[HSF] Full metal jacket

Sun Dec 16 16:44:53 EST 2007

Ani has given a good desription of my open ended point and ,yes, compliment. 

I would add a few others, but there is no limit to this way of thinking.

Your direct observation and analysis of your own work is a magnificant example of a type of evidence that rates a diminutive "annecdotal" in the world of our academic elites , which by extension is the world view of most of us servile want-a-be-s. Your observations that come from careful anaylsis of what you have doen in a none experimental way is considered nonscientific information. This in turn betrays the over exalted value we place on population studies. While this population information is certainly useful, it can only answer one specific and rather contorted, abstract question at a time, ie is A better than B overall. In clinical practice we never have just A verses B, but deal with an alphabet soup of possibilities. Population studies are hopelessly inefficient in sorting out these problems. I agree with Dr. Frater that specific and particular information is the ony basis for a question for population studies as well as patient care, and it is
 also the only true method of quality control. Our credentialing process is as suspect as our guidelines.

There are even deeper questions raised by Tohru's data that again can only be answered by even longer term, personal, and specific  observations. For example, if many patients do well with their grafts closed what is the true importance and meaning  of revascularization to start with. Why not fore go the operation or parts of "complete revascularization" that do not or may not effect outcomes. I do not think it is possible to ask such unclear questions with population studies. Clearly it is impossible to show the diversity of what works and what does not.

Why then do we so worship population studies as the basis of our modern craft? Why do we not recognize the "value" (since we recognize the cost) of other important evidence? Is it even possible to separate practice, teaching (or learning), and research? If we separate them for some "other" value (or cost), what do we as doctors and patients lose from this divorce both in the present and the future?

tea

----- Original Message ----
From: Asai <asaiasai at oregano.ocn.ne.jp>
To: OpenHeart-L at lists.hsforum.com
Sent: Sunday, December 16, 2007 9:30:18 AM
Subject: RE: [HSF] Full metal jacket

Dave
I appreciate your detailed comment. I agree in-situ RIMA is better than RGEA
but in-situ RIMA has limitation to reach target sites, such as PDA and low
marginals in many patients. These targets are not good for in-situ RIMA but
it consistently reaches anywhere in LAD and proximal parts of marginal and
ramus ( via oblique sinus). RIMA's patency is reported to be excellent, as
good as LIMA's, when it is used in in-situ fashion for grafting left
coronary territories. And free RIMA is not consistently as good as in-situ
LIMA. So free RIMA branching off LIMA is not the best. I can tell you that
even I see a few cases of distal LIMA after giving RIMA off became string at
a few years after CABG. Whereas in-situ RIMA-LAD, in-situ LIMA-OM, and
in-situ RIMA-OM are consistently good in mid and long term. This is not only
my opinion, but most Japanese surgeons ( who live in a strange country) know
it as a sort of common sense with watching many angiograms, I guess. 

I tell you that there were many patient recovering uneventfully with their
postop angiogram demonstrating graft occlusions! So how can you know you are
doing all right. I personally could achieve more than 95% patency including
vein graft in early postop angiograms, mostly due to avoiding
multi-branching composite configuration.

I am aware that some are concerned about RIMA crossing midline anteriorly,
but I don't mind to perform resternotomy ( actually did several cases for
redo cab, aortic arch, AVR, mitral, tricuspid cases) as long as I did the
first operation. I usually make vertical slit hole just anterior to SVC to
enter pericardial space, in-situ RIMA easily reach distal LAD almost always.
They did very well without entry problem at all in my experience.
Surprisingly skeletonized IMA and GEA conduits looked as if they had been
harvested yesterday. I recommend you not to make y composite LIMA and RIMA
routinely. I know it is not as good as you expect from my "strange" upside
down countryman view. 

Problems of arterial conduits are more related to flow competition. Once it
stringed, nobody can tell that it may come back when the native stenosis
becomes critical. There are a few reports of re-growing of "string sign",
but clinically many recurred angina or MACE in real (strange) world.

Only 75% stenosis of proximal RCA is not consistently good for any arterial
conduits. I had seen many early postop angiograms of shrinked RIMA, RA,
RGEA. Obviously saphenous vein is the best in the situation, unless you tie
off RCA, which I have never done.

Well, my logic became too long! In summary, I often do RIMA,LIMA,GEA all
in-situ skeletonized with some sequential graftings to young but severe
diffuse 3vessel disease. SV is still useful in moderately stenotic large
target vessels or hemodynamically unstable bad urgent cases. 
---
Tohru 

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