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Hypothermic ventricular fibrillation

Hypothermic ventricular fibrillation. Introduction. Cary W. Akins Basic principles developed in 1960 - 1970 Most surgeons use hyperkalemic cardioplegic arrest Useful tecnique 1984 - Akins operated 500 pts, demonstrated low peri op infarction and hospital mortality.

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Hypothermic ventricular fibrillation

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  1. Hypothermic ventricular fibrillation

  2. Introduction • Cary W. Akins • Basic principles developed in 1960 - 1970 • Most surgeons use hyperkalemic cardioplegic arrest • Useful tecnique • 1984 - Akins operated 500 pts, demonstrated low peri op infarction and hospital mortality

  3. Indications and contraindications • Successful with revascularisation and LV aneurism • No aortic cross clamp: • Redo mitral valve repair • Calcified aorta • Brittle aorta • Problematic in AI

  4. Principles • VF and no aortic cross clamp • Hydraulic argument • Root P 80 – 100 mmHg • Low P in LV • Hypothermia • Proximal anastomosis prior to bypass

  5. Principles • GA and IV TNT • Β blocker post induction • Heparin prior to cannulation • Proximal anastomosis • Mannitol and crystalloid prime • 28 – 32 ˚C • MAP 80 – 100 mm Hg • VF • Venting LV • No cross clamp • Vessel isolation • First graft • Circumflex • warming

  6. Pre operative • Regular preparations • Akins suggests non ischemic status

  7. Post op • Coronary perfusion • Diuresis • TNT • Aspirin

  8. Advantages • Less trauma to aorta • No retrograde cannula • Decreased global myocardial ischemia • Grafting in any order • Side effects of cardioplegia prevented • Pulsatile flow with balloon pump

  9. Disadvantages • Partial cross clamp for proximal anastomosis • Transient ischemia • Local isolation • Retraction of heart when doing posterior and lateral anastomosis • Blood in field • Fibrillating heart more MVO2 • Fibrillating heart decreased DO2 • High risk with hyper tropic myocardium • Air emboli

  10. Operative tecnique • Anastomosis as usual • Heparin prior to internal mammary A clamp • Papaverin • Aortic cannulation • Check veins • 5 grafts (Akins) • Proximal anastomosis • Avoid calcified areas • Side clamp ( check pressure) • Proximal anastomosis prior to bypass • Venous cannulation • 28 – 30 ˚ C - VF

  11. Operative technique • Venting • Distal anastomosis • Most ischemic area first • Left lat circumflex prior to LAD • Occluded vessels 1st • Regular technique • Remove air prior to tie • Warming • 34˚C • Pacing wires • Vent out • Weaning

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