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

Wed Dec 26 21:29:53 EST 2007

What should we expect, Michael? 

How fast was "traditional CABG" accepted and by whom. What was the rate of valve repair for large centers for the first decade or two? What was (and still is) the acceptance of thoracoscopic technique for standard type thoracic procedures? In being an early teacher of many of these techniques, I was surprised (and younger) at the push back we had for techniques that at least were not significantly worse and were in the mantra of the day "minimally invasive". And the push back came primarily from the "academic" centers.

You also seem to belittle "marketing". I wish that every idea that I had would be instantly recognized for what it is: crap, old stuff that i never bothered to look up, or pure genius. It would save me a lot of time, even if it likely would not help my reputation much. Mostly, however, I am just misunderstood. Who is understood and followed? We all, or at least I, wish we could just show up on Monday for a full work week of interesting and well funded cases. In some countries half of that formula works. In the US for most of us it is neither. There are a lot of things going on behind your pay check.

By and large most of the seminal ideas of any subject survive the death and occasionally the demise of their detractors. Inertia is not just a principle confined to physical objects. One of the things we continually forget is the patient in our view of medical practice (as in my simple minded model of patient and doctor). What have Jehovah Witnesses, vain patients who want small incisions, small groups of "well" patients who want afib ablation, mitral repair, or less invasive revascularization , and the 80% of all patients that don't want to see a doctor until they show up at 2am in the ER done to change the way doctors think and act? I would submit it is collectively more than the vast majority of us medical apologists or any of our papers. I will further suggest this trend will accelerate, especially in countries that don't have a full week of interesting and well funded patients.

tea

----- Original Message ----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Wednesday, December 26, 2007 2:40:56 PM
Subject: Re: [HSF] the great con...... another ONvOFF debate

OK, I know why I do not like OPCAB - so why do the vast majority of surgeons
who make their livings (and who constantly get beat for faster, cheaper,
safer, yadda yadda yadda) doing CABG not like it?  I can understand people
who do not feel comfortable with valve repairs - since they would see so few
in a year or valve sparing roots - but what are the deeper causes of why
people do not perform OPCAB - I guess I am looking for more philosophical
reasons than technical ones.  Maybe the point is finding the benefit v
effort v risk v comfort balance?

-michael

On 12/26/07, zzhoumd at pol.net <zzhoumd at pol.net> wrote:
>
> Ani,
>
> If the benefit is well worth the effort, I am sure a lot of people will do
> it and do it well. Although I had a lot of training in OPCAB, just do not
> have the motivation to do it on every patient. It is just more stress for
> both anesthesia and surgeons.
>
> Z Zhou
>
> Sent via BlackBerry by AT&T
>
> -----Original Message-----
> From: Ani Anyanwu <anianyanwu at hotmail.com>
>
> Date: Wed, 26 Dec 2007 19:25:39
> To:<openheart-l at lists.hsforum.com>
> Subject: RE: [HSF] the great con...... another ONvOFF debate
>
>
> Michael
>
> Yes it is that a different operation. Ability to do complex conventional
> surgery does not mean one can replicate it if done in mini-invasive or
> off-pump fashion
>
> That one pioneered complex mitral repairs does not mean one can also do it
> with a robot or endoscopic assist. That one has done lobetomies for last 50
> years does not mean one can do a VATs lobectomy. That one pioneered CABG
> does not mean one can adapt to do it off-pump. That the big names at
> Cleveland do not do OPCAB does not to me mean much - it is more likely to
> mean they do not know how to do it, do not want to learn how to do it or
> have tried it and could not do it as well as their tried and tested
> technique. Afterall how do you explain the fact that only about 20% patients
> at CCF have bilateral mammary artery grafts when the clinic are the ones who
> provided the most compelling data to support the approach. Even if all
> randomized trials showed OPCAB to be superior I bet you they still would not
> be doing it at all CCF (partly for reasons I outlined in a post 2 days ago).
>
> Ani
>
>
>
>
> > Date: Wed, 26 Dec 2007 14:06:09 -0500> From: msfirst at gmail.com> To:
> OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] the great con......
> another ONvOFF debate> CC: > > wait a minute - I thought people are saying
> that the "skill oriented factor"> is trivial?> or the cardiac pioneers to
> developed all of the new skills, tricks, and> operations (valve repairs,
> switches, transplants, etc) dont (or wont) have> the skills for off-pump or
> that is it such as different operation????> > > > > -michael> > > > > On
> 12/26/07, Prasanna Simha M <prasannasimha at gmail.com> wrote:> >> > Why is
> it popular in India - economics.(Reusable/Resterilized stabilizers)> > Why
> is it unpopular in US - there is no advantage economically there so> > why>
> > use a more "skill oriented technique" which may give you a few grey hairs>
> > when there is no difference and with the potential for litigation ?> >
> Prasanna> >> > On Dec 26, 2007 10:32 PM, Michael Firstenberg <
> msfirst at gmail.com> wrote:> >> > > On 12/26/07, don ross <
> donross at bigpond.com> wrote:> > > >> > > > 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> > >> > >> > > Don,> > > I am glad for you and your patients that
> you are getting good OPCAB> > > results. There is no doubt that eliminating
> bypass can eliminate some> > of> > > the M&M of heart surgery, but I think
> we are being unrealistic in> > thinking> > > that all of the M&M is
> associated with CPB with/without aortic clamping> > -> > > not to mention
> the variety of problems which can be introduced that are> > > unique or more
> common with OPCABs.> > >> > > I guess those of us who do a lot of On pump
> can justify it for many> > > reasons> > > - which begs the question to the
> hard core off-pumpers to come up with> > > answers (real answers) why the
> vast majority of surgeons in this country> > > (US> > > if not the world)
> still use a technique that is more expensive and time> > > consuming and "in
> theory according to the literature" associated with> > more> > > deaths and
> awful complications. Anyone know of a lawsuit were someone> > > said> > >
> "Mr X would not have had this complication has this surgeon not comitted> >
> > malpractice and crimes against humanity by using CPB"? As a group, we> >
> tend> > > to willingly accept advances in technology over time, so why has
> this> > not> > > caught on?> > >> > > -michael> >
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