[HSF] Too scared to touch.....
Ani Anyanwu
anianyanwu at hotmail.com
Sat Apr 28 20:38:44 EDT 2007
But what exactly would be the indication for surgery or for hybrid angioplasty?
I am not sure I would agree that Michael's patient is typical of the patient we see nowadays. His patient sounds to me like one dying of systemic disease who has incidental coronary disease; how CABG will affect the natural course of her illness I am not sure. Surely there seems no prognostic basis to operate (as her prognosis does not seem to be determined by her heart condition) and she does not seem to have crippling cardiac symptoms.
Why offer her a MIDCAB? Because we can?
Ani
----- Original Message -----
From: David Harris<mailto:drdharris at yahoo.co.uk>
To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
Sent: Saturday, April 28, 2007 5:06 PM
Subject: Re: [HSF] Too scared to touch.....
This would be the ideal patient for a hybrid / MIDCAB
approach. No risk from the sternotomy in obese
patient. If the MIDCAB is done properly, and I am sure
your cardiologist is aware of this, the risk will be
minimal. This is a typical kind of patient we see
thesedays......we become our worst enemies if we do
not accept these cases for surgery. The
(liberal)indications for the CABG in this patient
should be the same as any other patient. If you do
this one well via a MIDCAB, the cardiologist will take
notice and may think twice before stenting the LAD
next time.
Dave Harris
--- Ani Anyanwu <anianyanwu at hotmail.com<mailto:anianyanwu at hotmail.com>> wrote:
> Actually in this case Michael you do know the other
> devil. Easy to work out likely scenario if you did
> operate. How obese is obese here anyway?
>
> Ani
> ----- 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%3Cmailto:OpenHeart-L at lists.hsforum.com>>
>
> Sent: Saturday, April 28, 2007 11:01 AM
> Subject: Re: [HSF] Too scared to touch.....
>
>
> That is a major part of our argument not to
> operate.
> She came in with a RCA/RV problem - and that was
> taken care of.
> Everyone is just "scared" of the LAD/Cx disease
> (not that bad though)
> and thinks that CABG will save everything......
>
>
> resisting the oculo-graft reflex (i.e see
> blockage - needs graft)
>
> the devil you know vs the devil you dont.
>
> she needs medical management (I dont even think
> she came in on beta-
> blockers/statin/etc)
>
>
> -michael
>
>
>
> On Apr 28, 2007, at 10:51 AM, Ani Anyanwu wrote:
>
> > Michael,
> >
> > What would be the indication for surgery at the
> present time?
> >
> > Ani
> > ----- Original Message -----
> > From: Michael
>
Firstenberg<mailto:msfirst at gmail.com<mailto:msfirst at gmail.com<mailto:msfirst at gmail.com%3Cmailto:msfirst at gmail.com>>>
> > To:
>
OpenHeart-L at lists.hsforum.com<mailto:OpenHeart<mailto:OpenHeart-L at lists.hsforum.com%3Cmailto:OpenHeart<mailto:OpenHeart-L at lists.hsforum.com%3Cmailto:OpenHeart%3Cmailto:OpenHeart-L at lists.hsforum.com%3Cmailto:OpenHeart>>-
>
> > L at lists.hsforum.com<mailto:L at lists.hsforum.com<mailto:L at lists.hsforum.com%3Cmailto:L at lists.hsforum.com>>>
> > Sent: Saturday, April 28, 2007 10:36 AM
> > Subject: [HSF] Too scared to touch.....
> >
> >
> > Would anyone do anything different?
> >
> > 52 year/old, multiple medical problems (poorly
> controlled diabetes,
> > hypertension, high lipids of course - and dont
> forget obese). Known
> > brain AVM, cryptogenic cirrhosis with history
> of varices/bleeding/
> > blakemore tube (the works, but nothing recent
> and LFTs/proteins not
> > too bad) - treated with mesocaval shunt for
> portal vein
> > thrombosis in
> > 1999. Splenic embolization also. Chronic
> anemia and renal
> > insufficiency. CT scan of abdomen "suggests
> carcinomatosis" -
> > slightly worse over past "couple of years" -
> but no primary (CA125
> > elevated to ~60 baseline in our hospital
> 0-40, already had TAH-BSO
> > years ago). About six months ago, fell and
> got a "hairline"
> > fracture
> > of left hip - no intervention, but developed a
> DVT in right leg.
> > Recently, fell again (may have been near
> syncope) and broke right
> > ankle in several places. Admitted to outside
> hospital after fall,
> > hypotensive, found to have a troponin of ~20
> with a moderate RV
> > infarct. Taken to cath lab for PCI (BMS to
> occluded right -
> > interesting as she was on coumadin) - opened
> up, but also has
> > significant LAD/Cx disease. Good targets.
> Cardiology asking for
> > off-
> > pump LIMA-LAD and they will do a protected
> left main stent.
> > Anesthesia and Ortho doesnt want to fix her
> ankle until her heart is
> > taken care of.
> >
> > Would anyone operate?
> >
> > Cardiology somewhat understanding of our
> reluctance to "take the
> > high
> > potential operative mortality hit" and in fact
> they are not sure
> > they
> > even want to "take the PCI hit". To be
> honest, we all want to try
> > and help (not sure of the long term benefit as
> no one has any
> > idea of
> > her long-term prognosis), but no one wants to
> have a potential CABG
> > mortality.
> >
> > Hal - can I send her to you?
> >
> >
> > -michael
> >
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=== message truncated ===
Dr. David G. Harris, FCS, MMED,
Cardiothoracic Surgeon
Suite 207
Kuils River Private Hospital,
PO Box 1200, Kuils River, 7579, Cape Town, South Africa.
Tel +27-21-9006411
Fax +27-21-9006412 Mobile +27-83-3309587
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