From donross at bigpond.com Thu Feb 1 07:54:57 2007 From: donross at bigpond.com (Donald Ross) Date: Wed Jan 31 15:56:30 2007 Subject: RES: [HSF] Re: [HSF ] OPCAB pitfall In-Reply-To: References: <003601c744fe$e333c030$0401a8c0@OEM> Message-ID: <63436F55-84F4-445E-8654-FD35A5DAF86B@bigpond.com> Theofilo, I am sure your greater effort to achieve total arterial revascularisation is better than using a vein and will probably protect you from graft thrombosis in even severe cases of thrombophilia. There is no data of course but a can't recall an arterial graft failing in this manner. Why then do we occasionally use vein? Apart from non-significant lesions where an artery is containdicated the words lazy and stupid come to mind. Although in some elderly obese arteriopathic folk it may be meddlesome to take out another ima or do a laparotomy. What about putting the proximal SVG onto the ima? This has been done in our unit for some time without any apparent problems mainly to avoid aortic manipulation. We believe it should not be attempted if the vein is > 1 1/2 times the size of the ima at the site of anastomosis. It is sometimes done even for prophylactic vein grafts providing there is a competent valve in the vein to prevent back flow from the coronary into the ima which could compromise it due to competitive flow. Don On 01/02/2007, at 2:04 AM, Theofilo wrote: > Dear Don, > I've being doing BIMA's for more then 3 years now, mostly inspired > by you, > and hipercoag is something that calls the attention in OPCAB - > mainly in > endarterectomies where in initial cases I had 1 AMI interrupted by > mechanical thrombolisys and Antiplatelet drugs with considerable > muscle > loss. I used only a few SV attached to LIMA ("Y") fashion with no > knowledge > of problem (no knowledge). Since then I'm also always concerned about > hipercoag post anastomosys. Anyway the hole thing doesn't look ok > to me and > now I wouldn't put a vein unless no RIMA, Radial or Epigastric > available. > Would you tell us if you've seen the same problem with arterial or > it's a > venous thing? > BIMA's and OPCAB the medicine for CAD and stents as well. > Theofilo Gauze > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From donross at bigpond.com Thu Feb 1 08:04:22 2007 From: donross at bigpond.com (Donald Ross) Date: Wed Jan 31 16:05:47 2007 Subject: [HSF] Re: [HSF ] OPCAB pitfall In-Reply-To: References: <003601c744fe$e333c030$0401a8c0@OEM> Message-ID: <96EC413E-B4C5-41CD-9831-EB92EF10A37A@bigpond.com> Dear Thomas, As you know we don't own a flow probe so can not answer that question. Do you routinely measure flows in all grafts before and after heparin? It would, indeed, be interesting to know exactly when the graft goes down and I think you have previously indicated that it can occur soon after the heparin is given? If that is the case then my anti-thrombosis protocol may have some merit. Don On 01/02/2007, at 4:23 AM, Salerno, Tomas wrote: > would like to know if flows were measured prior to closure of this > patient. It is possible that all grafts were already occluded at > the end of the operation... > > Tomas > > ________________________________ > > From: openheart-l-bounces@lists.hsforum.com on behalf of Donald Ross > Sent: Wed 1/31/2007 4:52 AM > To: OpenHeart-L@lists.hsforum.com > Subject: [HSF] Re: [HSF ] OPCAB pitfall > > > > This is a cautionary tale about a case done for a colleague who is a > dedicated opcaber but has not yet developed a respect for the > dangers of hypercoagulation. > A routine off pump cabg X3 was done on his service with lima to Lad > and SVG to Cx,Pda ( T-graft from lima, vein used because radial > unavailable) > Pre-op TEG was slightly hypercoagulable but this result was ignored > and all the heparin was reversed and early post-op aspirin given. > Next day the patient looked okay but there was a small troponin leak > which triggered a re-cath. > This showed complete thrombosis of the SVG which obviously required > re-op. > > Because I have been similarly burnt I use a different protocol which > so far has been effective. > 1. Only reverse half heparin in all cases > 2. Give clopidogrel as well as aspirin within 30 min of returning to > recovery . ( clopidogrel ceased at 6 weeks) > 3. If TEG is suspicious don't reverse heparin and give intra-op > aspirin and clopidogrel > > A final observation is that the SVG is more prone to this annoying > complication than the IMA. Hopefully the radial is also protected. > Don > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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 > ----------------------------------------- From donross at bigpond.com Thu Feb 1 08:17:46 2007 From: donross at bigpond.com (Donald Ross) Date: Wed Jan 31 16:19:17 2007 Subject: [HSF] [Fwd: Image of the Week - Fixing a tube :)] In-Reply-To: <45C0D234.6010301@gmail.com> References: <45C0D234.6010301@gmail.com> Message-ID: Prasanna, I note that your manly form is stylishly clad in a disposable gown. I thought only we in the "first world" had to suffer such an environmentally unfriendly, industry driven foolishness! Here, they argue that is is too costly to launder and re-sterilise linen but surely that is not the case in India? Don On 01/02/2007, at 4:30 AM, prasannasimha wrote: > Resent > Prasanna > > -------- Original Message -------- > > Pictures of Vicryl thread fixing of a tube. Last picture is of me > desperately pulling on the tube to demonstrate that it holds well > (To address Hal's concern about its holding property - I am my the > toes and falling backwards to demonstrate its load bearing > capacity !!! > Picture 1 is showing th stitch as placed in Dr Levinson's video - > when tied it allows good edge to edge approximation of the skin > edges compared to a classical purse string. > I bet some will think it is much ado about nothing but it does help > and avoids "minor irritants" and at the end of it all that is what > the patient sees even if you have spent hours doing some wonderful > things inside him / her !! > Prasanna > > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From prasannasimha at gmail.com Thu Feb 1 06:57:42 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Wed Jan 31 20:28:15 2007 Subject: [HSF][OT] [Fwd: Image of the Week - Fixing a tube :)] In-Reply-To: <002001c74560$73647990$0401a8c0@OEM> References: <002001c74560$73647990$0401a8c0@OEM> Message-ID: <45C1420E.5010508@gmail.com> There better be one eye - that is my Wife who is the anesthesiologist there !! Prasanna Nasser F. Abou'Seada wrote: > Nice photo Prasanna > Incidentally, which eye colour do you prefer while you work? > Surgeons only see the yes of their teams during operations .. haha > > NFA > >> -----Original Message----- >> From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l- >> bounces@lists.hsforum.com] On Behalf Of prasannasimha >> Sent: Wednesday, January 31, 2007 9:30 AM >> To: OpenHeart-L@lists.hsforum.com >> Subject: [HSF] [Fwd: Image of the Week - Fixing a tube :)] >> >> Resent >> Prasanna >> >> -------- Original Message -------- >> >> Pictures of Vicryl thread fixing of a tube. Last picture is of me >> desperately pulling on the tube to demonstrate that it holds well (To >> address Hal's concern about its holding property - I am my the toes and >> falling backwards to demonstrate its load bearing capacity !!! >> Picture 1 is showing th stitch as placed in Dr Levinson's video - when >> tied it allows good edge to edge approximation of the skin edges >> compared to a classical purse string. >> I bet some will think it is much ado about nothing but it does help and >> avoids "minor irritants" and at the end of it all that is what the >> patient sees even