PerfWeb 1 TCD, Minimally Invasive Cardiac Surgery, ECMO, Trans-Cranial Doppler. Mitral Valve Repair


okay come on hey alright alright so kind
of if I could get those slides up that’d be great
good morning everybody welcome welcome to the inaugural presentation first
webinar of PerfWeb coming to you from our new the New Orleans conference
perfusion International and HET studios it’s a pleasure to have you all here
appreciates you logging on and getting your CEUs so through us we appreciate it
very much and we hope that we are able to provide you a really good service
we’ve got a great program today and in just a second I’m gonna have my slides
up so that I I know what I’m supposed to be saying here because I don’t have a
reference point but listen I mean and I’ll explain this a little bit more as
we move forward but the concept here is that as profusion professionals we have
some real problems in what we’re seeing as the trend in decreasing
reimbursements not having CEUs in our budgets practices where you don’t have
the ability to take time off a one-man practice to men or women practice as the
case may be cost associated with traveling and and the like so what we’re
trying to accomplish here is to provide a convenient professional forum
convenient in time for you to to be able to come and get your your CEUs here are
some information that you’re gonna really need to have which is your call
in for questions and discussion so you want to write this number down and we’re
going to be showing this throughout the conference it’s two eight one seven
three eight seven nine zero six so just on your regular telephone
call that number if you want to ask a question or you want to participate in
the conversation please wait until we open the phones we’ll let you know when
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to us live but what you hear on your end is a twenty or thirty second delay and
that’s just something that you do with the web it can’t help that so please
turn your volume down on whatever device you’re listening to the program on
please try not to monopolize the conversation you know there’s gonna be
times where you’ve got some important stuff to say and we definitely want to
hear it but we can’t have it go on too long because we do what a lot of people
to be able to call it and ask questions should they have any please try and then
your certificate will be emailed to you after the conference is over to the
email that you registered with I want to say a few things about the New Orleans
conference this year we are going to be back in New Orleans and we would love to
have you all come and join us there it’s gonna be a great conference as I think
you know the New Orleans conference is and we’re gonna be honoring dr. Tyrone
David from up in Toronto as our crystal heart Award recipient and of course you
know the New Orleans conference is approved for CEUs and CME’s for
perfusionist physicians nurses mid-levels pas NPS and the like everyone
that would be involved in the heart care team our history lecturer also has going
to be chaired again this year by dr. Trotter which is fantastic I’m really
happy to have him back and you know he’s a great historian and lecturer so please
come to New Orleans the New Orleans conference comm why are we doing this
well difficulty getting to meetings that kind of went over this already need for
category 1 CEUs which if you know the the system within the ABC P the SDC e’s
are only 10 maximum where we need 45 total and I think it’s
15 have to be category one we like to get all of them as category one I think
that’s just more convenient for everybody and this is going to give you
the opportunity to be able to do that without having to travel to a meeting
although in some ways that’s hard for me because I don’t want to see people not
coming to the New Orleans conference it’s a fantastic conference and a great
amount of fun and we talked about all of that already but something that’s as
much significant as all of that is that these webinars are frequently offered at
the same time the conference is going on if he can’t take time off from work to
go to a conference how are you going to take time off to actually sit and watch
the webinar so we’re doing these on Saturday apps aturday mornings Tuesday
Wednesday Thursday evenings please check our website perf web dot us that’s perf
and that’ll give you our schedule for the upcoming webinars we want quality
presentations we’ve got a terrific faculty we’re gonna be doing a lot of
discussion based stuff and interactivity so you can call and be involved we’re
using very advanced technology this studio was built for this purpose almost
this purpose alone this table that I’m sitting at here was actually hand-built
by the father and brother of our director of multimedia operations who
are fine furniture craftsmen from Mexico and it’s a beautiful table would love to
have you here in our audience if you’d like to come and actually visit us live
it’s also an opportunity for perfusionist s– who may have some great
content and great lectures that they would like to share with people that we
can bring you in remotely via Skype WebEx GoToMeeting or whatever format you
you like to use we can use all of those as well
and you can actually be one of our lectures would also love for you to come
here and actually sit at the desk and be a part of our at give a lecture and be a
part of our discussion groups we think this is going to improve learning
compliance and ultimately help to provide better care for our patients
because at the end of the day that what it is really all about it is free
to watch so we want to open this up we think the sharing of information is
extremely important and disseminating information to our colleagues shouldn’t
always come at a cost but if you need the CEU certificate then we do charge
for that so please be aware that you can watch these even if you are not actually
meeting the CEUs but you just want to learn which of course makes me feel
really good and we want you to participate so that’s my last slide I
want to move right forward with again welcoming you here and I want to bring
up our first lecturer dr. Zolt gourami from the DeBakey Heart and Vascular
Institute to talk about TCD dr. gourami good morning it’s good to see you and we
might be working out some kinks so if things run a little bit slow on our
first one we have to obviously you know get through any kinks so be patient with
us okay we appreciate that also very much and so why were you waiting for a
first slide I just want to thank you for the invitation and it’s a pleasure to
time the first one who can you are you’re our first speaker you’re our
first faculty on a Saturday morning at 7:30 yes I’m so glad that you guys don’t
see the outside weather because it’s a really welcoming weather
yes very foggy and yes and I really wanted to cut the ribbon so I think that
we missed it opportunity no no the ribbon ribbon cutting ceremony is at
lunch yes yes I understand that so you know dr. Romney’s gonna be talking about
tcd and you know I have to say this is a disclaimer if I can years ago Bob groom
was a strong advocate for the use of tcd and frankly I thought it was just a
bunch of hogwash and was sort of you know like really not too keen on the
idea but as I’ve gotten a little older and a little more experienced and gone
through some things and seeing patients who have suffered stroke during the
cases that I’ve done postoperatively it I really think I was wrong and I and and
Bob if you’re watching you know I apologize because you were right all
this time and certainly history has borne that out well thank you and we
would like to really tailor this talk as a tcd basics for perfusionist and my disclosures I definitely have some
teaching consultation agreement with few companies and because we are from
Houston I just want to show you when astronaut Kayla came back to Houston we
don’t waste time so we do a cardiac carotid and orbital Hooters on the same
time so I think my love to ultrasound is definitely the priceless disclosure and
on the right you can see a stunning image what the ultra shine can show you
so this is not a CT scan this is a frontal lobe transcranial Doppler image
of a brain so the first TCD was built by dr. Elsa Lydon 82 so this is not a new
technique and when her first TCD was built it was a single-channel TCD this
is on the this image right there and about 2000 mark mooring gave us an M
mode image the M mode images that red ribbon that what you see as a first
screen and at the top of the spectrum and that red ribbon is really gives us
the GPS for the entire hemisphere so it’s so much easier to find a signal
because you have like GPS coordinates where the blood vessels are so this
makes our life so much easier to find the signal and I think the under
utilization of the TCD is really coming from the lack of training and lack of
understanding how does this blood for real looks like on a Reuters hand image
so the ultrasound image what I’m going to show you today as it looks like this
and this is the first publication that on the upper side you see the red signal
when I ultrasound coming the signal coming towards your probe and these
ultrasound signals basically reflects from the red blood cells so the red
blood cells nice flat surface give you a nice unique signature and this is how we
can measure the speed of the red blood cell so we measured
centimeter per second that’s on the bottom screen and the centimeter per
second speed measurement is actually almost similar the miles per hour so a
normal person how you drive on a highway when it says 60 so that’s kind of normal
speed for our brain the mean flow velocity we calculated from systole and
diastole II and we have the expected range of mean flow velocity between 20
and 80 if a mean flow velocity is your speed limit goes above 80
we think there’s a narrowing in a blood vessel that’s what brings this speed up
or if you have a blockage then when we go slower than 20 seem like a traffic
jam on the highway the ACA is a blue signal because of the speed and the
vessel flow is directed away from your probe this is why your flow is blue
giving you a different direction and I think the interpretation of the signals
are depth direction and the resistance those are the key elements of how we can
describe these TCD signals and screens so this is just one more example that
how a tcd screen look like and what you see here on the right hand side is the
speed information on a left hand side it shows you the depth of the signal was
calculated and the signal is represented by this yellow line so that’s the depth
of the yellow line where the speed curves are received and calculated and
one more important information about TCD what I think is differentiating from eg
that it’s really objective so those numbers are real so on the top of the
velocities we also have a P I values that tells you how much the vessel is
open or how much resistances works the blood flow against so these P I values
are normal between 0.6 and 1.1 you can see it on the bottom of the screen
that’s your normal if the resistance is really minimal for example
an AVM this is when you have almost non positive wave form or when you have like
an opposite away from when you kinda see some examples on the pumps when your PI
R increased the PI’s will be like a chronic hypertension increased ICP are
going to shut down your diastolic perfusion that’s very important that we
can again describe where obstruction happens so during the case if we monitor
we can pick up those occluded vessels without waking the patients up and I
think that’s the advantage of T C D so can I just throw this out so when they
picked the heart up and they restrict the drainage from the superior vena cava
when they’re really torquing it over to get to a no M graft or something like
that would and and our flow goes down we’re
struggling for volume and we’re assuming of course I think reasonably that the
head is getting congested would you see that on that on that flow probe exactly
and I think the TCD I will call it almost like a your centralized blood
pressure Reed because the brain is probably attracting about 25 percent of
your total cardiac output so if your cardiac output is down definitely the DC
the signal going to show that and forget to show you I just want to go back to
the slide that this Delta percentage change on the bottom if I push that for
a hundred percent that would be my established baseline at the beginning of
surgery even before anesthesia will start the general anesthesia that will
be my one hundred percent baseline which would be the relative number that I need
don’t need to remember what was my mean flow velocity I’m just looking at and I
do not want to exceed about 20 percent flow changes so 20 percent is what we
can again communicate clearly that I have 20 percent drop and that kind of
learning the anesthesia as well as the surgeons that we have a flow change
quickly I just want to show you that and exactly similar how do you see this
blood flow change watch I’m just gonna put my fingers on the carotid
this is how the flow changes immediately so why an EGR waiting Jamie needs to see
some changes here the flow changes are immediate and milliseconds so this is a
normal flow pattern and when I pricked the finger on the carotid watch
immediately shows you there’s a blockage that blockage flow change tells you
there’s something between your measurement point in your heart which is
blocking your flow this systolic upstroke unless it on the DCT waveform
that systolic upstroke is a show yes – did the between your measurement in the
heart before there’s no blockage and I think that’s all basic information what
we’re getting and this is the other information I wanted to show you and
kind of make it nice and clear to understand is blow blood flow pattern
inside a middle cerebral artery and the ACA again just one more time this is the
two carotid coming up and this is the two MCS with the two red and two blue
signals let’s block the carotid and in a moment you block the carotid you’re
going to have a reverse flow coming from the other side and this is how you can
reverse the flow in the ACA and now even if you’re color blind you can probably
see that the waveform is switch from negative to the positive on the spectrum
so you see that the blue signal represented a negative value why the red
signal is a positive value so you can see it’s crossing then changing
direction if it’s needed so I think those are the flow Direction changes
that we can quickly see and this is for example a if your cannulating just
axillary artery you can you expect to see bilateral MCA flow but if your
circle Venus is not intact you’re not going to have what single cannulation
side by lateral flow signals so this is where the bilateral flow signals are
must have and this is why we are trying to teach our audience because I even in
the vascular ultrasound schools TCG’s probably underutilized there was a
questionnaire by the Society of rescue rotation and credentialing societies
about the thousand vascular labs running in ultra
Shannon answer the questions only 10% of them they even use 4d CD as a diagnostic
purpose and even from the 10% I would say the number of hospitals they use in
T CD for interpretive monitoring is even less and definitely you and me if I want
to have any kind of surgery my first question would be who is the
anesthesiologist not just a surgeon with the surgeon but I think it’s very
important as a team approach that someone is also looking after your end
organ I think the brain you can fix my heart but if my brain is blown and and I
have a stroke I really don’t care too much I was successful with the surgery
and and on type one two sections with deep hypothermia the secretory arrests
and you’re talking about antegrade versus of course you didn’t mention it
but retrograde so if you don’t have an intact Circle of Willis and you’ve only
cannulated unilaterally and you’re flowing along you won’t know until after
the procedure whether or not you actually perfuse the the contralateral
hemisphere of the brain and and this is the slide kind of teaching exactly the
same point that this is just the study of how many collaterals are missing so
let’s say that about 50% of the people they do not have a complete circle
Willis that 50% is really a scary number but and sometimes we really cannot
determine just by mr so we’re not gonna do MRI just to learn if you have a
circle with us or not but in a stroke patient when we study this you can see
that it’s also predicting how good is your survival chances after the stroke
so if you have onto your communicator post you communicate and even your Tomic
helping out all the three major collaterals working yeah a pretty good
chance with all those collaterals you can survive a main corridor clusion and
stroke but if you do not have those collaterals almost your chances are 50%
to achieve and survive your first year after the stroke so I think these are
really scary numbers and these are the numbers are also associated that not
money you’re looking at the extracranial stenosis and we do screen for carotid
disease before we go to the cardiothoracic surgeries the carotid
ultrasound screening is just not enough because the carotid is here the carotid
doesn’t end up here the carotid really hooks the middle Sir Roger behind your
eyes so we are investigating only the extracranial part and sometimes based on
extracranial flow we can predict maybe there is some disease distal
but I think you really look at the karate the rotation needs to be really
combined with the transcript doctor to really see what is the blood flow doing
in the brain so the carotid is definitely not enough to investigate the
blood flow in the brain for sure and that easily again is not a
investigational device these are the billing codes associated with a TC D and
this is I think since 2005 so this is not like last year definitely I don’t
