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

Mon Dec 24 11:25:01 EST 2007

These surgeries (Mitral valve repairs and OPCAB) are an "exercise in
patience". I have seen consistently that the "fastest" surgeons are the ones
who cannot or will not do OPCAB and many a time think it is due to simple
lack of patience which becomes their biggest enemy. After training in a fill
it shut it and forget it mode,they will not wait to allow hemodynamics to
stabilize and I have seen otherwise excellent surgeons "Mango picking" the
heart while lifting it and then blaming everyone else for the bad
hemodynamics etc etc. The same is true for mitral repairs. They basically
demand a different mind set apart from a skill set which some assimilate and
some do not. It is learnable for those who wish to do so and is not for
those who will not.
As far as consistency is concerned, when I initially started doing repairs I
treated every case as if it was a potential repair and spent initially 60
minutes time to "get it right" I f at 60 minutes the valve looked horrible I
replaced it. As my confidence level improved the time kept extending. Same
for OPCAB some one learning should try it in every case to define his
individual "comfort zone". After discovering  the comfort zone the number of
conversions will decrease. Better to convert early than late. The question
should not be the ego trip of the surgeon but the nature of the problem of
the patient. Defining let us say a minimal hemodynamic set and ability to do
"x" no of grafts preop as the trigger for converting to on pump makes it
easier for a surgeon to take a decision while doing an OPCAB rahter than
having a rushed affair  with a sinking heart.Paul  Sergeant's address was
specifically addressing this aspect of consistency in methodology and self
training to enable a good result
Prasanna
On Dec 24, 2007 11:09 AM, Ani Anyanwu <anianyanwu at hotmail.com> wrote:

> >OPCAB is definitely not the most technically challenging thing I do.> >
> Hal
>
>
> OPCAB may not be the most challenging thing we do as surgeons but it
> certainly requires a different skill set and mind set which we may or may
> not possess to the same degree as our skills for other cardiac procedures.
> An analogy would be for a great cardiac surgeon who could tackle the most
> difficult of congenital problems but only occasionally repaired the mitral
> valve, preferring to replace, and then told you he could repair all valves
> if he wanted to but didn't see the point. I remember in 1999 I was working
> with Yacoub when the OPCAB craze started. Now Yacoub all of us would
> recognize as one of the greatest surgeons of the present era. He dabbled
> into OPCAB too and abandoned the technique as quickly as he adopted it. That
> he was very skilled in the most complex of cardiac operations did not mean
> he could easily accomplish CABG off-pump to the degree that he could
> on-pump.
>
> We must not kid ourselves OPCAB is more challenging than routine CAB. It
> does not follow that if one can do the most complex reoperations, valve
> surgery, transplants, switch operations etc, that one can also sew conduits
> unto coronaries on a beating heart with similar strategy, effectiveness and
> outcomes. We certainly cannot all do 100% (intent to treat) OPCAB - those
> who can do 100% OPCAB possess a different (higher) level of skill in this
> operation than the rest of us do.
>
> The non-adoption of OPCAB is little to do with (lack of) evidence. The
> reason most of us do not do it because most of us cannot do it well or
> cannot be bothered to do it or are after that surgeon's 'comfort zone' as
> some call it. Nothing to do with the comfort zone of the patient. Even if
> evidence of its superiority the majority of surgeons would still be doing
> conventional CABG. After all what then is the excuse for the continued
> rampant usage of vein grafts and mitral valve replacement or do we also say
> there is no evidence of superiority of arterial grafts and mitral valve
> repair?
>
> Ani
>
>
>
> > To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] "Patients don't
> want cardiopulmonary bypass" - the great con> Date: Sun, 23 Dec 2007
> 12:38:10 -0500> From: hgrmd at aol.com> CC: > > > Tea,> > ? You unwittingly
> support my?argument.? Death from CABG is essentially a "10 sigma" event
> (whatever that is).? It's extremely difficult to prove that OPCAB patients
> have statistically significant superior outcomes simply because the results
> are so good, in the vast majority of cases, no matter what you do.> ? The
> point I raise again is that "100%" OPCAB'ers often have an air of
> intellectual and technical superiority over us unwashed plebes that I find
> specious, and, quite frankly, annoying.? Trust me, I could do essentially
> 100% OPCAB on the handful of stand alone CABG's I do each year if I really
> thought it made that much of a difference.? OPCAB is definitely not the most
> technically challenging thing?I?do.> >
> Hal??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
> ----Original Message-----> From: Tea Acuff <tacuff at swbell.net>> To:
> OpenHeart-L at lists.hsforum.com> Sent: Sun, 23 Dec 2007 12:07 am> Subject:
> Re: [HSF] "Patients don't want cardiopulmonary bypass" - the great con> > >
> > > Ani, Hal has already confirmed that your argument is on slippy ground.
> He agreed > with you.> > Your Dr. Sergeant argument against using the pump
> (or neutralizing it) may not > be what it seems. Imagine that were early in
> CT surgery a trial of lobectomies > on and off pump that found on pump
> easier to expose, had more blood loss, and > prevents the likely hood of
> arrest requiring CPB. There were also annedotal > reported differences in
> post op DVT and some suspected that more aggressive > resections could be
> done pump supported. Blah blah, blah, and etc. In a > different world all of
> this seems quite possible. Of course I may be FOS (full > of self). What
> would we learn from this study? The same thing that we learned > from the
> on/off debate. We learn a lot about our tools and a little about the >
> patients. Would we use CPB rountinely for lobectomies in this different
> world > that did not happen? Would that be proper in that world but improper
> in our > world? > > I find these abstract questions, what is better PCI or
> CABG, bloodless surgery > or not, or small incision or not are, well,
> abstract and not reality. Surgeons > see specific patients and learn by
> series. We never see "populations", the so > called unbiased scientific
> model, from which are supposed to act. By the time we > construct
> guidelines, best practices, and RCT, we are as far from the actual > patient
> as when we get "credentialed" to do "procedures" at a hospital. The only >
> question is what is best for whom and by whom. If these are questions with >
> binary answers, it is likely because we only can think of simple questions.
> Our > studies can by design only ask simple questions. That is why I
> proposed my (what > the hell is he thinking) model of practice. We get so
> far away from reality in > our theories we need a guide to redirect us back
> to the problem(s). That does > not mean, "Would you like it with or without
> CPB (or robot) in that ,Sir?"> > Nassim Taleb notes that when someone is
> describing a ten sigma event causally in > fine detail (that is, an event
> that based on time might happen a couple of times > in the history of the
> universe) likely one of two things is happening: the > author is a genius or
> it is very likely that the author knows nothing about what > he is
> describing. In mdeicine we seem to search, or can only find, therapies >
> that improve outcomes by a p of .01 to .001 in hundreds or thousands of >
> patients. These is the upside down version of the above ten sigma event. The
> > probabilities are less but still against us in understanding causality. I
> would > propose a corollary "reverse rule of universals" in medical therapy.
> The more > that a therapy is described as universally appropriate from large
> population > analysis, the less the prescription is useful. If the effect is
> not obvious to > any scrub tech or nurse assistant in between 10 and 100
> cases, then it has > nothing to do with universal> importance but it might
> help (or hurt) the few. This may be appropriate > thinking for simple
> interactions such as long term statins or preop beta > blockers, but I am
> not sure it is helpful thinking for complex interactions as > in techniques
> of cardiac operations. We should use our tools of evidence, but i > don't
> see how we can rigidly apply them. Does first do no harm, translate in >
> modern medicine as do complex things to the many to help the few?> > > tea>
> > > > > tea> ----- Original Message ----> From: Ani Anyanwu <
> anianyanwu at hotmail.com>> To: openheart-l at lists.hsforum.com> Sent:
> Saturday, December 22, 2007 9:00:05 AM> Subject: RE: [HSF] "Patients don't
> want cardiopulmonary bypass" - the great con> > And having your heart lifted
> out of the chest beating upside down is > physiological? The sometimes
> promoted notion that off-pump surgery is > physiological is part of the
> great con - I would like to know one thing about > general anesthesia, or
> being operated upon that is physiological. Let us not > pretend there is
> anything normal about having one's heart operated upon - which > ever way
> you dress it heart surgery is a big insult to the body.> > Again I say there
> may be benefits to avoiding CPB but let us not pretend the > patient's
> desire is what is driving this.> > In response to comments on Dr Sergeant's
> excellent results - I put it to you > that if he were to adopt his entire
> system and change only one thing - start > using CPB - his results would be
> exactly the same. His results are a marker of > good surgery,
> sub-specialization (my understanding is that his practice is > almost
> entirely CABG), and good systems management and not off-pump surgery.> >
> Ani> > > > > Date: Sat, 22 Dec 2007 15:54:30 +0530> From:
> prasannasimha at gmail.com> To: > OpenHeart-L at lists.hsforum.com> Subject: Re:
> [HSF] "Patients don't want > cardiopulmonary bypass" - the great con> CC: >
> > 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> >
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-- 
Prasanna Simha M