if you have spent hours doing some wonderful things >> inside him / her !! >> Prasanna >> >> > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > From prasannasimha at gmail.com Thu Feb 1 06:54:50 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Wed Jan 31 20:31:52 2007 Subject: [HSF] [Fwd: Image of the Week - Fixing a tube :)] In-Reply-To: References: <45C0D234.6010301@gmail.com> Message-ID: <45C14162.3060702@gmail.com> We have a peculiar problem. - We do use autoclavable clothes but what has happened is our Laundry has got "overwhelmed" and so we have had to use disposable clothes for some of the OR's - actually it is manufactured in India itself and it seems to work cheaper than the whole gamut of getting extra laundry machines , clothes and hiring extra people to run the machines according to our hospital!! It is supposed to be made of some environmentally friendly paper thing -I am not sure what !! At least that 's what the cover says :-) Prasanna Donald Ross wrote: > Prasanna, > I note that your manly form is stylishly clad in a disposable gown. > I thought only we in the "first world" had to suffer such an > environmentally unfriendly, industry driven foolishness! > Here, they argue that is is too costly to launder and re-sterilise > linen but surely that is not the case in India? > Don > On 01/02/2007, at 4:30 AM, prasannasimha wrote: > >> Resent >> Prasanna >> >> -------- Original Message -------- >> >> Pictures of Vicryl thread fixing of a tube. Last picture is of me >> desperately pulling on the tube to demonstrate that it holds well (To >> address Hal's concern about its holding property - I am my the toes >> and falling backwards to demonstrate its load bearing capacity !!! >> Picture 1 is showing th stitch as placed in Dr Levinson's video - >> when tied it allows good edge to edge approximation of the skin edges >> compared to a classical purse string. >> I bet some will think it is much ado about nothing but it does help >> and avoids "minor irritants" and at the end of it all that is what >> the patient sees even if you have spent hours doing some wonderful >> things inside him / her !! >> Prasanna >> >> >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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@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 > ----------------------------------------- > > > --No virus found in this incoming message. > Checked by AVG Free Edition. > Version: 7.5.432 / Virus Database: 268.17.17/661 - Release Date: > 1/30/2007 11:30 PM > > From prasannasimha at gmail.com Thu Feb 1 06:56:21 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Wed Jan 31 21:23:25 2007 Subject: [HSF] Re: [HSF ] OPCAB pitfall In-Reply-To: References: <003601c744fe$e333c030$0401a8c0@OEM> <96EC413E-B4C5-41CD-9831-EB92EF10A37A@bigpond.com> Message-ID: <45C141BD.4090604@gmail.com> I am not being cheeky but if the graft requires a redo if the flows are inadequate / blocked are you "reportable" Prasanna Salerno, Tomas wrote: > in my experience unless one confirms graft patency via flowmetry or spy, one runs the risk of closing the patient with grafts (vein or artery) already occluded, regardless of how easy the anastomoses were, and whether the patient was done on or off pump. Therefore, any study that assesses graft patency postoperatively must have documentation of flow patency at time of closure. > > Tomas > > ________________________________ > > From: openheart-l-bounces@lists.hsforum.com on behalf of Donald Ross > Sent: Wed 1/31/2007 4:04 PM > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] Re: [HSF ] OPCAB pitfall > > > > Dear Thomas, > As you know we don't own a flow probe so can not answer that question. > Do you routinely measure flows in all grafts before and after heparin? > It would, indeed, be interesting to know exactly when the graft goes > down and I think you have previously indicated that it can occur > soon after the heparin is given? > If that is the case then my anti-thrombosis protocol may have some > merit. > Don > On 01/02/2007, at 4:23 AM, Salerno, Tomas wrote: > > >> would like to know if flows were measured prior to closure of this >> patient. It is possible that all grafts were already occluded at >> the end of the operation... >> >> Tomas >> >> ________________________________ >> >> From: openheart-l-bounces@lists.hsforum.com on behalf of Donald Ross >> Sent: Wed 1/31/2007 4:52 AM >> To: OpenHeart-L@lists.hsforum.com >> Subject: [HSF] Re: [HSF ] OPCAB pitfall >> >> >> >> This is a cautionary tale about a case done for a colleague who is a >> dedicated opcaber but has not yet developed a respect for the >> dangers of hypercoagulation. >> A routine off pump cabg X3 was done on his service with lima to Lad >> and SVG to Cx,Pda ( T-graft from lima, vein used because radial >> unavailable) >> Pre-op TEG was slightly hypercoagulable but this result was ignored >> and all the heparin was reversed and early post-op aspirin given. >> Next day the patient looked okay but there was a small troponin leak >> which triggered a re-cath. >> This showed complete thrombosis of the SVG which obviously required >> re-op. >> >> Because I have been similarly burnt I use a different protocol which >> so far has been effective. >> 1. Only reverse half heparin in all cases >> 2. Give clopidogrel as well as aspirin within 30 min of returning to >> recovery . ( clopidogrel ceased at 6 weeks) >> 3. If TEG is suspicious don't reverse heparin and give intra-op >> aspirin and clopidogrel >> >> A final observation is that the SVG is more prone to this annoying >> complication than the IMA. Hopefully the radial is also protected. >> Don >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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@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@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@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 > ----------------------------------------- > > > From prasannasimha at gmail.com Thu Feb 1 08:23:00 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Wed Jan 31 21:53:43 2007 Subject: [HSF] Coronary Case In-Reply-To: <06f601c74568$392b85b2$07091fac@ad.uky.edu> References: <06f601c74568$392b85b2$07091fac@ad.uky.edu> Message-ID: <45C1560C.9010506@gmail.com> Yes Chand, Patients can buy health care of any level of quality if they can pay for it but a patient who wants subsidization of health care costs better stop smoking - if he wants to smoke he doesn't need the subsidy as he can afford to buy those packets of cigarettes. One pack of Wills = Rs 40 assuming 4 packs per day - 160 * 365 = 58400 which is nearly the cost of his CABG !! If he wants that subsidy in my opinion he shouldn't waste it on something that will ultimately jeopardize his operation either in the short or long term. A smoker is wasting health care subsidies -better to do surgery on a young diabetic rather than an old smoker. If he wants to "lead his life style" - so be it but let him pay for it fully. He can't have his cake and eat it too. At least the younger diabetic didn't "ask" for his disease. (Having said that we have to iterate the importance of tight glucose control).Also the whole process of attempting to stop smoking can be a part of educating him about his disease. I have known quite a few people in private practice who would not take up elective patients till they had made an attempt to stop smoking. I agree that this may be very trying at times Another factor is that most patients in India tend to be "passive" and "obedient" about Doctor's orders (as I said we usually set the Wife into "nagging mode" which she does with pleasure !!!) This is changing but then most patients