want to comment on those reimbursement and how does it change but definitely
each state has a different reimbursement rules I can tell you that the TC the
reimbursement is still better than a carotid for example probably for the
reason that it’s not as well utilized but also not available everywhere so I
think they are awarding those people who are doing their RT C DS and these are
the billing codes that we do the regular diagnostic the 86 but also I think it’s
very important that I believe the DC D where the peer protesting probably can
beat even the TE to detect those PFOS or as these the reason is real simple so
when you have an echo image of a 2d view of the heart it’s a cross section the
bubbles can go on the front of that screen or behind the screen you really
need those bubbles to able to cross and see those few bright spot on your own
your echo what we monitor with the TC is the entire 3d flow pattern and even a
single bubble is enough to pick up in your brain by Latorre unilateral doesn’t
matter but we see these testing are done in a sitting position so your wall
solver maneuver definitely has a better effect on you and we do not
have to sedate so I think without sedation definitely you can perform
better valve and I think that’s also triggers a better response for us the
other important part is these breath holding index when you the breath
holding index is with a simple twenty thirty Seconds interrupt your breathing
able to tell us how educated and how well trained your vessels so the vessels
needs to react immediately for lack of oxygen or the co2 increase and with that
diameter change the buzzer motor reactivity can be tested and our last
emboli detection I’m gonna show you some example for emboli detection first this
is the breath holding index zero simple calculation which try to monitor it on
both sign the same time so with the same co2 or hypoxia effect will have a same
effect and you compare the two side and this is how the position the sonographer
for the diagnostic TCD we’re sitting at the bedside at the patient head and we
start with off Tomic then we go to the trans-temporal window and finally the
turns occipital window and through this diagnostic test this is the different
signals we can use for the purpose of the monitoring an operating room or even
in the in our office we do utilize a hat frame and later on I’m gonna show you
the hat frame this is just one more image for the sub mandible or ICA that
if you don’t have temporal bone windows we can definitely utilize the soup money
but our ICA and also we use the submandibular IC for the super agent
hemorrhage patients because that’s how we can compare the flow the intracranial
and extracranial pattern and my boss dr. Lumsden
definitely believer of transcranial Doppler monitoring and we do all these
cases under DCD monitoring all the cords all the t bars and he believes
definitely t CD is the the best method for all the cardiovascular and several
rescue monitoring during the surgery for the heart now that’s for his vascular
surgery and garage at Houston Methodist you guys are using t CD on all of your
open heart surgeries as well just yesterday we had a type a and it was
affecting the brachiocephalic flow so it was a stunning differences again between
right and left and I think those are the really easy confirmation that if you
really fix the flap and that dissection is fixed you will see the improvement of
the flow right away or let’s say that the dissection is progressing and the
left side was not affected but during the surgery you something happens that
you see that the dissection progression to so I think it’s stunning that a live
monitoring of the blood flow tell us if the origin of those carotid are affected
we do provide monitoring all are the Tavor pieces so that ever is more
challenging because we started with a patient population average age of eighty
five eighty and especially the ladies and it’s not a sexist comment but
suddenly we noticed that it’s really hard to get through the ladies call
probably the osteoporotic air pockets are blocking our ultrasound to get
through the bone this is why we came up with a solution that the submandibular
icas it’s a good solution to really look and monitor those cases if you can get
the signal through the trans-temporal and this is how a micro and below signal
looks like see that red dot in the middle of this waveform so it means that
the ultrasound signal reflected in a background from all the red blood cells
and it is one single piece of AM bollocks
signal just reflected it means there’s something else traveling between those
flat red blood cells that could be a spheric air bubbles that could be an
irregular surface cloth we can tell you what it is but it tells me that it’s
something that we’re not supposed to so I think very important if we do a
surgery and yesterday we did a tea carcass also that we’re able to deploy a
stent in a carotid without embolization Wow
that’s a winner for the technology and also winner for us that we are
protecting the brain and able to do procedures with zero embolization
it means hopefully zero complications of winner per day and I think that zero
complication should be our goal so I think we shouldn’t have something like a
1% complication is acceptable for me and for I’m sorry for my brain and your
brain I would say zero procedure percent so and I think we have that goal to
really improve our new technology and investigate how we can make it better
and this is just one more example of how the embolus look like and this is
running in the middle cerebral artery the red signal the blue signal is in a
sea and this is how we able to see them and this is just for fun to probably
conclude our first etcd session is because we are in Texas so this is how
them easy to differentiate a cow here in Magnolia from a dolphin if I see a
dolphin just that in a picture so definitely an embolus needs to be moving
together with a blood stream if the signal is sitting on a zero line is mean
zero speed so unlikely you get a speeding ticket for not driving so you
must have a driving and you must have a speed for your ambulance signal so the
first signal this is an example of the am Balu signal needs to be in the blood
stream if something is sitting on a zero line it doesn’t go anywhere so these are
the examples and you can see it doesn’t give you a moving signal here on am mode
it just deleted because you are just having a jar movement muscle or just
stepping on a probe sometimes a blink I able to generate those signals and
there’s is there an angular component to it as well so the end angulation is
probably you can see it on the embolus if you see that the proximal MCA Y is
traveling to distal is takes time so this is the distance from 60 millimeters
to 30 millimeters so that’s only three centimeter trip so this is not a trip to
the moon but it’s just a trip to your cortex why are you traveling the three
centimeter you definitely have like a forward slash
kind of pattern that it takes time to get that the three centimeters and you
can tell what is the speed because the speed is here red on the right side of
the screen so it says 40 sorry you see underneath the tapping words yes and
this is where you can see that this is the scale for the speed that’s okay that
died so that’s my first part of introduction of what you see on the TCD
screen and with my second it’s moving again so with my second lecture I will
return and going to show you more life cases how we can utilize DCD technology
operating rooms I’m looking forward to that so thank you so much you’re welcome
thank you I’m going to be how about if we have a word from our sponsors and
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you I’ll give my talk on on what do we profuse is the title of it but it’s it’s
really about stroke and as I said earlier you know Bob groom really
deserves a lot of credit for bringing this to light some years ago when more
than more certainly more than ten years ago and maybe even more than that
and it wasn’t until I really met dr. Khurana that I recognized how much Bob
had actually contributed to the concept of monitoring the brain which is really
a critical organ for us to be profusing I mean as a perfusionist what are we
perfusing well you know certainly the body as a whole and certainly the limbs
and certainly the heart and the kidneys you know we use cardioplegia the liver
and and the gut and all of those things but at the end of the day you got to you
got to protect the brain and we do a terrible job I think really at at
focusing on this we assume a lot I think this picture for me says a lot there’s a
hundred billion stars in the Milky Way and a hundred billion neurons in the
human brain with over a hundred trillion synapses that’s staggering numbers
really and how do we measure the adequacy of profusion well we assume a
whole lot we do some fancy calculations we monitor the svo2 we do labs and look
at the acid-base balance we might even calculate the do – and we even use
cerebral oximetry but cerebral oximetry is kind of a tricky thing you know I
think we’ve been lulled into a sense of security with with this technology the
concepts are easy but making them work in a useable device is really very very
hard the big problem with these devices is figuring out the saturation
information coming from the skin the subcutaneous tissue the muscle the bone
and the brain and Venus versus arterial blood and being able to differentiate
from all of that for any technology is really quite complex and I would argue
and I’m going to show you a slide moving forward I would argue probably not very
reliable each of these devices of cerebral oximetry and we know there’s
several on the market uses a different approach for delivering light and
analyzing the light being reflected back each device uses a different approach to
compensate for adsorption by the different tissues the analysis algorithm
for every device is different from every other no to commercial oximeters measure
the same thing this specific algorithm used is secret and the companies keep
changing their algorithms technology so a study in 2005 was may not actually be
applicable in 2013 the algorithm in 2013 more than likely not applicable today no
device is capable to provide a pure brain Oh to saturation no matter what
the promotional literature may say the signal from the devices is contaminated
by a tremendous amount of extra cerebral blood and this is the slide that I think
says at all the cerebral oximetry readings there on
the left is of a live patient now if we were to kill the patient well we are
still going to actually get or but could get and and frequently get a brain Oh to
saturation with the patient deceased but it gets even better than that if the
patient is deceased and hopefully we would do this after they were deceased
and we simply removed their brain we will still get a reading and yes a lot
of people say an awful lot with very small or lacking any brain at all
well in stroke there is no good stroke or small stroke or you know anything
else a stroke is a stroke and it’s and it’s bad perioperative stroke rates in
cardiac surgery reign range from one point seven to two point nine but
encephalopathy race which we’re going to talk a little bit more about our seven
point seven to 13.8% with frequently harder these are frequently harder to
diagnose so you get the patient who comes in they have a stroke they’re
there they’re there have a hemiparesis they’re you know unable to speak their
faces drooped it’s obvious they had a stroke but there’s a lot of strokes that
are simply not seen because they’re not gross but the family says you know uncle
Uncle Joe is just simply not the same person they’re more forgetful their
personality has changed their attitudes have changed and and and these are these
subtle changes that you see and frequently these patients can become
very combative in the ICU delaying extubation and also delaying transfer
out of the ICU increasing costs at the end of the day so let me take a quick
break here and beat on myself and some of my perfusion colleagues do we as a
routine have any idea what happened to the case unless we get called and it’s a
callback for bleeding or whatever it might be or we’re putting the patient on
ECMO in the ICU generally speaking do we go and check on these patients in the
ICU do we ever see the patient postoperatively whether or
preoperatively and assess these patients before they actually roll into the
operating room which is really more than likely the first time we ever have any
exposure exposure to the patient and do we see the patient post-op at any time
in the ICU on the floor at discharge or are involved in any way beyond the
procedure that we did so how do we know we did a really good job on this patient
and they’re the same patient they were before we got them
the answer’s no or infrequently I’m not gonna say no entirely because I do think
that there are some who are more heavily involved of course you know there’s
considerations in terms of how much time we have how many cases they’re doing
staffing levels and so forth I do understand all of that but irrespective
of that I think that at least some level of following this patient
postoperatively may be something that me we as a profession may want to consider
to be more a part of our responsibilities I think it would teach
us a lot strokes are deadly there’s a three-fold increase in mortality at the
end of ten years they’re debilitating for many especially
the the elderly it’s worse than dying they would rather die during the
operation then wake up having had a stroke they can’t maintain their
independence they can’t enjoy normal activities while their quality of life
is severely compromised they have decreased cognition and mental ability
and it is incredibly financially devastating for the patient for the
hospital and for a society as well so there was a whole point of time in our
history where the pump was bashed it was all about the pump the wall street circ
Journal circa 1990 blamed the pump for cognitive dysfunction it was considered
pump head if you all remember that those of us old enough to remember that doctor
stump of course did a lot of work on scads of course we were transitioning
from bubble oxygenators to membrane oxygenators and of course that made a
big difference as well off pump cabbage craze came into vogue predominantly over
this concept of pump head and there’s a another article here of off pump versus
on pump coronary the coronary study I love the way they do that the coronary
study is coronary off pump on pump and something else it’s the acronyms
really are pretty good but this was forty seven hundred plus patients from
79 sites in nineteen countries and what they found if you take a look at this
slide here is that really on the primary endpoints that what was the real problem
and I can’t get this to work but if you look at stroke stroke was a little bit
worse on pump of thank you very much so on
pump then off pump but death rates were were the same non-fatal mi was a little
bit worse knew renal failure was actually worse in the off pump group but
when you look at the syntax trial for example you know they talked about when
the cardiologist goes and talks to the patient they say look you know your
stroke probability in this operation is going to be this if we do this stent
it’s going to be less or the surgeon says if I do it off pump I’m gonna have
a slightly lower stroke rate than if I do it on pump so you know those are the
kinds of things that I think really matter and how much of this stroke is
really related to the pump how much of it’s related to flow if you are on
bypass how much of it it really is embolic events we know the cross clamp
creates a problem the mBLAQ’s catheter used to be in existence of course it’s
been removed in the market sadly it was a great device but that was a political
problem with Edwards in the FDA and I think that really needs to come back but
the study the coronary study concluded that at 30 days there was no difference
in the primary outcome between off pump cabbage and on pump cabbage off pump
cabbage was associated with less transfusions and reoperation for
bleeding less acute kidney injury less respiratory infections and failure and
more early revascularisation so that’s very important so if you had an off pump
cabbage versus a non pop cabbage then your grafts were more likely to close
than if you had the operation with a still quiet heart so it really isn’t the
pump is this too early for this this morning I don’t know if it
or not but that’s that’s basically how I feel about this whole argument of off
pump and on pump I think you do a much better operation on pump than you do off
pump at least that’s how I would what my coronaries done and hopefully I won’t
need coronary surgery I’m at least I’m hoping that but I would rather have it
on pump but I think that if I had it I would like it to be with tcd so
something that has really brought stroke to the forefront and what we’re thinking
about it in terms of the cardiac surgery world whether it be coronaries or valves
or anything else is actually Tavor so it has opened our eyes and it occurs nearly
a stroke occurs in Tavor nearly 100% of the time and I’ll explain that majority
are embolic and all strokes whether they be gross Frank strokes or whether they
be these subtle changes that occur are consequential and it has launched a new
industry in cerebral embolic protection devices so let’s talk about that hundred
percent stroke rate here’s a diffusion weighted MRI of a brain and you see the
white lesions in there the arrows are pointing at it and also on the right and
these are embolic events these are new lesions on diffusion-weighted MRI so the
new stroke classification says that you have to have our new device a new Tavor
valve coming out for example you have to have a pre-op and a post procedure
diffusion-weighted MRI and you check to see if there are any new lesions if
there are then it is considered a class 2 stroke so class 1 stroke what we’re
