AW: AW: [HSF] The fallacy of surgical research

Thu Aug 2 16:55:50 EDT 2007

Ani,
you do not want to loose any discussion...
Forssmann was Urologist, this means:  a surgeon
I didn´t know Murray, 
Then, we have 3 cases.
Roberto

-----Ursprüngliche Nachricht-----
Von: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Ani Anyanwu
Gesendet: Donnerstag, 2. August 2007 12:07
An: openheart-l at lists.hsforum.com
Betreff: RE: AW: [HSF] The fallacy of surgical research

Carrel was not in recent times, same with Kocher before him. Forssman did
not receive a Nobel prize for surgery (but for cardiac cathetherization).
Murray in 1990  is the only surgeon to have been granted a Nobel in over 30
years - even it is regarded by some as a token Nobel as he did not make any
scientific discovery in particular (was for discoveries concerning organ
transplantation - Murray performed the first renal transplant).

Ani

> From: battr at medizin.uni-leipzig.de> To: OpenHeart-L at lists.hsforum.com>
Subject: AW: [HSF] The fallacy of surgical research> Date: Thu, 2 Aug 2007
11:18:26 +0200> CC: > > Ani,> Science in an art and science discipline
(surgery) is very complicate, near> the theory of caos. Tell the clinical
academics to come to surgical> services and do science. They are not going
to make it better than we> surgeons. > Of course, we are not as good in
biostatistics as they are. And the most> important factor, the surgeon
itself is never included in the studies!> > By the way, there are 2 Nobel
Prize surgeons, Carrel and Forssmann (together> with Cournand).> > Roberto>
> -----Ursprüngliche Nachricht-----> Von:
openheart-l-bounces at lists.hsforum.com>
[mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Ani Anyanwu>
Gesendet: Mittwoch, 1. August 2007 22:14> An: openheart-l at lists.hsforum.com>
Betreff: RE: [HSF] The fallacy of surgical research> > The other issue the
discussions on myocardial protection brings up is the> fallacy of surgical
research and the poor understanding of research method> by surgeons. This is
what prompted the Lancet editor many years ago to> describe surgical
research as 'comic opera'. The reality is that few in> academics or research
takes us surgeons seriously. Look at the> representation of surgeons in key
research bodies, funding of surgical> research by NIH or similar bodies,
surgical influence in research groups,> surgical publications in key
journals, guidelines committees, involvement in> key epidemiological efforts
etc. The only Nobel prize received by a surgeon> in the recent era wasn't
even for surgical research. The problem is we as> surgeons believe too much
in our individual selves and individual methods> that we become blinkered as
to the requirements of the scientific method.> > Examples include> > - there
is evidence that such and such an additive to cardioplegia is of> benefit
(this evidence comes from isolated animal hearts, animal experiments> and at
best clinical measures of surrogate markers - these do not mean the>
additive is benefit in the human, indeed it could be worse)> > - it has
worked well in my cases so it is okay (but as Dr Salerno and> Prasanna say
the heart has great reserve - that nothing goes wrong does not> mean all is
okay)> > - i have had no deaths (the patient came to you alive; why is it
an> achievement that he remains alive after surgery? (unless the aim of
surgery> was to save life))> > - Kirklin and Buckberg or Cleveland clinic
demonstrated...(i.e. eminence> based medicine; but how many have ever read
work of Kirklin or Buckberg? Do> they stand up to the requirements of
scientific proof? Indeed did either> really show clinical benefit of the
things we attribute to them? For example> the 'seminal' Cleveland clinic
NEJM paper purpurtedly showing benefit of IMA> over SVG barely constitutes
evidence of such)> > - There was no enzyme rise (has anyone cared to show
any relationship> between enzyme rise and any outcome of interest after
surgery? Does the> patient really care what his CK, troponin or coronary
sinus lactate are? Why> do we look at outcomes of no relevance to the
patient?)> > - Ventricular fibrillation means bad protection ( but has
anyone shown so> scientifically? maybe fibrillation is intrinsic to some