do take their Doctor's orders as sacrosanct at least for now !! The situation with patients are different in other countries but at least for my practice it needs to be done not just for the patients sake but also for just allocation of resources. Prasanna Ramaiah, Chandrashekar wrote: > Dear NFA, > Your point is well taken but unfortunately it does not apply to our country. You or prasanna may be able to carry out what you are saying. I don't know about your country, but I can guarantee you that in India people that have the money can and are buying the type of health care they want (even smokers and alcoholics). Does that make the doctors who provide care for them greedy and irresponsible? > For your information in US most surgeons (100% of the surgeons I work or worked with in the past) operate on patients who are smoking for CAD if surgery is indicated. We are strict in this policy only with transplants because of what Ani has said. > > Money is not the main issue for us to operate on these patients as I am in an Academic institution with salary. I don't think anyone in private practice will opertate to make a few bucks more if the risk of doing it was excessive (due to smoking). As you know cardiac surgeons in USA are the most scrutinized compared to any other professional in the world. If you want you can go to the web and get mine or any US surgeon's report card for a nominal fee. I don't know if you have such kind of reporting and accountability in your country. Infact the expectations in US are higher than even the western european countries ( see what risk scores for a patient with Euro score and compare it to STS you will understand the differential standards). > Finally one should not criticize without knowing the norms/or standards that exist in other countries. I could go on and critize about many things you could do to change the pathophysiology in your patient population instead of operating (i.e. Stop eating red and and eat more veggie or the `other white meat' but am not that ignorant or foolish to do that as I do know a little bit about the religion and the culture of your country). > > Sincerely, > > Chand > > .... I am not trying to be defensive but just trying to educate those that live and practice outside US. > > > -----Original Message----- > From: "Nasser F. Abou'Seada" > To: "OpenHeart-L@lists.hsforum.com" > Sent: 1/30/07 9:40 PM > Subject: RE: [HSF] Coronary Case > > Yes I agree that it is easier to be said than done. for sure. No one said it > is an easy thing ...... especially when you see the patients going for > another colleague to have the operation done .... at the same centre ... > > still, it has got a relation as to the definition of "my job" .... is it > just to handle a knife and start putting grafts in graftable vessels even > with no certain indication? .. > > Albeit, I can see that you are adopting a similar policy as mine regarding > transplant patients. > > the bottom line is that is it better to increase my workload for more income > and more cutting? .... or is it application of the best policy and strategy > to deal with the pathophysiological process ???? > > > > NFA > > >> From: Ramaiah, Chandrashekar >> It is easier said than done, especially in US. If I say no to everyone >> > that smokes then > >> I better find another job. >> We do have policy of not even listing a patient for Heart or Lung >> > transplantation until > >> we are sure that they are tobacco free for 6 months. >> Chand >> >> >> >> -----Original Message----- >> From: "Nasser F. Abou'Seada" >> To: "OpenHeart-L@lists.hsforum.com" >> Sent: 1/30/07 5:27 PM >> Subject: RE: [HSF] Coronary Case >> >> you are right Prasanna >> I do the same >> should she prefer smoking ... better save my time >> a policy I have learned long ago from my professors as a resident .... >> if not keen on her "Oxygen carrying capacity" ..... >> hahaha >> no "graft" will do >> I think it would be a Hippocratic thing ... doing an elective operation >> > for > >> someone smoking ... while we know that stopping smoking can have the same >> effect or even much better ... >> >> >> NFA >> >> >>> -----Original Message----- >>> From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l- >>> bounces@lists.hsforum.com] On Behalf Of prasannasimha >>> Sent: Tuesday, January 30, 2007 7:36 AM >>> To: OpenHeart-L@lists.hsforum.com >>> Subject: Re: [HSF] Coronary Case >>> >>> I don't take any elective case if they smoke !! They have to choose >>> between smoke and surgery. That is why I said she needs to go to a >>> shrink. If she can undergo 12 caths and not understand that she has to >>> quit smoking she needs professional help urgently as she seems self >>> destructive. >>> She probably will drive Ani nuts after surgery - she will probably whine >>> and whine and drive everyone around her crazy and at the end of it all >>> have "anginal" symptoms all over again. >>> Smoking can cause microvascular Ischemia that could exist even upto 1 >>> month after cessation of smoking. >>> >>> Prasanna >>> >>> hgrmd@aol.com wrote: >>> >>>> Ani, >>>> Before you wade into a possibly elective, ineffective, CABG >>>> > nightmare, > >> I would >> >>> insist that the lady absolutely undergo a trial of smoking cessation. >>> > If > >> necessary, this >> >>> should be confirmed by urine screening for nicotine metabolites. It >>> > could > >> be that >> >>> heavy smoking is producing disabling spasm. I am usually not that >>> > tough > >> on patients >> >>> about smoking (though I should be), but this is possibly the exception. >>> >> Tough case. >> >>>> Hal >>>> >>>> >>>> -----Original Message----- >>>> From: prasannasimha@gmail.com >>>> To: OpenHeart-L@lists.hsforum.com >>>> Sent: Tue, 30 Jan 2007 6:42 AM >>>> Subject: Re: [HSF] Coronary Case >>>> >>>> >>>> Could you dig out the IVUS report ?? >>>> >>>> I agree that angiography could underestimate the disease but you also >>>> say there is no inducible Ischemia on Thallium (that doesn't go hand >>>> > in > >>>> hand) >>>> Assuming that the lesion is the cause of Ischemia, I would have to >>>> > graft > >>>> LAD with all the diagonals and probably the RCA. It still seems like >>>> > we > >>>> are being "tricked" into saying graft. That makes me suspicious. >>>> I am still curious of the possibility of the open highway and blocked >>>> side roads.If that is really the case what you need to do then is >>>> > stent > >>>> endartrectomy, open up side branches and place a large patch over all >>>> > of > >>>> this and place an IMA or distal IMA and grafts (sequentialize the IMA >>>> > to > >>>> all the involved diagonals) >>>> No arterial graft on the RCA would use an SVG. >>>> Could probably consider partial cardiac denervation (though I am not >>>> sure if if the blessed thing works). >>>> >>>> 12 caths over 36 months still is a bit too much - one cath every 3 >>>> months on the average for 3 years still is a pincushion situation !! >>>> I strongly suspect that she will not have good relief of symptoms post >>>> surgery unless there is some objective evidence of Ischemia. Is the >>>> > gun > >>>> at our heads because she has become a pincushion and someone is trying >>>> to finally dump a problem on you ?? >>>> Prasanna >>>> Ani Anyanwu wrote: >>>> >>>> >>>>> Thanks for responses. >>>>> >>>>> I specifically had said to assume you will operate on the patient >>>>> > just > >> to >> >>>>> divert the discussion away from indications of surgery but as I >>>>> >> expected >> >>>>> that is where everyone decides to focus! >>>>> >>>>> The 12 caths were over 3 years not 18 months. She has been >>>>> > investigated > >> for >> >>>>> non-cardiac chest pain but it keeps coming back to the heart. Clearly >>>>> >> there >> >>>>> is a suspicion that something is not right with the stent or that >>>>> > some > >>>>> disease is being missed, which is why they keep re-imaging it. Had >>>>> > IVUS > >>>>> after second stent so they were clearly concerned about placement. >>>>> >> Symptoms >> >>>>> are almost certainly anginal and are relieved by nitrates (I know so >>>>> >> can >> >>>>> esophageal pain but that is rarely triggered by exertion). She did >>>>> > have > >> an >> >>>>> objective coronary lesion and ECG changes on first presentation and >>>>> >> also a >> >>>>> thallium that showed apical ischemia so the patient definitely has >>>>> > had > >>>>> symptomatic coronary disease. Has been worked up by cardiologists in >>>>> >> two >> >>>>> separate cities both of which come to same conclusion (coronary pain) >>>>> >> and >> >>>>> she has been managed on medical therapy. She shouldn't be smoking but >>>>> >> does >> >>>>> (again that's life - actually says she 'stopped' a month ago). >>>>> >>>>> Indication for CABG is intractable angina with angiographic (LAD) >>>>> >> disease. >> >>>>> Angiography can and does underestimate luminal narrowing so the >>>>> >> presumption >> >>>>> has to be that 40% ISR within a 5 cm of stent counts for more than >>>>> > that > >> (in >> >>>>> the absence of alternative explanations). The RCA spasm can be >>>>> > debated. > >> In >> >>>>> my view I suspect there may be a real lesion; I do not know if she >>>>> > had > >> pain >> >>>>> during the cath (I suspect many of them do if you watch what happens >>>>> > in > >> the >> >>>>> lab). She also has (minor) disease in her ramus. I am not sure if >>>>> > stent > >> has >> >>>>> pinched diagonals - will go back and have a look. I have not said I >>>>> >> would >> >>>>> graft any vessel - I was just presenting options of what is >>>>> > surgically > >>>>> graftable (the six vessels I listed) not what should be grafted >>>>> > (which > >> some >> >>>>> would say is none). >>>>> >>>>> Still waiting for operative suggestions - what if you had a gun to >>>>> > your > >> head >> >>>>> in the OR, what would you do for this lady! >>>>> >>>>> Ani >>>>> ----- Original Message ----- >>>>> From: prasannasimha >>>>> To: >>>>> >> OpenHeart-L@lists.hsforum.com >> >>>>> Sent: Tuesday, January 30, 2007 3:45 AM >>>>> Subject: Re: [HSF] Coronary Case >>>>> >>>>> >>>>> I still remember an elegant expose given by Unique pharma on cause >>>>> > of > >>>>> chest pain !! >>>>> I would also check for an esophageal motility disorder (cork screw >>>>> esophagus) and gall bladder dysfunction which can mimic angina in >>>>> > all > >>>>> aspects including relief with nitroglycerine. Especially in a >>>>> > smoker. > >>>>> Prasanna >>>>> >>>>> Tohru Asai wrote: >>>>> > Dear Ani >>>>> > >>>>> > What is the indication for CABG? I don't think bypass will help >>>>> >> this >> >>>>> > patient. Coronary spasm may complicate the procedure. >>>>> > >>>>> > What is pulmonary status? I experienced a case with giant bulla, >>>>> >> causing >> >>>>> > angina-like symptom. It is rare but was writen in Shields' >>>>> > textbook > >> of >> >>>>> > General Thoracic Surgery. >>>>> > >>>>> _______________________________________________ >>>>> OpenHeart-L mailing list >>>>> >>>>> Send postings to: >>>>> >>>>> > OpenHeart-L@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@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@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 >>>> ----------------------------------------- >>>> >>>> >> ____________________________________________________________________ >> >>> ____ >>> >>>> Check out the new AOL. Most comprehensive set of free safety and >>>> >> security tools, >> >>> free access to millions of high-quality videos from across the web, free >>> >> AOL Mail and >> >>> more. >>> >>>> _______________________________________________ >>>> OpenHeart-L mailing list >>>> >>>> Send postings to: >>>> OpenHeart-L@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@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@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@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@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@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 > ----------------------------------------- > > > From prasannasimha at gmail.com Thu Feb 1 08:31:33 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Wed Jan 31 22:30:47 2007 Subject: [HSF] Image of the Week - Fixing a tube :)(OT) In-Reply-To: References: Message-ID: <45C1580C.9030105@gmail.com> I am the shortest person in my department at 5' 6"and yes I may be even half your height if I remember the picture of you well but they say I have the most acerbic tongue and the loudest mouth in the department ;-) :-P !! Prasanna Hgrmd@aol.com wrote: > Prasanna, > Great pics! Though we all know you are an extremely well trained cardiac > surgeon, you look like a little kid pulling on that tube! > Hal > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > > From anianyanwu at hotmail.com Thu Feb 1 00:07:16 2007 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Thu Feb 1 00:08:17 2007 Subject: [HSF] Re: [HSF ] OPCAB pitfall References: <003601c744fe$e333c030$0401a8c0@OEM> Message-ID: This is a very good example of how a technique may be misapplied but the technique gets bad press for the result and again highlights the importance of adopting a procedure (from a successful colleague) whole meal and not picking and choosing the bits one likes. I see this (surgeons inventing how they chose to do their OPCAB) as the major reason why OPCAB was generally unsuccessful in the USA. IMHO the main reason why surgeons have problems with OPCAB or claim OPCAB has inferior results is because they are not doing it properly. There are nuances to every technique and unless all these are followed then one can have a bad result and while the operation gets the bad name, in truth it is the technique that is to blame. A (non-surgeon) colleague once told me that when colleagues rubbish a (new) technique, it is usually because they either don't know how to do it or are not good at it - this is often true. I know many surgeons will say well they did 50, 60, 70 or 80% OPCAB but in reality unless you were able to do up to 95 to 100% OPCAB then you are not really versatile with the procedure and will encounter similar problems to the one you describe, then blame OPCAB for bad results and then abandon it and say ONCAB is safer. Having seen several different surgeons do OPCAB in my training there is no doubt in my mind that only a select group of us have the skills and mindset required to execute this procedure in a systematic and routine manner, without appropriate (OPCAB) training. Lacking the skill to instantaneously shift to OPCAB does not make one less of a surgeon - I have worked for great surgeons who do the most complex of surgery but struggled with (and abandoned) OPCAB. IMHO, unless an 'OPCAB' surgeon is doing, or is able to do, 100% intention to treat OPCAB then they cannot be doing it properly, for if they were there would be practically no indication for planned CPB (except those scenarios where the heart is not beating). I remember a similar scenario in my training - one surgeon does 100% OPCAB with conversion rate below 1%, other surgeon next door - a much more experienced surgeon - feels he is equal to the task and does OPCAB in 50 to 70% but not systematically - one night patient has ST changes back to cath lab, LIMA to LAD blocked so back to OR - mid LAD full of thrombus. Of course surgeon blames OPCAB and says that's why CABG should be done on-pump. In reality this disaster had happened