jim break down the age groups? I guess > one > > could > > > > > use age as a surrogate for plaque build up in the aorta. > > > > > > > > > > Thanks for the feedback. > > > > > > > > > > Ed Bender, MD > > > > > > > > > > > > > > > On 1/26/10 6:31 PM, "Ani Anyanwu" wrote: > > > > > > > > > > > > > > > > > redos were excluded from this analysis > > > > > > > > > > > >> Date: Tue, 26 Jan 2010 18:28:44 -0600 > > > > > >> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > > >> From: ebender001@me.com > > > > > >> To: OpenHeart-L@lists.hsforum.com > > > > > >> CC: > > > > > >> > > > > > >> Very interesting. I would, as you stated, be cautious in using > > peripheral > > > > > >> cannulation as a proxy for MICS. I use it liberally for redo > > approaches with > > > > > >> a full sternotomy (as at least one other person on this forum > > does). Could > > > > > >> it be that the reop rate might reflect a redo staus rather than > a > > MICS? > > > > > >> > > > > > >> Ed Bender, MD > > > > > >> > > > > > >> > > > > > >> On 1/26/10 6:04 PM, "Ani Anyanwu" > wrote: > > > > > >> > > > > > >>> > > > > > >>> I was at the STS for just a day. Only one paper caught my > > interest. Dr > > > > > >>> Gammie > > > > > >>> presented an excellent analysis of mitral valve surgery > reported > > to the STS > > > > > >>> database to compare analysis of conventional mitral valve > > surgery vs > > > > > >>> minimally > > > > > >>> invasive cardiac surgery. Becausesurgical incision is not > > collected by STS, > > > > > >>> Gammie and colleagues used cannulation strategy as surrogate > for > > > > > >>> invasiveness. > > > > > >>> If patient was cannulated centrally (aorta, right atrium) was > > assumed a > > > > > >>> conventional appproach, if cannulated femoro-femoral, then was > > assumed to be > > > > > >>> minimally invasive approach. Other permutations of cannulation > > were excluded > > > > > >>> from analysis. Isolated MV only (?). They reviewed over 20,000 > > operations > > > > > >>> performed in US between 2004-2008. > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> Summary of findings > > > > > >>> > > > > > >>> . > > > > > >>> > > > > > >>> About 15% of all mitral operations were done with MICS as > > defined. Frequency > > > > > >>> increased from 10% in 2004 to 20% in 2008. > > > > > >>> > > > > > >>> 35% of MICS robot assisted. > > > > > >>> > > > > > >>> Median number of MICS cases per center was 3. Over 75% of > > procedures in US > > > > > >>> were done by institutions doing less than 5 procedures a year. > > > > > >>> > > > > > >>> Endoaortic balloon used in 35%. > > > > > >>> > > > > > >>> More valve repair in MICS group (85% Vs 67%) > > > > > >>> > > > > > >>> Clamp and bypass times 20 and 27 min longer in MICS group. > > > > > >>> > > > > > >>> 41% transfusion rate in MICS (51% conventional). > > > > > >>> > > > > > >>> More (yes - more) reoperations for bleeding with MICS (Odds > > ratio 1.22). > > > > > >>> > > > > > >>> Shorter length of saty and ventilation with MICS. > > > > > >>> > > > > > >>> Mortality same. > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> KEY FINDING: Twice more strokes with MICS (Odds Ratio 1.96). > > Strokes defined > > > > > >>> as stroke with permanent deficit. Higher stroke rate with MICS > > seen in all > > > > > >>> groups examined, regardless of risk factors, center case > volume, > > use of > > > > > >>> endocclamp, use of clamp. However, highest rate of stroke was > > seen in those > > > > > >>> cases done without a cross clamp (beating or fibrillation) > > associated with > > > > > >>> odds ratio of 3. > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> Limitations: Definition of MICS based on cannulaation strategy > > likely > > > > > >>> misscalssified some patients. While very likely almost all > > femorofemoral > > > > > >>> approachs were truly MICS procedures, a lot of MICS would have > > been called > > > > > >>> conventional if centrally cannulated. Of importance because > some > > high volume > > > > > >>> MICS centers like NYU, Cleveland, BWH I believe use central > > cannulation > > > > > >>> liberally for thoracotomy or hemisternotomy approach. Also > > hybrids eg > > > > > >>> femoral > > > > > >>> artery and central venous cannulation, used by some, were > > excluded. > > > > > >>> > > > > > >>> Patients in MICS were less sick, younger etc and more likely > > repairable > > > > > >>> hence > > > > > >>> introducing bias - of concern though is despite lower risk > there > > was still > > > > > >>> double stroke incidence. > > > > > >>> > > > > > >>> No data on true outcomes of surgery such as results of repair, > > reoperation, > > > > > >>> 12 > > > > > >>> month symptoms or survival. > > > > > >>> > > > > > >>> No data on mitral pathology and disease treated. > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> Response from disscussants (most MICS enthusiasts) largely > > ignored or > > > > > >>> dismissed the stroke risk and felt the data were sufficient to > > show that > > > > > >>> MICS > > > > > >>> 1) is valid approach for MV surgery 2) Does not compromise > > repair 3) Is safe > > > > > >>> 4) Has better 'outcomes' but 5) other explanations likely exist > > for higher > > > > > >>> stroke and 6) MV surgery without a clamp should be strongly > > discouraged. One > > > > > >>> discussant cautioned that the stroke risk cannot be ignored as > > this is the > > > > > >>> second mega-analysis of a database presented at STS in recent > > years showing > > > > > >>> higher stroke risk with MICS (the other being a paper by Mehmet > > Oz group 5 > > > > > >>> years or so ago I think presented by our Dr Cheema which also > > found doubling > > > > > >>> of incidence of stroke in NY State). > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> Ani > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>> > > > > > >>>> From: msfirst@gmail.com > > > > > >>>> To: OpenHeart-L@lists.hsforum.com > > > > > >>>> Subject: Re: [HSF] STS Meeting > > > > > >>>> Date: Tue, 26 Jan 2010 18:23:52 -0500 > > > > > >>>> CC: > > > > > >>>> > > > > > >>>> Guess not > > > > > >>>> > > > > > >>>> -michael/iPhone > > > > > >>>> > > > > > >>>> On Jan 26, 2010, at 4:50 PM, Edward Bender > > > wrote: > > > > > >>>> > > > > > >>>>> Anything new and/or interesting coming out of the STS > meeting? > > > > > >>>>> > > > > > >>>>> 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 > > > > > >>>> ----------------------------------------- > > > > > >>> > > > > > >>> > _________________________________________________________________ > > > > > >>> Got a cool Hotmail story? 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Tell us > > > > > > now > > > > > > > > > http://clk.atdmt.com/UKM/go/195013117/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 > > > > > ----------------------------------------- > > > > > > > > _________________________________________________________________ > > > > We want to hear all your funny, exciting and crazy Hotmail stories. > > Tell us now > > > > > > > http://clk.atdmt.com/UKM/go/195013117/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 > > > ----------------------------------------- > > > > _________________________________________________________________ > > Got a cool Hotmail story? Tell us now > > > http://clk.atdmt.com/UKM/go/195013117/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 > ----------------------------------------- > -- Prasanna Simha M From prasannasimha at gmail.com Tue Feb 2 20:30:06 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Tue Feb 2 10:00:27 2010 Subject: [HSF] STS Meeting - MICS Vs Conventional MV surgery In-Reply-To: References: <133f.125d0014.389969be@aol.com> <1758616812-1265119214-cardhu_decombobulator_blackberry.rim.net-776307233-@bda730.bisx.prod.on.blackberry> <89c4ed2d1002020618v69dbbf0ciafac7bf02df6ab12@mail.gmail.com> Message-ID: <89c4ed2d1002020700q4f241da1g71923eec3da88bf3@mail.gmail.com> There is literature. In fact when I was as a student my teacher pointed it out to me. Prasanna On Tue, Feb 2, 2010 at 8:25 PM, Roberto Battellini < robertobattellini@hotmail.com> wrote: > > Professor!! did you investigated that or have bibliography? > > Roberto > > > Date: Tue, 2 Feb 2010 19:48:12 +0530 > > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > From: prasannasimha@gmail.com > > To: OpenHeart-L@lists.hsforum.com > > CC: > > > > The source of that oil is not actually from the cut sternal edge (or else > > you should be seeing oil running around with say a thymectomy !! The > actual > > source for majority of the oil is activation of lipoprotein lipase which > > gets activated by Heparin (obviously high dose due to CPB requirements) > and > > which breaks triglycerides into triacyl glycerol and free fatty acids. In > > the days before statins I bet all of you remember the fatty butter > churned > > up and often seen in the venous line or inthe venous reservoir filter > when > > clamped after CPB . The pools of oil are the free fatty acids that are > > released. > > If the long bone fracture analogy was true we would be swimming with fat > > embolism cases. The femur has a higher fat to marrow ratio and that is > one > > reason for fat embolism. In fact the current theory is not fat getting > > injected into the systemic circulation as classicaly held but an > > inflammatory reaction causing micellar instability in the blood leading > to > > fat globule. formation. > > Prasanna > > > > On Tue, Feb 2, 2010 at 7:31 PM, wrote: > > > > > No, Ani, but the fat droplets you see in the pericardial well come from > > > some where. > > > > > > Hal > > > > > > Sent from my Verizon Wireless BlackBerry > > > > > > -----Original Message----- > > > From: Ani Anyanwu > > > Date: Tue, 2 Feb 2010 13:56:44 > > > To: open heart list > > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > > > > > > > From my conversations with other MICS surgeons, fat emboli from the > cut > > > sternal edge is eliminated. > Hal> > > > > > > >Fat embolism can be associated with long bone fractures. A sternotomy > is > > > something like a long >bone fracture. John Flege > > > > > > > > > Are we saying the sternotomy is implicated in etiology of stroke after > > > cardiac surgery? > > > > > > > > > > > > Must say not something I have read about previously. To my knowledge > > > non-bypass cases done via sternotomy, principally thymectomy, > mediastinal > > > mass excision and anortic OBCAB had not been associated with higher > rate of > > > stroke? And all large datasets available show lower stroke rates with > > > sternotomy than non-sternotomy approaches to heart surgery. Is this a > real > > > phenomenom or a theoretical justification used by enthusiasts to > promote > > > their (non-sternotomy) approach? > > > > > > > > > > > > Hal - from gammies paper, even looking at high-volume centers there has > > > higher incidence of stroke in MICS so not sure it is true that > experienced > > > centers necessarily have less stroke. We do about 300 mitrals a year > and > > > certainly do see a few strokes a year, maybe at least 3 with major > deficit. > > > A surgeon may not see it because he does say 100 MICS mitrals a year > > > (therefore expect only one, two or none most years) but when you pool > 20 > > > centers each doing 100, you will find the strokes (for some unlucky > surgeons > > > would have had a bad run with four of five in the year another had > none). If > > > a center is doing a few hundred MICS mitrals a year and telling me they > have > > > had no strokes in last few years (like some discussants seemed to imply > at > > > STS) then either they are not looking, dont recollect or are not being > > > truthful. > > > > > > > > > > > > The other thing we need to talk about one day is vascular complications > - I > > > have started reading between the lines in the emerging literature and > > > discussions on the subject, and although often carefully hidden or > brushed > > > over, it seems the number of patients requiring vascular intervention > or > > > fasciotomy after MICS is not insignificant. Last week a surgeon > mentioned he > > > was an expert witness on two robotic cases with vascular complications, > one > > > of which ended in a below knee amputation, so peripheral arterial > access is > > > also something we need to focus on (i personally take chand's approach > of > > > sewing a side-graft to femoral artery, and I think you mentioned you > place a > > > distal cathether - maybe overkill but at least one does not have to > worry > > > about the leg). > > > > > > > > > > > > Ani > > > > > > > From: Hgrmd@aol.com > > > > Date: Tue, 2 Feb 2010 06:42:54 -0500 > > > > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > To: OpenHeart-L@lists.hsforum.com > > > > CC: > > > > > > > > Ani, > > > > I wish I could have heard Gammie's talk, and I look forward to > > > > scrutinizing the paper when it is published. However, the problem is > that > > > it looks > > > > at the incidence of strokes for all MICS. As we know, MICS is not a > > > > uniform procedure, so these results are really a mish mash. I agree > with > > > Fred > > > > Mohr that the incidence of strokes in experienced MICS centers is > > > probably as > > > > low or lower when compared to sternotomy. From my conversations with > > > > other MICS surgeons, fat emboli from the cut sternal edge is > eliminated. > > > In > > > > addition, in the closed chest filled with CO2, you rarely see ANY > bubbles > > > on > > > > TEE. > > > > > > > > Hal > > > > > > > > > > > > In a message dated 2/2/2010 12:24:17 A.M. Eastern Standard Time, > > > > anianyanwu@hotmail.com writes: > > > > > > > > > > > > Roberto > > > > > > > > > > > > > > > > Yes I have done mitral MICS. What I say about view from camera's is > from > > > > personal observation where I have sometimes seen debris (under direct > > > > vision) in the atrium in an area that was not in camera's view (which > is > > > focused > > > > on the valve). I think valve repair without TEE is rarely, if ever > > > > practiced. > > > > > > > > > > > > > > > > I found it strange at STS all discussants (Mohr included ) seemed to > give > > > > *impression* strokes were no longer seen in MICS and the problem had > been > > > > 'solved' with CO2, deairing, changes to perfusion and clamping etc. > Heck > > > we > > > > see stroke with sternotomy - indeed in 2008 you may recall I posted > for > > > > advice on the forum after having two patients in a month with > devastating > > > > strokes after mitral repair via sternotomy - so what is strange about > > > saying > > > > strokes occur after MICS? Any surgeon who says he has not seen > strokes in > > > > mitral repair needs to do more and sooner or later willl have a > stroke > > > come > > > > to visit. Those who do MICS will have those visits a bit more > frequently. > > > > > > > > > > > > > > > > I personally have my doubts as to whether air is a predominant cause > of > > > > stroke with permanent deficit - the definition used in STS. When I > worked > > > > with Yacoub in early days of routine TEE (and no CO2) there was often > a > > > > snowstorm on echo just before coming of bypass - he just put a needle > in > > > aorta - > > > > like he had in 30 years of practice without TEE tellling him what to > do - > > > > and came off bypass ignoring the echo (unless big pockets of air). > Maybe > > > > there were neuro changes we could not measure, but rarely did the > > > patients > > > > wake up with an STS defined stroke. I think we can blame air for > global > > > > changes like delirium, cognitive dysfunction etc, but when a patient > is > > > > hemiplegic I think we need to first look for, and exclude, other > causes > > > before we > > > > blame air. > > > > > > > > > > > > > > > > Ani > > > > > > > > > From: