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

Mon Dec 24 22:30:05 EST 2007

Well, Ani, you have really stirred up a mess of worms with this one. If our evidence concerning techniques is bad, our evidence concerning surgeon characteristics and their correlations is extremely tenuous.
I don't have time to offer a counter presently, but my evidence is at least as speculative as yours so it probably doesn't matter much. It is an interesting speculation, however.
I do have a couple of thoughts.
What about the adage that those that can't do, teach? Completely false?
How exactly would it be that surgeons that hold minority opinions become surgical leaders? 
Off pump surgeons are slower?
Do better surgeons make a operation look hard or easy? 
Is planning as Tom has suggested done for "easier" later operations?
Is not one of the characteristics of the best solution an "easy" one?

None of this proves anything of course.

Have a Merry Christmas and New Year all.

tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Monday, December 24, 2007 12:24:59 PM
Subject: RE: [HSF] "Patients don't want cardiopulmonary bypass" - the great con

Hal

With respect I think you miss the point here. Doing 50 percent opcab is very different from 100 percent. The analogy is someone who has 50 percent mitral repair rate likening themselves to you who has a 100 percent repair rate and saying it is easy - after all I used to repair half my valves so I could repair them all. You and I know that ability to repair half the valves does not mean one can repair them all. Of course maybe you could do 100 percent OPCAB if you wanted to but somehow I doubt that. I am yet to see a surgeon with a high complex surgery work load as yourself that also consistently does CABG without CPB with excellent results  - usually they have more pressing things to focus on and worry about than avoiding CPB. I gave the example of Yacoub and I have seen a few other great surgeons dabble woefully in OPCAB. I do not think the skills to do sixth time reops, aortic root remodelling, ross operation, lvads, TAA, arches, switches, multiple
 valves etc are necessarily transferable to OPCAB. Indeed cardiac surgeons who specialize in complex or high risk surgery thrive on CPB; doing cases that keep them on pump for three, four, five, six hours, so CPB is hardly the enemy they seek to eliminate in their practice but is their greatest friend. Name 10 big name complex cardiac surgeons, academic leaders or society presidents and I bet you will struggle to find one who is also a (100%) OPCAB surgeon. 

I am not saying either that OPCAB is a difficult operation. An OPCAB is an easier operation by far to do than any operation I have done in the last month. On a scale of one (easiest) to ten (most difficult)  in difficulty I would rate OPCAB as a three. As a junior trainee OPCAB was the first operation I was allowed to do as my attendings felt more comfortable allowing you to learn to suture lima-lad on a non-ischemic beating heart with a shunt as (within limits) you had all the time in the world. All I am saying is one needs a particular skill set and mindset for OPCAB and we don't all have it and possibly the more high risk and complex surgery you do the less likely it is to have the time, skill and patience for OPCAB. That one can do the most difficult reop does not mean they can also do 100 percent OPCAB as well. The corollary is that most OPCAB surgeons despite their (superior) dexterity, patience and skill set do not or cannot tackle the more
 complicated or complex surgeries. Sergeant, for example, I am told (others could confirm if this is indeed the case) almost exclusively does CABG and refers complex cases to colleagues.

As regards robotic mitral, having watched Chitwood do the case in leipzig, I am not convinced it is the most difficult procedure either - a bit of nip and tuck here and there, a flexible band and he was done in an hour (just teasing you Hal as I know you will have your views on that operation)! 

Best

Ani

> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] "Patients don't want cardiopulmonary bypass" - the great con> From: hgrmd at aol.com> Date: Mon, 24 Dec 2007 16:40:38 +0000> CC: > > Ani,> As I've said many times before, I used to do about 50 per cent of my stand alone CABG's off pump. Indeed, it does require a different, more intense, set of skills. I still maintain it's not nearly the most technically demanding operation I do. Try doing a complex bileaflet repair with a robot.> > Hal> Sent from my Verizon Wireless BlackBerry> > -----Original Message-----> From: Ani Anyanwu <anianyanwu at hotmail.com>> > Date: Mon, 24 Dec 2007 05:39:19 > To:<openheart-l at lists.hsforum.com>> Subject: RE: [HSF] "Patients don't want cardiopulmonary bypass" - the great con> > > >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> > 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> >
 ----------------------------------------->_________________________________________________________________> Get Hotmail on your mobile, text MSN to 63463!> http://mobile.uk.msn.com/pc/mail.aspx_______________________________________________> 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> ----------------------------------------->_______________________________________________> 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> -----------------------------------------> > >________________________________________________________________________> More new features than ever. Check out the new AOL Mail ! - http://webmail.aol.com>_______________________________________________> 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> -----------------------------------------> _________________________________________________________________> Telly addicts unite!> http://www.searchgamesbox.com/tvtown.shtml_______________________________________________> 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> -----------------------------------------
_________________________________________________________________
Who's friends with who and co-starred in what?
http://www.searchgamesbox.com/celebrityseparation.shtml_______________________________________________
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
-----------------------------------------