all used to seeing you’re you’ve got a major problem or worse and in a class 2
stroke so with Tavor procedures and I’ll say it again 100% of those patients are
having strokes now with that said we don’t know what’s happening on pump we
don’t know what’s happening was just heart surgery in general manipulate
the order clamping the aorta but I would suppose if we did diffusion weighted MRI
on patients who have heart surgery they too would have new new lesions and it’s
probably pretty close to a hundred percent of the time I would think well
this is a great purple study we definitely do not have DWI after cabs
and I think the previous publication was the four thousand numbers really
impressive a dramatic coronary study yeah because I remember publications
just twenty twenty patients in the same group and in those cases when we studied
with a CD or DWI we saw immediately a position difference but at the six-month
outcome there was no difference so even if he’s looking for this subclinical DWI
lesions or cognitive changes I think we still need to define our and we need to
better tune even our cognitive function changes so this subclinical stroke or
DWI picks up it’s maybe not subclinical at all because they are accumulating we
do not have the clinical effect right now but maybe a three months down the
road when the patient don’t remember the name those are the the changes may
result of these DWI lesions not at that moment but maybe
now these are these are embolic religions yes but these these these this
white that means that those are dead Nura dead neurons with free fluid
outside means that the cells they release their contents mm-hmm that cunt
is never gonna come back sometimes we talk about diffusion changes which are
irreversible and reversible sure reversible but it means that they are
gone so I think it’s very important that they these white lesions are only
positive up to seven days mm-hmm so if you had a procedure done and you
do a DWI ten days later you’re never gonna see anything hmm so you really
want to do the DWI MRI as closest to the procedure as possible so you also have
the DWI lesions related to that procedure so you don’t want to do it
five days after procedure because you don’t know what happened the
post-operative five days those possible you five days blood pressure changes
anything can relate and result on this DWI lesion so I think it’s very
important that within a few hours after the procedure we need to see this DWI
lesion and that’s that’s difficult that’s difficult to do when you are you
know in the ICU maybe maybe they do a neck early excavation maybe they’re
still on the ventilator it’s gonna be very difficult to do this for Cavett’s
patients but I do think that we don’t it really the end of the day we just simply
don’t know and that’s I think one of the biggest problems that we have so I want
to show you this video and kind of explain a little something to you how
marketing works you see the catheter going up this is a TAVR procedure and
you see the balloon right there and I want you to take note look at how
beautiful almost right in the central lumen that catheter goes out now here
comes the device and it goes up the vessel and they just gonna deploy it now
here it comes watch it come up and go around the arch I want you to watch this
this is why a hundred percent of Tavor patients have strokes so this is what
the marketing shows you this is what the public sees and there it is right there
okay now we’ve deployed the device and here we go we’re rapid pacing now
the valve has been deployed and the heart’s beating again normally and they
extract the device catheter the the there you go and the wire comes out
did you see how pretty that was I’m not gonna show it again but if you want to
go back and reverse it and see it you can but this is a reality of what you
see in picture a you see that same catheter coming around so when those
wires go up they tend to ride up high and that catheter is a pretty good size
Kathryn what’s that it’s a 20 French right 20 French or 20 18 French it’s
still pretty big and that has to make that curve around the arch and it
scrapes the wall and as it scrapes the wall it knocks off calcium atheroma and
anything else that might be there and then it goes in and then you deploy it
or inflate the balloon or whatever the case may be that you’re doing and of
course there’s calcium on the valve that’s gonna get broken off and go
flying upstream and then there you see the device with some residual and this
is what the cerebral embolic protection devices look like so it gets deployed in
the innominate and comes down and then you block the innominate and you block
the the left carotid the left subclavian we’re not worried about their fingers
and this is something I think you’re gonna see more of in cerebral embolic
protection devices it’ll be interesting to see if it becomes a standard of care
for routine procedures well I think we still need to study this because
interesting trials and fda-approved definitely for example scribe device
it’s important that these treatment and control arms they have similar lesions
so until you really don’t see the huge improvement of that you are protecting
the brain you have less DWI lesions you have less ambos
material picked up by the TCD we shouldn’t be happy so I think we started
to care about protection but I think these devices are still not the perfect
devices definitely why you placing these protections you have a case you have
unprotected period exactly so you do have unprotected tons and when you’re
retrieving it you’re closing that filter up you definitely gonna squeeze out few
of those hamblett material right there so I think these these deployment of
versus collecting those debris needs to be probably improved a little bit yeah
that’s really interesting I mean it’s it’s really amazing at how something
that that looks so simple when you look at marketing material is so difficult to
actually do in real life I think there’s if you really do the
science with 100% honesty you know that these filters are not going to capture
everything so if you look at the filter Porou size which is a hundred micron
what what is your filter I’m right it’s 40 that’s right
think about the hundred micron versus a 40 filter on your on your palm yeah so
definitely we learned that majority I think we did a study in the carotids 80%
of the materials passing these filters so definitely we need to learn more
about my problem is that if you go down to 40 you may be definitely clotting out
because you will collect so much material that you’re not gonna provide a
flow so we need to find a better way how to feel the filter the materials hundred
is definitely not a perfect size forty is probably hard to do just because a
surface area yes but I think this debris is when you’re looking at even those
pictures this is a micro embolus this is a big piece of chunk on that picture yes
you’re not going to see these with your eyes so I think the same thing how we
see DWI is the subclinical stroke these are probably need to look as a
only tiny pieces so TCD will pick up something bigger than the red blood
cells red bottle 7 micron mm-hmm so think about 7 micron to 100 micron so
definitely there’s a huge room for the deep breeze to really size them up and
and I think the sizes does matter I’m so sorry to start hahaha starter any
morning conversation but after the elephant joke I think I’m ready to know
one pump thank you thank you very much so you know these are really really
incredible being interesting points but you know one of the things and I’ll get
to my slides here but one of the things that I find fascinating about all this
it’s it’s not only about embolic events its flow and we just always seem to talk
about emboli emboli emboli but we don’t really talk about flow we don’t talk
about capillary opening pressure we don’t talk about the the resistance to
flow caused by venous congestion for example as I was mentioning earlier and
how that affects the flow patterns through the brain so we just we keep
focusing on this embolic phenomenon but we don’t really think about or talk
about it’s about flow it’s about flow it’s about your co2 level it’s about
your oxygen carrying capacity all of those functions are relevant to this
conversation yes and I cannot wait to show my slides which are going to list
you the hypo and hyper perfusion so I think we didn’t need to study the flow
as how the hypoperfusion affects the brain but also something the lost
reperfusion the too much flow it’s not good so I think we need to learn a
little arias person yes sir so I think the cooling part and how fast you warm
up those are the time periods I think the brain is really sensitive and we
shouldn’t rely on well when I’m called easier to control the
bleed versus what what does it really do to the brain so I think we learned a lot
from all those ascending surgeries when you have a circuit arrest cases we do
learn a lot from those high complications to how to make it safer
and and how to control and how to even provide flow for the Secretary’s cases
very good so so not all strokes are caused you know by the pump
cross-clamping the aorta for example is is a big opponent removing the clamp is
is in fact touching the aorta at all can can create these problems it could be
anatomical it can be a lot of different things but the pump is certainly not
free of stroke risk hyper profusion gas or particularly embolic events hypo
carby or gross hypercarbia cannula position drainage and of course pump
failure all of these things can result in in a big problem for us in terms of
hypoperfusion of the brain we know that clamping and on clamping the aorta is a
problem heart position affects flowed and of course we’re trying to help the
surgeon get through the operation and we’re you know we’re you know another
thing too something that I just thought of is there are a lot of perfume some
perfusionist when the surgeon says down on the flow
to put the aortic cross-clamp on or to take it off we’ll take a clamp and
they’ll clamp their arterial line they’ll just put a clamp on it and close
it off and of course the flow goes down the pressure goes down and they apply
the clamp or remove it some perfusionist s– and I think probably most turned the
rheostat control down turn the RPMs down but sometimes you do it faster and go
back up faster sometimes you do it a little slower and a little back up we
have no clue how that variation acute sudden change affects the brain we have
no idea if we go down too fast does it create a problem come up too fast as it
create a pop I think it’s gonna be interesting if we were to start using
the on a routine basis I’m pretty confident
that how we practice would change significantly we think we’re doing a
great job I think I’m the best perfusionist ever walked the earth I
don’t want to know the data because it’s gonna reveal how wrong I really am I
think you you’re still the best perfusionist and I think because you’re
really sensitive for the new knowledge and you are open for the TCD and all
this information and going back to your slides I think it’s very important to
and not to blame the perfusionist not to blame the surgeon and also the
anesthesia in your team but kind of work together so I think very important to
York emulation sighting surgeons they learn well not just looking at the aorta
but really do an ultrasound on that aorta and look at the other side make
sure there’s no plaque there would be safer cannulation that you’re not
dislodging a plaque in that moment when you’re just cannulating so I think those
are very important and I think our anesthesia is always asking our tcd flow
information because when they see any pressure issues and so much easier to
see did how is it affected in brain and it’s stunning how the autoregulation
still works so pressure change of between 20 it just
reacts and the brain compensate with only 10 percent change so I think those
are the important information how as a team we need to really communicate and
as well as a surgeon perfusion is but also the anesthesia perfusion
communication is to be really strong very good so do we know whether our flow
is adequate and and I think we assume a lot serveral oximetry certainly is
something that people use but I don’t have confidence in it do we know whether
VAD or kinetic assist vacuum assisted drainage or kinetic assist has an effect
does going on with a drive venous line really create the problems that some
people say it does or doesn’t it is a closed system like a bag better or worse
than an open system when we go on down on the flow I talked a little bit about
that already how do we do that and what is the best way to do that does pulsing
some surgeons now are wanting us to pulse on bypass you know and I mean I
mean you got a cannula that’s 20 French you’re really not going to be generating
much of a pulse pressure or much of an upstroke and does it in does it cause
more harm than good in terms of cerebral protection for what we’re benefiting by
trying to profuse the kidneys better and how are we managing our temperatures in
terms of cooling and gradients and warming and and so forth the brain is
very sensitive to hypoxia we all know that it’s very good at our regulating
the cerebral perfusion pressure and co2 are critical dr. gouramis going to give
us more examples about that but it consumes 15 percent of the cardiac
output compared to about five percent for the heart so the brain is a huge
consumer of oxygen it needs a lot of blood flow uninterrupted to continue to
function properly for the patient after their procedure is finished and has this
very conveniently positioned the brain has this very conveniently positioned
vascular system so I’m gonna go through this very quickly we’ve seen this more
with dr. gourami the carotid is coming up the middle
cerebral artery you’ve got this temporal bone window which is very good some
women I know you said have a problem with it but it’s very easy for us to be
able to put a probe on there and aim it and capture that MCA and in this article
detection of embolic events we have I’m so sorry there I’m not even sure why I
have that in there so I’m gonna skip that slide but how can we be a part of
the solution we’ll look I think we need to learn more about TCD I really want to
in my in my group in my practice use TCD at some facility on a routine basis just
to learn what’s actually happening it’s for us a newer technology
the TCD devices of today are not the TCD devices of the past and I think you’ll I
like that a little bit there are little laptops very easy to use it’s also the
headframe you talked about very easy for us to apply now there’s complications
we’ll talk about that later about getting anesthesia by in with it I know
at your facility you have it but that’s not a private practice facility and it’s
problematic for us well the other thing is I think tcd as a technology can
monitor your line so right now we’re talking about monitoring the patient
head but I think the TCD probe itself can be applied and can tell you hey
you’re sending embolization from your equipment so I don’t I’m so sorry I’m
not a perfusionist but I hope that behind your filter there’s a flow meter
or sensing what is the filter function is so definitely that would be my idea
of to really see what you what your filter functions how does it work and do
you really filtering everything out or you can really blame on your machine
that you’re sending debris back to the patient yeah they do have they do have
you know devices for that what’s the name of that device that we were trying
to forget the name of it now the– what’s the name of that double rubbing
do you remember yes I remember no I’m good lord have mercy well you know we
have that emboli detection system for the pump that a couple of researchers oh
yeah eid AK the eid app but they’re you know they’re not something that anybody
uses and there’s a german come but if ID tax off the market there’s a couple of
them still around but you’re absolutely right we don’t monitor the pump for
embolic material coming from the pump so is the emboli you’re seeing with the TCD
being generated from me or from the aorta or the carotid or wherever else if
IV we simply don’t know but it does look it has billing codes so there is revenue
generation from it and I think it’s probably I think from what I understand
I mean nobody’s gonna get rich off of it but it certainly helps pay the bills in
terms of the the the utilization of the device the cost of the device and the
time that it takes to actually utilize the device I would think for them pay
for the stroke so I think we’re a billion dollars when you’re mentioning
how much is a stroke treatment in the US I think this is we’re not just making us
rich it’s more about keeping those costs related to the stroke down absolutely
that’s very true but you know trying to convince an administrator of that they
just look at the cost they don’t think about that’s very hard to convince them
about these protective devices and if this happens this is what it will cost
they they you know it’s very hard to convince them of that sometimes it is
very highly specific for both flow an embolic events I think it can definitely
help change the practice can be easily learned by perfusion can be a perfusion
tool which i think would be something that would be fantastic for us as a
profession and I think we basically just all need to get more involved to know
what is happening with our patients so this I think says it all
there are known knowns these are things we know that we know there are known
unknowns that is to say there are things that we know we don’t know but there are
also unknown unknowns and these are things we don’t know we don’t know Don
Rumsfeld that is prophetic and in honor of dr. gourami being our very first
speaker thank you all very much I think we’re gonna get a word from our sponsors
and because we got to keep the lights on and then we’re gonna come back with dr.