robertobattellini@hotmail.com > > > > > To: openheart-l@lists.hsforum.com > > > > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > > Date: Mon, 1 Feb 2010 21:33:02 +0100 > > > > > > > > > > > > > > > Ani, > > > > > > > > > > Have you ever done Mitral Mics to talk like that? > > > > > > > > > > The view is Superb with cameras, if you have doubts just go to > leipzig > > > > and look at Mohr doing it. > > > > > > > > > > may be the higher stroke problems are with deairing the heart if > the > > > > surgeon is not very strict and does > > > > > > > > > > not uses TEE. > > > > > > > > > > For MICS, camera and TEE are obligatory. > > > > > > > > > > Roberto > > > > > > > > > > > From: anianyanwu@hotmail.com > > > > > > To: openheart-l@lists.hsforum.com > > > > > > Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > > > > > Date: Wed, 27 Jan 2010 02:13:54 +0000 > > > > > > > > > > > > > > > > > > MICS was a risk factor independent of age and endoclamp use was > not a > > > > predictor of stroke if I recall correctly. > > > > > > > > > > > > > > > > > > > > > > > > I doubt it is all retrograde perfusion as the MICS cohort were > > > largely > > > > younger patients with minimal risk factors so should have clean > aorta. > > > > > > > > > > > > > > > > > > I think poor debris management due to the limited surgical view > is > > > > certainly a possibility. Dr Gammie mentioned this in passing and I > > > believe > > > > could well be the reason why a higher stroke rate in MICS persists > > > regardless > > > > of age and risk factors. In MICS especially port access or robotic > > > variety > > > > the surgeon's eye is by definition just on a limited area of the > surgical > > > > field, and the assistant often sees less. Whereas via big incision > the > > > > surgeon sees most of field and assistant sees areas surgeon doesnt. > Jim > > > > postulated that maybe small bits of fat or valve, annular or > ventricular > > > tissue or > > > > surgical material could fall into the atrium or pulmonary veins > unnoticed > > > > and go on to cause stroke. Whereas in sternotomy, the surgeon or > > > assistant > > > > is more likely to spot that particle of fat or calcium on the atrial > > > wall; > > > > with a robot, one would not see it as can see only the valve (i > presume). > > > > This explantion, rather than air, could also tie up the observation > of > > > higher > > > > strokes with no-clamp methods as with the heart beating and blood in > the > > > > field you are probably even less likely to see loose bits of tissue > in > > > the > > > > ventricle and around the annulus or leaflets. > > > > > > > > > > > > > > > > > > > > > > > > Ani > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > Date: Tue, 26 Jan 2010 19:30:40 -0600 > > > > > > > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV > surgery > > > > > > > From: ebender001@me.com > > > > > > > To: OpenHeart-L@lists.hsforum.com > > > > > > > CC: > > > > > > > > > > > > > > Besides operating without a cross-clamp and air embolus (which > > > > obviously > > > > > > > must be prevented no matter what approach), I assume the > increased > > > > stroke > > > > > > > risk was due to retrograde perfusion and athero emboli from the > > > > aorta, plus > > > > > > > a small number due to malpositioned endo clamp or poor debris > > > > management > > > > > > > through a small incision or port approach. Obviously these are > > > > concerning > > > > > > > numbers, and stresses the need for a pre-op study of the aorta > > > (most > > > > use CTA > > > > > > > through the femorals) Did Jim break down the age groups? I > guess > > > one > > > > could > > > > > > > use age as a surrogate for plaque build up in the aorta. > > > > > > > > > > > > > > Thanks for the feedback. > > > > > > > > > > > > > > Ed Bender, MD > > > > > > > > > > > > > > > > > > > > > On 1/26/10 6:31 PM, "Ani Anyanwu" > wrote: > > > > > > > > > > > > > > > > > > > > > > > redos were excluded from this analysis > > > > > > > > > > > > > > > >> Date: Tue, 26 Jan 2010 18:28:44 -0600 > > > > > > > >> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV > surgery > > > > > > > >> From: ebender001@me.com > > > > > > > >> To: OpenHeart-L@lists.hsforum.com > > > > > > > >> CC: > > > > > > > >> > > > > > > > >> Very interesting. I would, as you stated, be cautious in > using > > > > peripheral > > > > > > > >> cannulation as a proxy for MICS. I use it liberally for redo > > > > approaches with > > > > > > > >> a full sternotomy (as at least one other person on this > forum > > > > does). Could > > > > > > > >> it be that the reop rate might reflect a redo staus rather > than > > > a > > > > MICS? > > > > > > > >> > > > > > > > >> Ed Bender, MD > > > > > > > >> > > > > > > > >> > > > > > > > >> On 1/26/10 6:04 PM, "Ani Anyanwu" > > > wrote: > > > > > > > >> > > > > > > > >>> > > > > > > > >>> I was at the STS for just a day. Only one paper caught my > > > > interest. Dr > > > > > > > >>> Gammie > > > > > > > >>> presented an excellent analysis of mitral valve surgery > > > reported > > > > to the STS > > > > > > > >>> database to compare analysis of conventional mitral valve > > > > surgery vs > > > > > > > >>> minimally > > > > > > > >>> invasive cardiac surgery. Becausesurgical incision is not > > > > collected by STS, > > > > > > > >>> Gammie and colleagues used cannulation strategy as > surrogate > > > for > > > > > > > >>> invasiveness. > > > > > > > >>> If patient was cannulated centrally (aorta, right atrium) > was > > > > assumed a > > > > > > > >>> conventional appproach, if cannulated femoro-femoral, then > was > > > > assumed to be > > > > > > > >>> minimally invasive approach. Other permutations of > cannulation > > > > were excluded > > > > > > > >>> from analysis. Isolated MV only (?). They reviewed over > 20,000 > > > > operations > > > > > > > >>> performed in US between 2004-2008. > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> Summary of findings > > > > > > > >>> > > > > > > > >>> . > > > > > > > >>> > > > > > > > >>> About 15% of all mitral operations were done with MICS as > > > > defined. Frequency > > > > > > > >>> increased from 10% in 2004 to 20% in 2008. > > > > > > > >>> > > > > > > > >>> 35% of MICS robot assisted. > > > > > > > >>> > > > > > > > >>> Median number of MICS cases per center was 3. Over 75% of > > > > procedures in US > > > > > > > >>> were done by institutions doing less than 5 procedures a > year. > > > > > > > >>> > > > > > > > >>> Endoaortic balloon used in 35%. > > > > > > > >>> > > > > > > > >>> More valve repair in MICS group (85% Vs 67%) > > > > > > > >>> > > > > > > > >>> Clamp and bypass times 20 and 27 min longer in MICS group. > > > > > > > >>> > > > > > > > >>> 41% transfusion rate in MICS (51% conventional). > > > > > > > >>> > > > > > > > >>> More (yes - more) reoperations for bleeding with MICS (Odds > > > > ratio 1.22). > > > > > > > >>> > > > > > > > >>> Shorter length of saty and ventilation with MICS. > > > > > > > >>> > > > > > > > >>> Mortality same. > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> KEY FINDING: Twice more strokes with MICS (Odds Ratio > 1.96). > > > > Strokes defined > > > > > > > >>> as stroke with permanent deficit. Higher stroke rate with > MICS > > > > seen in all > > > > > > > >>> groups examined, regardless of risk factors, center case > > > volume, > > > > use of > > > > > > > >>> endocclamp, use of clamp. However, highest rate of stroke > was > > > > seen in those > > > > > > > >>> cases done without a cross clamp (beating or fibrillation) > > > > associated with > > > > > > > >>> odds ratio of 3. > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> Limitations: Definition of MICS based on cannulaation > strategy > > > > likely > > > > > > > >>> misscalssified some patients. While very likely almost all > > > > femorofemoral > > > > > > > >>> approachs were truly MICS procedures, a lot