AW: AW: AW: [HSF] The fallacy of surgical research (OT)

Thu Aug 2 20:16:09 EDT 2007

Yes, then he went to the X Ray lab and took a picture. He was criticized and
the thing was forgotten until Cournand, then Forssmann was a hero.

-----Ursprüngliche Nachricht-----
Von: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von prasannasimha
Gesendet: Donnerstag, 2. August 2007 16:18
An: OpenHeart-L at lists.hsforum.com
Betreff: Re: AW: AW: [HSF] The fallacy of surgical research

And He had to "cut down" his vein to get a catheter inside !!
Prasanna
Dr. Roberto Battellini wrote:
> 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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> FRCSEd FEBCTS> Consultant Cardiothoracic Surgeon> > Two things are
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