[HSF] Too big for the Cardiologist? It is all about the size.....

Tea Acuff tacuff at swbell.net
Thu Apr 12 14:53:06 EDT 2007 

Why the NG tube? Was it the only unprobed orifice?

"no apparent problems"...just like the guy flippin' quarters on the corner to keep the elephants away...
tea


----- Original Message ----
From: Donald Ross <donross at bigpond.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Thursday, April 12, 2007 12:10:50 AM
Subject: Re: [HSF] Too big for the Cardiologist? It is all about the size.....


Ben,
To my simplistic mind I give clopidogrel to cover the 15-25% of  
partial or complete asa resistance which can't easily be diagnosed
( possibly the reason the cardiologists need to use both for their  
contraptions )
I give both down ng tube as soon as the patient gets to recovery and  
stop the clopidogrel after 6 weeks when the grafts should be over the  
surgical insult.
No evidence of course, just common sense and over the years no  
apparent problems.
On 11/04/2007, at 3:40 PM, Ben Bidstrup wrote:

> Only compared to placebo. Need a head to head with ASA. If you look  
> at the  rates, they are not dissimilar from some of the ASA  
> studies. Consider also cost. Many patients discontinue clopidogrel  
> even after DES because of cost.
>
>> If Ticlopidine showed a significant reduction in graft occlusion  
>> why do you then not recommend using  additional Clopidogrel since  
>> the real reason we use Clopidogrel Vs Ticlopidine is due to the  
>> lower incidence of neutropenia .
>> Ben Bidstrup wrote:
>>> Michael,
>>> The IMA will respond to the flow demands over time. Why LSV (how  
>>> old was he?). Radial if he had a high grade proximal lesion.
>>>
>>> Any way, can't change that - there is no evidence that  
>>> clopidogrel is better than ASA - I would suggest 375 mgm/day. You  
>>> could check for ASA resistance if you can (TEG)
>>> There was a study many years ago using ticlopidine and that has  
>>> been extrapolated to clopidogrel wrt graft patency.
>>> Limet et al 1987 JTCVS 94;773
>>>
>>> The efficacy of coronary bypass grafting obviously being linked  
>>> to graft patency, it is compulsory to look for any innovation  
>>> that could improve the patency rate. Ticlopidine, an antiplatelet  
>>> drug, was tested against placebo in a double-blind trial: 173  
>>> patients (475 grafts) subjected to venous coronary artery bypass  
>>> grafting were randomly treated with ticlopidine (250 mg twice  
>>> daily) or placebo from the second postoperative day for 12  
>>> months. Graft patency was assessed by digital angiography on days  
>>> 10 (99.4% of the patients), 180 (98.2%), and 360 (91.7%). The  
>>> effect of treatment on platelet aggregation and bleeding time  
>>> were measured concomitantly; a clear-cut effect was demonstrated  
>>> at each interval. Intention-to-treat graft-by-graft analysis  
>>> shows that ticlopidine significantly reduced the graft occlusion  
>>> rate on day 10 (7.1% versus 13.4%, p less than 0.05), day 180  
>>> (15.0% versus 24.0%, p less than 0.02), and day 360 (15.9% versus  
>>> 26.1%, p less than 0.01). Sequential grafts to the left anterior  
>>> descending coronary artery, with side-to-side anastomosis to  
>>> diagonal branch(es), are less frequently occluded than individual  
>>> grafts. On the contrary, grafts to endarterectomized vessels  
>>> occlude more frequently. Individual patient-by-patient analysis  
>>> shows that patency of all grafts at each study time, is more  
>>> frequent in the ticlopidine group. The difference is significant  
>>> when one considers patients without sequential or  
>>> endarterectomized grafts. The difference is also present at each  
>>> study time: day 10 (84.4% versus 66.7%, p less than 0.05), day  
>>> 180 (74.4% versus 52.3%, p less than 0.05) and day 360 (75.0%  
>>> versus 52.5%, p less than 0.05). Results are even more impressive  
>>> if one excludes from analysis the four patients in the  
>>> ticlopidine group in whom administration of the drug was delayed.  
>>> This supports previous suggestions that early therapy is  
>>> necessary. These results show that graft occlusion occurs mainly  
>>> in the first 6 postoperative months. The incidence of occlusion  
>>> is significantly reduced by ticlopidine therapy.
>>>
>>> My thinking is that clopidogrel should be used if there is  
>>> evidence of AS resistance only.
>>>
>>>
>>>> I just operated on a guy who was sent to me since the  
>>>> Interventionalist, a
>>>> good friend, said that he coronaries were too large for stents  
>>>> (he had focal
>>>> high grade lesions).  His IMA actually was a little on the small  
>>>> side for
>>>> what I would have expected, but there was good flow.  His saph.  
>>>> vein was
>>>> twice the size that I usually see, but a good looking vein  
>>>> nevertheless and
>>>> a good fit for this large right.  Things like this scare  
>>>> me......any
>>>> thoughts?  (should I keep him on plavix for example for the  
>>>> large vein,
>>>> although the large RCA should accept the flow and hopefully the  
>>>> IMA will
>>>> dilate to deal with the above average size LAD).
>>>>
>>>> -michael
>>>
>>>
>>
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>
> -- 
> Ben Bidstrup FRACS FRCSEd FEBCTS
> Consultant Cardiothoracic Surgeon
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