of MICS would > have > > > > been called > > > > > > > >>> conventional if centrally cannulated. Of importance because > > > some > > > > high volume > > > > > > > >>> MICS centers like NYU, Cleveland, BWH I believe use central > > > > cannulation > > > > > > > >>> liberally for thoracotomy or hemisternotomy approach. Also > > > > hybrids eg > > > > > > > >>> femoral > > > > > > > >>> artery and central venous cannulation, used by some, were > > > > excluded. > > > > > > > >>> > > > > > > > >>> Patients in MICS were less sick, younger etc and more > likely > > > > repairable > > > > > > > >>> hence > > > > > > > >>> introducing bias - of concern though is despite lower risk > > > there > > > > was still > > > > > > > >>> double stroke incidence. > > > > > > > >>> > > > > > > > >>> No data on true outcomes of surgery such as results of > repair, > > > > reoperation, > > > > > > > >>> 12 > > > > > > > >>> month symptoms or survival. > > > > > > > >>> > > > > > > > >>> No data on mitral pathology and disease treated. > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> Response from disscussants (most MICS enthusiasts) largely > > > > ignored or > > > > > > > >>> dismissed the stroke risk and felt the data were sufficient > to > > > > show that > > > > > > > >>> MICS > > > > > > > >>> 1) is valid approach for MV surgery 2) Does not compromise > > > > repair 3) Is safe > > > > > > > >>> 4) Has better 'outcomes' but 5) other explanations likely > exist > > > > for higher > > > > > > > >>> stroke and 6) MV surgery without a clamp should be strongly > > > > discouraged. One > > > > > > > >>> discussant cautioned that the stroke risk cannot be ignored > as > > > > this is the > > > > > > > >>> second mega-analysis of a database presented at STS in > recent > > > > years showing > > > > > > > >>> higher stroke risk with MICS (the other being a paper by > Mehmet > > > > Oz group 5 > > > > > > > >>> years or so ago I think presented by our Dr Cheema which > also > > > > found doubling > > > > > > > >>> of incidence of stroke in NY State). > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> Ani > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> > > > > > > > >>> > > > > > > > >>>> From: msfirst@gmail.com > > > > > > > >>>> To: OpenHeart-L@lists.hsforum.com > > > > > > > >>>> Subject: Re: [HSF] STS Meeting > > > > > > > >>>> Date: Tue, 26 Jan 2010 18:23:52 -0500 > > > > > > > >>>> CC: > > > > > > > >>>> > > > > > > > >>>> Guess not > > > > > > > >>>> > > > > > > > >>>> -michael/iPhone > > > > > > > >>>> > > > > > > > >>>> On Jan 26, 2010, at 4:50 PM, Edward Bender < > ebender001@me.com > > > > > > > > wrote: > > > > > > > >>>> > > > > > > > >>>>> Anything new and/or interesting coming out of the STS > > > meeting? > > > > > > > >>>>> > > > > > > > >>>>> 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 > > > > > > > >>>> ----------------------------------------- > > > > > > > >>> > > > > > > > > > > >>>_________________________________________________________________ > > > > > > > >>> Got a cool Hotmail story? Tell us now > > > > > > > >>> > > > > > > > > http://clk.atdmt.com/UKM/go/195013117/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 > > > > > > > >> ----------------------------------------- > > > > > > > > > > > > > > > > >_________________________________________________________________ > > > > > > > > We want to hear all your funny, exciting and crazy Hotmail > > > > stories. Tell us > > > > > > > > now > > > > > > > > > > > > > > > > http://clk.atdmt.com/UKM/go/195013117/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 > > > > > > > ----------------------------------------- > > > > > > > > > > > >_________________________________________________________________ > > > > > > We want to hear all your funny, exciting and crazy Hotmail > stories. > > > > Tell us now > > > > > > > > > > > > > > http://clk.atdmt.com/UKM/go/195013117/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 > > > > > ----------------------------------------- > > > > > > > >_________________________________________________________________ > > > > Got a cool Hotmail story? Tell us now > > > > > > > > http://clk.atdmt.com/UKM/go/195013117/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 > > > > ----------------------------------------- > > > > > > _________________________________________________________________ > > > Got a cool Hotmail story? Tell us now > > > > > > > http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________ > > > OpenHeart-L< > http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________%0AOpenHeart-L>mailing > list > > > > > > Send postings to: > > > OpenHeart-L@lists.hsforum.com > > > > > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > > > http://mmp.cjp.com/mailman/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 > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > -- Prasanna Simha M From hgrmd at aol.com Tue Feb 2 15:04:15 2010 From: hgrmd at aol.com (hgrmd@aol.com) Date: Tue Feb 2 10:03:49 2010 Subject: [HSF] STS Meeting - MICS Vs Conventional MV surgery In-Reply-To: <89c4ed2d1002020658mabc1a49q6a0b29a9b3c25308@mail.gmail.com> References: <133f.125d0014.389969be@aol.com><89c4ed2d1002020658mabc1a49q6a0b29a9b3c25308@mail.gmail.com> Message-ID: <331854621-1265123000-cardhu_decombobulator_blackberry.rim.net-1706183406-@bda730.bisx.prod.on.blackberry> UHJhc2FubmEsDQogIEkgZGlkbid0IHNheSB0aGUgIm1ham9yaXR5IiBvZiBmYXQgZW1ib2xpIGNv bWUgZnJvbSB0aGUgc3Rlcm51bS4gIEkgbWVyZWx5IHNhaWQgaXQgd2FzIGEgc291cmNlLiAgV2Un dmUgYWxsIHNlZW4gZmF0IGFuZCBvdGhlciBwYXJ0aWN1bGF0ZSBtYXR0ZXIgb296ZSBmcm9tIHRo ZSBjdXQgc3Rlcm5hbCBlZGdlcy4gIEFzIHRvIHRoZWlyIGNsaW5pY2FsIHNpZ25pZmljYW5jZSwg SSd2ZSBubyBpZGVhLiAgDQoNCkhhbA0KU2VudCBmcm9tIG15IFZlcml6b24gV2lyZWxlc3MgQmxh 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Vs Conventional MV surgery In-Reply-To: <331854621-1265123000-cardhu_decombobulator_blackberry.rim.net-1706183406-@bda730.bisx.prod.on.blackberry> References: <133f.125d0014.389969be@aol.com> <89c4ed2d1002020658mabc1a49q6a0b29a9b3c25308@mail.gmail.com> <331854621-1265123000-cardhu_decombobulator_blackberry.rim.net-1706183406-@bda730.bisx.prod.on.blackberry> Message-ID: Hal, I do not perform MICS till now but if I were the chief of myself I would do them. However, even if there are many advantages of mini- mitrals, the fact of avoiding fat embolism from the sternum is, IMHO, not significant, as well as the fact the sternotomy allows to remove the debris from the atrium! MICS is generally performed in pts with degenerative disease with minimal calcium etc. MICSers and NON- MICSers are like OPCABers and ONCABers; there will never be a consensus. Giuseppe Il giorno 02/feb/10, alle ore 16:04, hgrmd@aol.com ha scritto: > Prasanna, > I didn't say the "majority" of fat emboli come from the sternum. > I merely said it was a source. We've all seen fat and other > particulate matter ooze from the cut sternal edges. As to their > clinical significance, I've no idea. > > Hal > Sent from my Verizon Wireless BlackBerry > > -----Original Message----- > From: Prasanna Simha M > Date: Tue, 2 Feb 2010 20:28:46 > To: OpenHeart-L > Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery > > I was replying to the statement tht the source of majority of that > fat was > from the sternum > Prasanna > On Tue, Feb 2, 2010 at 8:23 PM, Roberto Battellini < > robertobattellini@hotmail.com> wrote: > >> >> Without sternotomy you eliminate bone marrow, bone wax,thymus >> fat.We always >> see fat bubbles like olive oil when we suck. >> >> In MICS these are less. >> >> And you surprise me talking about thymectomies and no embolies, >> the heart >> there is not open!!! >> >> I sucked always these fat bubbles before closing the atrium. >> >> Roberto >> >>> From: Hgrmd@aol.com >>> Date: Tue, 2 Feb 2010 06:42:54 -0500 >>> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery >>> To: OpenHeart-L@lists.hsforum.com >>> CC: >>> >>> Ani, >>> I wish I could have heard Gammie's talk, and I look forward to >>> scrutinizing the paper when it is published. However, the problem >>> is that >> it looks >>> at the incidence of strokes for all MICS. As we know, MICS is not a >>> uniform procedure, so these results are really a mish mash. I >>> agree with >> Fred >>> Mohr that the incidence of strokes in experienced MICS centers is >> probably as >>> low or lower when compared to sternotomy. From my conversations with >>> other MICS surgeons, fat emboli from the cut sternal edge is >>> eliminated. >> In >>> addition, in the closed chest filled with CO2, you rarely see ANY >>> bubbles >> on >>> TEE. >>> >>> Hal >>> >>> >>> In a message dated 2/2/2010 12:24:17 A.M. Eastern Standard Time, >>> anianyanwu@hotmail.com writes: >>> >>> >>> Roberto >>> >>> >>> >>> Yes I have done mitral MICS. What I say about view from camera's >>> is from >>> personal observation where I have sometimes seen debris (under >>> direct >>> vision) in the atrium in an area that was not in camera's view >>> (which is >> focused >>> on the valve). I think valve repair without TEE is rarely, if ever >>> practiced. >>> >>> >>> >>> I found it strange at STS all discussants (Mohr included ) seemed >>> to give >>> *impression* strokes were no longer seen in MICS and the problem >>> had been >>> 'solved' with CO2, deairing, changes to perfusion and clamping >>> etc. Heck >> we >>> see stroke with sternotomy - indeed in 2008 you may recall I >>> posted for >>> advice on the forum after having two patients in a month with >>> devastating >>> strokes after mitral repair via sternotomy - so what is strange >>> about >> saying >>> strokes occur after MICS? Any surgeon who says he has not seen >>> strokes in >>> mitral repair needs to do more and sooner or later willl have a >>> stroke >> come >>> to visit. Those who do MICS will have those visits a bit more >>> frequently. >>> >>> >>> >>> I personally have my doubts as to whether air is a predominant >>> cause of >>> stroke with permanent deficit - the definition used in STS. When >>> I worked >>> with Yacoub in early days of routine TEE (and no CO2) there was >>> often a >>> snowstorm on echo just before coming of bypass - he just put a >>> needle in >> aorta - >>> like he had in 30 years of practice without TEE tellling him what >>> to do - >>> and came off bypass ignoring the echo (unless big pockets of >>> air). Maybe >>> there were neuro changes we could not measure, but rarely did the >> patients >>> wake up with an STS defined stroke. I think we can blame air for >>> global >>> changes like delirium, cognitive dysfunction etc, but when a >>> patient is >>> hemiplegic I think we need to first look for, and exclude, other >>> causes >> before we >>> blame air. >>> >>> >>> >>> Ani >>> >>>> From: robertobattellini@hotmail.com >>>> To: openheart-l@lists.hsforum.com >>>> Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery >>>> Date: Mon, 1 Feb 2010 21:33:02 +0100 >>>> >>>> >>>> Ani, >>>> >>>> Have you ever done Mitral Mics to talk like that? >>>> >>>> The view is Superb with cameras, if you have doubts just go to >>>> leipzig >>> and look at Mohr doing it. >>>> >>>> may be the higher stroke problems are with deairing the heart if >>>> the >>> surgeon is not very strict and does >>>> >>>> not uses TEE. >>>> >>>> For MICS, camera and TEE are obligatory. >>>> >>>> Roberto >>>> >>>>> From: anianyanwu@hotmail.com >>>>> To: openheart-l@lists.hsforum.com >>>>> Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery >>>>> Date: Wed, 27 Jan 2010 02:13:54 +0000 >>>>> >>>>> >>>>> MICS was a risk factor independent of age and endoclamp use was >>>>> not a >>> predictor of stroke if I recall correctly. >>>>> >>>>> >>>>> >>>>> I doubt it is all retrograde perfusion as the MICS cohort were >> largely >>> younger patients with minimal risk factors so should have clean >>> aorta. >>>>> >>>>> >>>>> I think poor debris management due to the limited surgical view is >>> certainly a possibility. Dr Gammie mentioned this in passing and I >> believe >>> could well be the reason why a higher stroke rate in MICS persists >> regardless >>> of age and risk factors. In MICS especially port access or robotic >> variety >>> the surgeon's eye is by definition just on a limited area of the >>> surgical >>> field, and the assistant often sees less. Whereas via big >>> incision the >>> surgeon sees most of field and assistant sees areas surgeon >>> doesnt. Jim >>> postulated that maybe small bits of fat or valve, annular or >>> ventricular >> tissue or >>> surgical material could fall into the atrium or pulmonary veins >>> unnoticed >>> and go on to cause stroke. Whereas in sternotomy, the surgeon or >> assistant >>> is more likely to spot that particle of fat or calcium on the atrial >> wall; >>> with a robot, one would not see it as can see only the valve (i >>> presume). >>> This explantion, rather than air, could also tie up the >>> observation of >> higher >>> strokes with no-clamp methods as with the heart beating and blood >>> in the >>> field you are probably even less likely to see loose bits of >>> tissue in >> the >>> ventricle and around the annulus or leaflets. >>>>> >>>>> >>>>> >>>>> Ani >>>>> >>>>> >>>>> >>>>> >>>>>> Date: Tue, 26 Jan 2010 19:30:40 -0600 >>>>>> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery >>>>>> From: ebender001@me.com >>>>>> To: OpenHeart-L@lists.hsforum.com >>>>>> CC: >>>>>> >>>>>> Besides operating without a cross-clamp and air embolus (which >>> obviously >>>>>> must be prevented no matter what approach), I assume the >>>>>> increased >>> stroke >>>>>> risk was due to retrograde perfusion and athero emboli from the >>> aorta, plus >>>>>> a small number due to malpositioned endo clamp or poor debris >>> management >>>>>> through a small incision or port approach. Obviously these are >>> concerning >>>>>> numbers, and stresses the need for a pre-op study of the aorta >> (most >>> use CTA >>>>>> through the femorals) Did Jim break down the age groups? I guess >> one >>> could >>>>>> use age as a surrogate for plaque build up in the aorta. >>>>>> >>>>>> Thanks for the feedback. >>>>>> >>>>>> Ed Bender, MD >>>>>> >>>>>> >>>>>> On 1/26/10 6:31 PM, "Ani Anyanwu" wrote: >>>>>> >>>>>>> >>>>>>> redos were excluded from this analysis >>>>>>> >>>>>>>> Date: Tue, 26 Jan 2010 18:28:44 -0600 >>>>>>>> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV >>>>>>>> surgery >>>>>>>> From: ebender001@me.com >>>>>>>> To: OpenHeart-L@lists.hsforum.com >>>>>>>> CC: >>>>>>>> >>>>>>>> Very interesting. I would, as you stated, be cautious in using >>> peripheral >>>>>>>> cannulation as a proxy for MICS. I use it liberally for redo >>> approaches with >>>>>>>> a full sternotomy (as at least one other person on this forum >>> does). Could >>>>>>>> it be that the reop rate might reflect a redo staus rather than >> a >>> MICS? >>>>>>>> >>>>>>>> Ed Bender, MD >>>>>>>> >>>>>>>> >>>>>>>> On 1/26/10 6:04 PM, "Ani Anyanwu" >> wrote: >>>>>>>> >>>>>>>>> >>>>>>>>> I was at the STS for just a day. Only one paper caught my >>> interest. Dr >>>>>>>>> Gammie >>>>>>>>> presented an excellent analysis of mitral valve surgery >> reported >>> to the STS >>>>>>>>> database to compare analysis of conventional mitral valve >>> surgery vs >>>>>>>>> minimally >>>>>>>>> invasive cardiac surgery. Becausesurgical incision is not >>> collected by STS, >>>>>>>>> Gammie and colleagues used cannulation strategy as surrogate >> for >>>>>>>>> invasiveness. >>>>>>>>> If patient was cannulated centrally (aorta, right atrium) was >>> assumed a >>>>>>>>> conventional appproach, if cannulated femoro-femoral, then was >>> assumed to be >>>>>>>>> minimally invasive approach. Other permutations of cannulation >>> were excluded >>>>>>>>> from analysis. Isolated MV only (?). They reviewed over 20,000 >>> operations >>>>>>>>> performed in US