gouramis talk thank you all very much that was a good session thank you Joe hello everybody and I
would like to continue our our tcd lectures with some improv intraoperative
images and I definitely would like to quote dr. Lumsden one more time imaging
imaging imaging we do have a fancy hybrid operating room and probably the
TCD equipment is still the cheapest piece in that room so TCD is what you
see in the middle that yellow box sorry get your that yellow box in the middle
anyway you see you see the Mouse’s yes yeah thank you so the yellow box in the middle with the
head frame connecting to the head and this is our TC d screen we already
learned but if someone came in late the right signal represent the middle
celebratory the blue signal represent the anterior cerebral artery it means
red coming towards your rotation probe blue going away and all these signals
basically the auto sound 2 megahertz signal reflecting on the red blood cells
these are a few sorry it was a bit too fast so this is a few papers what should
be our practice standard and this is something that we already have practice
standard for interoperative monitoring but I just want to educate about the
perfusion how does the brain is profuse and this is like I think the easiest
example the top is how the normal flu looks like when you
have a low intracranial pressure and your systolic diastolic perfusion
pressure nicely flowing a low resistance flow pattern in a moment your
intracranial pressure increasing or your pressure is too low that your diastolic
perfusion pressure is matching your intracranial pressure
you’re not perfusing the brain in diastole so if you’re just perfusing in
systole that’s the spike is just not enough for the brain the brain really
likes to have a flow throughout systole and diastole and finally this is a
really sad part when you interest intracranial pressure can shut down your
circulation so that’s your brain that situation when you’re increased ICP is
right between a systole and Esther perfusion pressure the flow goes back
and forth goes back and forth so it doesn’t really progress all the way to
the tissue and I just want to show you an example how does a hypo perfusion
looks like so hypoperfusion means that right now we have a mean arterial
pressure of 30 you see the gap in systole and diastole and now what we
going to do sorry I need to go back Roger can you start this movie for me
please so right now from a 30 we’re going to
increase the pressure to aiding so watch that blue flow gap between those red
signal so this is we’re going from hyper perfusion and we assume this person’s
brain dead and it’s not brain dead we’re just not perfusing the brain so suddenly
when we start to perfuse the brain and we raise the pressure from 30 to 80 mean
arterial pressure we have a gorgeous flow to the brain so that how we why we
call the TCD is almost like a stethoscope to the brain that you you
can really see and listen to what is the blood flow we deliver so that’s where
the perfusion is really crucial and I agree with you amble eye is just one
story but this is how the embolisation look like on the
screen in the middle of the screen that huge dip you see this is a good valsalva
the was servo by increasing the pressure in your chest maybe just preventing the
the venous return that’s the best example if your venous return is not
there heart would love to pump but there’s nothing to pump out so that is
the main maneuver what you can really control and see how the TCD blood flows
changes so that’s actually done with a during the PF o test and this is how the
TCD signal can improve by a contrast material this is like a contrast agent
injected in a circulation so TC d definitely sees the entire hemisphere
not just that focused part so what we learn from the carotid surgeries and
again we had data from the 90s that the d c– dy monitoring the cerebral
circulation we can see the pooka laterals we can see the ambles ation but
we can also check the vasomotor reactivity and but the most important
how we described the hypo and hyper perfusion and as you can see on this
paper from dr. spencer from 97 the incidence of hypoperfusion and hyper
perfusion almost similar so the similar rit is coming that if either you have
really de hypoperfusion but the loss of perfusion markers they double the
velocity is 1.5 times of your baseline and it’s caring we didn’t change too
much but end of 90s we had 93 percent of the cases had micro no signal and that
is always predicting stroke and t is after these procedures this is just a
few signal that if you prep your line properly and you do not have any air in
it you can see the flow arriving to the brain and you can see that brightness
can I have the Masters let’s try it again so on this left side p of a pad is
anybody have something piece of rubber or something that’s a little harder try
the backside it just doesn’t want to reuse my hand this BB – romantic joke it
works so anyway the idea of that you see the brightness improving that there’s
another material arrived in your bloodstream and this is your probably
your prep line your contrast agent something when you have too much air
that’s also shows up on the right hand side that right lots of white line those
are you really don’t want to see and a big piece which is on the lower image
that you see you do not want that big piece of trim because almost like it’s
deleting the signal and it’s changing right so that’s at the bottom the bottom
body okay I’m sorry yeah sorry so this is the micro embolus when you have like
a big piece of chunk and it’s immediately changing your blood flow
that you see that your mountain mountain becomes flat it means that you’re not
perfusing that vessel this is immediate occlusion and with ADD immediate
occlusion you don’t need to wake up the patient you can tell that this middle
sobriety or that blood vessel is definitely obstructed and you need to
start your rescue therapy and able to fish on that car mm-hmm so so now how
can you differentiate between that and air so this is not a question of air or
what it is it has to be a solid piece because it’s obstructing the flow I
think it’s more about obstructing the flow or not obstructing the flow and so
too much air is not good for the brain so I remember one of the first first
case I learn about the cerebral perfusion and the retrograde severe
perfusion was utilized when you pump with the malfunctioning pump air into
the patient’s so if you pump air into the patient’s what your only option is
reverse your flow and try to pump artery arterial blood flow through the venous
system and flush out the air debris so that too much air I don’t
know if you’re planning to kill someone but you need to inject at least 50 cc of
air into the heart able to stop the heart if we are showing you later a
video that you were injecting three cc of air into your palm
that was embolizing for two minutes but yeah I’m gonna show you yeah I have a
pretty video of how the three CC my ohio connector was played a roll so that
connector bubble what you said is like this tiny less than that once he see air
bubbles they were embolizing for minutes and minutes a minute but they did not
affect the flow and I think that’s what’s important to differentiate when
we are talking about the micro ambles versus a macro emboli or something was
obstructing your flow and definitely is harmful to I have taught you very well
because you said you know if your pump malfunctions and you’ve pumped a lot of
air to the patient that was very good it’s never the perfusionist fault I know
never never okay I’m gonna skip the carotid because I think are we not
interested in a karate surgery this is just one picture the junior carotid we
using a shunt to bypass the surgical field if you don’t have perfusion and
this is the same thing if your cannula or the shunt is not perfusing you can
see there’s no flow in the brain and this is just a simple clamp action that
you put a clamp on so on your flow is definitely decreasing and we can
immediately see that how the clamp placement and the releasing of the clamp
able to help us so this one is one release thing I’m sorry guys let’s go
back maybe slow down it might be yes so this is a coin placed in one carotid but
looks like it’s a bilateral disease both carotid goes down so I think that’s not
the important information why we try to monitor both hemisphere yes
unilateral change is going to indicate stroke but bilateral change is gonna
tell you there’s something wrong with your heart the cardiac output must be
decreased so this is why the bilateral flow
decrease I think it’s really crucial information this is how we monitor
bilateral mcs but when we’re interested and say we have a changes in ACA we can
also monitor the blue signal the anterior cerebral artery because the
changes of the flow direction in AC also triggers that there’s a problem with
your carotid and I think for the open a or tech surgeries that’s really crucial
and not just a new technology how we advance with deployment of the stand and
how we improving the flow that’s a great confirmation so here why the AC becomes
a good direction you can see on the bottom signal that suddenly your signal
collaterals do not need it anymore so Sunday your change and the flow is
changes and this is the hyper perfusion so when you’re releasing your clamp and
you remember that Delta percentage we studied a hundred percent and suddenly
shows you 220 percent that’s hypoperfusion that’s a hyper perfusion
is what’s gonna give you headache and seizure postoperatively but you can
control it in the operating room by decreasing the pressure decreasing the
pressure and also hyperventilation this is just few video examples dr. Lumsden
putting the clamp on immediately you see the flow changes he’s going to release
the clamp and the flow changes so the improvement of the flow is always a clue
that indeed we did a good surgery and our flow is improving now we’re putting
a clamp on and you don’t see a flow this is the time to call first and so we need
to place a shunt to able to provide but when you place a shunt and this is why
the air is always there sometimes it’s impossible to properly the air even that
tiny tiny amount of hairs really picked up on the TCD and then finally when you
release the clamp you see the flow improving and again and we accept that I
mean I mean at the end of the day we accept that we are you know in that
particular procedure many other procedures we know we even when we do
open valves and the left eight for a mitral valve and the left atrium has
you see it on the t ee you see the starburst floating around that is air
and that air is going to eventually make its way through the system and we we
just accept it but I think we can learn something how to get rid of that air so
we had few approaches for example the ultrasound if you put it on an arch with
a high energy you can destroy those airs or you have air may be coming from your
pump and you censor it but it’s sensor maybe with the high pressure ultrasound
wave can destroy the air but I want to talk more about that so those here by so
those those air bubbles we if we capture it we know they bear I think there’s
some technology that we can improve to get rid of them and I just want to
compare the open carotid versus a stent in the same way how are we comparing
your on pump of cases indeed when we put a stent in there’s debris going to the
brain but also with a recent improvement of how to protect the brain we can
definitely place a protection device that we are really minimizing the amount
of bubbles going to the brain this is example that you’re just pulling on a
carotid look at how the flow is changes when the blood pressure is not so you’re
not monitoring you think you’re just fine exactly and I and I think this is
where these video captures are synced and these are real time and I think
that’s the perfect teaching rule a tool for us and this is you are deploying a
stent you’re deploying pulling back between the tooth those two black dot
what’s the T CDC no you see nothing it means if you really put your markers
down hey I do not with this really sensitive toy of T CD which picks up
everything and you’re telling me that I can deploy a stent without a single
embolus material going to the brain I’m not a marketing guy but definitely this
is the protection I want in my brain with
I need a standing someday so these are what we learn and you know we can have
thousands thousands of cases but this one video clip is more than you know
thousand words in the publication New England Journal and I think this is
where we need to be open and able to share our experience and I was like how
can we get to this level sure when you’re a beginner even an open carotid
surgery you have a lot of air but this is a t CT perfect teaching – for our
fellows that you can the air send everything to the eca but to protect the
ica and i think this is where we’re learning a lot and able to teach them so
this case is we are deployed a stent and we did not see the improvement of the
flow so proximal there’s something blocking that flow and we had a tiny
dissection so we had two balloon and put a second stem proximal and then you’re
able to see that the flow improvement let it catch up
I think sometimes if you keep yeah so you see the flow improvement after the
balloon and I think I’m oh here’s your favorite it’s my favorite yes so so much
are you very welcome sir so this is an off pump case and see the blue co2
blower came in and suddenly blow the air into the brain so for us this is still
stunning hard to explain that how but right well we alerted the surgeon and I
think after that we really went to a bunch of different testing testing the
angle of the co2 blower what can we do and also I really like the idea to have
fill up the cavity with co2 to try to get rid of the air that way so I think
we do learn those protections what’s the best technique and I think where we say
we have a perfect most sensitive tool to really compare devices or if you just go
for the proximal anastomosis I can tell you between the two device which is
better the one doesn’t give you sheriff emboli but
able to carve out the the the buttonhole and able to put your proximal protect
proximal bypass in without a hair so I think this is where we can definitely
compare this and this is my favorite when you initiating the bypass and when
you’re perfusion is de air properly and you see that the heart is barely pumping
now but your your your fluid arrive to the blood stream you see the density
changes so right because it’s at baseline exactly there’s no bright as
the sensitive change you see this is when Ambilight comes
oops sorry this is a number line so when you release your clamp and you see a
bunch of emboli and I think this is were really interesting that why you we are
doing the perfusion we have a perfect way of really the sizing the embolized
so this is where you’re talking about sizing emboli you do have a
non-pulsatile waveform why you are on pump so why you are done
pump you can see the different sizing material let’s yeah so thank you for
your luck so let’s look at the left button image the when you see the letter
A that’s a high speed probably small ambling material so the bottom line the
bottom or little corner bottom line is because it’s yeah but when you see
something closer to the base line this is a slower-moving it has to be a bigger
piece okay something is higher up in your waveform probably a small piece
because it’s traveling at a higher speed so based on the speed I’m trying to
differentiate them but definitely what I’m really scared of is the left upper
corner see the left upper corner materials they are deleting your
ambulance in oh they are really ting also your blood flow signal yes I see
the gap these are huge gaps these are huge chunk pieces that we are lucky that
we still have a floor to them so this is where we definitely
need to pay attention all those tiny details not just a big shower of amber
light but now this is a good example so you see the speed higher up closer to
the green line there’s a lighter material the third a is sitting in the
middle of the blood flow so definitely it’s a real bigger piece because it’s a
traveling slower so I have a few of those several examples for you and I
just want to show you one of our experience with a retrograde super
perfusion because I think we learned a lot from that too so when you are
stopping the pump and you would like to have a retrograde cerebral perfusion
indeed the flow in a middle cerebral artery can be detected in a reverse
fashion so you need to overcome that capillary opening pressure at least like
40 American millimeter and you can increase the retrograde flow from 500 up
to 600 1700 to open up that flow after that you can decrease it and we can
detect the flow up to four 450 and I think this is you do you want to prevent
the edema tcd can guide your receiver perfusion so you’re not over perfusing
but you profuse enough to get the capillary opening pressure get the flow
going and then you can back it off exactly and and because we are in a
barbecue business in Texas I just want to show you this was dr. Safir dr.
Stratis slide to train me why the hypothermia is not enough you need some
other protection by the blood flow so look at this barbecue so if you just do
circuit arrest 5 dead if you do hypothermia – barbecue and you have
three strokes why you do additional several protection you can have four
healthy animal and you have only one stroke so you’re gonna be hungry because
there’s no no no barbecue out of that group so I think that’s very important
that how from from these animal experience we can really learn how to
perfuse the brain even in a retrograde fashion so we can change the direction
the middle server artery by a proper cannulation
and because we are adults but we like to play this is our playground in Houston
there’s that handsome guy there in the middle not the middle I want to point
out the guy on the right see that that guy Hey do you recognize yourself from
the back the handsome guy in the middle is our NASA hat frame that NASA gave us
and we’re able to use that as a cerebral perfusion model for the TCD the TCD is
sitting on that head and why you guys are hooking up your pump we were
profusing our head model and we have a TC d signal placed on that on the head
oops can you go back three one advanced one don’t play just advanced one slide
so I want you to watch the GCD screen the upper listen to our conversation
because we recorded that bite so you are purposely injecting air to really test
it how do we pick it up and we also played how to decrease the flow pattern
and increase the flow pattern be able to change the flow and again this is
provided by your yeah this is why it’s a non positive no cutting and this is
where you try to create some positive flow pattern by just like holding the
flow back and you’re heating you’re connected because you had some air stuck
in your connectors and I think this is where we really had fun can you play
this video we injected gnomes where material size this is a 250 micron so they went through the circulation and
we were caught in them and this is we were watching how we amble eyes and we
were testing also your filter and that and then you see the sudden stop so this
is your filter function your filter filtering out so they were not
recirculating so if I dad was really stunning that we tested the second one
was a hundred micron can you play this again please so the hundred micron
really able to see that we able to to get through the circulation it’s a short
injection and definitely filtered out and I think we really kept your guys
happy but I just really want to show you this because I got you and sunny of it was what you then
defeated ad there’s an air pocket somewhere of the connector and this is
why no scope no scope embolizing so got you up like this when we’re sleeping in
your circulation was done yeah it is it’s in it’s in the circuit itself and
of course this was crystalloid that we were using circulating around through
this head but at all of those connector points that air will hang up and it’ll
just continue as we keep hearing this shower little by little but little by
little by little until it is gone and so I think that’s you know you don’t see it
you can’t see it but it’s there in this proof yes and I think the happy moment
was when we injected the 40 micron it filtered out so we have that clip to
that definitely filters everything else so going back to the Tavor this is when
it ever a DWI lesion started to show up in year 2009-2010
look at that 86% of the patient they had this DWI legions
Wow so compared to the surgical which is about 50% but definitely smaller lesions
and again in Europe they were ahead of us and in Europe we got this data from
Germany 2010 and they did DWI and also the TCD monitoring when you did tcd
monitoring compared to the different companies valve and the different
deployment as balloon assisted versus yourself deployed and also the TA and us
destroyers epical approach you really don’t see difference is the
total amble I can’t is there but it’s interesting that the self deployment is
that the implantation alone is the majority of the am position happens why
the adverts valve recipient when you positioning the valve you have the
highest number of embolisation and those are showing an Appy study has
significance I have few videos for you and this is the first one we just did
the balloon valvuloplasty and this is the submandibular monitoring because you
see sometimes the balloon is quite stable is not moving too much but here
we are deploying the core valve and you see lots of lots of Emeril’s ation and
you can see the wires that this we are not the first guys in this heart so you
