[HSF] Too scared to touch.....
Tea Acuff
tacuff at swbell.net
Mon Apr 30 19:33:41 EDT 2007
So we were right by accident (ie it is generically and always right not specifically right) in recommending CEA before CABG?
tea
----- Original Message ----
From: psimha <prasannasimha at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Sunday, April 29, 2007 10:33:41 AM
Subject: Re: [HSF] Too scared to touch.....
Incidentally the mortality of non cardiac surgery is higher post
stent/CABG compared to maximal medical management with beta blockade.
There was an elegant article a few years back on vascular surgery in
patients (Seminars in vascular surgery - if I remember right) with IHD
and it was pretty strong in its arguments about this.
This data is coming up again (and actually has been around for quite
some time). The perturberations of anesthesia and postoperative state
actually enhance stent/plasty/graft closure leading to a higher
mortality (and this applies even to bare metal stents and grafts)
Prasanna
Ani Anyanwu wrote:
> To me Michael, the greater question, which is yet unanswered is what would this poor lady benefit from having a heart operation? Only if there is potential tangible benefit should we talk about the risks and how to make it safer. There is no doubt that we can do surgery, and various iterations have been suggested including avoiding CPB, GA and sternotomy. These iterations are however of academic value as the ability to do an operation safely does not itself imply reason to do surgery.
>
> For a bed-bound inactive chronically ill patient with no active cardiac symptoms, and with quality of life severely restricted by non-cardiac disease, I cannot see any reason for surgery and if we operate we are treating the angiogram and not the patient. If your cardiologists had chosen to stent those (left) vessels, I bet we would be castigating them for performing an unnecessary procedure (in my center those stents would have been in long ago). Even if (and I doubt so) we have the ability to do the procedure with minimal morbidity, that we can does not mean we should. Somehow, however, it seems a taboo in the US to die without a scar on the chest, so I suspect it is a matter of time before you (or your colleagues) will be inside her chest.
>
> Ani
> ----- 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: Sunday, April 29, 2007 9:37 AM
> Subject: Re: [HSF] Too scared to touch.....
>
>
> Although her comordities overall dont scare me too much - my major
> concern is her functional status (and long term prognosis from her
> undefined medical problems - Oncology doesnt want to do anything to
> help figure this out). A poorly compliant diabetic with a broken
> ankle which will need surgery and be non-weight bearing for a while
> (months?) combined with a "healing" hip fracture and DVT on the other
> side. We can get her thru an operation and a hospital stay
> (hopefully) - but once she leaves us, who know. Another fall in
> rehab, all of that stress on what I am sure is a brittle sternum, and
> now I am dealing with a catastrophe, particularly if she is going to
> be on coumadin for her DVT (lets not forget her possible hypercoag.
> state - she did clot off her portal vein). I am not a big fan of
> operating on non-motivated non-ambulatory patients - every other
> comorbidity we can deal with, be non-motivated rehab patients I think
> are a huge problem. If the patients dont care, then no one else
> does...... except maybe us and these are hard battles to fight.
>
>
> -michael
>
>
> On Apr 29, 2007, at 3:16 AM, David Harris wrote:
>
> > Yuck. I think Hal had the right word....punt!
> > This is really the problem of anaesthesiology, they
> > must just dope her and keep the pressures high. If she
> > then becomes unstable we always have the Kantrowitz
> > pump on standby, to stabilise her for emergent off
> > pump via lower sternal split, or....? MIBCAB
> >
> > Dave Harris
> >
> >
> > --- Michael Firstenberg <msfirst at gmail.com<mailto:msfirst at gmail.com>> wrote:
> >
> >> Have not done too many MIDCAB - my partners have
> >> done a few.
> >> She has a lot of abdominal obesity and pretty large
> >> breast (the kind
> >> you lift up to find a nice red rim of moist candida)
> >> these patients have enough would/skin problems
> >> from midline
> >> incisions - I can only imagine a MIDCAB incision.
> >>
> >> Again, I am not sure of the indications other than
> >> she has known LAD
> >> disease.
> >>
> >>
> >> michael
> >>
> >> On Apr 28, 2007, at 5:06 PM, David Harris wrote:
> >>
> >>> 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<mailto: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<mailto:msfirst at gmail.com>>>
> >>>>> To:
> >>>>
> >>>
> >>
> > OpenHeart-L at lists.hsforum.com<mailto:OpenHeart<mailto:OpenHeart<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart<mailto:OpenHeart>-
> >>
> >>> L at lists.hsforum.com%3Cmailto:OpenHeart<mailto:L at lists.hsforum.com<mailto:OpenHeart>>-
> >>>>
> >>>>> L at lists.hsforum.com<mailto:L at lists.hsforum.com<mailto:L at lists.hsforum.com<mailto: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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> >>>>>
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> >>>
> >>
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> >>
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> >>>>
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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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