techniques and rare> with others and is a reflection of the technique rather
than the degree of> protection; certainly a fibrillating heart in Salerno's
beating heart> technique has different implications to an Arch done by
Martin on DHCA)> > - The patient was extubated the next day (and so what?
Several times you go> back to ask what happened to the patient 2 months
later and you hear a> different story. This outcome is of no relevance at
all unless aim of> surgery was to allow extubation in patient previously
ventilator dependent)> > - My method of cold myocardial preservation works
(but how do you know that> that is what is working? As Salerno says if you
don't know the myocardial> temperature how do you know it is the
hypothermia, and not some other> factor, that is in play?)> > - Since I
changed I use less inotropes (but you decide what you use- could> you not be
just biased towards the success of your change? Maybe you should> compare
two methos objectively)> > - Multiple defibrillation harms the heart and
leads to bad outcome (maybe> but could it be the condition requiring
defibrillation that is resulting in> the bad outcome rather than the
shock?)> > - I have done it this way for 10 years and never had problems
(how do you> know? Have you actually measured the outcomes on all your
patients? Kocher> said the same about his thyroidectomies and was shocked
when he recalled his> patients and found the majority had myxedema)> > etc>
The inability to critique within the scientific framework and a lack of>
understanding of, or refusal to apply the research method, is a major>
problem in surgery and is in part the reason why we are so diverse in>
opinion and yet so opinionated and firm in our belief that what we do is>
right (when yet examined there is often no evidence to support it). No>
internist or scientist or epidemiologist would approve a drug based on any>
of the criteria we list above yet we swear by what we do to the degree that>
we suggest alternative approaches are inferior. > > Until we start thinking
in a scientific and epidemiological manner, we as> surgeons will remain the
laughing stock of academic medicine.> > Ani> > > Date: Thu, 2 Aug 2007
04:52:48 +1000> To: OpenHeart-L at lists.hsforum.com>> From:
benjamin.bidstrup at bigpond.com> Subject: Re: [HSF] Inotropes,> ventricular
fibrillation and myocardial protection> CC: > > What this does> is once
again ask the question, how do we measure > myocardial> preservation?> > We
can look at the highly sensitive markers such as> Troponin which > indicate
some element of damage to components of the> myofibrils. and > so on. Echo -
RWMA ECG and the list goes on.> We need to> look at use of inotropes, IABP,
survival. Khuri published > on his> intramyocardiall pH device stating that
poor preservation as > reflected by> pH changes resulted in altered long
term survival.> > Much of the cocktails'> components have been determined by
isolated > rat heart experiments. They> have translated well to the human,
but it > is very hard to measure total> water content of an intact heart or
> regional blood flow distribution in a> human model.> > Why is it that
there is no universal cocktail. Put 100> cardiac teams > in a room and you
will have 120 different ways of preserving> the > myocardium.> I review
papers that look at different methods of> preservation and > they use
markers such as inotrope use to determine> improvement. How > variable that
is is a whole new debate.> > > > > >Tomas,>> >> > A fibrillating heart is a
dying heart? Is this an edict of some >> >sort? I've seen plenty of hearts
that fibrillated during some part > >of> their open heart operation only to
have a completely, and I mean >> >completely, normal EF on remote echo.
Speaking in absolutes serves > >no> purpose.> >> >> >> >Hal> >> >>
>-----Original Message-----> >From: Salerno,> Tomas
<TSalerno at med.miami.edu>> >To: OpenHeart-L at lists.hsforum.com> >Sent:> Wed, 1
Aug 2007 11:19 am> >Subject: Re: [HSF] Inotropes, ventricular> fibrillation
and > >myocardial protection> >> >> >> >> >A fibrillating heart> is. "Dying"
heart.> >The brain does not have seizure during CPB; neither> should the
heart > >fibrillate.> >Tomas> >> >----- Original Message ----->> >rom:
openheart-l-bounces at lists.hsforum.com >>
><openheart-l-bounces at lists.hsforum.com>> >o: OpenHeart-L at lists.hsforum.com>
<OpenHeart-L at lists.hsforum.com>> >ent: Wed Aug 01 10:45:53 2007> >ubject:>
Re: [HSF] Inotropes,ventricular fibrillation and myocardial > >rotection>>
>Ani,> >aving graduated from voodoo homemade cocktails to blood and its>>
>ariants, you would easily be able to see that the bad cardioplegia's> >id>
have a higher (more accurately uniform) incidence of fibrillation> >hich>
came down with better modifications of cardioplegia's. That does> >ake us>
wary and anyway fibrillation is not something by any stretch>>
>ormal.Transient defibrillation may appear innocuous but then it has> >een>
shown that such hearts have indeed been improperly preserved (from> >orks
of> Buckberg and Kirklin).Remember that sometimes speed etc etc may>
>ompensate> but this may become an issue in longer case.> >rasanna> >ni
Anyanwu wrote:>> > I still do not understand why we are alarmed about
transient ventricular>> >ibrillation on reperfusion and why using drugs to
suppress it will have> any> >mpact on outcome.> >> > Ani> >> >> >> > > >>
Date: Wed, 1 Aug 2007> 11:51:47 +0530> From: prasannasimha at gmail.com> To:>>
>penHeart-L at lists.hsforum.com> Subject: Re: [HSF] Inotropes, ventricular>>
>ibrillation and myocardial protection> CC: > > I am not saying that the>>
>rocaine or lignocaine is still acting. What I> meant is that since the>>
>ibrillation is occurring with the hotshot delivery> with high local>
lignocaine> >hanging the drug class may be beneficial.> Prasanna> > On>
8/1/07, Ben Bidstrup> >benjamin.bidstrup at bigpond.com> wrote:> >> > I beg>
respectfully to differ. The> >idocaine (a fast Na channel> > blocker) is
all> but gone after a short while in> >he cardioplegia> > scenario. Getting
a> suitable level back into the > >circulation> >nd thus> > the heart at>
release of the clamp is what is > >needed.> >> > Perhaps a> >andomised
study> is in the offing.> >> > >>
>http://circ.ahajournals.org/cgi/content/abstract/79/5/1106>> >> > This>
reference relates to defib energy levels but i think you will> > see> >here>
I am coming from.> >> > At James Cook, I was involved in the development>
>f> a non> > depolarising cardioplegia solution, which is slowly > >working
its> way>> > up the development path. The main components are lidocaine and>
>> adenosine.>> >> >> >> >> > >Ben,> > >I use Amiadorone in the pump for
all> emazes > >>(and postop)> >nd> > >Amiadorone in the pump for all aortic>
valves. Since the St Thomas> >> >Cardioplegia (which we mix in blood)>
already has procaine > >adding> > >Lignocaine> >ould be>
redundant.(Incidentally Amiadorone is very cheap> > >in India !!)> >>>
>Prasanna> > >Ben Bidstrup wrote:> > >>Why the amiodarone. Surely with
some>> >erfusion, the electrolyte> > >>imbalances within the myocardium
would> correct> >nd SR ensue. If> > >>anything use lidocaine. Less toxic
and> cheaper, not a> >egative> > >>inotrope. It is what Yacoub taught me
many> years ago, and I have>> > >>used it to good effect (infrequently I
might >> >add).> > >>> > >>>Tohru,> > >>>> > did an AVR on an 87 yo man as a
2nd case> just a couple of> > >>>hours ago.> >gain, no LV vent, only a sump.
While> closing the> > >>>aortotomy, I began the>> > >>>continuous warm
retrograde> blood. The heart began fibrillating> > >>>after> > couple of> >
>>>minutes.> I gave amio and then cardioverted. The > >heart had a> >>
>>>slow> junctional> > >>>rhythm until the clamp was released. A sinus
rhythm>> >eveloped shortly> > >>>afterwards. He came off with no inotropes.
It's> much> >asier on> > >>>the heart and> > >>>your nerves to cardiovert a
>> >clamped, flaccid> >eart rather than> > >>>trying to do it> > >>>after
the> clamp has been> >eleased.> > >>> I look forward to your visit at the
STS. As> I said before,> >'ll> > try to> > >>>have a couple of interesting
cases for> you and other> >nterested> > >>>members of HSF> > >>>to watch and
criticize> to your heart's> >ontent.> > >>>> > >>>Hal> > >>>> > >>>> > >>>>
>> >>>**************************************> >et a sneak peek of the> >>
>>>all-new AOL > >at> > >>>http://discover.aol.com/memed/aolcom30tour>> >>
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