[HSF] The Great con....

Sun Dec 30 12:14:25 EST 2007

Nice analysis, Ani.  
I get the sense there is both depth and skepticism in your analysis, so i don't think that you believe in evidence (EBM) as much as you say from time to time. Did you not question the evidence for LIMA to LAD? Are you playing the shell game with us hiding "meaning" under different shells as the analysis dazzles us?
I type way too slooowwwlly to continue this at present. 

do you like beer?

tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Saturday, December 29, 2007 9:09:31 PM
Subject: RE: [HSF] The Great con....

If we say there are a few patients who benefit from OPCAB then how would we be able to apply the technique to those patients if we cannot or do not routinely perform such an operation in a seamless and stress-free manner? There is really no room for the selective OPCAB surgeon if this selection is based purely on patient need (e.g. atheromatous aorta). Such patients who 'need' or will specifically benefit from OPCAB are few as Hal and others repeatedly remind us. So there are two approaches - do OPCAB often and then be able to provide it seamlessly to those who may benefit or do not do it at all. If a surgeon does 97% ONCAB and the 3% he does OPCAB are these high-risk cases how could he do those well? How does one do LIMA to LAD through small thoracotomy if not doing them via sternotomy? Indeed if you look at such surgeons who say they reserve OPCAB for diseased aortas you will often find under-revascularization with many such patients receiving a
 LIMA-LAD only and 'the rest can be stented' (see that now and then in on-pump surgeons in my institution). Now this is not what Don and others are preaching as even these 'high risk' cases will get complete or near complete revascularization based on or both IMAs. For this reason, a surgeon wishing to keep the option of OPCAB open for a specific patient group who needs it must also perform OPCAB on many who wont have a specific benefit. If only to maintain the team's skill and routine a center should probably do at least one OPCAB a week (my arbitrary figure) so the surgeon - even if not convinced of superiority - should do a substantial number. 

What then does the ONCAB surgeon do faced with these patients who will 'benefit' from OPCAB? Let us remember that OPCAB is not the only solution to these problems. Indeed I would argue that for the majority on-pump surgeon, the best outcome in a 'high-risk' case will likely be obtained by doing the procedure on-pump and not off-pump. Take the calcified aorta. Don makes a point - and I agree - of anaortic surgery. But anaortic surgery can also - indeed arguably more safely - be accomplished on pump. Cannulate the axillary artery and perform as many anastomosis on the beating or fibrillating or rapid paced and vented heart. Surgeons for years had solution to this problem before OPCAB was popularized in the last decade. Inflow can be taken off IMAs or the innominate artery or, using brief circulatory arrest, the aorta itself (as one of my senior colleagues did two weeks ago). Or the bleeding problem. How come this argument all vanishes when a patient is
 having an AVR? We also have tools to minimize blood loss and avoiding pump no longer becomes an issue. One of my colleagues did an emergency AVR and CABG on a patient who arrested during a diagnostic cath and on plavix - life goes on and patient got the pump and got no blood. So we must not cloud the data. In 1989 Ovrum from Oslo presented a series of 100 consecutive (on-pump) cases without blood transfusion. People have been doing bloodless surgery for ages. All the things we say are indications for off-pump are accomplishable with good results on-pump. The indications for OPCAB themselves are dubious as many of these patients with the slightest intra-operative complication or hiccup rapidly become CPB cases. I would like to know how many of these cases are done without perfusion back-up present because 'CPB is contraindicated'. Zero I suspect.

So why avoid the pump? Of course from Tea's dissertation we might as well also do lobectomies on pump - you would almost never lose a patient from hemorrhage. The reason to avoid the pump is that, provided you can consistently achieve the same operation with the same efficacy off-pump, then by definition it will be better for the patient. The proviso must be that the surgeon is capable of achieving the same operation. As i have said before I am convinced that all surgeons who have excellent results off-pump will achieve the same on-pump. The converse is not true. So if a surgeon is able to do all his cases off-pump (Hal it is the intention to treat that matters - it does not matter that one occasionally converts, this is intrinsic to any technique that it has a failure rate) then there will be net benefit to the patients by avoiding the complications of cannulation and CPB. The anaortic benefits of Don do not however apply here, strictly speaking, as
 they have nothing to do with off-pump as anortic surgery is doable on-pump. Off-pump will carry a small incremental risk but provided the conversion rate is low (below 5% has been quoted) and the hemodynamic insult at surgery is minimal then the results will at least be equivalent to on-pump (by avoiding the excess strokes, CPB related morbidity associated with on-pump) and more likely superior. There are also economic advantages to OPCAB which several papers have shown.

>From the individual patient view it really does not IMHO matter whether you are done on or off, but what matters is who does your operation and what conduits they use. From the doctors point of view it does not matter what you do - either do all on-pump, almost all off-pump or some on and some off, but the indication for doing off-pump in most cases should be nothing more predictable than toss of a coin (i.e. there should be ability and a track record of doing OPCAB in all sorts of cases. I cannot see much justification for anything in between. Of course all said is with the assumption that the relative hypercoagulable state after OPCAB has no implications for long-term patency - which may or may not be the case.

