[HSF] how others will see us

Salerno, Tomas TSalerno at med.miami.edu
Sun Dec 3 09:32:54 EST 2006 

My major change in practice of coronary artery surgery has been abandoning the heart lung machine for these operations, and making sure that all constructed grafts, especially the LIMA-LAD is patent. The only way to determine that, is by using quality control of all anastomoses via one of the technologies available, such as flowmetry or SPY techniques. 

By doing this, the incidence of EKG changes, MIs, return to OR urgent due to ischemic changes, and others have practically disappeared. I have trouble understanding how surgeons can perform coronary artery surgery, with the need of loops, and yet do not determine the quality of their work before and after protamine administration, regardless whether this operations is done on or off pump

 

 

Tomas

 

 

Tea,
Very interesting  and plausible hypothesis regarding the reason for a 
lower MI incidence  for opcab!  There is little doubt that grafting 
tiny arteries is not beneficial except when that is all on offer.
I don't know the incidence of routine shunting by dedicated opcabers 
but my MI incidence almost disappeared when I became a shunter.
Perhaps if the on pumpers had a fat tube in the artery during 
anastomosi they would also find it hard to muck them up.
Don.

PS We received a call from a country hospital about a problem with a 
post-op cabg and the young doctor made the comment that It must have 
been done on pump because the patient had some cognitive decline. He 
was correct but the pity of it was that he was not a cardiologist.

On 02/12/2006, at 5:26 PM, Tea Acuff wrote:

> As mentioned earlier in a thread about bias, evidence and aprotonin 
> I have thoughts
> in referrence to http://stroke.ahajournals.org/cgi/content/
> 37/11/2759 (In Stroke, 2006, "Off-Pump Surgery is associated with 
> reduced occurence of stroke and other mordidity as compared to 
> traditional coronary artery bypass grafting..." by Sedrekyan, 
> Wu, ...Treasure)
> I don't read much of our literature, but am occasionally shown 
> articles by those trying to interact with us and learn a lot. I 
> found this an interesting perspective for those that seek to know 
> us. In general I believe the findings to agree with my past decade 
> of beating heart experience. (I think "off pump " is a simplistic, 
> yet commonly discussed, benchmark for patients even if I do that as 
> my standard.) I try to do only what is required. I, perhaps like 
> the authors (is that why it is in "Stroke"), have stoppped trying 
> to change surgeon's minds, although there may be reason to 
> reexplore these issues. The discussion does point out the fact that 
> the RCTs tend (as do more so the cardiology papers) to pick the 
> "better" patients of which I think there is general agrement will 
> have less benefit with a particular technique, but let's just deal 
> with the findings.
> To wit:
> 1) 255 abstracts were narrowed to 41 RCTs by two authors for a meta 
> analysis of 3996 patients, not all endpoints were so represented as 
> patients available for mortality were 3996 but patients for 
> reintervention were only 1660
> 2) significant differences favoring off pump were stroke 0.6% vs 
> 1.6% (p=.03), afib, 16.9% vs 24.8% (p<.001), wound infection  3.8% 
> vs 7.7% (p<.001), MI 2.6% vs 3.4% (p=.26) renal failure 1% vs 2%(p=.
> 26)
> 3)favoring on pump: reintervention (9 trials only) 2.4% vs 1.2% (p=.
> 08) cross over 7.9% vs 1.6% (duh!) (p=.08)
> 4) neutral: mortality 1.6% vs 1.6% (p=.89)
> 5) there were less grafts per patient in the off pump (-.26) but 
> this varied inversely by study size of the number of patients per 
> group with the "large" groups >50 (-.15) and small <25 (-.61). also 
> studies with much higher on pump mortality (heterogeneity) than the 
> norm were excluded.
>  Interesting the authors also did elsewhere a meta analysis of 
> aprotonin as statistical analysis appears to be an interest of theirs.
>
> My reflections:
> This is a (very) good risk group: mortality = 1.6%
> Surgeons are the least able to be objective about the data, and 
> with good reason. If it takes 10 or more years to be good at 
> something and you plan to do surgery anyway, it is stupid to change 
> unless you think it is worth 10 more years of your life (or 5 if 
> you a are a quick learner). It is not like changing types of stents 
> that can be learned in a couple of weeks or even 50 cases. I 
> personally think off pump skills take >500 cases to be similar to 
> on pump (assuming that you have done 500 on).
> If the main reason more surgeons don't adopt off pump techniques is 
> for concern of poor anastomoses, why do on pump techniques have 
> more MI's?
> How many surgeons would prospectively trade 1% MI intraop for 1% 
> reintervention postop? (I did not note that angina was LESS common 
> in the postop off than on pump patient by the away which may be a 
> futher bias...the "we did all we could"...)
> One of the keys to understanding this data is to think about what I 
> claim EBM (evidence based medicine) is about. It is the study of 
> the behavior of doctors to therapy as much as the patients response 
> to our behavior.
> Here is how I logically think (I may be completely wrong, but it is 
> my logic) about how off pump can have less MI, equal (? if we use 
> these numbers as real world) mortality, and more reintervention. 
> Surgeons over time become comfortable with their ability to do 
> "necessary" anatomoses. All things being equal, which only is 
> imagined to happen in a study not the real world, it is easier to 
> do tinier and more diseased vessels with the heart still (intra 
> surgeon not inter surgeon). More intra surgeon MI's come from 
> stupid choices than stupid technique. (It may well be that surgeons 
> with bad technique have more MI's , but this will not show up in 
> randomization.) Just because you can sew it does not mean you 
> should sew it. That is, surgeons adjust to their techniques ( if 
> they have any brains at all) to their comfort which is in no 
> (necessary) way similar to the needs of the patient. OFF and ON 
> pump techniques are like bulls in a china shop. Just beacuse one is 
> smaller and can go
>  down a smaller isle doesn't mean it will do less damage 
> automatically.
> Reasons for less stroke are both simple and impossibly complex.
> Reasons for less afib are so far and remain largely the newest 
> conjecture.
> Ultimately the reasons for less morbidity of any kind is that IF 
> you can accomplish what you need, less is always a better technique 
> than more.
>  If you can't and didn't (do what was needed), you may have to go 
> back earlier  (reintervention) than you thought which is a 
> judgement call.
> If we don't stop reading papers for statistics and think about what 
> they mean, we (and our patients) are dead in the water.
>
> Tea
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