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

Tue Dec 25 07:11:59 EST 2007

Metaprolol is not the same as Propranolol in outcomes etc etc in varying
subsets.
Prasanna

On Dec 25, 2007 3:33 AM, Tea Acuff <tacuff at swbell.net> wrote:

> My comment is so simple that it is almost imperceivable. It is rather easy
> to look and the body of data for preop beta blockers, say, and even more
> simple to apply the challenge to mimic the evidence. But , say CAB? What are
> we treating ,with what technique for the anastomosis, in what
> confirguration, and what do we do with Tom's stent, etc. If we hold
> everything steady the patient does not resemble what we threat, and if we
> apply the same operation it does not represent what we do. It is apple and
> oranges, so to speak. A trial is not like a series of patients. A
> betablocker is not a CAB. Is even metoprolol the same as propanolol?
>
> tea
>
>
> ----- Original Message ----
> From: Ani Anyanwu <anianyanwu at hotmail.com>
> To: openheart-l at lists.hsforum.com
> Sent: Sunday, December 23, 2007 10:50:12 PM
> Subject: RE: [HSF] "Patients don't want cardiopulmonary bypass" - the
> great con
>
> > From: tacuff at swbell.net> 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?
> But Tea, are complex interactions not an amalgamation of simple
> interactions and do we not make complex interactions more predictable by
> applying simple interactions in a logical and consistent manner as the likes
> of Sergeant and de Leval have demonstrated? By definition we have to do
> complex things to many to help the few - how many of the patients did you
> operate this year that you think benefitted from your surgery - hopefully
> the majority but no doubt a sizable minority (including for example those
> who died or had a stroke) did not. Unfortunately varied surgical skill,
> teams skills and infrastructure and logistics mean that few operations or
> surgical therapies can be reproduced consistently decreasing utilization of
> practice guidelines (such as OPCAB as recommended practice if evidence of
> superiority is unequivocal: despite what Hal says, we cannot all do all our
> CABGs off pump. I am yet to see a surgeon who is truly capable of doing 100%
> CABGs
>  off-pump with good results that prefers to do them on bypass). However,
> even within our individual skill sets we can usually get an idea from the
> 'evidence' for what is best for the individual patient (even if what is best
> involves referring patient to a colleague).
>
> Applying population based data to the individual patient is the closest we
> can get IMHO to improving the health of the population.
>
>
>
> Ani
>
>
>
> > Date: Sat, 22 Dec 2007 21:07:58 -0800> From: tacuff at swbell.net> Subject:
> Re: [HSF] "Patients don't want cardiopulmonary bypass" - the great con> To:
> OpenHeart-L at lists.hsforum.com> CC: > > 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> > recipes (
> http://food.aol.com/top-rated-recipes?NCID=aoltop00030000000004)<http://food.aol.com/top-rated-recipes?NCID=aoltop00030000000004%29>>
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> -----------------------------------------> >> > > > -- > Prasanna Simha M>
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-- 
Prasanna Simha M