[HSF] OPCAB

Tue Dec 5 20:13:38 EST 2006

Ajit, 
I found your reflections quite well measured and would in no way try to convince you to be otherwise. A surgeon needs to first understand his own his personal observations (experiments) before he can translate those of others to himself.
Regards,
Tea

----- Original Message ----
From: Donald Ross <donross at bigpond.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Tuesday, December 5, 2006 7:16:35 PM
Subject: Re: [HSF] OPCAB

Ajit,
As I understand it from your well presented experience, you actually  
think ocab is better particularly when the aorta is not manipulated
but you felt after giving it a prolonged try that revascularisation  
on the arrested heart was more reliable.

I wonder whether your decision to change back to the dark side was  
prompted by an opcab disaster which wasn't mentioned  in your  
confession?
I think this is a common and understandable reason. Tea is correct  
when he claims that you need to do 500 opcabs before a degree of  
comfort and confidence is achieved. A caveat to that is being taught  
the art by an experienced obcab surgeon.

I think your experience is quite common and even at my unit three out  
of the five surgeons do the majority of their cabgs on pump.

You and they are prepared to accept the small neurological penalty   
associated with aortic clamping to achieve better and perhaps safer   
revascularisation.
There is no doubt ( despite Hal ) that avoiding the clamp is  
beneficial and that is born out by the data from our unit where the  
stroke rate for oncab is very low and that for anaortic opcab is  
almost non-existent .

This debate always touches a nerve because most of us acknowledge  
aortic clamping is best avoided but  it is awkward and sometimes  
dangerous to do so.

One final question, Ajit:  Did you ever consider doing the difficult  
cases "beating heart on pump"  a method I use at the hint of an  
actual or potential problem?

Don

On 06/12/2006, at 8:26 AM, Ajit Damle wrote:

> Tea and Tushar,
>
>
>
> My argument: on-pump CABG is the best approach in my practice. My  
> argument
> is rather lengthy, but I hope, not rambling.
>
>
>
> I was an early enthusiast for off-pump. I started in 1997 with  
> MIDCABs, did
> not like those and 1999 switched to OPCAB. I slowly became quite  
> adapt at
> it, and by 2004, I was doing 80-85% off pump, a total of several  
> hundred
> patients.  I became quite good and managed to convince myself that  
> I was as
> good off-pump as on. In retrospect, though, I was never as perfect  
> as with
> on-pumps.
>
>
>
> I am quite certain that eliminating CPB could reduce the  
> complication rate
> substantially. However, I think this is negated by the heart's  
> dislocation
> and subsequent reduction in cardiac output for an hour or two. This  
> seems to
> matter in elderly atherosclerotic patients. Also, the quality of  
> anastomoses
> in difficult situations left me with some doubt and uncomfortable  
> feelings.
>
>
>
> One of the important advantages of off-pump CABG is avoiding the  
> aortic
> manipulation. If you have to side occlude the ascending aorta, this
> advantage is lost.  I was exclusively using the LIMA-LAD with the  
> LRA as a
> side branch to re-vascularize the Cx and RCA.  With the recent  
> papers from
> multiple institutions regarding the unsuitability of the RA to  
> graft the RCA
> and any vessel with less than severe stenosis, I changed my  
> practice. I have
> been using the endoscopically harvested SVG for the right sided  
> anastomosis
> and any Cx vessels with less than severe stenosis. I have decided  
> not to use
> the IMA as a source for the vein grafts and so use the aorta. This  
> I do not
> want to do on a beating heart. The anastomotic devices for the  
> proximal vein
> graft-aorta may provide a solution, but that is not feasible and  
> practical
> for now.
>
>
>
> I also found that I sometimes did fewer anastomoses off pump. I do  
> not know
> how important this is, as the vessel I would not do off pump would be
> relatively small. What do we know about the completeness of
> revascularization? Well, for one, CABG has worked very well as a  
> shotgun
> therapy for CAD, not worrying too much about the "culprit vessel".  
> One good
> argument in this regard is the cardiologist's utter inability to  
> predict the
> location and timing of future ischemic events by looking at the  
> current
> coronary angiogram. Secondly, there is evidence in the literature  
> that, at
> least, the initial morbidity and mortality is less with complete
> re-vascularization, although when you look carefully this is  
> certainly not a
> class I evidence.
>
> Again, it is known that up to 10% of SVGs occlude in a short time.
> Presumably these are grafts to smaller vessels, with poor flows. So  
> what
> would it matter if they were not done in the first place? I do not  
> know.
>
>
>
> Next, I also had a tendency to graft the vessels a little more  
> distally, so
> as to minimize the heart's dislocation and produce less ischemia on  
> coronary
> occlusion. The vessels are a little smaller distally. If it is true  
> that
> grafts to smaller caliber vessels occlude earlier, then this may  
> not be
> desirable.
>
>
>
> I have always kept abreast with CMEs and studied the literature  
> carefully.
> When I looked at my clinical outcomes I did not find that I had better
> results with my or my partners'off-pumps. I do understand that such a
> comparison is not scientific, but I (and the hospital) have these  
> numbers to
> use for quality control.
>
>
>
> If my off-pumps were any better (and indeed the blood transfusion  
> rate was
> lower in off-pumps) the advantage was offset by the above grafting
> considerations. I did have a higher incidence of graft closure in my
> learning curve, which improved dramatically with practice.
>
>
>
> I think all these are good reasons. Now I am going to be honest and  
> give you
> some not very good reasons. Initially, I not only thought that off- 
> pump was
> clinically superior and wanted myself be seen as a progressive  
> surgeon, but
> there was also some competitive pressure (the billboard saying "We do
> beating hearts here! Come to us!"). The cardiologists were enamored  
> and it
> helped the practice to get referrals. Many patients (yes, even in  
> North
> Dakota and Minnesota - our referral base) asked about "beating heart".
> Slowly, though, with many publications that could not settle the  
> issue, the
> cardiologists in their national meetings felt that off-pump was not  
> the
> answer to the CABG issue. Coupled with this was the fact that most  
> major
> institutions did not adopt off-pumps. So any pressures from the
> cardiologists and the public ceased to be problem.
>
>
>
> I still think that in some cases, particularly with diseased aortas,
> off-pumps are better, and in such a patient this I do, or better  
> still have
> one of my partners do it as they both do off-pumps. I am fortunate  
> to be in
> a confident, secure practice and do not have to stick to "not very  
> good"
> reasons anymore.
>
>
>
> In my CABGs, I do all patients on-pump. I use low dose Aprotinin in  
> all
> cases (1million before bypass and 1 million in the pump), use LIMA  
> in all
> cases, endoscopic LRA for Cx and SVG for RCA. I use an intra- 
> coronary shunt
> (1.5mm) and check the flows, just as I did with off-pumps. I use high
> perfusion pressure (80-100 mm of Hg), do all the proximal  
> anastomoses with
> the aorta cross-clamped, and use the Embolex aortic filter in high  
> risk
> cases. Pump time is usually an hour, sometimes up to 90 minutes.  
> The current
> blood/blood product  transfusion rate in our practice is some 19%  
> for all
> comers.
>
>
>
> I think one has to thoughtfully weigh all the factors including the  
> clinical
> evidence, practice circumstances, one's own level of skill and  
> judgment (one
> of my trainers always said the easiest person to deceive is  
> yourself), and
> the external factors. What is more important is an honest  
> evaluation of
> one's outcomes and how one can improve them by whichever way one can.
>
>
>
> Sincerely,
>
>
>
> Ajit Damle
>
>
>
> PS
>
>
>
> Tushar,
>
>
>
>
>
> Now, if in your practice, if you can maintain good cardiac output  
> with the
> heart dislocated, can do the anastomoses very quickly, can go  
> proximally, do
> as many grafts, and feel that LIMA-LRA combination is good for all  
> patients
> or side occluding the aorta is OK and so on, then my arguments do  
> not apply.
> Good luck to you. I do think though, that since the issue of  
> superiority of
> OPCAB is still contentious, personalize.
>
>
>
> I also think that the comparison with MV repair is rather  
> misleading. There
> is no contention that repair is superior to replacement. So one should
> strive and keep on learning to do repairs. I am not so sure regarding
> OPCABs.
>
>
>
> Ajit
>
>
>
>
>
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