[HSF] "Patients don't want cardiopulmonary bypass" - the great con...... another ONvOFF debate

Michael Firstenberg msfirst at gmail.com
Tue Dec 25 19:57:13 EST 2007 

Don,

Since this has evolved into another off vs on CABG topic (hmmm, it  
has been how long since this topic came up?  cant remember), I will  
change the subject header.
I was not actually going fishing on this, but since it was tossed out  
there......
ok, regardless of "my" young, inexperienced, tremor-inflicted, pump- 
loving perspective (again, in training I did lots of off-pump CABGs -  
it does kind of beg the question of why some of these meccas and CABG  
mavens have not adopted off-pump coronary surgery?  Are "they" afraid  
of learning curves?  will it compromise reputations?  When you talk  
to these people, they frankly dont believe the operation is as good -  
in their systems with their patients overall.  There are reasons why  
the vast majority of CABGs are performed on-pump and there is no one  
single answer.  If you can do it well (that means you can probably do  
on-pump well also) and your system works, then that is great, but the  
"ability" to perform off-pump CABG safely and with good results (the  
two do not go hand in hand) actually, I think, requires more skill  
from the team and system (good anesthesia, nursing staff, assistants,  
etc) than just the surgeon practicing the technique in the animal  
lab.  To think that switching from off to on will "eliminate the last  
few percentages of cabg morbidity" is, IMHO, very unrealistic if not  
false (but may be good marketing).  When I look back on my own poor  
outcomes (not that I have accumulated enough experience to make true  
qualified judgements) they were actually in patients who got good off- 
pump CABGs.  Furthermore, over the years, at all of the different  
hospitals I have trained at, let me just say off-pump CABG is not  
exactly like a "small poke in the groin".

-michael



On Dec 25, 2007, at 7:20 PM, don ross wrote:

> Michael,
> I have to rise to the bait after reading, yet again, the on going  
> OP/ONCAB debate.
> There is nothing wrong with CPB or arrested hearts.
> However clamping 1000 aortas will result in 15-20 strokes half of  
> which will die not to mention the grams of brain that will randomly  
> infarct "without clinical consequence"
> The extra effort to learn safe opcab is therefore well spent if you  
> want eliminate the last few percentages of cabg morbidity.
> You shouldn't care how WFMC or CCF do their coronary surgery if you  
> can do it better.
> Don
> On 26/12/2007, at 5:50 AM, Michael Firstenberg wrote:
>
>> I think there is a huge "comfort zone issue" combined with "giving  
>> patients
>> the best operation".  In training I did a lot of OPCABG and got  
>> pretty good
>> at them and they clearly take less time.  But, I also noticed in  
>> my hands
>> (and in my institution and with my patient population) that I did  
>> not think
>> the results were any better.  Do I think that it is a bad  
>> operation - no, I
>> just dont like it - I dont agree with the literature (as it  
>> applies in my
>> situation) and I have a firm believer in CPB and good myocardial
>> protection.  I dont think the anastamosis are as good (either in  
>> general or
>> in my hands - contrary to the literature and the handful of OPCAB  
>> hybrids
>> where I make them shoot the graft - all have been open or the  
>> patients who
>> have had problem and got re-cathed with few grafts being down -  
>> and those
>> not entirely unexpected.
>>
>> There are several major meccas (i.e. The Mayo and CCF) who perform  
>> very very
>> few OPCAB - and one must ask why???  Are "they" inferior  
>> surgeons?  lazy?
>> afraid of new technology/techniques?  Maybe the just dont believe  
>> that it is
>> good in "every case" or should be widely applied.  Having asked  
>> some of the
>> coronary surgery "mavens" the arguments are the same - they dont  
>> believe it
>> is as good as an operation.
>>
>> I am sure there is a lot of psychology behind all of this and it  
>> probably
>> reflects an issue of views on CPB - some either view it easier as  
>> a friend
>> while so as a foe.
>>
>> -michael
>>
>> happy holidays to all
>>
>>
>>
>>
>> On 12/25/07, wftjrtyler at aol.com <wftjrtyler at aol.com> wrote:
>>>
>>>
>>> In a message dated 12/23/2007 11:57:46 P.M. Central Standard Time,
>>> prasannasimha at gmail.com writes:
>>>
>>> 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
>>>
>>>
>>>
>>> Excellent post,Prasanna.  I would also add "perserverance" as
>>> the  learning
>>> curve for some of us is (was?) steep.    bill  turner
>>>
>>>
>>>
>>> **************************************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
>>> -----------------------------------------
>>>
>> _______________________________________________
>> 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 anddisclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------

More information about the OpenHeart-L mailing list