can see the history and you can see how they valve now is deployed on those
chicken wires and I think the videos synchronize what you see on the C arm
and what you see in the brain on a TC d is first and the best example you’re
gonna see now with a fast rapid pacing before we see this rapid pacing gap you
know P you can see and again you need to deflate your balloon before you stop the
rapid pacing and then you’re lucky that you stop the rapid pacing the heart
beats came back this is a beautiful great examples of the behavior but also
you see that the diastolic velocity kind of giving us a clue how good was this
behavior how good is the valve implantation how good is the and I
select perfusion is for the brain so now in that case you’ve got good flow
exactly as your diastolic pressure is not going to baseliner below exactly so
good nice open valve area and right now watch when the valve is arriving in the
into the aortic valve see the how the diastolic flow just disappeared so
you’re blocking your flow track sure you’re not gonna see diastolic perfusion
you want to deploy it so you want to help the perfusion in the eyes Tony this
is a short period of time you want to faster deployment for sure but this is
just giving you a clue that how the flow is changes why you even
have you were ever in a or t12 so this is the dead lucky moment because this is
another balloon valvuloplasty and in this moment you have a balloon going up
you know 200 or 160 or enough to balloon inflated you do not see the heart start
beating again so this is what we can about on the screen CPR starting and
later I almost like what the you detected the first moment of comes back
stunning how much stopped heart or hemisphere in
the catheter the deployment catheter the valve itself I mean it had to come from
somewhere it certainly didn’t just create it and I hope it’s just there but
definitely there’s a debris you’re saying it’s air but it could be a bomb
it could be particulate and this is my stunning how the brain not perfused so
here’s your valve sitting and you don’t see that usually mountains and anything
so this is again you do not have a brain perfusion when you do not have a bit
perfusion you start CPR so this is our fellow hand on the left hand side wanted
to make sure the hand is in a proper position and I want you to pay attention
how much the CPR flows to the brain tiny tiny spikes and I think after a
young fellow got tired we got our senior surgeon look at the highest peaks I’m
not going to name our senior surgeon but I think doctor reading will be really
happy to see the flavors so we can you lating the femoral artery now and you
see the perfusion starting non-pulsatile flow but we have too much air so we
stopped the pump and we said okay let’s check connections let the air and start
our perfusion slower and why would the earring look at the
slow start and a profusion how we really minimize the error so I think that’s why
the immediate feedback to saying hey that was too fast there was too much air
and tried to slow her I think this is a perfect example how you can direct your
your blood flow I think I’m gonna skip this one and because we’re running out
of time let’s see this deployment so this is a Edwards sapien valve you can
see the sheet going and we have the PTL in the autoclave and now we are trying
to go cross around the arch and you can see it push it you can see
it pushing it get fast forward to see the valve crossing the arch see here
comes the valve crossing the arch okay slow it down see a few embolic materials
rain right away so that is your example that definitely not as your car to show
that your valve is thing in the midline it’s bouncing and again how you sticking
it to him despite that you have a clever bowl to take that turn this is the
America Tyrael this is no protection used ends up in the brain for sure it’s
a little jackhammer all the way around yes
so this is when let’s see the next one please and this is again a synchronized video
can you play it for us please and watch the TCD on the left upper corner is the
right side and the bottom is your left side and here comes the Tavor crossing
your arch again and this is the core valve a little bit longer look at the
materials going to the left side there’s not much material going to the right but
you are embolizing and trashing everything to the left hemisphere so why
we are passing in the arch so we’re not even close to the valve but we had major
unilateral embolization and after this unilateral embolization I am losing
signal I lost my left MCA signal and few debris going to that left MCA but you
can compare to the upper screen on the right side you still have a flow this is
stroke happening front of your eyes and I do not need to wake up this patient so
this patient transferred to the narrow intervention and with 30 minutes later
after a quick deployment of the can you advance the slides Roger please can you go back okay we skipped it so
the answers are there definitely there’s a bunch of different ambling that takes
deflection air filters this one of them is the umbrella and you showed the other
device and we definitely studying these as not just DWI lesion is less and where
are they but also if they can decrease the amble
o’clock you can see in this case there was like
820 with the control group and we decrease them half so almost like 340 by
using the umbrella the TCD count and this is the umbrella deployment from the
right arm so when you deploy the umbrella and this is the first case was
done in Germany with DCD monitoring and you’re able to protect the brain with
that filter and now we are deploying a valve with that umbrella protection and
definitely you see I think that’s the way of to really study different
cerebral protection to really sure it in a most sensitive way of that the TCD do
not so I’m just looking for my last slide I want to skip these we saw enough
examples with doctor lumps and we try to bring tcd in the in the suburb hospitals
so we try to provide monitoring with this remote proctoring this is a stored
in touch device that dr. Lumsden able to see the TCD remotely and we able to how
opened and can you advanced Roger please so
this is the TCD device in the operating room and this is the I’m able remotely
able to control and this is my revote you that are able to see the operating
field and also the TCD and this is my head just behind the
surgeon to be able to present from hundreds of kilometers away to remotely
able to assist you thank you so much that was very good I like thank you very
much for that okay so Roger could you put our number up for calling in and
we’ll go to a commercial break doctor Metoyer just got here so we’re gonna
bring him up to the table as well because I think you can weigh in a
little bit on this tcd stuff I’d like to be able to implement this and in your
practice so if if you’re gonna call in go ahead and call we’re gonna go to a
quick commercial break and then when you get back we’ll take some phone calls I
think we have some YouTube chat and if we have any questions or you want to
discuss any of this with dr. gourami dr. mccoy or myself please please call
in the phone lines are open okay and don’t forget there’s a 20 second delay
so turn your volumes down and and be a little bit patient if you call the lines
busy just call back thank you all very much so playoff
octavo arterial cannula less jet more natural dispersion neurologic
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flow Opta flow provides the optimal dispersion flow with no jetting compared
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twenty one and twenty four french sizes for all patient needs the unique basket tip design reduces the
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more transparent look and feel available with and without yr reinforcement or scholar get your mic on my cousin
should be green light hello hello hey we lost the girl with a lady we gotta call
her oh she’s on hold okay okay well we’ll go we’ll go to you first hey how
are you is this Patrick O’Toole hey Patrick what’s going on man good are we
lot more not live right now are we are live oh great well I have a question
then for dr. tehrany yes okay uh so dr. Graeme can you see
the difference between an air embolism and a particulate embolism with the TCD
depending on the mood and depending on the device I’m using few companies claim
that with two different frequency on a t CD you can differentiate but in my
experience I think these devices still fail to differentiate 50 percent of the
time they are rejecting even thinking about it so if 50 percent of the time
you don’t want to even differentiate I think that’s a bad move so we tried to
and two point five megahertz and two different frequency to see the different
signature of air versus solid I think we’re not there yet so we continue our
research and trying to find a better tools how to differentiate those
signatures between side of air emboli right now my commitment is I’m counting
emboli and the total my count what for me is matter okay great we’re using the
cerebral oximetry of course and it does change what I do behind the pump a
little bit especially if we’re doing a circulatory arrest type of case but if
we were to start implementing the TCE regular basis how do you think that
would change our practice specifically what would we do yeah before we go any
further I would like to ask you what did you observe on a saber oximeter when
you’re cooling your patient well we know your your saber oximeter goes up so when
you call in your patient down sometimes you see unrealistic changes so not just
by decreasing the flow obviously you’re gonna see decrease of oxygenation but
when you’re calling your patient down sometimes you see the increase of your
Neer’s cerebral oximeter and I think sometimes
my explanation sure maybe it’s less metabolism this is why you see a higher
counting on the nears but I think if you ask an expert on near say oh my device
is best and and I just wish that we have more than one sensor so when you have
just two sensors on the forehead one each depth one inch is not covering
majority of my middle cerebral artery territories mostly it’s covering your
frontal lobe and maybe some ACA territories not even MC territories why
my TCD signal is is properly placed in the proximal MCA I’m going to cover 80%
of the flow going to the brain definitely we can improve our monitoring
to monitor the vertebra basal system as well so you cover the posture
circulation which me even more sensitive for embolization than then a carotid
system but I feel that better coverage is better so that would be my simple
answer going to deep details comparing your present tool monitoring your flow
versus the TCD and I just think are issues that when you buy a TC d device
did the company just want to sell you a box they don’t want to sell the
knowledge and I think we need to continue the education efforts with Joe
does to really give you the education not just to buy a box but to really
understand what that box shows you and again after a few months for you years
experience you will definitely will be comfortable
seeing the TCD screens and what you observe and I think it’s a tremendous
help how you will direct your pump how you the air and how you provide flow
during your cases do you see a difference between when you do
retrograde Surrey bull versus antegrade Oh big time because this is this was one
of the video I showed that when you do the retrograde super perfusion you do
have a filter function while you do the integrate cannulation there’s no filter
function so with antegrade even bilateral carotid or axillary
cannulation you have bunch of D breeze going up so I think I’m big fan of
retrograde super perfusion for the purpose that I can direct the pump after
opening up a capillary perfusion pressure that yes you can dial down and
maybe even 400 is enough you don’t need to shoot 6 or 700 for retrograde if I
see the flow but my flow is confirmed not just like dripping blood into your
operating field but I can really see that it’s really reached the brain so I
think on a retrograde zebra we can find some core laterals that you assume your
perfusing the brain no you can come back from the ECA and it comes back to your
venous system the true confirmation that indeed you see the MCA flow direction
changed and you detect that flow in your brain
I think that’s the true perfusion so I think that’s the difference between
doing a cerebral perfusion versus monitoring several perfusion make sure
it’s really there and reach the brain eliminating the Gestalt Theory kind of
it looks good there’s blood coming out yes and I think I remember there was a
Austrian gentleman who warned me after we first published that the TCD can
detect the flow with the retrograde I’m seeing is like well you’re going to
balloon all the brain and this is dr. Schilling theory that we are causing
edema we don’t see that edema if you clever and you dial down your
perfusion after you detect the flow and I think that’s where the cerebral
perfusion has to be confirmed so we shouldn’t assume I learned this so
favorite words like we assume too many things we shouldn’t assume we just
detected objective measures well you think that’s
exactly right we just assume a lot right you know we you you you you cut the
aorta open and we’re going retrograde and we see blood coming back so we
assume that’s adequate flow because we see blood coming back but is it is it
really globally perfusing the brain yeah and I think that’s that’s the issues I
think that’s what tcd offers okay Patrick thank you very much can we go to
our next caller Thank You Patrick thank you thank you hello you’re on the air
hello hey dureena my question is what are practices the cardiac surgeon team
can implement in my stroke and cerebral devices and my question is should this
be used babari or anything to support this so so
let me make sure I got your question right we had a little bit of a difficult
signal you’re asking whether cerebral protection embolic protection devices
should be used on every Tavor and whether it should be used for just
standard cardiac surgery is that is that what your question is for the Tavor so
you know that 100 percent stroke there is if you were to measure if your so
there’s the new classification is you have type 1 which is that obvious stroke
that we talked about you look at the patient and they’re in the bed and you
know they had a stroke and then there’s the type 2 stroke which is the new
classification which is any new lesion on DWI and these are the subtle changes
you see in patients and they’re both cumulative and ongoing and sometimes
they even get worse over the course of time and when the cardiologists in where
they’re studying any new device and the clinical trial they now have to I
believe this is correct you correct me if I’m wrong but they have to consult
the patient and advise them the difference between class one and class
two stroke and that their risk of stroke in the class two is essentially a
hundred percent is that is that what I’m understanding so indeed there’s certain
trials demonstrated hundred percent majority of the data I showed today that
was like eighty eighty six percent of the patient and DWI lesions and indeed
if we have an fda-approved protection we still sounds like a choice for having a
protection or not and I think what I hear from your question was all of the
Tavor should be done with protection and I think I’m on that side that if we have
an fda-approved device for that indication all the Tavor should be done
with several protection when we know what our complication and I think this
is where we need to go back with our honesty and saying that with the hundred
percent DWI type 2 stroke we saw the decline of 10 percent clinical stroke
down to 3 percent but I think the clinical strokes are still you know 3
percent we’re going back to our accepted complication it should be 0 I think we
still have room to protect the brain and at the moment I do not see the sabra
protection used in every Dever cases today I mean that’s three out of a
hundred that’s a lot yeah that’s a lot and let me let me throw this at you so
first question our first added question to you is okay thank you we’re short
we’re running a little over but I hope you all don’t
what’s going on dude did we finish that oh I think well let me let me finish up
on this thought if I can and I’ll be I’ll be right there
she was asking whether every patient should that’s getting Tara should have
Ambala protection devices should every patient having Tavor regardless of where
they are have TCD monitoring that’s to you and then I have a question for you
as well today I would say it’s impossible I
think there’s so many centers doing Tavor and they focus on TEVAR that the
TCD is not a potential equipment available for everywhere but it should
be a best monitoring for stroke prevention so when we’re talking about
stroke prevention when it’s really count we move the patients from general
anesthesia to a wave patient so I think that’s also changed our method of
monitoring if you do have a wake patient during the Tavor that’s the best know
monitoring because you can ask the patient how are you doing
count backwards and again have a data communication to patient you can see the
clinical stroke that way some on a wake patient I see the best monitoring is
talking to the patient’s when you do have general anesthesia I think it is
well I’m not getting tamarin if I do I’m not getting it awake I can assure you of
that that’s not gonna happen I don’t want to know what the hell’s going on or
you one TCD on your head I want something so let me ask you something is
it as a surgeon you go in to talk to a patient would you how are you how are
you going to approach saying to them let’s say you were at a bore advocate
how would you go in and explain to them look we want to do this Tavor on you we
don’t want to do an open procedure which i think is still better but we want to
do this Tavor and you’ve got an 80% to 100% risk of having new
lesions in your brain which could result in a stroke or cognitive dysfunction or
whatever it is how do you reckon so how do you do that I’ll just give the
analogy to Saveur you know surgical AVR which when we had em bollocks available
every aortic valve I did not every cardiac case put an embolic sin sent off
the filters for the first two or three years and he always had something only
one or two times anything you know as big as your fingernail but that does
happen as well so and I would counsel them and I’d literally would spend the
time with him and said look I’m putting a filter in it may or may not get paid
by your insurance so if you’re okay with an extra 300 bucks being charged to you
to minimize or decrease the risk of stroke which fear of my mom I’d do it
and so I put it carte blanche into everybody and just because of the
experience of always seeing something you know microscopic macroscopic in
knowing that there’s always something whether it’s clinical or subclinical
going to the brain and that’s without TCD monitoring that’s without cerebral
oximetry in a community setting again it just makes sense you’re scraping out a
valve and putting one in and now you’re in a tavern where you’re not taking the
valve out it’s a lot it’s a little less controlled although it’s borne out to be
a very safe operation I would I would filter everybody
I mean if it’s available on filter and there’s a lot more filter devices
available for Tavor than there were for open Samer yeah absolutely you want to
go to I think we have time for one more call Roger they hung up oh do we have
any we have anybody else no okay so listen I want to want to list let’s
transition out of this I think with just some music and we’ll take a break and
then we’ll put dr. metoya’s video on that he can narrate about the mitral
valve simplification of minimally invasive mitral valve I want to thank
everyone for attending this session I want to thank particularly dr. gourami
for coming all the way up here from the meds of the big
Center in Houston Houston Methodist Hospital and giving us a great I think
overview of tcd and its application I’d like to see it used more common place
I’d like to be see us using it and seeing what we’re doing you know going
back to the there’s these know these unknown unknowns as Don Rumsfeld said
and it’d be really nice to know what we are actually doing and if it would
change anything that we are doing whether it be the tools that we’re using
the the conduct of the perfusion possible flow vacuum assist non vacuum
assist whatever it may be I would just love to know and I hope that it comes to
a point in time where where tcd becomes a standard of care for any patient who
is going to be undergoing a cardiac procedure requiring the use of
extracorporeal circulation I think it’s extreme I think it’s
extremely important I’d want it I agree thank you thank you so much thank you
sir thank you you pretty good
like they’re laughing and we’re let me know we’re live on
camera and welcome back everybody okay so for
our next session it’s going to be on minimally simplifying minimally invasive
mitral valve surgery and dr. McCoy is gonna start us off we’ve got an
exceptional team panel with us of course to the left of dr. McCoy is Stephanie
Busse and she is a perfusionist extraordinaire who has become an expert
at the art of systemic hyperkalemia and removing the potassium to my right of
course Minh Tran he’s also he’s the male version of the perfusion extraordinaire
there’s a female version of the male version and Clint Robertson my old
friend from Alexandria Louisiana who have known now for about 12 years 12
years that’s crazy yeah he used to be young and good-looking but now you know
that’s my job I’m sort of look like okay so we’re gonna get moving I think dr.
