[HSF] the great con...... another ONvOFF debate

don ross donross at bigpond.com
Wed Dec 26 20:55:19 EST 2007 

Michael,
You are correct in your assessment of the penetration of opcab and I  
find it  a bit puzzling.

Perhaps I was lucky with my anaesthetists and the fact that I seem to  
have developed a simple technique, the key to which is the home made  
shunts and having no hesitation to use the pump if needed. (but no  
aortic clamp)

It is true that it is not for everyone  as I have trained some  
surgeons to do competent opcab who ,nevertheless, have fallen back  
into the bosom of cardioplegia.

Although no one will believe it , I have done 1000 anaortic opcabs  
with no strokes so I can't help believing that some of the last few  
morbidity percentage points can be addressed.
Don
On 26/12/2007, at 11:57 AM, Michael Firstenberg wrote:

> 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
>>>>
>>>>
>>>>
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