[HSF] Aprotinin

Wed Nov 22 20:49:22 EST 2006

I am wider than you therefore a bigger target ?

>Except, of course, when you sound like a paid consultant... Maybe 
>you should sound more like me, Ben. No one has ever accused me of 
>sounding like I was getting paid, whether I was or not. Go figure. 
>Tea ----- Original Message ---- From: "hgrmd at aol.com" 
><hgrmd at aol.com> To: OpenHeart-L at lists.hsforum.com Sent: Tuesday, 
>November 21, 2006 11:26:53 AM Subject: Re: [HSF] Aprotinin Ben, 
>Thanks for your response, which I've always highly respected.  See 
>you in a couple of months. Hal -----Original Message----- From: 
>benjamin.bidstrup at bigpond.com To: OpenHeart-L at lists.hsforum.com 
>Sent: Tue, 21 Nov 2006 10:53 AM Subject: Re: [HSF] Aprotinin >Ben, > 
>I'm starting to get a little thin skinned about those cracks 
>regarding me >using articles in the WSJ and NYT as a frame of 
>reference. Let me tell you, >those are the articles that will fire 
>up the public and the lawyers, not some >paper stuck keep in the 
>bowels of a peer reviewed journal. As for me, I >keep up with both 
>sides of the fence. As an admitted paid >consultant for Bayer >for 
>many years, I'm starting to get the impression that you "doth 
>protest too >much." I've yet to hear you say that there is anything 
>possibly harmful >with aprotinin. Do you honestly think that this 
>side effect of ATN is just a >"vast right wing conspiracy" that has 
>no basis whatsoever? Really, I think >your credibility suffers 
>somewhat if you don't at least acknowledge >that there >might be 
>some possibility that some of these aprotinin side effects >are 
>real. >Shortly after the infamous Mangano article came out, I was 
>cornered by a >couple of Bayer reps in the surgeon's lounge who 
>whipped out a laptop and >fervently tried to convince me that all of 
>these aprotinin allegations were >statistical poppycock. Quite 
>frankly, your postings kind of remind >me of them. Hope >you're not 
>offended, but I really felt the need to clear the air. >Hal When you 
>have done the work, you tend to believe in your own research. If you 
>read the FDA transcripts, you will see how Mangano defends his 
>research. Is ATN associated with aprotinin use? I do not believe so. 
>Does it have issues? Yes. The one we all need to be aware of is 
>related to previous exposure. It is a foreign protein and can cause 
>hypersensitivity and anaphylaxis. This is a reason why 'routine' use 
>in some groups of patients needs to be deprecated. For example, use 
>of a tissue valve in a younger patient. This is a group where many 
>on this Forum have advocated non use of it and I agree with that. 
>Bear in mind that not a lot of patients will undergo a redo in the 
>future, so one must balance the current risks vs future risks. It 
>has an effect on ACT. Now reasonably well know, but does need to be 
>considered in managing heparin. Do I consider the ATN issue a 
>conspiracy? No. There is a spectrum of renal change that can and 
>does occur after cardiac surgery. We all know that. Many drugs can 
>influence these changes. Aminoglycosides, NSAIDs use of FFP and 
>other blood products to name but a few. What does a rise in 
>creatinine portend? Especially if it returns to normal after a few 
>days. Not all ATN needs dialysis, and not all creatinine rises = 
>ATN. That is a specific pathological condition. It is an interesting 
>point, as the renal people have trouble truly defining renal 
>impairment after cardiac surgery. Patients receive many drugs during 
>the course of a cardiac case. What is the impact of this cocktail? 
>We are all taught about poly-pharmacy at medical school. In the 
>majority of our patients, it does not seem to matter as they tend to 
>get well. However, it is puzzling to see patients with persisting 
>nausea after an OPCAB or a lung resection, or other non cardiac 
>symptoms with which we have to deal. So it is all a balance. I have 
>discussed the issues of propensity analysis with many people. There 
>are ways to use it, and ways not. So where does truth lie? How do we 
>determine truth in science ? We have a belief and we assess evidence 
>to make that determination. It is the size and shape of that 
>evidence base that that often differs for each of us. I do not take 
>issue with your support for MV repair. I concur, although my base is 
>possibly smaller than yours. The one beauty of this Forum is the 
>ability to raise issues and concerns and have them discussed without 
>the editorial constraints we see say in the NEJM. Well Mark does 
>occasionally step in if he sees it straying too far from the track. 
>It is also timely and done in the vein of improving patient care. Am 
>I offended - no way. I respect your views and I hope I have in some 
>small way added to your evidence base on not just drugs for stopping 
>bleeding. I do hope to be in San Diego as well. -- Ben Bidstrup 
>FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon 
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-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon