[HSF] To "T" or not to "T"

[Tea Acuff]

Actually, Don, anyone can argue with Tohru...if they have their own data. That is the beauty of the diversity of biology. That is why surgeons should be much more interested in imaging. Not to do catheter work, but to validate their work.
 
tea


----- Original Message ----
From: Donald Ross <donross at bigpond.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Sunday, December 16, 2007 10:13:39 PM
Subject: Re: [HSF] To "T" or not to "T"

Tohru,
Nobody can argue with surgeons who has such a high incidence of early  
recaths as yourself.
However, I was intrigued by your observation that the lima to LAD was  
more likely to go down distally  if it supported a T graft.
How often do you see this and are you sure the cause wasn't a non  
significant LAD lesion?

This is an important question for me as I have put 944 arteries  onto  
the LMA as T grafts. ( 617 radials, the rest rimas )
I only get a recath if the clinical result is sub-optimal and  
fortunately that is rare. ( Usually the grafts are patent)
If, as you say, there are a lot of graft occlusions which have no  
clinical consequence then I probably have my fair share.
Hopefully they are associated with non significant lesions which  
explains my blissful ignorance.
Don


> 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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