Certainly we are focusing on the wrong thing (avoiding CPB) and hence we continue to lose the battle with PCI. It would make more sense for the future of CABG if we were to promote, investigate and market more anaortic surgery (regradless of use of pump), multiple arterial grafts in ALL patients, small incisions, robot assistance (even with on pump), maybe (though not my idea of progress) hybrid revascularization etc. OPCAB while occasionally beneficial and very sexy and appealing, has certainly not been the progress in the field of revascularisation that we had hoped for - and for all the reasons highlighted in this debate will likely never be.

(again I declare my conflict of interest that i believe opcab is superior to oncab)

Ani

> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] The Great con....> From: zzhoumd at pol.net> Date: Sun, 30 Dec 2007 01:02:21 +0000> CC: > > Tea,> > Very elegant argument, although OPCAB is somewhat different from ONCAB, the basics are the same. I am no world class expert, I think the key is patience. Like all surgeries, if things setup right, the anastomosis part is not difficult.> > The main advantage for OPCAB is in patients with aortic disease. OPCAB also have much less bleeding. I once operated on a Jeehova Witness patient on plavix on very urgent basis. She did not bleed at all.> > Z Zhou> > > Sent via BlackBerry by AT&T> > -----Original Message-----> From: Tea Acuff <tacuff at swbell.net>> > Date: Sat, 29 Dec 2007 16:06:52 > To:OpenHeart-L <OpenHeart-L at lists.hsforum.com>> Subject: [HSF] The Great con....> > > One of the questions raised by this thread was why do we do what we do as surgeons. In answering a little more of that question I would
 like to shift the focus from what we do to who we are, that is, what are some of the elements that make successful surgeons. I made a comment earlier about effort over talent on which I would like follow up. Consider the following excerpt:> > "The emerging picture from such studies is that ten thousand hours of practice is required to achieve the level of mastery associated with being a world-class expert – in anything. In study after study, of composers, basketball players, fiction writers, ice skaters, concert pianists, chess players, master criminals, and what have you, this number comes up again and again. Ten thousand hours is equivalent to roughly three hours a day or twenty hours a week, of practice over ten years. Of course, this doesn't address why some people don’t seem to get anywhere when they practice, and why some people seem to get more out of their practice sessions than others. But no one has yet found a case in which true
 world-class expertise was accomplished in less time. It seems that it takes the brain this long to assimilate all that it needs to know to achieve true mastery."> From: This is Your Brain on Music by Daniel J. Levitin> Daniel J. Levitin runs the Laboratory for Musical Perception, Cognition, and Expertise at McGill University, where he holds the James McGill Chair and the Bell Chair in the Psychology of Electronic Communication. Before becoming a neuroscientist, he worked as a session musician, sound engineer, and record producer working with artists such as Stevie Wonder and Blue Oyster Cult. He has published extensively in scientific journals and music magazines such as Grammy and Billboard.> > > Levitin further states that this repetition matches well with the brain's reconnection process of neurons. Therefore if we may be conscious of some of what we do as experts, it not exactly like a linear link of rational logic that enables us, but an extra
 logical pattern of associations that we perceive and are transformed in our brains without specific grammatical logic. It becomes neuronal "logic"(my term). This in turn informs and associates with the rational logic and language constructs that we use to describe our actions and beliefs as we consciously interact with others as in my writing and your reading this paragraph. > > As to Ani's point about surgeon's belief in themselves regardless of the evidence, which is either true or not, the brain remembers better and associations become more important if we have emotional connection to what we believe. We tend to remember what we believe in and dismiss that which we do not or that which does not match our patterns of association. So it is important and good for Hal to believe that he is right, even if it seems unlikely or provisional to me, assuming it is also working okay for Hal. If not, which is a judgment call since past traditional thought always
 has some benefits, it would be better for him to look for other ways of thinking about things. He of course does precisely that when he decides that, say, robotic surgery now makes sense as do incomplete rings.> > This begs the question of how do agnostics or skeptics like myself or Ani achieve anything if we seem to be conditional or provisional in our understanding of our techniques or solutions. I would point out to those of you that consider yourselves "non-believers" be it medicine or religion that the meaning of things is an emotive position based on the "facts" or lack there of. It is "better" to believe in something that "works" however you see it.> > Another way (also borrowed from Levitin) to think about doctors and their theories and particularly surgeons and their surgery is to compare it to learning a language. On and off pump surgery for CABG can be thought of as different languages. We could argue whether English or Spanish is a better
 way to think about medicine. I would presume that some medical words don't translate well into Spanish and the English is used and visa versa. The English lexicon is apparently twice as large as the Spanish lexicon, but clearly the personal lexicon of the speaker is much more important than either extant lexicon in its importance to thinking.> > These patterns cognitively and associations neuronally are both reinforcing or empowering and limiting. That is why, perhaps, some artists and practitioners are always playing with new combinations and approaches to stimulate new associations to build different hierarchies in their minds. It is why, or why I think, I spend so much time off topic (OT) and tearing down and trying to rebuild categories of evidence and thinking. It builds patterns of patterns. It is also a tool to move to a possible new world and new future for those of us without the genius to imagine one de novo or the obsession to work through
 all of the present world's unnamed possibilities. > > tea> _______________________________________________> 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> -----------------------------------------
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