Metoyer is going to do some narration on a procedure that we did for him here at
CH I st. Luke’s The Woodlands hospital where he is the chief of cardiac surgery
and medical director and he’s going to narrate this and talk a little bit about
just minimally invasive mitral valve surgery and how that is just such a I
think a beautiful technique compared to the sternotomy for isolated mitral valve
okay Roger ready okay so basically we have your ideal patient here and we’ll
talk about some of the other body habitus that you can utilize with this
technique when I was approached by Joe with this several years ago one of my
colleagues that trained with a chance to wit in Louisiana was doing some of these
and some of his high-risk patients ever redo and not one to do a redo sternotomy
and femoral access for this is key so that’s one of the things you have to
evaluate and utilizing fen-phen bypass but I trained with dr. Cooley
his quote was you know the kiss method keep it simple stupid and I trained in
more of a traditional cardiac surgery type program where sternotomy ‘s big
incisions etc and didn’t really have any reason to try a minimally invasive
approach other than the public kind of starts demanding it and where we are in
the woodlands which is come out to Beverly Hills of Texas you start getting
some pressure to do these types of things are you end up losing the cases
however so Jo introduced me to this technique you can see here a little
axillary thoracotomy this is a little bit generous because it’s one of my
first ones and you’re basically going about the fourth intercostal space and
the reason I even considered this technique was the simplification of it
not that it was a new technique to repair or replace a mitral valve it’s
well-established it was the taking the load off of me as the surgeon and very
importantly the anesthesiologist and putting all the burden really on
perfusion and they’re the experts in perfusion and this shouldn’t be
terrifying because the very first case that Stephanie did with me was her very
first time to do it so the learning curve is extremely steep a couple cases
and you got it from a perfusionist and point from a surgeon’s standpoint the
techniques are there if you know how to do a mitral valve you’re going to love
the exposure most importantly from a surgeon standpoint is the technology for
access you can see here I use esta tech you can use pretty much whatever
minimally invasive type of retractor system I’ve even used to phase small
finished shadows hit finish set us here but the main component is the atrial
lift and we’ll show that in a minute I don’t use port access we’re not going to
utilize an endo balloon we’re not going to put in a retrograde cerebral artery
catheter which slows everything down because those can be done
call to place and it also again puts that burden on the anesthesiologist and
while you’re sitting there drinking coffee and for me I’ve got a full day
usually and I can’t spend all day doing one case cover multiple hospitals
although this is my main hospital at CH I st. Luke’s the woodlands so you can
see the phrenic nerve easily here at the bottom part of the incision this one I
used Alexis which is utilized by the general surgeons and robotic surgeons
for hand assisted surgeries so nothing fancy relatively cheap and cheap device
you can go I’ve even started using the smaller Alexis because it gets creates a
lower profile especially leaving on your larger patients the largest patient I’ve
done with this is about six five six six and was about 350 pounds and he was big
all over and this guy at a massive chest and that was about the limits of the
instrumentation we did have to use some of our long bariatric laparoscopic
instruments to kind of help in that from the you know the gastric sleeve
operation types from our general surgery colleagues but it was definitely doable
and the results even though it took about an extra hour longer it was a
repair he did awesome and to do it through that incision for him it’s gonna
be hard either way mister not I mean that guy is gonna be difficult because
dr. OTT David I’ve done it takes his heart always said mitral valve surgery
generally is your hardest most difficult procedure to do in the chest and I tend
to agree with that although there’s some easy ones through a sternotomy but this
way the exposure is excellent so what we’re seeing here on the te images is
the severe regurgitation this particular gentleman had previous mitral
endocarditis have perforated valves we have originally planned to try to repair
with core matrix and even put a ring of core matrix in to keep everything clean
from a tissue standpoint because he had a cute component to this however when we
got in there the valve was irreparable it was
it was really quite disgusting so here we are priming the the femoral artery
and femoral vein cannula for bypass obviously key to get the air out I don’t
use transcranial Doppler we’ve tried to get it in it’s as a Community Hospital
you know their cost to consider but I think once we once we get to a point
where this becomes more of a mainstay that should shouldn’t be a problem so
this particular decision here the bottomland this is one I use for
multiple different instruments but most importantly during the case using your
pump sucker to retract and to give you additional suction the drawback of this
technique because you’re not cross clamping is that if you have more than
one plus a I may or take insufficiency the amount of drainage into your field
is high one plus is a lot of drainage to almost moderate but with this sucker and
a way to drop sucker an appropriate angle and lift on your atrial lifter you
can usually control it enough to be able to see what’s going on and for me you
can take not all day but you are continuously perfusing the coronaries
with oxygenated blood so you have a rest because your systemic potassium is 10 12
13 whatever it takes to stop the heart 18 I know it’s crazy right but you’re
getting oxygenated blood to the heart you’re basically just shorting it out
but the tissues are getting perfused and they fly off pump I mean it is it is
just smoothest transition you’ve ever seen when step one Stephanie or men
start doing their job in the back again the burden is on them and they’ve taken
the burden off of anesthesia in the surgeon you’re not on a time limit other
than a pump run so I consider this basically like you know ECMO mm-hmm
doing heart surgery on ECMO and you know how long you can do VA ECMO on people
and do it for quite some time so here we are looking at
we’re on pop we have a nice sharp QRS interval and we’re starting to slow the
heart rate down yeah and and once you give the potassium you have almost
immediate arrest okay yeah atrial lifts are real okay the atria lifter yeah what
happens when you don’t have it you try to hold it well the first one I did that
was the only thing that the Aztek company before they were bought they
didn’t bring the atria lifter part so I had my partner holding a handheld lifter
from the mitral set and it was miserable you can’t there’s just no way to have
somebody well I guess you if you have the perfect assistant you can have them
hold it but you got to have the atrial lifter again you’re taking this out of
the hands of a person and putting into something that’s not going to move
throughout throughout the case because you got to have that role lifter that is
the key I don’t care Edwards I think makes one if we’ve used before for me
it’s this I’m sure doctor oh gosh what’s Miami instruments the guy takes his
heart downtown now dr. lamell aslam Ellis he has assets that he uses so but
the aid they’re all basically the same as far as the atria lifter you got to
have it okay hey ROG can you go back on that to that echo that black-and-white
image that was just about 10 seconds before this cuz I think you want to
comment on that now thinking there you go you know thinking also is a
particular guy is like I got to be careful putting this in so you don’t hit
the mamrie yes yeah get the memory that’s a problem but anyway and we did
and fix it or clip it but anyway so you see the hand held sucker here that’s
actually pulling down on the posterior aspect of the atrium we’re good two
centimeters in front of the phrenic nerve you want to stay away from that
and there’s the atrial lift or you can see the the metallic instrument in there
and it’s on a post on the contralateral side of the bed there’s co2 coming in
from about two o’clock and I’m using a lighted sucker by intuitive
intuitive and I use those on a or take vowels my travails cuz I really don’t
like we’re in a headlamp I do wear one on a mitral it’s about the only case and
a thoracotomy from go back to me I use a headlamp so you can see I mean you’re it
got a direct shot in the hearts perfectly still this valve is garbage we
test it we look at it this isn’t going to be irreparable because the whole
almost all of the valve is diseased and the annulus is calcified too so for him
and we counseled them beforehand the 50-50 repair versus replacement my
repair rate is about eighty percent it’s not ninety or ninety five and I use the
dr. Lowery method generally speaking to repair valves I don’t cut any leaflets
out if I can help but I think you need to utilize the tissue you’re given and
even though I trained at Texas Heart you know I’m obviously I’m open to new
techniques so clearly all right so visualization here for me is great for
the video camera you know I’m trying to get out of the way a little bit but
again we’re I think we’ve made the decision to remove the valve if there’s
any posterior leaflet that’s normal with Corday I leave that and again that
surgeon choice because if you know as we know that we’d like to leave some of the
chordae intact but again this is a heavily diseased valve it was just a
floppy myxoma spell those are pretty easy to fix Barlow’s type I think those
are great actually to just repair but again you know we’re sitting here
chatting and talking and and you’re not only that time constraint of
cardioplegia being administered every for me I do it every ten minutes
most guys did every twenty minutes back to what we talked about using retrograde
perfusion whether it’s in the brain or in the heart do you think there’s a
right corner ever get perfused with a retrograde cannula if you have an
antegrade cannula and that’s more tubes and wires you get Chitwood clamps all
through this small hole and this hole can get smaller and smaller mean you
don’t have all of that instrumentation in there so you saw will remove them the
valve multiple fenestrations just a goodness awful looking thing and
here’s Stephanie being attentive as usual and we’re still flatlined I think
we’re about to start coming off and we do be cool this guy we did cool in and
that does help with the amount of potassium that you give and as far as
being last but we’ve given upwards of how many minutes on that big guy was
what six or eight hundred yeah yeah so that’s what we call in Texas a
Huntsville dose and if you’re in from Texas that’s where you know we still
believe in the death penalty but there it’s compassionate and that’s what we
give them so that’s what you’re basically giving patients is an
intravenous dose of high-dose potassium and with the aid of the heart-lung
machine and a competent or moderately competently ordered valve you can
profuse the heart and it I mean it just you really don’t get it you don’t get a
scheme yet which is the best part of this especially if you’re on a learning
curve to try to learn how to do minimally invasive I think this would be
a great way to start because it is simplified maybe if you want it to
progress to something more advanced where you’re doing a guy that has
moderate AI and maybe look at a more normal technique where you’re
cross-clamping or using an endo balloon or something like that then that could
be utilized as well later on but this is a this is for all intents and purposes
the perfusionist are your training wheels you can be rest assured that the
heart’s getting profused and you’re not under the time constraints that you
normally have maybe you can see here there’s a fair amount of perfusion
there’s a fair amount of blood in the field but this is controlled with the
wetted drop sucker and that pump sucker that’s retracting down that was this was
are kind of almost moderate AI patient and I’ve been pushing the envelope with
that because at the bottom of the bottom the day or at the excuse me
bottom line end of the day if it doesn’t work out and you can’t see
because there’s too much drainage you can still convert to a sternotomy and
you haven’t had an ischemic period so you closed it up and I have done that in
my very first case when we didn’t have a nature lifter I did that the guy did
fine not ideal but I did tell him that that would be possible I don’t tell them
now because we’ve gotten good at great patient selection so the next best thing
ever invented most recently and I think most heart surgeons will agree that I’ve
used it as the core not you got to have a – overrated suture I still use the
David op method which is 12 sutures for a replacement
they ordered valve that’s if it’s 21 or less it’s 9 3 3 and 3 if it’s 23 or
higher it’s for 4 & 4 it works great it’s simple it worked for pretty much
everybody so here are 12 sutures the core knot comes in a pack of 12 and this
easily shaves off 30 minutes or more if you’re using a knot pusher which really
hurts us a little bit because we’ve got to be even faster now getting that
potassium out and getting rewarm well true but if you communicate and you guys
see that I’m using that then you know to remind me yeah except well no we can’t
start too early because we don’t want the heart to beat true that’s true but
you can once the the valve is in especially on a replacement where you’re
not as concerned about a significant leak you don’t have to really worry
about that no in a repair I get it you want to be a little slower but again you
have the benefit of being on thin film you regardless at the right slow coming
off you can you can wait a little bit especially if you’re learning with this
new technique that’s simplified you have time you can these guys can spin it off
a lot quicker than you think I mean you kind of you kind of yeah you’re you’re
hurt yourself a little bit there on that because it doesn’t take as long as you
would think to dialyze and get this off and larger patients you gotta consider
them I think surprise this guy’s super skinny
so it’s yeah it’s not that hard so now we’re checking the valve you put your
weight don’t forget now you got co2 in there put your wetted drop sucker
through the the leaflets make sure you have plenty of slack because you know
they’re kind of sticky with other cannulas and your suckers and you’re
going in and out you want to keep that into the atriums closed and I’m testing
the valve with you know usual method there you really don’t have to
especially this guy he’s got pretty good eh I just let it fill up and test it
with a pickup okay I’ve done mechanical valves the
replacements obviously they’re even easier this way than it is with an open
procedure because the you can see the anterior portion of the annulus so we’re
trying to get the atria lifter out don’t forget your pacing wires
I always forget because you’re so good like you’re jazzed about getting
finished the pacing wires that can be a little challenging putting in I just
always use ventricular wires because that’s the way I was trained you can do
atrial and ventricular get you a good piece of epicardium and put it in and
bring it up to the right upper quadrant of the abdomen or right lower portion of
the chest I usually just used one and a grounding
wire because I’m a big believer also this is the other reason I wanted to use
this technique was I believe the fewer holes you have in the heart the less
chance you have the bleed okay so same thing for aortic valves I don’t put a
superior pulmonary vein vent in dr. OTT dropped one through the route and you
just get you kind of get blind to it it’s kind of like a fire hydrant your
yard when you buy that house you’re like man there’s a fire hydrant my yard and
that it’s a eyesore nobody notices the fire hydrant new yard
mm-hmm we just recently had a big freeze down here nobody notices where the water
meter is I had to go find a water meter for my sister-in-law and turn it off is
yet leaking her house oh yeah but you think all these things you know that you
don’t they’re kind of like eyesores but you don’t you kind of get into Gluck
full of it so same thing with for me with that with the aortic root there so
that’s just a little aside so I don’t put a superior pulmonary veins in it I
do not like it but give you back to that pacemaker mm-hmm making
sure you put it on before you fill the heart yes but you come off it is very
painful to put in it’s not the other day if you do you could you’re there in the
operating room you could flow to temporary if you want make sure you at
least get an atrial cuz that’s easy to put in because you let your in this
particular instance you’re more likely to have bradycardia from kind of a slow
atrium than you are to have heart block from hitting the bundle of hiss on a on
a or tack valve replacement so if you have an intact bundle this natural wire
should suffice so at least have that if you forget I haven’t done that yet but
mainly that’s because Stephanie these guys have reminded me I think I forget
about 50% of the time on the wires you never because you’re ready you’re
ready to get done I never forget anything sir not they’re super important
parts I forgot in facing worse anyway so the heart you can see was filled there
and now we’re coming back to the monitor and we’re rewarming and we’ve obviously
stopped the potassium hearts the LV decompressed although the right heart
still has some water in it you can see there’s a little bit of air in there but
that’s not significant now on this particular one the LV ven has slipped
back once the heart filled up so you’ve got to put it all the way into the apex
but again it it sucked out enough of the air to be insignificant oh you got to
have sing-alongs ventilation obviously and it’s easy just to put in a dual
lumen tube for this contraindications are you know if you get in there and you
got dance adhesions it’s your level of comfort on taking those down and looking
but there really are very few contraindications to trying this
technique it’s the same ones you would utilize for what you what I would call
it traditional is kind of funny saying that now traditional minimally invasive
module bowel surgery but this technique simplifies it to where if you’re have
been hesitant to use it or you feel like you have resistance from anesthesia
because it does put a large burden on the
this technique basically they’re sitting back there you know in the case of one
of our CRNAs you know listening to YouTube videos while perfusion is doing
all the work if you’re perfusionist drinking coffee and watching The Wall
Street Journal correct alright so in our institution we use CRNAs that are very
well trained and so if you’re hesitant about that and you get the right CRNA
and in a lot of ways I like them better than the anesthesiologists no offence
Dana Susie ologist but as a surgeon you tend to have less of that dynamic of you
know it’s my way no it’s my way so that’s just a little preference of mine
in the timing of this is once you decide to come off and stop the potassium and
there rewarm I mean it is see the sharp QRS complex it’s not that kind of wide
ischemic you know coming off sluggish I mean it’s pretty snappy it’s because
you’ve not had an ischemic arrest so this is a skinny guy pretty generous
incision it’s one of my first ones I li use JP drains put one in the pericardial
space just fit it in there and one posterior Lee in the pleural space and
see your wires coming out we decannulated repaired the arteries and
getting ready to go to the ICU very good that’s excellent that is great
did we ever find dr. Jones can you just call on the telephone
no okay yeah hey you have to call our callin number it’s just have him call
our callin number and it could just be on the phone and I think would be okay
with that yeah you know just my background I mean I think I traded the
best place in the world but I was a great laparoscopic surgeon at least in
my own mind 20-minute gallbladders 15 min ago bladders heart surgery I didn’t
want to do anything like this I mean this technique basically one said
revolutionize my practice because I still do a lot of open complex stuff but
this is a nice adjunct to my practice and it’s only because of the
simplification of it I mean because last thing I need is to be running anesthesia
running perfusion worried about all these different variables and by the
number of variables are decreased by at least half I would say by using this
technique this is so mean it is truly so simple and so safe and I think you’ve
even thought it out there you’re willing to teach anybody how to do this this is
a proprietary I mean no no I mean look you know this is Joe Bosh’s technique I
mean anybody anybody going Finn Finn bypassing you have high K but the point
is yeah but but you know from a especially a community surgeons
standpoint like me or maybe even an older surgeon who’s not really willing
to do this or a younger surgeon just coming out he’s by himself this is a
this takes a lot of the burden off of the surgeon it really does well how many
how many people here on the panel have used port access say I’ve never used it
so I can’t wait you know okay so you know it used to be heart poured and then
it became port access and look I mean it was it was agonized painful I mean you
would sit there at you know start the case at seven o’clock in the morning
with the pay in the room and it was 11 o’clock before
they got all these lines and I know that’s what y’all saw but you know the
same contraindications for this technique or the same contraindications
right that actually exists report access with the exception you brought it up I
think very eloquently you don’t have any ischemic time there’s no having to give
cardioplegia so if you have more than one plus AI you’re not supposed to use
port access to plus AI certainly is a contraindication but I think with this
technique and enough sucker I got was pretty close I think we got misread
right but we just had a big session on TCB and putting the valve it I mean even
if you put a wire around the arch to get down to the leprechaun a cat you’re
knocking off at the Roma there is embolic events occur so now you’re gonna
put this big endo balloon around the arch and inflate it and it migrates and
it moves we’re not measuring that you know I think that is a you know is it as
a serious problem and then what I like if we could get back to Jones on the
phone no okay so while we’re waiting to get dr. Jones on the phone to kind of
discuss that first case Stephanie do you know I think that might be him right
there yeah please hey dr. Jones Hey Joe how are you doing
I’m doing great hey dr. Jones you’re here on our panel here is dr. mark
Metoyer Stefan yeah he’s I think you know dr. McCoy yeah the conference hello
Jones yeah Stephanie Stephanie eBoost perfusionist Minh Tran perfusionist and
of course you know Clint I think he works with you on a fairly routine basis
and the doctor Metoyer just gave an excellent overview of with an action
with actual surgery surgical video of the hyperkalemia technique for minimally
invasive mitral valve surgery and I was wondering if you would be so kind as to
sort of describe that first procedure that we did when we did this technique
so the technique I did originally with dr. Jones is the first case and maybe
talk about of the resistance people may have had
but how it ended up essentially you know your decision to try it because of the
patient’s Anatomy having previous surgery and the Lima on the the the
sternum and just talk about how that first procedure actually went okay first
of the teacher I want to congratulate you on your webinar program actually I
was watching you guys we’re gonna get connected I’m serious with my computer
and apparently I’m honored Wi-Fi but for some reason that that’s okay everybody
everybody knows how good-looking yard doc so and you got a great voice so so
we’ll just put a picture I wish I had a picture of dr. Jones I put a picture of
you up if I’d have known would have had a trouble connecting but you know what
everybody everybody in the audience go ahead and register for the New Orleans
conference today and come visit with and meet dr. Jones in June so that’s the
best way I think to handle that but go ahead doc play better ways to do
meddling faces much of that work and actually that traveled to several
locations to view their procedures and actually came back a little photos
because I thought there might be a birthday so when I was presenting with
the cage the lady had previously underwear Courtney poppers dressing and
all the grass were Oakland and she did a microcell procedure I knew
I didn’t want to do a reduced Anatomy if at all possible so put it together that
change enjoyed you and intimately involved and put in this idea together I
had seen this done but it was done temperature arrest and that keeps left
in about an hour and although the patient has did recover
the post-op then wasn’t keep that you did another hospital
so that’s outlying have the my card in use it that much ATP when we can arrest
the heart and do the procedure and hopefully get a better outcome so again
put it in high they into practice I can’t keep up there by this just dr.
