[HSF] "Patients don't want cardiopulmonary bypass" - the great con

[Michael Firstenberg]

I dont like hitting my thumb with a hammer when I hang a picture in  
my home, but sometimes I need to use the tool.  CPB is one of the  
greatest inventions to modern medicine and when I need my CPB I want  
it done with bypass (and I want my heart arrested with antegrade and  
retrograde when I get my AVR).  There have been countless papers  
talking about the harmful neuro effects of CPB - and while I do not  
have the reference, I recall the NEJM article (ok, stop laughing)  
that said there was no different in CBP pts vs age matched controls  
vs matched patients getting hip replacements.  As people have  
mentioned, there are good surgeon and bad surgeons who give good and  
bad operations, but I think at the end of the day not using bypass  
when it should have been used has probably hurt more people than  
using bypass.  Yes, there are micro embolic, air, alterations in  
flow, etc - but in the long run are there longterm problems - I guess  
if is knocks out the random part of your brain where your anniversary  
date, children's names and birthdates, or wife's name are stored.   
Like any useful tool - misapplication can result in a catastrophe.  I  
do most of my CABGs on-pump for a variety of reasons, many of which  
are related to my youth, but I do off-pump when the targets are big  
(which in our practice is rare) or when patients need a LIMA to LAD  
only.  Contrary to much of the "literature" by those to make their  
careers writing about off-pump, I still find it hard to believe that  
the anastamosis is as good or that the patients get as complete a  
revasc.  I have seen and grafted many small OMs, diags, even LADs  
that would have been a pain in ass to graft off-pump - I guess one  
could argue that those didnt need grafting at all.  Furthermore, as I  
am sure Ani can attest to, many patients have significant neuro- 
cognitive improvements when they get more blood flow to their brains  
- whether this is accomplished with a VAD or CABG or valvular surgery  
- separating this out from the obvious potential harmful effects of  
CPB on the brain is impossible......besides heart surgery is not  
cosmetic surgery or botox injections, we are dealing with major  
problems and sometimes a few small battles are lost to win a war.

-michael





On Dec 22, 2007, at 5:24 AM, Prasanna Simha M wrote:

> I would like to know one thing that is physiological  wrt to  
> cardiopulmonay
> bypass ?
> Prasanna
>
> On Dec 22, 2007 3:14 PM, <NielsB at aol.com> wrote:
>
>>
>> This discussion is always interesting. I must again   one of the many
>> excellent quotes of my   great friend and previous partner in  
>> Buffalo:
>>
>> "Why do people feel so safe when they enter an airplane? Because  
>> the pilot
>> goes with you, and he would probably not go if the plane was unsafe.
>> But when the cardiac surgeons say: we are going on pump it is not  
>> exactly
>> true, because the surgeons does not go on pump himself, only the  
>> patient"
>>
>> Of course it does not mean that the pump is   a priori bad,  
>> sometimes we
>> need
>> it sometimes not, it is a tool and an important one some times.
>>
>> We should not be so fixed on this issue any more, but also not  
>> ignore the
>> issues. As the previous writer said, maybe a couple of hours on  
>> the pump
>> will
>> rejuvinate the brain. Of course that is   a joke as far as we know,
>> because I
>> really dont find much evidence that the brain is better with than  
>> without
>> pump.
>> Most sudies show that   cognitive functions etc are worse or equal  
>> with
>> pump
>> not better.
>>
>> So maybe   most patients do not understand all this things, but as
>> surgeons
>> maybe it   is our responsibility to use the tool when it is  
>> indicated and
>> necessary, and in my opinion in CABG it is not usually required.
>>
>> Jacob Bergsland
>>
>>
>> **************************************
>> See AOL's top rated
>> recipes (http://food.aol.com/top-rated-recipes? 
>> NCID=aoltop00030000000004)
>> _______________________________________________
>> OpenHeart-L mailing list
>>
>> Send postings to:
>>  OpenHeart-L at lists.hsforum.com
>>
>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>> http://mmp.cjp.com/mailman/listinfo/openheart-l
>>
>> All messages transmitted by the OpenHeart-L are subject to the  
>> policies
>> and
>> disclaimers posted at:
>> http://www.hsforum.com/listdisclaim
>> -----------------------------------------
>>
>
>
>
> -- 
> Prasanna Simha M
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
>  OpenHeart-L at lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the  
> policies and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------