because he had not done the procedure as it should have been done - he had asked for protamine to be started as he was finishing the LIMA-LAD while the vessel was still clamped and the anastomosis leaked so few extra stitches and protamine was almost all in by the time we unclamped vessel (no shunts). He also gave half dose heparin. I am by no means a proponent of OPCAB; one can substitute OPCAB for any other complex alternative procedure (e.g. Ross Vs AVR, Yacoub Vs David, MV repair Vs Replacement etc), but having seen several different surgeons do or attempt OPCAB, my observation has been that when a surgeon blames OPCAB for disasters, it is usually because of bad technique rather than the avoidance of bypass per se. Of course are egos are so constituted that we could not accept this and we rather blame the patient or the procedure. Similar stuff said about OPCAB was said about things that are well accepted therapies, such as LIMA in 1970s or the switch operation in the 1980s; the reaction when surgeons are faced with a more difficult technique is usually to rubbish it. Procedures often get a bad name because the operators are not following or understanding the rules, and not because the procedure is intrinsically bad. Just my thoughts but as usual I know I will be in the minority and you will all crucify me! Ani ----- Original Message ----- From: Donald Ross To: OpenHeart-L@lists.hsforum.com Sent: Wednesday, January 31, 2007 4:52 AM Subject: [HSF] Re: [HSF ] OPCAB pitfall This is a cautionary tale about a case done for a colleague who is a dedicated opcaber but has not yet developed a respect for the dangers of hypercoagulation. A routine off pump cabg X3 was done on his service with lima to Lad and SVG to Cx,Pda ( T-graft from lima, vein used because radial unavailable) Pre-op TEG was slightly hypercoagulable but this result was ignored and all the heparin was reversed and early post-op aspirin given. Next day the patient looked okay but there was a small troponin leak which triggered a re-cath. This showed complete thrombosis of the SVG which obviously required re-op. Because I have been similarly burnt I use a different protocol which so far has been effective. 1. Only reverse half heparin in all cases 2. Give clopidogrel as well as aspirin within 30 min of returning to recovery . ( clopidogrel ceased at 6 weeks) 3. If TEG is suspicious don't reverse heparin and give intra-op aspirin and clopidogrel A final observation is that the SVG is more prone to this annoying complication than the IMA. Hopefully the radial is also protected. Don _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From donross at bigpond.com Thu Feb 1 16:19:40 2007 From: donross at bigpond.com (Donald Ross) Date: Thu Feb 1 00:20:07 2007 Subject: [HSF] [Fwd: Image of the Week - Fixing a tube :)] In-Reply-To: <45C14162.3060702@gmail.com> References: <45C0D234.6010301@gmail.com> <45C14162.3060702@gmail.com> Message-ID: sounds like spin to me On 01/02/2007, at 12:24 PM, prasannasimha wrote: > We have a peculiar problem. - We do use autoclavable clothes but > what has happened is our Laundry has got "overwhelmed" and so we > have had to use disposable clothes for some of the OR's - actually > it is manufactured in India itself and it seems to work cheaper > than the whole gamut of getting extra laundry machines , clothes > and hiring extra people to run the machines according to our > hospital!! It is supposed to be made of some environmentally > friendly paper thing -I am not sure what !! At least that 's what > the cover says :-) > Prasanna > Donald Ross wrote: >> Prasanna, >> I note that your manly form is stylishly clad in a disposable gown. >> I thought only we in the "first world" had to suffer such an >> environmentally unfriendly, industry driven foolishness! >> Here, they argue that is is too costly to launder and re-sterilise >> linen but surely that is not the case in India? >> Don >> On 01/02/2007, at 4:30 AM, prasannasimha wrote: >> >>> Resent >>> Prasanna >>> >>> -------- Original Message -------- >>> >>> Pictures of Vicryl thread fixing of a tube. Last picture is of me >>> desperately pulling on the tube to demonstrate that it holds well >>> (To address Hal's concern about its holding property - I am my >>> the toes and falling backwards to demonstrate its load bearing >>> capacity !!! >>> Picture 1 is showing th stitch as placed in Dr Levinson's video - >>> when tied it allows good edge to edge approximation of the skin >>> edges compared to a classical purse string. >>> I bet some will think it is much ado about nothing but it does >>> help and avoids "minor irritants" and at the end of it all that >>> is what the patient sees even if you have spent hours doing some >>> wonderful things inside him / her !! >>> Prasanna >>> >>> >>> >>> _______________________________________________ >>> OpenHeart-L mailing list >>> >>> Send postings to: >>> OpenHeart-L@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@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 >> ----------------------------------------- >> >> >> --No virus found in this incoming message. >> Checked by AVG Free Edition. >> Version: 7.5.432 / Virus Database: 268.17.17/661 - Release Date: >> 1/30/2007 11:30 PM >> >> > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From donross at bigpond.com Thu Feb 1 16:25:14 2007 From: donross at bigpond.com (Donald Ross) Date: Thu Feb 1 00:26:27 2007 Subject: [HSF] Re: [HSF ] OPCAB pitfall In-Reply-To: References: <003601c744fe$e333c030$0401a8c0@OEM> <96EC413E-B4C5-41CD-9831-EB92EF10A37A@bigpond.com> Message-ID: Thomas, I expect that is so but you didn't say whether you tested flow before and after protamine. I am interested as such a protocol would give some insight to graft closure which could be prevented by anticoagulant measures Don On 01/02/2007, at 9:24 AM, Salerno, Tomas wrote: > in my experience unless one confirms graft patency via flowmetry or > spy, one runs the risk of closing the patient with grafts (vein or > artery) already occluded, regardless of how easy the anastomoses > were, and whether the patient was done on or off pump. Therefore, > any study that assesses graft patency postoperatively must have > documentation of flow patency at time of closure. > > Tomas > > ________________________________ > > From: openheart-l-bounces@lists.hsforum.com on behalf of Donald Ross > Sent: Wed 1/31/2007 4:04 PM > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] Re: [HSF ] OPCAB pitfall > > > > Dear Thomas, > As you know we don't own a flow probe so can not answer that question. > Do you routinely measure flows in all grafts before and after heparin? > It would, indeed, be interesting to know exactly when the graft goes > down and I think you have previously indicated that it can occur > soon after the heparin is given? > If that is the case then my anti-thrombosis protocol may have some > merit. > Don > On 01/02/2007, at 4:23 AM, Salerno, Tomas wrote: > >> would like to know if flows were measured prior to closure of this >> patient. It is possible that all grafts were already occluded at >> the end of the operation... >> >> Tomas >> >> ________________________________ >> >> From: openheart-l-bounces@lists.hsforum.com on behalf of Donald Ross >> Sent: Wed 1/31/2007 4:52 AM >> To: OpenHeart-L@lists.hsforum.com >> Subject: [HSF] Re: [HSF ] OPCAB pitfall >> >> >> >> This is a cautionary tale about a case done for a colleague who is a >> dedicated opcaber but has not yet developed a respect for the >> dangers of hypercoagulation. >> A routine off pump cabg X3 was done on his service with lima to Lad >> and SVG to Cx,Pda ( T-graft from lima, vein used because radial >> unavailable) >> Pre-op