[HSF] Stent-vs-surgery debate heats up again
Ani Anyanwu
anianyanwu at hotmail.com
Sun Apr 1 20:24:38 EDT 2007
Michael
When you say your current operation is not same as Cleveland's 1970s CABG, on what basis do you say this? Certainly you were not around in the 1970s so either you just believe so, were told so or read so. I suspect it is not the latter because if you read some of the original descriptions of the procedures we do now, you will be surprised how little has changed.
For example, I was last week reading a paper of Dr Starr from 1961 on his first 8 MVRs in humans and really there has been not much change in the technique of MV replacement in the ensuing four decades. Similarly if you read Barnard's 'the operation', or indeed Dr Lower's paper a decade earlier, you will see that aside from modifications in right atrial anastomosis, heart transplantation technique has not changed much. At the beginning of my training I used to read an out of print book from 1981 written by Hank Edmunds called I think atlas of cardiothoracic surgery. I have never come across a better written book on operative technique and I was amazed to find that the book was more than adequate for operative learning of majority of cardiothoracic techniques and procedures I was exposed to as a junior trainee in late 1990s.
We believe things do change because we can't know all of history and we can't read all the literature, but if we could, we would realize that most of what we think is new in surgical technique, has been done or thought of before. For example in the field of mitral repair, the groundbreaking alfieri stitch was described over 60 years ago, external splinting (ala coapsys) was tried experimentally (I believe by Harken but sure Dr Frater will know correct reference) in the 1950s, suture rather than resection of the mitral leaflet was described by McGoon in the 1950s etc. Whatever you consider state of the art CABG was done 30 years ago. Koselov was doing off-pump LIMA-LAD via thoracotomy (which we now give the sexy name MIDCAB) in 1960s even before Favalaro popularized his operation. We just go round in circles - there are few real original ideas, often just a recirculation of old ones.
I sent an report of a novel operative technique to a journal two months ago and one of the reviewers said I need to be clear if this a a new technique and add a statement to the effect that " we report the first xxxyyy..." I refused replying that there are thousands of cardiac surgeons round the world and there is no way I can know that someone else has not come up with or used the same technique independently; indeed it would be extremely unlikely that one is the only surgeon past or present to ever have thought up the idea - others either just have not published it or have done but I have not read it (there is literature beyond pubmed) . I often laugh when surgeons describe their 'own' technical innovations and tricks - if you go around the block often enough you will often find other surgeons who have independently come up with the same 'original' ideas you have.
Whilst there have been some true innovations in the last decade, the essence of what we do has not changed that much. The more things change the more they are the same. Maybe the future is in those catheters after all ...now that is progress. Or is it?
Ani
PS - As is generally the case, I expect to be crucified by the usual suspects but to spare me some bombardment please note I am referring to surgical technique and not to peri-operative management which I agree has changed much!
----- Original Message -----
From: Michael Firstenberg<mailto:msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
Sent: Wednesday, March 28, 2007 7:29 AM
Subject: Re: [HSF] Stent-vs-surgery debate heats up again
Hal,
I agree that we must continue to advance, define, redefine, develop, and
innovate. However my question is how many referring Docs (or patients) come
to you, ask for, want, insist on a specific operation? I dont deny that a
subset of people "must have a mini-mitral to beach season" but what is the
data? How many patients show up in your office with an internet page and
say "I want a MIDCAB"?
Interesting how we have spent the past week, in honor of ACC, slamming
stents and proclaiming CABG as the greatest thing since sliced bread and yet
we criticise a 40 year/old operation. Having spent time in Cleveland where
CABG was first mass-produced (not discussing "invented") - I can clearly
attest it is not the same operation. But, gee - it works and from the data,
it works well - the concept and the basic application are sound and proven.
Thinks like incisions, sternal approaches, retractors, oxygenators, shunts,
wigets, and so on may change - but the basics will be around. No one is
doing the same operation that they did 40 years ago (well except that
surgeon who does not use retrograde). Hal - do you still drive a car? Fly
an airplane? Watch TV - all old technology using current logic.
Besides, you sound pretty busy (although you have time to contibute
frequently to this forum) - you went out and got new business, perfected new
operations, expanded your product line so to speak. That is what we need to
do. I think the dying surgeons are the open who only want to 3 graft CABG
on healthy people with normal EFs - those days are gone. Yes, we still see
those patients - did 2 last week in fact - but the difference is the
comorbidities that come with them. 1 had a huge SAH from a ruptured
aneurysm a few years ago and the other has awful diabetes. Between the 2
they had a working pair of eyes and kidneys. Surgeons who dont take on
those problems are the ones who dont or wont find work.
Got to go round, and see the 79 year/old who I took a LVAD out of last
night..........
-michael
On 3/27/07, hgrmd at aol.com<mailto:hgrmd at aol.com> <hgrmd at aol.com<mailto:hgrmd at aol.com>> wrote:
>
> Michael,
> The "best, busiest, and most respected surgeons who don't do anything
> fancy" are a dying breed. You have to stay cutting edge if you are to
> remain relevant. I highly doubt a 40 yo operation (CABG) is going to be the
> mainstay for the rest of your career. Don't believe me? Stay tuned.
>
> Hal
>
> -----Original Message-----
> From: msfirst at gmail.com<mailto:msfirst at gmail.com>
> To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
> Sent: Tue, 27 Mar 2007 7:50 AM
> Subject: Re: [HSF] Stent-vs-surgery debate heats up again
>
>
> Hal,
> I think the key is polishing skills - while some patients and referring
> docs
> want specific operations or approaches (particularly if offerred) - from
> what I have seen over the years (granted not too many), is beyond a safe
> operation and getting discharged alive the approach is a distant second.
> Although, I have (as we have discussed time and time again), patients,
> referring docs, and surgeons play too much emphasis on cosmetic results or
> macho approaches. Patients want someone who cares.
>
> Many of the best, busiest and most respected surgeons that I have known
> dont
> do anything fancy - they just provide good patient care and safe
> operations
> with good outcomes.
>
> -michael
>
> On 3/26/07, Hgrmd at aol.com<mailto:Hgrmd at aol.com> <Hgrmd at aol.com<mailto:Hgrmd at aol.com>> wrote:
> >
> > MIchael,
> > I understand a provincial view when you are polishing your basic skills.
> > However, if you think no catheters and full sternotomies are the way you
> > will
> > practice for the foreseeable future, I predict you'll one day regret
> that
> > policy.
> > Hal
> >
> >
> >
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