with high-dose pretended and now as you remember there was no literature that we
found that had described anything of that nature so we were so like on that
fertile ground I guess you said but knowing that this could be a bit of
peach with a patient we embarked on this what turns out to be the fridge chase
actually that we end up getting printed of high protein and me arrest much as
well okay our prisoner so hate Roger do you have that article
by any chance that you can throw up there and dr. Joe Jones we did find a
picture of you so you know getting back to that port access you brought up a
really good point because this was a redo with all Payton graphs so you’ve
got the mammary and now you’re gonna if you’re using port access your going to
have to deal with that and you have cuz you’re um on pump right and so that’s
gonna continuously profusing and if you have Payton vein grafts in
the aorta you’re going to occlude them with the endo balloon so that’s it or
you you know think so we’re well depends on where they are but yeah yep possibly
yeah so you give this basically given retrograde the whole time yeah right see
you have circular respiratory certainly exactly so yeah so that first case so so
I had that patient do so you know did you have any fear when we first did it
were you afraid no I think we well it’s the same thing I discussed earlier dr.
Jones if if it’s not gonna sit upright then you could you can even be committed
to the sternotomy mm-hmm and you’re already on with him you’re already on
the fin fin bypass and it actually makes it a little you knows you know a little
safer to do redo sternotomy i think in my opinion we don’t always like to do
that but I’m always I’m always wired out on a redo anyway for it media so not me
for Fenton bypass so let me ask the perfusion in here
can you guys discuss the circuit so you’re actually the first four so I
got to do the procedure first with you now what did you think what I told you
what we were gonna do dr. Jones may not have been nervous but
I was a little nervous okay it’s Stephanie so I did I got to do it first
with your Stephanie’s eyes or that you’re uncomfortable and min I didn’t
know what I was getting into but I was I was ready for it but it was a little bit
that’s what I miss my favorite by the way cuz everybody didn’t know that so
talk about the circuit Stephanie can you describe the perfusion circuit and how
we set that up well initially we always have a human concentrator in our circuit
anyways so we had the one and then we added another one through the roller
head where we would usually do the cardioplegia hey Raj do we have that
diagram I’m sorry to bother you forgive me go ahead Stephanie we’ve had
questions of do you really need to hemo concentrators and I would say yes so
that you could get it all off in a good amount of fast amount of time then we I
also used one of our other pump heads to lie in our do us all for continuous
infusion I can you talk about do us all what do us all is yes so um these are
the things a couple of the things that would make maybe if you’re starting at a
small community hospital you might be uncomfortable with the things we’re
telling you to get at st. Luke’s they do continuous renal replacement therapy so
they are already have the B brawn you have to but you have to have zero
potassium bicarbonate be Brun so that you can continuously infuse we’re
basically Z buffing and people have asked us oh why can’t you just drop a
leader take it off drop a leader but you know
if if we’re replacing about 10 to 15 liters of fluid it works a lot better
just to have a continuous infusion so what I noticed the speed basically ends
up being around we’re taking off about 250 MLS every minute and that’s what
we’re replacing with so in 30 minutes that’s 7 liters 7,500
and those so you can see in 30 minutes you can get off quite a bit with the to
him now he talked about that one of those patients where we gave a massive
amount was an outlier but how much how much a replacement fluid or ziba CD vh
did you do on that patient liters and we still had a little bit of a problem
postoperatively with the with a little bit of rebound hyperkalemia I remember
we have seen that a little bit our patients the big patients it’s the
larger patients so we’ve been actually just giving lasix before we leave the
room and I think that’s helped alive mm-hmm so yeah that’s a good idea and of
course you could do you know glucose and done that we’ve done that as well and
you just have to remind the ICU because they’re being educated on this as well
that you know feel felt comfortable in ordering more labs my stats follow your
potassium and believed your potassium and it’s not gonna sneak up on you but
it’s unless you you know draw labs for 12 hours but yeah it’s the larger
patients we’ve been had a not in trouble with that but we’ve had a couple of out
that out that outlier another large lady we did but you know it’s part of the
critical care management our how many critical care physicians and nurses are
now more comfortable with it mm-hmm well Clint so you’ve done now you’ve probably
done the most cases using this thing you give anybody at this table so what’s
your sort of what kind of wisdom can you impart to our colleagues out there and
web world about this technique well I think you know our circuit and our setup
is basically pretty similar to what you described I think the to Hima
concentrator technique is definitely the way to go I think the the first couple
of cases that you and I did together we weren’t we didn’t you know cool very far
we didn’t that we weren’t using as well all and I think once we started doing
I mean we saw the amount of potassium that we had to give these patients I
mean go down I mean dramatically I mean I think when
we first started we were you know starting with a bolus of you know to 40
to 60 milli equivalents and I think you know now in our protocol what we use
back home as we start out with a hundred eighty million to see where we’re at
from there we need to get more we get more if we you know and I’d say more
times than not we don’t but I mean to go back on that I mean uh schooland down to
you know 30 degrees 28 degrees 25 degrees whatever we need to do and
anesthesia given as Milad bolus and starting to nezam a long trip once we go
on pump has helped out tremendously mm-hmm men what’s your thoughts now
you’ve done now you’ve only done one case better but I’ve watched four cases
about four cases what are your thoughts what could you tell our colleagues out
there about who want to try this technique you know let me tell you this
before you you know it’s kind of give you a sort of a background Stephanie now
we published that case online on view Medi and anybody out there that is
looking for a great resource for educational videos is view Medi calm
they do a fantastic job and there’s a lot of material out there for learning
about stuff that he’ll I’d ever heard of and it’s really really interesting but
we have gotten about six calls from people three of them who said they
really wanted to do this but then they they ultimately they didn’t and dr.
Jones maybe you guys you and dr. metier could could weigh in on this too but why
is that why do they say they want to do it but they seem to have this level of
fear and they just won’t do it because it seems like a no-brainer to me
much better technique I think I think in the perfusion community and you know
just in surgery you know doing a case you know there’s always the fear of you
know safety issues and the unknown and what people aren’t really familiar with
but you know I think if you know you have the right people setting things up
and kind of getting you on on track on how to do the cases
what protocols to do how to approach it from anesthesia or surgical standpoint
and perfusion standpoint and everything’s laid out I think it’s a
safe method to arrest you know arrest the heart with no ischemia and you know
as long as you get the heme concentrators in to get the potassium
off adequately you know when a patient comes off I think you know it could be a
great case especially for the you know because you want to do minimally
invasive procedure and then that haven’t you then yeah for me go ahead dr. Jones
sorry well for me I don’t know I I think I was particularly tired when Joe
approached me with it so I was like sure let’s do it but I’m not putting any
forth any brain ATP and doing this I’m gonna do the mitral and you do
everything else and anesthesia oh oh my gosh they were like you know hesitant
fortunately for me I didn’t have the perfusion pushing back because it was
Joe and so I didn’t have to fight that battle but we got one of our more
aggressive anesthesiologist involved who pretty much do any case and doesn’t care
and so you know because he put all the burden on perfusion as well and for me
that’s where I left it and again your fin fin bypass I mean the wheels aren’t
gonna fall off the cart I mean even if you give a whole bunch
worst-case scenario you’re gonna let it wear off and we give a bunch of lasix or
whatever so but the learning curve like I said before is I mean would you agree
it’s steep and that’s mean I’d to be honest with you I mean I don’t want to
learn how to do it but it doesn’t seem to me like I would have to do that many
cases at least watching to be able to instruct somebody how to do it you got I
mean Stephanie did one case is like no yeah you can do it I mean this is easy I
mean it’s not it’s short your operation to dr. Jones doesn’t make the operation
itself shorter and I think you have the perfect song and what I mean by that is
but I’m saying I wasn’t afraid when that first business case no one’s the first
time I had used that a fruit to do my travell that had been an honor
material for a long time you’re talking about the right anterior thoracotomy
exactly I meant as much as well Midland vases your 2010 making so what was my
first time doing it it was the first time we gonna use this particular
protocol to the rest of us so I mean I don’t think this should be someone’s
first how’s the game kind of doing a minimization by somehow did you tried it
well it was great that Joel is there and if we had topical for a while
it’s worth anesthesia with concern they came along without any difficulty so
mm-hmm well it was my first yeah I’d seen
George rule do one through a big huge right thoracotomy and yeah I was my
first but you know if the patient doesn’t get a sternotomy that is better
for them I mean in terms of the recovery and and everything else I mean I’d
rather have it done especially women yeah you know I mean that’s my there’s a
lot of a lot of benefits I mean you know a thoracotomy is not without problems
too I mean getting chronic post thoracotomy syndrome but yeah I agree I
mean it’s if it’s isolated mitral valve I don’t even care about that to be
honest with you I don’t care if you know about it it’s a sternotomy or or
thoracotomy for me it’s exposure on this mm-hmm
I mean it’s so much easier and I think anybody that does minimally invasive
mitral valves robotic modules whatever knows that it’s easier I mean I don’t
see why this wouldn’t if like you know at a Robotics enter the does module so I
don’t know why that yeah this is this is this is in my opinion than the easier
way to do it especially if your animal and most of those are in residency
training programs mm-hmm I mean temp them okay and there’s
no rush no rush you’re the red you can do it you know you can do or get
through part of it or whatever yeah so Clint man Stephanie one of the things
that I’ve noticed is that when we come off pump with these patients and and dr.
Jones dr. pretory as well but but we I noticed that their hearts almost appear
even if they were a little depressed to start with hyperdynamic what do you what
do you attribute that to 110 fio2 they tend to go back but how
much of the high volume ultra filtration do you think you tributes to the removal
of an arson understand it either that’s true it’s not swollen no walls you don’t
have just yeah you can close you can close the pericardium if you want I
usually put just a couple stitches but it’s not like after doing an open where
you get that reperfusion and swelling you don’t have the swelling yeah well I
mean I think it’s it’s all of that I do and I think a hundred percent as well
when when you’re doing high-volume CRT in particular CVH on these cases I mean
you’re removing these inflammatory mediators control yeah I think it’s
absolutely it’s a big impact huge I do want to touch on the yeah dr. Jones go
ahead yeah that’s true that’s the best cardioplegia in the
world would I see a minute the question I’ve been getting a lot is what does all
that potassium do to the rest of the body are we causing any harm and I’ll
tell you we haven’t seen any issues they’re awake excavated the next day
talking have you see no well no the fit the physiology of the
human body is if you have systemic potassium is to get rid of it whether
it’s pee it off drive it into the cells I mean the otic gradients are such that
it’s going to happen mm-hmm you just I think unless you know once you get most
of it off with what you guys do the the human body takes care of the rest it’s
not it’s it’s you’re resetting that and then that mechanism the potassium sodium
ATP sodium pumping potassium well you know interestingly enough 400 potassium
is barely 10% of the total body load of potassium so it’s really not that and
not as much as you think it is it’s just extracellular it stops the
heart down to caveats to that don’t give it fast that’s because if you do if
we’ve seen that more you’ll see a big spike in your blood pressure you’ll
you’ll see that that reaction occur but you know in talking to every
physiologist and pharmacologist and intensive care doc that I could find for
ologist everybody there is no morbidity associated with giving someone 400
potassium except cardiac arrest diastolic arrest which is what we’re
trying to achieve unless you’re in Huntsville and then you know the
consequences so you need to be on bypass to do this but going back to that
solution the pediatric folks are very very familiar with this so we’ve all as
perfusionist we bibzy bluffed in the past using normal saline
it’s acetate based not barkay bicarb based so you get the pH adjustment but
you dilute your bicarb as you constantly are doing removing fluid and replacing
it with saline this solution is normal physiologic bicarb based but they just
take the potassium and you get multiple formulas with calcium without calcium
with potassium to a zero potassium to potassium three potassium for potassium
whatever it is you want so we use zero potassium but we can do
this enormous volume of hemofiltration z buffing in essence for you know people
who are watching this familiar term and have the bicarb just the acid-base
balance just stays perfect I would be like they’d be a horrible idea doing
horrible idea so so with all of that said dr. Jones any any any final
thoughts and what we’re gonna do would not would like I don’t know if you have
the time but if you could just hang on for a little bit I think we want to go
to a quick commercial break and then that gives people time to call in
because they may have some really good questions about this and I think we’ll
put the call in number so if you want to call in and ask any questions up the
panel that’s here and also dr. Jones whose remote over in Louisiana
Rogers putting the number up right now go ahead and call in and the phone lines
are open and dr. Jones do you have a few minutes to hang around sure that’d be
great ok so we’re gonna go to a quick commercial break you’ll still be on the
line with actually however gonna do that Roger
how can he be on the line he can stay on the line through it all ok good so yeah
if you’ll just stay on the line you’ll still be live with us but we’re gonna go
ahead to commercial break and then when we come back some people will be calling
in with some questions ok so we’ll see you all back and just watch the
commercials ok remember we got to keep the lights on and we monitor who’s
watching so if you leave and try to go to the bathroom right now
I’ll see you left your computer so hurry back ille cannula blessed jet more natural
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I thought the phone line dr. Jones you still with us I’m here
okay are we gonna get me sir Rogers people can call in okay so how would we
know if they were calling you just see uh-oh nobody’s called so far oh come on
we don’t have any calls everybody left listen yeah they’re listening no no no
no no questions so I guess what we could talk about is I think Clint and and and
men wanted to talk about how the Saints got robbed and so that’s that was dr.
Jones did you cry Jimmy did you cry where when the Saints lost
oh well require the true face man wouldn’t cry is one of our perfusionist
that we work with as a he’s actually from Pittsburgh so he was a Steelers fan
that was about that close that morning to calling him the messin with him about
Pittsburgh illusion I said I better wait a little bit well if we’re if we don’t
have any calls you know how about we just go around the table in case some
unless somebody does call in and and well well well God you let me know and
we’ll just start with the left side over actually let’s start with the the
speaker first dr. Jones any final thoughts regarding what we’ve been
discussing today and we’re just going to kind of go around the table here and and
move forward you want to have in your materia with certain cases and benefit
the patient nothing that you can take the hey hey
Doc I’m sorry to interrupt you we did get a call for a question so I’m waiting
interrupt you okay we’re gonna merge the calls hold on
so appearance okay hello you have a question Terrace I sure do
can you talk a little bit about yeah I’m so sorry do you mind telling us who you
are where you’re from sure okay you actually work with us but I didn’t
recognize your voice okay what’s your what’s your question so we initially
started out I have a hundred and eighty million comments drawing up a potassium
in a syringe and I just give it slowly over a few minutes and you’ll just see
the heart gradually start to stop I say more times than not we do add another
I’d say 40 to 80 over time but only so that if we need it if you if dr. Midori
is complaining that the heart still beating and he needs it a little more
still I’ll just keep giving a little bit at a time until we get to where we need
to be would you say that’s about right yeah we’re like a few minutes we do the
same like I said we start out with 180 millions as well more likely than not we
do have to add a little bit throughout the procedure every once in a while
you’ll get a little little beat here there you know here either doctor Jones
or dr. DeWitt who dr. McCoy was talking about earlier who we trained with of
course they’ll let you know as soon as you get a B heart beating the heartbeat
oh my god yeah it’s just it’s chaining you dynamic
really that’s what it is I think the biggest key is is a gradual delivery and
like I said what helped us out with the cases that we’ve done we’ve done quite a
few here lately is when we kind of put our heads together and kind of figured
out you know cooling this patient a little bits gonna you know help us out
anesthesia starting some as well putting the decimal all drip on it like I said
it’s significantly reduced the amount of potassium that we have to give during
these cases and I’m assuming y’all yep you guys probably do the same over there
cuz we did exact same and I don’t want to you know I think that you know I
don’t want ever fusionist out there to be freaked out about you know cases like
this I mean honestly yes it is helpful to see one and it’s you know kind of
freaks you out the first time you hear about what you’re doing but you know for
us and I know you know I of course I had Joe the there to help me learn how to do
it but you know now it’s it’s like any other case I mean it really is I mean
the the setup is not extremely difficult I mean you know you take your car deeply
just set up out and you know replace it with you know the the setup to do the CV
pH and I mean there’s not much to it so I don’t want to you know freak everybody
out think that this is something you know create them do yeah we had put the
diagram up you know that diagram that your your brother drew that for us right
and he’s a CAD design or CAD draw or whatever but let me just ask everybody
here dr. Jones dr. Metoyer Stephanie men Clint of course myself as well if
anybody out there that’s watching this wants to try that whether you want to
talk surgeon to surgeon or perfusionist a perfusionist or whatever the case may
be you’re welcome to reach out to any of us
we’re happy to discuss the case with you and help you get through the first one
if that’s what you’d like to do know one thing I switch to I did have the second
humans going through a roller head and that
just helped ensure that we didn’t get any backflow or air into the system but
we had a case where we needed an extra vent so I had a pump for our dialysate
and then I had a pump for the humic concentrate and I had to pull make him
concentrate or help to vent and what what I found is that once I added a
one-way valve into the second humic concentrator so I wasn’t worried about
backflow in that anymore it really simplified it for me because
I’m not running that as an extra pump and having watch it it just it just
might continuous now see I I don’t like that I don’t like it because when you
have that line going in to the top of the reservoir and we use vacuum assisted
in this return that’s a negative pressure and so I like to use the roller
pump because I can generate a much higher pressure in the blood phase of
the of the fibers and it helps to push the ultra filtrate out a lot faster and
I can ultra filtrate a lot more volume in a short period of time so that’s why
I like to use the roller pump not necessarily for the flow I do it for the
pressure for that positive tension on in the inside of the of the little pipettes
the little fibers I haven’t seen that it slows down yeah I mean you know if I I’m
still ran my dialysate at the same rate I don’t yeah but you hooked up to a
Neptune though right yeah that’s massive negative so you know do you recommend
you use a Neptune or you you use suction or do you let it just flow through just
the pressure gradient into atmospheric pressure do you hook it up to a suction
I’ll hook it up associate to the next step yeah gravity drainage is just gonna
take way too long that it’s gonna extend the procedure out and you know it’s
gonna get these guys you know on our back they say they’re patient but they’re
ready to come out well but that that’s directly contradictory to what you just
said a minute ago you know there’s no worry you know it comes what I’m doing
yes that’s exactly would your ready chances like that – doctor – it’s
another call okay Patrick thank you another call oh
no hello hello hey who’s this yeah yeah this is Joe oh this is Gopi Carelli
profusion it hey Gopi how are you nice to talk to you what you what you got
where what you got Gope I just got a question about getting touched the basis
of the perfusionist point they use sex I’m sorry
Gopi could you say that again I didn’t understand your question I said what
killer what cannulation Tech need you to use oh yeah oh yeah
film film I mean you gotta be mm-hmm I mean that’s that that’s well you could
do do any other yeah if you got a horrible peripheral vascular disease you
could do venous ephemeral venous and an axillary yeah yeah I haven’t done that
but you know having patients wanted to know what kind of cannulas did you use
oh you can use the Edwards yeah yeah Gopi you could use the Edwards majority
or the Medtronic you know or the Soron I think or liba Nova whatever they’re
called now has has their own version of Aztec cannulas I think is what they’re
selling okay and I mean any standard femoral femoral kinda like though you
would use if you had a redo and you just wanted to cannulate and go on popper
well you’re doing VA ECMO right appart a percutaneous cannula set but do an open
technique so you’re not sold into the artery or you know using umbilical tapes
or silastic loops or whatever basically
sometimes have to but basically you know you want
to get enough of the cannula in there you know as it Texas Harve use the old
we’re cheap beveled they order candles and barely there’s like a centimeter tip
in there and but the Edwards percutaneous kits but just just yeah but
just do an open technique that because the surgeons got to fix it afterwards
you know and but the options would be axillary film or phantom hey hey dr.
Jones you still with us yeah hey can you talk about placement of
the venous cannula because if you’ve got crummy drainage the procedure is is is
is horrible you know so you know placement and drainage is critical so
what what is your your your placement where are you where do you shoot what
are you where do you attempt to place the tip of that vfm cannula to get the
best ramage yeah area in visitors indicator because then I know that I
have the back you know opening in dividers writing to so where do you put
it again I didn’t hear you okay so you put the tip so you go all the way up
through the atrium into the super ear in a cable with it and you can actually
feel that through you can feel your throat ah to me
generally I’m unless you’re that unless you’re six five and 300 pounds and then
anesthesia help because sometimes that tip does go into the atrium and then you
have drains problems I use about any of these about an ink inside that sleazy
correct yeah the atrium lifter will sometimes change that so you may have to
modify that place some in a little bit further when you lift because it may
pull it out of the SVC but it it’s it’s pretty easy to manipulate from the groin
and the chest at the same time now we had a case one time here I don’t
was you I was doing the case with and the drainage was horrible not if you
remember that or not and I think they were just yanking up on that lifter and
it was you know just a really difficult Anatomy and they’ve really had to ganged
up on it and that cannula wasn’t in the super he Clips out it goes into the
atria and we stuck that cannula in the right IJ you remember that so you put an
opt in the right IJ wide them together and it was beautiful right that’s
another option is you can dual cannulate that way kind of like you know
traditional mitral surgery except you do it through the high J and yeah in the
femoral veins and you just use a little smaller turnip cannula and with the
vacuum assist it just work it really worked well I mean it got us out of the
the heart decompressing lit just calmed everything right back down again yes you
have bad drainage and the heart stuffed and you can well that’s the other videos
I’m not having a retrograde cardioplegia catheter in you got that access the next
open ready to be used in case that happens you can really stick a right IJ
catheter in there where did we have another caller the same did we have
anybody else online I’m still there okay go be ok go pee all right well I hope
that answers your question dr. Jones you’re still there I’m here
all right well I think we’re gonna I think we need to wrap this up I think
are we are we on time here a lot guys or a little early 11 2000 we are a little
more thing yeah just from a perfusion standpoint I mean if you know I got a
question okay don’t be go ahead good morning to all the panel and morning
hello Gopi yeah using Dhoni before you play here um I mean you know for this
type of procedure or are you saying just in general this type of procedure well
no because we we have no need to arrest we have no need to give cardioplegia
because the heart is being continuously perfused with oxygenated blood so it
wouldn’t make any sense we don’t ever touch the aorta
having to cross-clamp asking me right no ischemic time at all so yeah be I think
del Nido on its own merit is probably a good a good solution you know but but
that would only be applicable if we were planning on cross-clamping the aorta
because you know me you can do your technique you can use the Chitwood clamp
you know that articulating one and snake it in there you know you make another
incision and you put it in there but those things slip but I think you’ve
done a lot of cases with the chip would clamp haven’t you in it and it it slips
off you’ve got the heart stop now it’s beating again and it’s pretty
frustrating so you know I mean your questions a good question but I don’t
think it’s applicable in this scenario okay well yes we have really an
astounding heart I would say and one thing that helped me a lot was having
good circulators we get a ton of calls from the lab from the pharmacy you want
how much potassium you know potassium I need get any things to lab quickly I
think that really helped alleviate a lot of the problems that if you are trying
to do this as a perfusionist by yourself and the surgeons like okay you take care
of it and no one’s helping you in the room then I do think like you know to be
really prepared and planned out and talk to each department many well let me well
you know you brought up a very good that’s a very good point in it and I’ll
add something to this what we use to monitor labs okay we really need this
you’re talking to the rabbit on point in it st. Luke’s Tama and I’m being
serious about this we use the ice that mmm
the ice that will only read a potassium to eight all it says is greater than
eight right we don’t know if it’s 8.1 or it’s 15 so it’s hard for us to kind of
assess and of course you know I don’t want to get into the the minutiae of you
know the simplicity of just I mean what do you think of that Siemens machine
what’s your view nobody’s paying me to say anything by the way so I love it I
mean it made ours you know the the process I mean a lot simpler
I mean you gives you the result right there in front of you not having to wait
I mean you’re not guessing that like you said you know where you’re at I mean you
have it basically right there I mean if you’re 13 it’s gonna tell you you’re 13
you’re just gonna say you’re 12 and you have confidence in the values not a
percent okay with now yes when we first started I mean we’d got up to 18 and kid
it doesn’t my point is it yeah it sounds crazy but it’s no different than 12 it’s
nice it sounds like pure insanity but it’s not it’s a lot of new stuff out
there from heart surgery this is I think this is pretty innovative well I think
unless anybody has anything else we’ve had a great session we’re gonna go ahead
and you know we have a studio audience me do you have any quit you know I
didn’t even address the studio Nate shaking his head no absolutely not he’s
retreating now out of the door he’s running he just said a word has not said
a word and that is highly unusual because it is in the
yes yes yeah he’s doing the next one he’s doing it gonna have to Nate I’m
sorry it’s just part of the program but we’ve had a great time and I can’t thank
all of you enough for participating in our first webinar of our webinar series
don’t forget our website perf web dot us don’t forget think conference the New
Orleans conference com and so on behalf of myself and this
illustrious panel that I feel so privileged in dr. Jones on the phone
from from Louisiana beautiful state you know crawfish seasons here but I’m
worried cuz it got really cold gonna be smoke gonna be small the Saints are out
of the the playoffs and the Super Bowl chances but that’s okay but I hope to
see you again at our next one I think it’s scheduled for February 7th but you
go online and see that we’re gonna try to keep these topics fresh and new and
different so if you have any ideas look email me you want to be part of this and
do it remotely through Skype or through the telephone like dr. Jones did let us
know we’re happy we’re looking for people that want to be involved and part
of the education process and part of the overall goal which is to help improve
the outcomes for our patients and to share educational information
information was meant to be shared not just held to yourself to make yourself
look good it’s about it’s supposed to be about a greater calling so let’s all
keep that in mind and once again thank you all very much
did your yes sir I’m gonna say one thing the way off 300
birthday that’s right so the Norman cops will be here and
things are gonna really happen in New Albany hotel rooms so we’ve got a booked
whilst what I’m saying we haven’t belong you better get the block right yeah so
dr. Jones do we need to add a day to the block for recovery all right thanks doc you take care of
yourself great talking to you and thank you so much for participating thank you
thank you all very much again out in web world have a good day enjoy your
Saturday you you