TEG was slightly hypercoagulable but this result was ignored >> and all the heparin was reversed and early post-op aspirin given. >> Next day the patient looked okay but there was a small troponin leak >> which triggered a re-cath. >> This showed complete thrombosis of the SVG which obviously required >> re-op. >> >> Because I have been similarly burnt I use a different protocol which >> so far has been effective. >> 1. Only reverse half heparin in all cases >> 2. Give clopidogrel as well as aspirin within 30 min of returning to >> recovery . ( clopidogrel ceased at 6 weeks) >> 3. If TEG is suspicious don't reverse heparin and give intra-op >> aspirin and clopidogrel >> >> A final observation is that the SVG is more prone to this annoying >> complication than the IMA. Hopefully the radial is also protected. >> Don >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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@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@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@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 > ----------------------------------------- From donross at bigpond.com Thu Feb 1 16:40:56 2007 From: donross at bigpond.com (Donald Ross) Date: Thu Feb 1 00:42:25 2007 Subject: RES: [HSF] Re: [HSF ] OPCAB pitfall In-Reply-To: References: <003601c744fe$e333c030$0401a8c0@OEM> <63436F55-84F4-445E-8654-FD35A5DAF86B@bigpond.com> Message-ID: <026B6644-78D1-4E3F-944C-7C3DBC0B96A7@bigpond.com> > > > When you say 'prophylactic vein grafts' what exactly do you mean > and in what circumstances do you use it? when an artery is contra-indicated because the coronary lesion is only 50% > > Also as Dr Salerno says, without objective testing it is difficult > to be certain that placing your vein on the mammary as a > justifiable strategy in preference to an aortic inflow. Every aorta is a potential source of athero-emboli. In our experience there does not seem to be the risk you believe. I have only done it 57 times out of 1490 opcab cases but my colleague who is not keen on no-clamp top ends uses it in 10% of his cases. Don > Except where the aorta is calcified, I am not sure the benefit (of > avoiding aortic manipulation) outweighs the risks (of graft > failure). I am aware of one study that systematically studied Y > veins of the mammary with angiography, albiet in a small group > (N<30), and found several of the distal lima (to LAD) to have > stringed, the vein preferentially taking the flow. > > Thanks > > Ani > ----- Original Message ----- > From: Donald Ross > To: OpenHeart-L@lists.hsforum.com L@lists.hsforum.com> > Sent: Wednesday, January 31, 2007 3:54 PM > Subject: Re: RES: [HSF] Re: [HSF ] OPCAB pitfall > > > Theofilo, > I am sure your greater effort to achieve total arterial > revascularisation is better than using a vein and will probably > protect you from graft thrombosis in even severe cases of > thrombophilia. There is no data of course but a can't recall an > arterial graft failing in this manner. > Why then do we occasionally use vein? > Apart from non-significant lesions where an artery is containdicated > the words lazy and stupid come to mind. Although in some elderly > obese arteriopathic folk it may be meddlesome to take out another > ima > or do a laparotomy. > What about putting the proximal SVG onto the ima? > This has been done in our unit for some time without any apparent > problems mainly to avoid aortic manipulation. We believe it should > not be attempted if the vein is > 1 1/2 times the size of the ima at > the site of anastomosis. It is sometimes done even for prophylactic > vein grafts providing there is a competent valve in the vein to > prevent back flow from the coronary into the ima which could > compromise it due to competitive flow. > Don > > On 01/02/2007, at 2:04 AM, Theofilo wrote: > >> Dear Don, >> I've being doing BIMA's for more then 3 years now, mostly inspired >> by you, >> and hipercoag is something that calls the attention in OPCAB - >> mainly in >> endarterectomies where in initial cases I had 1 AMI interrupted by >> mechanical thrombolisys and Antiplatelet drugs with considerable >> muscle >> loss. I used only a few SV attached to LIMA ("Y") fashion with no >> knowledge >> of problem (no knowledge). Since then I'm also always concerned about >> hipercoag post anastomosys. Anyway the hole thing doesn't look ok >> to me and >> now I wouldn't put a vein unless no RIMA, Radial or Epigastric >> available. >> Would you tell us if you've seen the same problem with arterial or >> it's a >> venous thing? >> BIMA's and OPCAB the medicine for CAD and stents as well. >> Theofilo Gauze >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/listinfo/openheart-l> 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> listdisclaim> >> ----------------------------------------- > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l 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 listdisclaim> > ----------------------------------------- > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From prasannasimha at gmail.com Thu Feb 1 11:35:04 2007 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Thu Feb 1 02:07:05 2007 Subject: [HSF] [Fwd: Image of the Week - Fixing a tube :)] In-Reply-To: <000c01c745c5$c3a40a50$0401a8c0@OEM> References: <000c01c745c5$c3a40a50$0401a8c0@OEM> Message-ID: <89c4ed2d0701312205r1395c607ke668aca77d636c41@mail.gmail.com> Nope they are all waering the same thing that I wear . If we use a disposable set it contains enough gowns for the entire team + drapes etc etc. Prasanna On 2/1/07, Nasser F. Abou'Seada wrote: > > good observation Don, also note the normal gowns of the assisting team > !!!! > > NFA > > > -----Original Message----- > > From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l- > > bounces@lists.hsforum.com] On Behalf Of Donald Ross > > Sent: Wednesday, January 31, 2007 1:18 PM > > To: OpenHeart-L@lists.hsforum.com > > Subject: Re: [HSF] [Fwd: Image of the Week - Fixing a tube :)] > > > > Prasanna, > > I note that your manly form is stylishly clad in a disposable gown. > > I thought only we in the "first world" had to suffer such an > > environmentally unfriendly, industry driven foolishness! > > Here, they argue that is is too costly to launder and re-sterilise > > linen but surely that is not the case in India? > > Don > > On 01/02/2007, at 4:30 AM, prasannasimha wrote: > > > > > Resent > > > Prasanna > > > > > > -------- Original Message -------- > > > > > > Pictures of Vicryl thread fixing of a tube. Last picture is of me > > > desperately pulling on the tube to demonstrate that it holds well > > > (To address Hal's concern about its holding property - I am my the > > > toes and falling backwards to demonstrate its load bearing > > > capacity !!! > > > Picture 1 is showing th stitch as placed in Dr Levinson's video - > > > when tied it allows good edge to edge approximation of the skin > > > edges compared to a classical purse string. > > > I bet some will think it is much ado about nothing but it does help > > > and avoids "minor irritants" and at the end of it all that is what > > > the patient sees even if you have spent hours doing some wonderful > > > things inside him / her !! > > > Prasanna > > > > > > > > > > > > _______________________________________________ > > > OpenHeart-L mailing list > > > > > > Send postings to: > > > OpenHeart-L@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@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@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 > ----------------------------------------- > -- Prasanna Simha M From rsboova at comcast.net Thu Feb 1 07:23:25 2007 From: rsboova