[HSF] OPCAB

[A]

I am surprised that no mention was made about doing coronaries on pump
beating. That what our group does most of the time. We are happy with it one
can avoid the awful cross clamp. Our mortality with ischemic mitrals and
CABG has gone way down. We clamp only for the mitral and do the grafting
without a clamp. 

 -----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Ajit Damle
Sent: Wednesday, December 06, 2006 12:47 AM
To: OpenHeart-L at lists.hsforum.com
Subject: RE: [HSF] OPCAB

 

Thank you Hal, Tea, Ben, Don, Ashok and Murali, Ani and many others, for
your kind and thoughtful comments.

 

Ben, you are right about Dr. Salerno. I was a little out of line, and I
apologize. His standing is higher than many like me. To see names like Ben
Bidstrup, Tom Salerno, Bob Frater, Tea Acuff, and so many others on the
Forum can be intimidating. Nevertheless, Science (partly represented by
evidenced based medicine) humbles us all and commands us on equal footing
before Her.

 

Ashok, I am delighted to read you can "routinely do OPCABs and always graft
the vessel right close to the AV groove without any starfish like device".
Obviously this is the right strategy for you and I wish you good luck. Do
you measure continuous cardiac output, or do you rely mostly on
intra-operative blood pressure and post-operative outcomes? I presume the
latter.

 

Hal, perhaps land sharks are poikilothermic and do not tolerate the prairie
winters! Also, with so thinly spread a populace, we are slim pickings.

 

Don, my "confession" did not mention a particular disaster after which I
stopped doing OPCABs, because that was not the way it happened. I was uneasy
all along with my OPCAB re-vascularization and had some late graft
occlusions, more than I saw in my on-pump patients. I did have some
intra-operative close calls and a higher rate of conversion earlier in the
learning curve that progressively fell. I started doing OPCABs gradually,
and stopped doing them gradually as well, going through many shades of gray
before finally melting in the "dark side". This was mostly from
introspection and the reports about the unsuitability of the RA in many
circumstances. To my mind, aortic manipulation during OPCABs takes away half
the charm. Yes, I have thought doing (but have done only a few) CABGs on
pump and without cross-clamping, particularly the acute ones. I should be
doing more of these. Thank you.

 

Murali, you echo the comments of many OPCAB surgeons. Indeed, it is
astonishing how reproducible the CABG surgeons behavior is across the world
when the technique is "surgeon specific and not reproducible". It is correct
that it takes "quite a bit of dedication, perseverance and team work to
succeed". But that is true of most of our practice. On-pump surgeons do
complicated cardiac, congenital, valvular, aortic, vascular and thoracic
surgery, and do it so well as to be leaders in the field. It does not stand
to reason that they are somehow deficient in the skills required for OPCABs.
After all CABG is not some exotic, rare, complicated operation but the
commonest, the bread and butter procedure for us.

 

Again, Murali, you have pin-pointed the issue with the phrase "the surgeon's
mind set". Having talked to so many surgeons, the mind set of on-pumpers is:

 

            Show me the money. What kind of evidence do we have? Class I,
II,III?

            Second, to quote Wendy's, where is the beef? Are my in-hospital
OPCAB patients doing better?

 

Most on-pumpers believe, as I do, that avoiding the CPB has to be good.
Avoiding the aortic manipulation has to be good. But how much better? And
more importantly, at what cost? Is it worth accepting less certain, or less
successful re-vascularization? For up to five hundred cases?

 

In the mental calculation of on-pumpers, it is not worth it. Clearly, like
Don said, we do accept a small (and we do not know how important)
neurological deficit. But that is for the overall good of our patients. If
in your mind, there is no downside to OPCAB, particularly in terms of
adequacy of re-vascularization, then that is what you will do.

 

If I were to see clinical evidence for OPCABs comparable to the superiority
of mitral valve repair over replacement, I would persist in doing OPCABs.
Would I do the more difficult repairs, if the difference in outcome of
repair versus replacement was not compelling, and (because) the pros and
cons balanced each other out? I think not.

 

I am glad that at least we can have some discussion on this issue more
objectively. When Dr. Ani Anyanwu asked me this question, I was apprehensive
and did not answer for the fear of starting some mud slinging. But I am
pleased to see we are in calmer waters now.

 

Finally, I do have a question for OPCAB surgeons. What grafts do you use? Do
you use LIMA and RA in all cases? When do you, or not use SVGs? Do you use a
side occluding aortic clamp? Anastomotic device for the proximals?

 

Ajit Damle

Fargo ND

 

I have a huge number of references both for OPCABs and RAs in Power Point,
not very well organized. The files are very large, and if you are interested
I can e-mail these to you.

 

 

            

 

 

 

 

 

 

 

 

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