[HSF] OPCAB

[Nasser F. Abou'Seada]

Ajit:
I'm too much impressed indeed 

NFA

> -----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 3:47 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.
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> _______________________________________________
> OpenHeart-L mailing list
> 
> Send postings to:
>  OpenHeart-L at lists.hsforum.com
> 
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
> 
> All messages transmitted by the OpenHeart-L are subject to the policies
and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------