between 2004-2008. >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>> Summary of findings >>>>>>>>> >>>>>>>>> . >>>>>>>>> >>>>>>>>> About 15% of all mitral operations were done with MICS as >>> defined. Frequency >>>>>>>>> increased from 10% in 2004 to 20% in 2008. >>>>>>>>> >>>>>>>>> 35% of MICS robot assisted. >>>>>>>>> >>>>>>>>> Median number of MICS cases per center was 3. Over 75% of >>> procedures in US >>>>>>>>> were done by institutions doing less than 5 procedures a year. >>>>>>>>> >>>>>>>>> Endoaortic balloon used in 35%. >>>>>>>>> >>>>>>>>> More valve repair in MICS group (85% Vs 67%) >>>>>>>>> >>>>>>>>> Clamp and bypass times 20 and 27 min longer in MICS group. >>>>>>>>> >>>>>>>>> 41% transfusion rate in MICS (51% conventional). >>>>>>>>> >>>>>>>>> More (yes - more) reoperations for bleeding with MICS (Odds >>> ratio 1.22). >>>>>>>>> >>>>>>>>> Shorter length of saty and ventilation with MICS. >>>>>>>>> >>>>>>>>> Mortality same. >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>> KEY FINDING: Twice more strokes with MICS (Odds Ratio 1.96). >>> Strokes defined >>>>>>>>> as stroke with permanent deficit. Higher stroke rate with MICS >>> seen in all >>>>>>>>> groups examined, regardless of risk factors, center case >> volume, >>> use of >>>>>>>>> endocclamp, use of clamp. However, highest rate of stroke was >>> seen in those >>>>>>>>> cases done without a cross clamp (beating or fibrillation) >>> associated with >>>>>>>>> odds ratio of 3. >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>> Limitations: Definition of MICS based on cannulaation strategy >>> likely >>>>>>>>> misscalssified some patients. While very likely almost all >>> femorofemoral >>>>>>>>> approachs were truly MICS procedures, a lot of MICS would have >>> been called >>>>>>>>> conventional if centrally cannulated. Of importance because >> some >>> high volume >>>>>>>>> MICS centers like NYU, Cleveland, BWH I believe use central >>> cannulation >>>>>>>>> liberally for thoracotomy or hemisternotomy approach. Also >>> hybrids eg >>>>>>>>> femoral >>>>>>>>> artery and central venous cannulation, used by some, were >>> excluded. >>>>>>>>> >>>>>>>>> Patients in MICS were less sick, younger etc and more likely >>> repairable >>>>>>>>> hence >>>>>>>>> introducing bias - of concern though is despite lower risk >> there >>> was still >>>>>>>>> double stroke incidence. >>>>>>>>> >>>>>>>>> No data on true outcomes of surgery such as results of repair, >>> reoperation, >>>>>>>>> 12 >>>>>>>>> month symptoms or survival. >>>>>>>>> >>>>>>>>> No data on mitral pathology and disease treated. >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>> Response from disscussants (most MICS enthusiasts) largely >>> ignored or >>>>>>>>> dismissed the stroke risk and felt the data were sufficient to >>> show that >>>>>>>>> MICS >>>>>>>>> 1) is valid approach for MV surgery 2) Does not compromise >>> repair 3) Is safe >>>>>>>>> 4) Has better 'outcomes' but 5) other explanations likely >>>>>>>>> exist >>> for higher >>>>>>>>> stroke and 6) MV surgery without a clamp should be strongly >>> discouraged. One >>>>>>>>> discussant cautioned that the stroke risk cannot be ignored as >>> this is the >>>>>>>>> second mega-analysis of a database presented at STS in recent >>> years showing >>>>>>>>> higher stroke risk with MICS (the other being a paper by >>>>>>>>> Mehmet >>> Oz group 5 >>>>>>>>> years or so ago I think presented by our Dr Cheema which also >>> found doubling >>>>>>>>> of incidence of stroke in NY State). >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>> Ani >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>>> From: msfirst@gmail.com >>>>>>>>>> To: OpenHeart-L@lists.hsforum.com >>>>>>>>>> Subject: Re: [HSF] STS Meeting >>>>>>>>>> Date: Tue, 26 Jan 2010 18:23:52 -0500 >>>>>>>>>> CC: >>>>>>>>>> >>>>>>>>>> Guess not >>>>>>>>>> >>>>>>>>>> -michael/iPhone >>>>>>>>>> >>>>>>>>>> On Jan 26, 2010, at 4:50 PM, Edward Bender >> >>> wrote: >>>>>>>>>> >>>>>>>>>>> Anything new and/or interesting coming out of the STS >> meeting? >>>>>>>>>>> >>>>>>>>>>> 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 >>>>>>>>>> ----------------------------------------- >>>>>>>>> >>>>>>>>> >> _________________________________________________________________ >>>>>>>>> Got a cool Hotmail story? Tell us now >>>>>>>>> >>> >> http://clk.atdmt.com/UKM/go/195013117/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 >>>>>>>> ----------------------------------------- >>>>>>> >>>>>>> ________________________________________________________________ >>>>>>> _ >>>>>>> We want to hear all your funny, exciting and crazy Hotmail >>> stories. Tell us >>>>>>> now >>>>>>> >>> >> http://clk.atdmt.com/UKM/go/195013117/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 >>>>>> ----------------------------------------- >>>>> >>>>> _________________________________________________________________ >>>>> We want to hear all your funny, exciting and crazy Hotmail >>>>> stories. >>> Tell us now >>>>> >>> >> http://clk.atdmt.com/UKM/go/195013117/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 >>>> ----------------------------------------- >>> >>> _________________________________________________________________ >>> Got a cool Hotmail story? Tell us now >>> >> http://clk.atdmt.com/UKM/go/195013117/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 >> ----------------------------------------- >> > > > > -- > 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 > ----------------------------------------- From prasannasimha at gmail.com Tue Feb 2 22:43:25 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Tue Feb 2 12:21:37 2010 Subject: [HSF] Image of the week -Mitral endocarditis Message-ID: <89c4ed2d1002020913ida423c1vd1d8949f65c95e01@mail.gmail.com> Endocarditis epidemic continues for whatever reason so since I put up tricuspid and aortic endocarditis photo panorama's and thought I would complete the picture series with a mitral case. (I had posted a fe years back a case of pulmonary endocarditis that had been repaired and since that rarely comes up for surgery I now think apicture set of all 4 valves is complete) Man with history of tuberculoma in the brain (drained) , hypothyroidism and has a myxomatous valve and developed endocarditis. Was in cardiogenic shock and unweanable inotropes/IV afterload therapy.Had been intubated once and arrested but revived and was extubated thereafter with aggressive diuresis.Thoracic Echo showed an AML perforation and also a P2 prolapse with two distinct jets.Patient had moderate TR with TV also myxomatous and floppy. Patient had 1.5 X 1.2 cm perforation excised and debrided. Patched with glutaraldehyde treated pericardium.Pseudocleft between P1/2 and P2 prolapse was managed by a McGoon type imbrication and an additional Goretex chorda to supplement it. A 26 3D Profile ring was implanted and tricuspid valve was repaired with a 40 P Goretex steel inidgenous ring. Epicardial and postop echo showed nil MR and TR.Got another endocarditis case in the waiting - when it rains it pours !! Still not so sure about this epidemic. -- Prasanna Simha M -------------- next part -------------- A non-text attachment was scrubbed... Name: mitral endocarditis aml perforation P2prolapse eml.jpg Type: image/jpeg Size: 169560 bytes Desc: not available Url : http://mmp.cjp.com/pipermail/openheart-l/attachments/20100202/687a1f06/mitralendocarditisamlperforationP2prolapseeml-0001.jpg From hgrmd at aol.com Tue Feb 2 18:08:00 2010 From: hgrmd at aol.com (hgrmd@aol.com) Date: Tue Feb 2 13:08:33 2010 Subject: [HSF] STS Meeting - MICS Vs Conventional MV surgery In-Reply-To: References: <133f.125d0014.389969be@aol.com><89c4ed2d1002020658mabc1a49q6a0b29a9b3c25308@mail.gmail.com><331854621-1265123000-cardhu_decombobulator_blackberry.rim.net-1706183406-@bda730.bisx.prod.on.blackberry> Message-ID: <745351546-1265134025-cardhu_decombobulator_blackberry.rim.net-498294950-@bda730.bisx.prod.on.blackberry> R2l1c2VwcGUsIA0KICBJIGFncmVlIHdpdGggYWxsIG9mIHlvdXIgcG9pbnRzLg0KDQpIYWwNClNl bnQgZnJvbSBteSBWZXJpem9uIFdpcmVsZXNzIEJsYWNrQmVycnkNCg0KLS0tLS1PcmlnaW5hbCBN ZXNzYWdlLS0tLS0NCkZyb206IEdpdXNlcHBlIFJlc2NpZ25vIDxncmVzY2lnbm9AbWFjLmNvbT4N 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In-Reply-To: Message-ID: <970507.3167.qm@web24714.mail.ird.yahoo.com> The arch and descending are not normal, and may give problem in the future. However not indicated for arch repair at this stage. I have had similar cases, where I do the following: bypass via femoral artery, right atrium, moderate hypothermia. Clamp between innominate and left common carotid. Clamp innominate proximally. Place retrograde cardioplegic cannula in innominate via pursestring, and perfuse from side attachment from arterial line. Do distal anastomosis. Attach 10mm graft to innominate, and attach this graft lower down on aortic graft. Clamp below this and remove retrograde cannula. Do proximal. ? If the arch dilates, carotid-carotid graft can be performed, and stent placed over arch. It is acceptable to stent over subclavian without grafting it. I had a similar patient done 5 years ago with 35mm arch, now 40 mm. She was lost to follow up and came last year with symptomatic TAAA from mid aorta to just above coeliac, measuring 75mm at its maximum diameter. This was fixed with 2X 45mm Gore Tag stents. Interesting that the descending dilated so much more than arch. I think its best to replace only what is indicated at the time of surgery 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 +27-21-9006411 Fax +27-21-9006412 Mobile +27-83-3309587 --- On Tue, 2/2/10, Michael Firstenberg wrote: From: Michael Firstenberg Subject: [HSF] Aortic guru's - Where to stop? To: "openheart-l" Date: Tuesday, 2 February, 2010, 13:39 I recently saw a lady in clinic (smoker, hypertension) with an ascending aortic aneurysm. She is not very large and a MRA showed the following: The entire thoracic and supra renal abdominal aorta is aneurysmal. The aortic sinuses measure 3.8 x 3.9cm, STJ 3.8 x 3.5cm,? AscAo 5.5 x 5.3cm, mid transverse ? ? ? ? arch 3.5 x 3.2cm, proximal DescAo 3.6 x 3.5cm. Her aortic valve is normal with only trace/mild AI Clearly her ascending needs to be replaced - but do you just do a hemi-arch and follow her or do you replace the arch as well with an Elephant trunk now (obviously a much larger operation)? (or some other strange endovascular thing). She had a relatively normal cath in 2007 (getting repeated) but otherwise appears to be a reasonable operative candidate. thanks -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 Rwmfglycar at aol.com Tue Feb 2 16:47:08 2010 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Tue Feb 2 16:48:16 2010 Subject: [HSF] STS Meeting - MICS Vs Conventional MV surgery Message-ID: <64f0.59961ced.3899f75c@aol.com> We should not be conflating stroke with diffuse cerebral damage. They are two distinct phenomena with very little overlap. I found , miraculously, seven posts of mine on air embolism from 2007 and 2008. I enjoyed rereading them (vanity , vanity, all is vanity, Eclesiastes). They are too long to reproduce in this post but I think the principles are worth repeating. Prasanna your reference to a different mechanism for the formation of oil floating in the pericardium is interesting and important, but I do not agree with your comment "we would be swimming in fat embolism cases". Maybe we are, but not in the form of stroke; more likely in the form of diffuse damage. We are poor at detecting this and very poor at applying what modern technology there is to help us detect it. In the early days I used the NY Times test, not the crossword, but merely being able and interested enough to read the front page on postop day 2. Obviously we could make a list 3 pages long of all the possible mechanisms of cerebral damage during open heart surgery. We are obliged to avoid all the possible mechanisms that we know. In 1956 guess what John Kirklin was doing with blood in the pericardial cavity? He was assiduously discarding it and would not allow it to be returned to the pump. (Prasanna can probably supply a reference from the last 5-10 years confirming a beneficial result of this old practice). I agree with you Ani, that the "snowstorm" like echo appearances that were ignored at Harefield when you were there probably did not cause strokes. I once was the moderator of a conference on the brain and heart surgery held at Oxford University in which several surgeons showed snowstorm echo's in patients coming off bypass as though this was a normal state which corrected itself without harm. My response to this kind of thinking at that meeting was to say prove to me that it does no harm and don't tell me that it does no harm because you did not notice stroke as a postoperative complication. Air bubbles visible on echo are big enough to plug endarterioles. The question is what happens when they block Central Nervous System arterioles? When residents would argue that other surgeons let these echo visible bubbles into the ascending aorta without grossly detectable effects I would say would you be prepared to take 1cc of air into your carotid artery? The answer was always "no". There is a long list of perturbations and circumstances accompanying cardiac surgery that could harm the central nervous system. If we cannot say that any one of these is NOT harmful, then we are duty bound not to allow it to occur. Bob In a message dated 2/2/2010 2:37:50 P.M. South Africa Standard Time, jbflegejr@aol.com writes: Fat embolism can be associated with long bone fractures. A sternotomy is something like a long bone fracture. John Flege On Feb 2, 2010, at 12:22 AM, Ani Anyanwu wrote: > > Roberto > > > > Yes I have done mitral MICS. What I say about view from camera's is from personal observation where I have sometimes seen debris (under direct vision) in the atrium in an area that was not in camera's view (which is focused on the valve). I think valve repair without TEE is rarely, if ever practiced. > > > > I found it strange at STS all discussants (Mohr included ) seemed to give *impression* strokes were no longer seen in MICS and the problem had been 'solved' with CO2, deairing, changes to perfusion and clamping etc. Heck we see stroke with sternotomy - indeed in 2008 you may recall I posted for advice on the forum after having two patients in a month with devastating strokes after mitral repair via sternotomy - so what is strange about saying strokes occur after MICS? Any surgeon who says he has not seen strokes in mitral repair needs to do more and sooner or later willl have a stroke come to visit. Those who do MICS will have those visits a bit more frequently. > > > > I personally have my doubts as to whether air is a predominant cause of stroke with permanent deficit - the definition used in STS. When I worked with Yacoub in early days of routine TEE (and no CO2) there was often a snowstorm on echo just before coming of bypass - he just put a needle in aorta - like he had in 30 years of practice without TEE tellling him what to do - and came off bypass ignoring the echo (unless big pockets of air). Maybe there were neuro changes we could not measure, but rarely did the patients wake up with an STS defined stroke. I think we can blame air for global changes like delirium, cognitive dysfunction etc, but when a patient is hemiplegic I think we need to first look for, and exclude, other causes before we blame air. > > > > Ani > >> From: robertobattellini@hotmail.com >> To: openheart-l@lists.hsforum.com >> Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery >> Date: Mon, 1 Feb 2010 21:33:02 +0100 >> >> >> Ani, >> >> Have you ever done Mitral Mics to talk like that? >> >> The view is Superb with cameras, if you have doubts just go to leipzig and look at Mohr doing