at comcast.net (rsboova@comcast.net) Date: Thu Feb 1 02:24:29 2007 Subject: [HSF] Gibbon Paper Message-ID: <020120070723.11236.45C1956D000E31F100002BE422135285730E9001010D9C9D@comcast.net> copy sent , undergoing review by HSF due to size of file sorry for delay RSB -------------- Original message -------------- From: "Nasser F. Abou'Seada" > Dear Robert > can you post a copy ? > should you have a digital copy "scanned" ... would you send me a copy please > > > NFA > > > -----Original Message----- > > From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l- > > bounces@lists.hsforum.com] On Behalf Of rsboova@comcast.net > > Sent: Sunday, January 07, 2007 9:08 AM > > To: OpenHeart-L@lists.hsforum.com > > Subject: Re: [HSF] Gibbon Paper > > > > I have a copy of Dr. Gibbon's operative summary from the first successful > open heart > > procedure ( ASD repair ) performed at Jefferson Medical College . It is > of historic note > > , and remarkably similar to our operative dictations today . > > RSB > > > > -------------- Original message -------------- > > From: prasannasimha > > > > > Victor Aldrete got the PDF file of Gibbon's [paper from Minnesota > > > medical. It is copyright free. Anyone who wants it tell me I will send > > > it directly. Incidentally am trying to convert into JPEG so that it can > > > be transmitted to the HSF but it is proving more difficult than I > imagined. > > > Prasanna > > > _______________________________________________ > > > OpenHeart-L mailing list > > > > > > Send postings to: > > > OpenHeart-L@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@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@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 > ----------------------------------------- From donross at bigpond.com Thu Feb 1 18:41:23 2007 From: donross at bigpond.com (Donald Ross) Date: Thu Feb 1 02:41:52 2007 Subject: [HSF] [Fwd: Image of the Week - Fixing a tube :)] In-Reply-To: <89c4ed2d0701312205r1395c607ke668aca77d636c41@mail.gmail.com> References: <000c01c745c5$c3a40a50$0401a8c0@OEM> <89c4ed2d0701312205r1395c607ke668aca77d636c41@mail.gmail.com> Message-ID: <1BEC53E4-790A-4E06-91B2-C3840CF5FAD2@bigpond.com> Prasanna, I bet they give some purchasing officer a warm glow but the land fill engineers a headache. Don On 01/02/2007, at 5:05 PM, Prasanna Simha M wrote: > Nope they are all waering the same thing that I wear . If we use a > disposable set it contains enough gowns for the entire team + > drapes etc > etc. > Prasanna > > On 2/1/07, Nasser F. Abou'Seada wrote: >> >> good observation Don, also note the normal gowns of the assisting >> team >> !!!! >> >> NFA >> >> > -----Original Message----- >> > From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l- >> > bounces@lists.hsforum.com] On Behalf Of Donald Ross >> > Sent: Wednesday, January 31, 2007 1:18 PM >> > To: OpenHeart-L@lists.hsforum.com >> > Subject: Re: [HSF] [Fwd: Image of the Week - Fixing a tube :)] >> > >> > Prasanna, >> > I note that your manly form is stylishly clad in a disposable gown. >> > I thought only we in the "first world" had to suffer such an >> > environmentally unfriendly, industry driven foolishness! >> > Here, they argue that is is too costly to launder and re-sterilise >> > linen but surely that is not the case in India? >> > Don >> > On 01/02/2007, at 4:30 AM, prasannasimha wrote: >> > >> > > Resent >> > > Prasanna >> > > >> > > -------- Original Message -------- >> > > >> > > Pictures of Vicryl thread fixing of a tube. Last picture is of me >> > > desperately pulling on the tube to demonstrate that it holds well >> > > (To address Hal's concern about its holding property - I am my >> the >> > > toes and falling backwards to demonstrate its load bearing >> > > capacity !!! >> > > Picture 1 is showing th stitch as placed in Dr Levinson's video - >> > > when tied it allows good edge to edge approximation of the skin >> > > edges compared to a classical purse string. >> > > I bet some will think it is much ado about nothing but it does >> help >> > > and avoids "minor irritants" and at the end of it all that is >> what >> > > the patient sees even if you have spent hours doing some >> wonderful >> > > things inside him / her !! >> > > Prasanna >> > > >> > > >> > > >> > > _______________________________________________ >> > > OpenHeart-L mailing list >> > > >> > > Send postings to: >> > > OpenHeart-L@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@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@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 >> ----------------------------------------- >> > > > > -- > Prasanna Simha M > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From prasannasimha at gmail.com Thu Feb 1 13:17:34 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Thu Feb 1 02:48:04 2007 Subject: [HSF] Gibbon Paper In-Reply-To: <020120070723.11236.45C1956D000E31F100002BE422135285730E9001010D9C9D@comcast.net> References: <020120070723.11236.45C1956D000E31F100002BE422135285730E9001010D9C9D@comcast.net> Message-ID: <45C19B16.8010008@gmail.com> RSB, I think if it bigger than 512 Kb it will not go through. If you send it to medirectly I will Pando it to all those who want it Prasanna rsboova@comcast.net wrote: > copy sent , undergoing review by HSF due to size of file sorry for delay RSB > > -------------- Original message -------------- > From: "Nasser F. Abou'Seada" > > >> Dear Robert >> can you post a copy ? >> should you have a digital copy "scanned" ... would you send me a copy please >> >> >> NFA >> >> >>> -----Original Message----- >>> From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l- >>> bounces@lists.hsforum.com] On Behalf Of rsboova@comcast.net >>> Sent: Sunday, January 07, 2007 9:08 AM >>> To: OpenHeart-L@lists.hsforum.com >>> Subject: Re: [HSF] Gibbon Paper >>> >>> I have a copy of Dr. Gibbon's operative summary from the first successful >>> >> open heart >> >>> procedure ( ASD repair ) performed at Jefferson Medical College . It is >>> >> of historic note >> >>> , and remarkably similar to our operative dictations today . >>> RSB >>> >>> -------------- Original message -------------- >>> From: prasannasimha >>> >>> >>>> Victor Aldrete got the PDF file of Gibbon's [paper from Minnesota >>>> medical. It is copyright free. Anyone who wants it tell me I will send >>>> it directly. Incidentally am trying to convert into JPEG so that it can >>>> be transmitted to the HSF but it is proving more difficult than I >>>> >> imagined. >> >>>> Prasanna >>>> _______________________________________________ >>>> OpenHeart-L mailing list >>>> >>>> Send postings to: >>>> OpenHeart-L@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@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@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@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 > ----------------------------------------- > > From nfaabouseada at gmail.com Thu Feb 1 00:07:52 2007 From: nfaabouseada at gmail.com (Nasser F. Abou'Seada) Date: Thu Feb 1 03:15:48 2007 Subject: [HSF] Coronary Case In-Reply-To: Message-ID: <000201c745d8$1a4a5500$0401a8c0@OEM> Dear Ani I do see your point of view, though I may argue against some pints in it. Yet the logic in your argument is evident and well organized. Mind You, I never meant to deny any patient what he / she would seek for him / herself. All I was stressing at is to attain the optimal conditions before embarking on the second step, interference I mean. I do agree with you that a patient wish should always be respected, within the frame of standard code of practice. I am sure we both agree to that, as I do remember the logic that we were taught in the same school of training, preparing