[HSF] PCI Vs CABG - not all about evidence

Tea Acuff tacuff at swbell.net
Sun Dec 30 15:49:55 EST 2007 

I probably would agree with your own #2, but consider what I say about #1.

I don't believe what we name as equals are equals, so I would wish to look at the lesion if I weren't in the middle of a heart attack. I think it makes prefectly good sense to PCI technically easy lesions. The data would support this also (or so I read it). So does your family experience. If the interventionalist (who is now left out of the decision) has any doubts or reservations then certainly CAB with LIMA. I doubt I would ask for a DES.

tea


----- Original Message ----
From: Edward Bender <ebender001 at charter.net>
To: OpenHeart-L at lists.hsforum.com
Sent: Sunday, December 30, 2007 5:06:08 PM
Subject: Re: [HSF] PCI Vs CABG - not all about evidence

Answering my own questions:
1.  Tainted by my family history since my father had PTCA by Grunzig  
in 1981 at Emery U.  He developed recurrent angina 20 years later and  
got re-cathed, revealing normal appearing LAD (previous PTCA using  
Grunzig balloon) but a tight mid RCA which was stented.

2.  I would choose LIMA to LAD and good quality SVG to RCA.  I am  
worried about recurrent disease or some other process requiring re- 
sternotomy.  In my hands, re-entry is easier with SVG to RCA than RIMA.

Ed Bender, MD


On Dec 30, 2007, at 4:50 PM, tdmartin2000 at aol.com wrote:

> Ed
> I would have CAB surgery.
> Tom Martn
>
>
> -----Original Message-----
> From: Edward Bender <ebender001 at charter.net>
> To: OpenHeart-L at lists.hsforum.com
> Sent: Sun, 30 Dec 2007 4:16 pm
> Subject: Re: [HSF] PCI Vs CABG - not all about evidence
>
>
> I would like to ask the forum members what choice they would make  
> for themselves in the following two circumstances:?
> ?
> ?You are a 62 year old heart surgeon and getting chest pain with  
> moderate exertion (class 2-3 angina) already on meds for  
> hypertension (beta blocker/ACEI). You go to the cardiologist whom  
> you think has the best clinical judgement and that cardiologist is  
> not an interventionalist but does do caths (so if you need PCI a  
> referral will happen). You get cathed and:?
> ?
> 1) you have a 95% proximal LAD stenosis at the first septal  
> perforator but not a branch lesion. Surgery or PCI? What graft or  
> what intervention??
> ?
> 2) you have the same lesion as #1, but you also have a 70% mid  
> dominant RCA stenosis. Same questions.?
> ?
> In our minds we probably are thinking about early and late hazard  
> curves and Eugene Blackstone in addition to the what and where of  
> treatment options.?
> ?
> Just curious.?
> ?
> Ed Bender, MD?
> ?
> On Dec 30, 2007, at 2:05 PM, Ani Anyanwu wrote:?
> ?
>> Hal?
>> ?
>> A lot of the drive for PCI comes from the patient themselves. >  
>> Patients do not want surgery. Unless we reinvent ourselves we will  
>> > continue to lose this 'battle' with PCI. Taggart's logic is  
>> flawed > because evidence is not the main driving factor as to how  
>> patients > are revascularised (else many more would have CABG). How   
>> many other > examples do you know where an inferior therapy is more   
>> used than a > more effective one? There are reasons why this is the   
>> case with PCI. > Cary just talked about his colleague - an  
>> established coronary > surgeon - who opted for PCI over CABG for  
>> his LAD disease and I know > of two rather prominent London  
>> surgeons that have done the same. One > of my cardiologists who is  
>> really pro-CABG had his mum come in with > angina and she left with   
>> stents in RCA and Cx. A senior doctor in > our hospital dropped  
>> dead after an LAD DE stent thrombosed two years > ago. There are  
>> numerous senior doctors who opt for PCI and we cannot > say they  
>> were also c
> onned on the cath table. Surely all these > doctors know or have  
> access to the data and are not being > misinformed by cardiologists.   
> Even well informed patients will chose > PCI over surgery in many  
> instances.?
>> ?
>> Indeed in the last 3 months I have had two patients - one with left   
>> > main stenosis and another three vessel disease - referred (by an  
>> > interventional cardiologist) for surgery and they both asked me  
>> cant > this be done by angioplasty? I explained the risks and  
>> benefits of > surgery to both patients. One was a Child B cirrhotic   
>> and he was > rightly concerned about the risk of surgery. Both  
>> patients asked for > a consult with an interventional cardiologist  
>> (who to be fair told > them both that he advises surgery over PCI)  
>> and they both weighed > pros and cons chose to have PCI (and this  
>> was not on same day as > diagnostic cath).?
>> ?
>> We focus on the wrong thing if we keep selling this 'CABG is better   
>> > than PCI' message. Everyone knows CABG is better. The reality is  
>> > humans are so constituted that they are more concerned with >  
>> immediate loss (death, disruption and pain from surgery) than they  
>> > are of future benefit (longer life free of intervention) which is   
>> > why we smoke for example. Most given the option - even cardiac >  
>> surgeons - would prefer to avoid an operation even if they may be >   
>> compromising their long term outcomes. I remember even as a child >   
>> (11 year old) I was in tropical africa and bitten by a stray dog. I   
>> > never mentioned this to my parents till few days later because i  
>> did > not want to receive the mandatory passive rabies prophylaxis  
>> > required for dog bites (which then consisted of daily >  
>> intraperitoneal injections for 21 days) - i decided i would rather  
>> > risk death than go through the ordeal of injections. Similarly I  
>> > have refused immunizations and been prepared to suffer
> the > consequences of deadly infection because I have a phobia for >   
> needles. So as long as PCI involves a prick to the groin and surgery   
> > a general anesthetic with a large painful incision then *many* >  
> patients will opt for PCI. That they come back in 6, 12 or 60 months   
> > for repeat revascularization or that they die later, is in the >  
> future and the future will take care of itself.?
>> ?
>> If we want a CABG rennaisance we don't need surgeons standing in >  
>> meetings spurring animosity between surgeons and cardiologists and  
>> > showing slides and slides as to how CABG is better than PCI. We  
>> have > heard the message of Taggart and many before him for decades   
>> - those > messages have done nothing and will do nothing to reverse   
>> the > imbalance between PCI and surgery. We need to refocus  
>> ourselves away > from evidence and back to ways we can make CABG  
>> more appealing, more > effective, less traumatic and more  
>> acceptable to patients. As I > often bring up on HSF for example  
>> (which whenever I raise it the > response is a controlled silence)  
>> how could we all be putting in > vein grafts in people and yet  
>> criticise cardiologists for dishing > out an inferior  
>> revascularisation therapy? Walking into our cath lab > there is  
>> hardly a day I do not see a diseased vein graft on the > monitor  
>> being intervened upon - how then can we seriously expect > them to  
>> believe we have the solu
> tion for CAD. The future has to be > more collaboration rather than  
> animosity - as strange as it might > sound, we all want the best for   
> the patient (even if we interpret > the best in different ways).?
>> ?
>> Evidence is only one of many factors that comes in consideration >  
>> when patients or doctors chose therapy...there are several others,  
>> > and in the revascularization debate these others have proven more   
>> > overriding.?
>> ?
>> Ani?
>> ?
>> ?
>> ?
>> ?
>>> From: Hgrmd at aol.com> Date: Sun, 30 Dec 2007 13:57:52 -0500> >>  
>>> Subject: Re: [HSF] The Great con....> To: OpenHeart-L at lists.hsforum.com 
>>> >> > CC: > > Michael,> I beg to differ. Stents have been terrible  
>>> for >> our business. That is > unequivocally reflected by the  
>>> declining >> numbers of stand alone CABG's done in > the U.S. In  
>>> spite of the >> fact that there is nothing to back it in the >  
>>> literature, >> cardiologists continue to restent recurrent  
>>> stenoses as well as > >> multivessel disease. I have heard Taggart   
>>> address this at the last >> STS as well as > the ACTS meeting. One   
>>> of his main points is that >> the interventional > cardiologist  
>>> usually makes the decision on the >> table with minimal input from   
>>> a sedated > patient, and without the >> advice of the surgeon. I  
>>> can't tell you how many > times I've heard >> the  
>>> interventionalist tell me the patient didn't want surgery > as >>  
>>> he gamely justified the reason for a multivessel PCI. The only >>  
>>> solution > is to stop cath
> /possible PCI on stable patients. These >> stable patients should >  
> have the diagnostic cath, be presented the >> options by the  
> cardiologist as > well as the surgeon, and then >> proceed from  
> there.> > Hal> > > > >> **************************************See  
> AOL's top rated recipes > >> (http://food.aol.com/top-rated-recipes?NCID=aoltop00030000000004 
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