it. >> >> may be the higher stroke problems are with deairing the heart if the surgeon is not very strict and does >> >> not uses TEE. >> >> For MICS, camera and TEE are obligatory. >> >> Roberto >> >>> From: anianyanwu@hotmail.com >>> To: openheart-l@lists.hsforum.com >>> Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery >>> Date: Wed, 27 Jan 2010 02:13:54 +0000 >>> >>> >>> MICS was a risk factor independent of age and endoclamp use was not a predictor of stroke if I recall correctly. >>> >>> >>> >>> I doubt it is all retrograde perfusion as the MICS cohort were largely younger patients with minimal risk factors so should have clean aorta. >>> >>> >>> I think poor debris management due to the limited surgical view is certainly a possibility. Dr Gammie mentioned this in passing and I believe could well be the reason why a higher stroke rate in MICS persists regardless of age and risk factors. In MICS especially port access or robotic variety the surgeon's eye is by definition just on a limited area of the surgical field, and the assistant often sees less. Whereas via big incision the surgeon sees most of field and assistant sees areas surgeon doesnt. Jim postulated that maybe small bits of fat or valve, annular or ventricular tissue or surgical material could fall into the atrium or pulmonary veins unnoticed and go on to cause stroke. Whereas in sternotomy, the surgeon or assistant is more likely to spot that particle of fat or calcium on the atrial wall; with a robot, one would not see it as can see only the valve (i presume). This explantion, rather than air, could also tie up the observation of higher strokes with no-clamp methods as with the heart beating and blood in the field you are probably even less likely to see loose bits of tissue in the ventricle and around the annulus or leaflets. >>> >>> >>> >>> Ani >>> >>> >>> >>> >>>> Date: Tue, 26 Jan 2010 19:30:40 -0600 >>>> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery >>>> From: ebender001@me.com >>>> To: OpenHeart-L@lists.hsforum.com >>>> CC: >>>> >>>> Besides operating without a cross-clamp and air embolus (which obviously >>>> must be prevented no matter what approach), I assume the increased stroke >>>> risk was due to retrograde perfusion and athero emboli from the aorta, plus >>>> a small number due to malpositioned endo clamp or poor debris management >>>> through a small incision or port approach. Obviously these are concerning >>>> numbers, and stresses the need for a pre-op study of the aorta (most use CTA >>>> through the femorals) Did Jim break down the age groups? I guess one could >>>> use age as a surrogate for plaque build up in the aorta. >>>> >>>> Thanks for the feedback. >>>> >>>> Ed Bender, MD >>>> >>>> >>>> On 1/26/10 6:31 PM, "Ani Anyanwu" wrote: >>>> >>>>> >>>>> redos were excluded from this analysis >>>>> >>>>>> Date: Tue, 26 Jan 2010 18:28:44 -0600 >>>>>> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery >>>>>> From: ebender001@me.com >>>>>> To: OpenHeart-L@lists.hsforum.com >>>>>> CC: >>>>>> >>>>>> Very interesting. I would, as you stated, be cautious in using peripheral >>>>>> cannulation as a proxy for MICS. I use it liberally for redo approaches with >>>>>> a full sternotomy (as at least one other person on this forum does). Could >>>>>> it be that the reop rate might reflect a redo staus rather than a MICS? >>>>>> >>>>>> Ed Bender, MD >>>>>> >>>>>> >>>>>> On 1/26/10 6:04 PM, "Ani Anyanwu" wrote: >>>>>> >>>>>>> >>>>>>> I was at the STS for just a day. Only one paper caught my interest. Dr >>>>>>> Gammie >>>>>>> presented an excellent analysis of mitral valve surgery reported to the STS >>>>>>> database to compare analysis of conventional mitral valve surgery vs >>>>>>> minimally >>>>>>> invasive cardiac surgery. Becausesurgical incision is not collected by STS, >>>>>>> Gammie and colleagues used cannulation strategy as surrogate for >>>>>>> invasiveness. >>>>>>> If patient was cannulated centrally (aorta, right atrium) was assumed a >>>>>>> conventional appproach, if cannulated femoro-femoral, then was assumed to be >>>>>>> minimally invasive approach. Other permutations of cannulation were excluded >>>>>>> from analysis. Isolated MV only (?). They reviewed over 20,000 operations >>>>>>> performed in US between 2004-2008. >>>>>>> >>>>>>> >>>>>>> >>>>>>> Summary of findings >>>>>>> >>>>>>> . >>>>>>> >>>>>>> About 15% of all mitral operations were done with MICS as defined. Frequency >>>>>>> increased from 10% in 2004 to 20% in 2008. >>>>>>> >>>>>>> 35% of MICS robot assisted. >>>>>>> >>>>>>> Median number of MICS cases per center was 3. Over 75% of procedures in US >>>>>>> were done by institutions doing less than 5 procedures a year. >>>>>>> >>>>>>> Endoaortic balloon used in 35%. >>>>>>> >>>>>>> More valve repair in MICS group (85% Vs 67%) >>>>>>> >>>>>>> Clamp and bypass times 20 and 27 min longer in MICS group. >>>>>>> >>>>>>> 41% transfusion rate in MICS (51% conventional). >>>>>>> >>>>>>> More (yes - more) reoperations for bleeding with MICS (Odds ratio 1.22). >>>>>>> >>>>>>> Shorter length of saty and ventilation with MICS. >>>>>>> >>>>>>> Mortality same. >>>>>>> >>>>>>> >>>>>>> >>>>>>> KEY FINDING: Twice more strokes with MICS (Odds Ratio 1.96). Strokes defined >>>>>>> as stroke with permanent deficit. Higher stroke rate with MICS seen in all >>>>>>> groups examined, regardless of risk factors, center case volume, use of >>>>>>> endocclamp, use of clamp. However, highest rate of stroke was seen in those >>>>>>> cases done without a cross clamp (beating or fibrillation) associated with >>>>>>> odds ratio of 3. >>>>>>> >>>>>>> >>>>>>> >>>>>>> Limitations: Definition of MICS based on cannulaation strategy likely >>>>>>> misscalssified some patients. While very likely almost all femorofemoral >>>>>>> approachs were truly MICS procedures, a lot of MICS would have been called >>>>>>> conventional if centrally cannulated. Of importance because some high volume >>>>>>> MICS centers like NYU, Cleveland, BWH I believe use central cannulation >>>>>>> liberally for thoracotomy or hemisternotomy approach. Also hybrids eg >>>>>>> femoral >>>>>>> artery and central venous cannulation, used by some, were excluded. >>>>>>> >>>>>>> Patients in MICS were less sick, younger etc and more likely repairable >>>>>>> hence >>>>>>> introducing bias - of concern though is despite lower risk there was still >>>>>>> double stroke incidence. >>>>>>> >>>>>>> No data on true outcomes of surgery such as results of repair, reoperation, >>>>>>> 12 >>>>>>> month symptoms or survival. >>>>>>> >>>>>>> No data on mitral pathology and disease treated. >>>>>>> >>>>>>> >>>>>>> >>>>>>> Response from disscussants (most MICS enthusiasts) largely ignored or >>>>>>> dismissed the stroke risk and felt the data were sufficient to show that >>>>>>> MICS >>>>>>> 1) is valid approach for MV surgery 2) Does not compromise repair 3) Is safe >>>>>>> 4) Has better 'outcomes' but 5) other explanations likely exist for higher >>>>>>> stroke and 6) MV surgery without a clamp should be strongly discouraged. One >>>>>>> discussant cautioned that the stroke risk cannot be ignored as this is the >>>>>>> second mega-analysis of a database presented at STS in recent years showing >>>>>>> higher stroke risk with MICS (the other being a paper by Mehmet Oz group 5 >>>>>>> years or so ago I think presented by our Dr Cheema which also found doubling >>>>>>> of incidence of stroke in NY State). >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>> Ani >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>>> From: msfirst@gmail.com >>>>>>>> To: OpenHeart-L@lists.hsforum.com >>>>>>>> Subject: Re: [HSF] STS Meeting >>>>>>>> Date: Tue, 26 Jan 2010 18:23:52 -0500 >>>>>>>> CC: >>>>>>>> >>>>>>>> Guess not >>>>>>>> >>>>>>>> -michael/iPhone >>>>>>>> >>>>>>>> On Jan 26, 2010, at 4:50 PM, Edward Bender wrote: >>>>>>>> >>>>>>>>> Anything new and/or interesting