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

[David Harris]

At least half the operations are different, as in the
70`s they would have been turned down. Kolesov` s
innovations were forgotten / unheard of, internal
mammaries not used, no cell savers, no haemostatics,
no arrhythmia surgery, etc, etc


--- 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.
> 
=== message truncated ===


Dr. David G. Harris, FCS, MMED,
Cardiothoracic Surgeon        
Suite A2                                
Tygerberg Hospital, 7505       
Cape Town, South Africa.            
Tel +27-21-9762347             
Fax +27-21-9761157      Mobile +27-83-3309587