[HSF] Stent-vs-surgery debate heats up again

Mon Apr 2 18:33:46 EDT 2007

Ani,
Well from a technical stantpoint, you are correct - not much has changed
since Alexi Carel perfect the vascular anastamosis (Nobel Prize I recall).
And in fact, after watching and learning from Bruce Lytle doing several
hundred with 7-0 interrupted silks and listening to his perspective on why
they are better it is easy to understand his point - and he and his
experience is a little hard to question.  He was around in the 1970's and
has seen the evolution - and changed it, wrote about it, educated about it.
However, for some of us the "operation" (i.e. a CABG) is a little more than
sewing a couple of distals and proximals.  So having said that - what in
fact has changed (other than anesthesia and peri-operative care).

1) Myocardial protection -probably the biggest (not to raise that issue
again with Tom) but more to the point our understanding of it and the
various techniques - antegrade/retrograde/cold/warm/blood/crystalloid/etc.
2) Conduit selection - the LIMA-LAD, at least in the history of CABG, as the
gold standard is a relatively new concept as is arterial revascularization
and methods of accomplishing it.
3) Intra-operative TEE (ok, may you want to claim that belongs to
anesthesia, but that is another debate)
4) Instruments for making things easier - various refractors/cutting
devices/stability devices/etc.

Do you still cool the heart with topical ice?
Anti-fibrinolytics?
Valve selection/durability?
How do you approach your redo's?
Cannulation tools/techniques
Oxygenators and pump technology (for those of us who still use it)
Do your PA's use endo-vein?
How do you (or your fellows) harvest the IMA?

Granted there are thousands of steps from skin to skin and many of done
differently.  But, there is a lot of science, trial and error, and thought,
and development (typically from mistakes that young people like me - and
probably you and Hal - sorry to drag you into this - sometimes make or try
not to make).  On this forum we may discuss pros-cons of different steps -
and that is what the learning is about.  At some point someone had to use
protamine for the first time in a human.  To say not much has changed in
30-40 years is, and please excuse me, a little narrow
minded....................

-michael

HAPPY PASSOVER to all

On 4/1/07, Ani Anyanwu <anianyanwu at hotmail.com> wrote:
>
>
>
> 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 - 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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