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

Fri Apr 6 09:13:23 EDT 2007

Ani,
Thanks the information. As is often the case provocation leads to clearer understanding by all. Sometimes taking coals to New Castle is also rewarded with more than derision.
tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Thursday, April 5, 2007 8:52:22 PM
Subject: Re: [HSF] Stent-vs-surgery debate heats up again

Dear Dr Frater,

Thank you for your comments. I have checked up on the references.

The first paper I was referring to was by Harken, Black, Ellis and Dexter presented at the 34th AATS meeting in 1954. The accompanying manuscript in the journal of thoracic surgery the same year titled "The surgical correction of mitral regurgitation" describes  a device placed through the ventricle from anterior to posterior wall straddling the valve - strictly speaking this was not a splint as this device was not just a thread but contained a baffle which would help obstruct the residual defect that occurs during systole - while the goal was to plug the gap in coaptation, some of the effect of this device however would have been achieved by narrowing the septolateral dimension.

The early reference to the edge-to-edge I alluded to was also presented at the AATS, but in 1956, by Henry Nichols. His paper was titled "Mitral Insufficiency-Treatment by Polar Cross-Plication of the Annulus Fibrosus". He described a technique of suturing the anterior to posterior annulus thereby creating a double orifice valve which he found cured regurgitation in selected patients. In his later work he sutured various areas of the annulus and/or leaflets together to treat mitral regurgitation.

Apart from advances in technology (such as endoscopic surgery), I suspect the majority of surgical "advances" have been long been previously applied. For example the 'innovation' of beating or perfused heart valve surgery will be laughed at by many surgeons active in the 1960s because for many this was the only way valvular operations were executed in that (pre-cardioplegia) era. My previous chief Yacoub was doing homografts on perfused beating or fibrillating heart without cardioplegia well into the 1990s. Similarly for all the talk about minimally invasive surgery, I did a reoperation on a patient who had an ASD repair in the late 1960s - I was puzzled I could not find her scar till I looked under her right breast and saw a barely visible 3 to 4 inch incision. The easiest way to come up with new ideas is to read the literature form 1940s to 1960s - then there was no valve replacement and CPB just introduced so the literature is abound with innovative ways of curing valve
 disease without prosthetic replacement and some without CPB.

Ani
  ----- Original Message ----- 
  From: rwmfglycar at aol.com<mailto:rwmfglycar at aol.com> 
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
  Sent: Monday, April 02, 2007 10:13 AM
  Subject: Re: [HSF] Stent-vs-surgery debate heats up again

  Dear Ani,
  You are basically right. Most of the cut and sew techniques of surgery were developed after anesthesia came along and that takes us back more than a hundred years. Look up the history of surgeons who gave their names to instruments (often the same instrument with a different surgeon's name depending on which country you were in). Check out Metzenbaum, for example.
  There are a few details that have changed: in the early days of vascular surgery silk was threaded on a needle, after which the scrub nurse would put a blob of vaseline on thumb and forefinger and drag the suture through the vaseline to make it pass easily through the vascular wall.
  In the early 70's vein to coronary anastamoses were still being done with interrupted silk at the Cleveland Clinic.
  What made cardiac surgery different was the need to duplicate the functions of the heart and circulation in order to use those cut and sew techniques that had evolved starting in the 19th century. In the last 40 years the greatest advances probably came from anesthesia.
  I am puzzled by your description of an Alfieri stitch 60 years ago. Can you give me a reference? Neither do I know of Dwight Harken doing any form of external splinting experimentally.
  Yours 
  Bob

  -----Original Message-----
  From: anianyanwu at hotmail.com<mailto:anianyanwu at hotmail.com>
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
  Sent: Sun, 1 Apr 2007 11:23 PM
  Subject: Re: [HSF] Stent-vs-surgery debate heats up again

  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<mailto:msfirst at gmail.com>> 
    To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto: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<mailto:hgrmd at aol.com<mailto:hgrmd at aol.com>> <hgrmd at aol.com<mailto:hgrmd at aol.com<mailto:hgrmd at aol.com<mailto:hgrmd at aolcom>>> 
  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<mailto:msfirst at gmail.com<mailto:msfirst at gmail.com>>
    > To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto: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<mailto:Hgrmd at aol.com<mailto:Hgrmd at aol.com>> <Hgrmd at aol.com<mailto:Hgrmd at aol.com<mailto:Hgrmd at aol.com<mailto:Hgrmd at aolcom>>> 
  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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