for the final RCS exams ... we both share the same school of logical thinking, albeit making different arguments. I do still remember Marc E. Lambert, Consultant vascular Surgeon my first mentor in England, teaching me the attitude for answers "if you can argue for your answer and substantiate it, you can pass with it". I am sure you agree with me that there is nothing dogmatic in life, neither in surgery, and that everything "depends on the determinants of its variables" .... Still, I can assure you that I would NOT let down a patient, would certainly advise to the best of my knowledge and experience, about the best conditions to be taken before a certain procedure. I am sure you are aware of the dictum in vascular surgery "not to operate on any female should she have been on the pill in the previous (-) months before surgery" .... the number differs as per surgeon's conviction .. .... certainly NOT letting down a patient .... put surely optimizing the conditions before attempting a serious interference. I'd think the Case for DeBakey was a function of the ability of the operating team and Skillful resources available rather than a personal opinion of a certain surgeon, meaning that the decision was dependant on the PROFESSIONAL personal judgment of the expected results weighed against the risks involved. Certainly a landmark pointing to the school that he has initiated in the history of Aortic Surgery. Thank you indeed for your logical input and objective comments. that really was very enriching to the discussion and display of different opinions and arguments. Yours NFA > From: Ani Anyanwu > NFA > If doctors had a central logic or science to base their decisions then that is fine for us > to to be societies gate-keeper. Otherwise, what we are left with is what we call a > postcode lottery in the UK. The treatment you get depends on where you go. If you > go to Hal or Yourself you get turned down if you come to me or Chand or Salerno you > get surgery etc. That is why we cannot gate keep for society because we all see things > differently - some smokers will get surgery others wont. Some might die of an MI > because they were turned down, others might die of respiratory failure because they > were not - you can argue it either way. > > On the other hand if the government through the medical purchasers or regulatory > bodies proscribes CABG will not be performed unless urine nicotine is absent for 3 > consecutive weeks, then we will all do that and it can work. > > Transplantation is unique because the resource is finite (unlike other resources though > limited often not visibly finite). So with 100 people competing for one donor and the > opportunity cost of using the heart in one person is the loss of a chance to life in > another, society asks that we allocated these organs in a rational and judicious way. > You are right we should do the same with all healthcare resources but the problem > arises when patients can (and do) buy (or think they buy) their own health care. In > the same way you could walk in a shop and buy a mercedes or a rickety 30 yr old > jallopy, health economists argue that you should also be able to buy your own > healthcare. So if a smoker chooses to buy a CABG then all he needs is to find a > provider willing to sell it. To deny him would be do deny him the right to choice in a > free market. After all was that not how DeBakey supposedly got his surgery? How > many on here would have agreed to offer him surgery - I bet none or maybe one or > two - but his family and doctors looked around till they found a willing surgeon; and > he is supposedly doing well (from the recent thread) despite the conventional wisdom. > > Ani > ----- Original Message ----- > From: Nasser F. Abou'Seada > To: OpenHeart-L@lists.hsforum.com > Sent: Wednesday, January 31, 2007 1:06 AM > Subject: RE: [HSF] Coronary Case > > > > I encourage patients to stop smoking but apart from transplantation, where > ethical > > and (donor) resource issues force rationing, I would generally not deny a > patient > > therapy for smoking alone , except where there is a strong medical basis > (usually 1 or > > 5 above, but I would argue such instances are rare). It is up to society, > and not I, to > > decide who deserves health care dollars and who doesn't and what levels of > relative > > benefit (and risk) justify such expenditures. > > Such an argument seems a little bit twisted. Isn't rationing resources for a > complex complicated highly technical demanding procedure like a cardiac > revascularization procedure, an ethical issue in itself ? ... > Do you consider providing and establishing the PROPER preoperative milieu - > in terms of patient's physiology and pathophysiology- a denial of treatment > ???? ... I trust we all have certainly been exposed to that logic in > preliminary basic surgical training .... at least I can confirm that as of > my training in UK ... !!! > > Is not being certified as a surgeon with a respectable credentialed > training, by a society, an admission of the society, to those credentialed > in their prospective field of expertise, to delegate the responsibility of > decision making of who deserves the health care dollars ???? ..... giving > that responsibility up, would just down rank our surgical "institution" to > the rank of a paid expert manual worker doing the "cutting" for payment .... > !!!! > > Who else should the society, in first place, delegate that responsibility to > ????? .... to decide for " what levels of relative > benefit (and risk) > justify such expenditures." ????? > the concept of course differs from looking at "it" from within "context" .. > or else as an outsider to the "system" ....!!!! > > your thoughts and discussions are greatly enriching and appreciated > > NFA > > > From: Ani Anyanwu > > I suspect this has either been tried before (and did not work) or tried > before (and > > failed). > > > > Are you turning her down because > > 1) you believe the smoking is directly the cause of the symptoms (and the > only > > effective treatment is cessation) or > > 2) you believe the smoking is directly the cause of the symptoms (and > while other > > therapy may be helpful that you will not offer them because there is what > you believe > > a simpler way to treat it) > > 3) smoking reduces the chances of success of therapy > > 4) smoking is detrimental to the longevity of the procedure or disease. > > 5) smoking virtually eliminates chances of immediate success of therapy > > > > Unless it is the first, I would argue that serious ethical questions > exist. What would > > you write in the charts and what would you tell your (Florida) attorneys > if she has an > > infarct tomorrow? > > > > Smoking is an addiction and as much a disease as is the coronary disease, > diabetes, > > obesity, hypertension, renal failure etc - in the same way some cases of > HTN or DM > > are very difficult or impossible to control, some cases of smoking are > impossible to > > control. > > > > I encourage patients to stop smoking but apart from transplantation, where > ethical > > and (donor) resource issues force rationing, I would generally not deny a > patient > > therapy for smoking alone , except where there is a strong medical basis > (usually 1 or > > 5 above, but I would argue such instances are rare). It is up to society, > and not I, to > > decide who deserves health care dollars and who doesn't and what levels of > relative > > benefit (and risk) justify such expenditures. > > > > Ani > > ----- Original Message ----- > > From: > hgrmd@aol.com .com>> > > To: OpenHeart-L@lists.hsforum.com L@lists.hsforum.com L@lists.hsforum.com>> > > Sent: Tuesday, January 30, 2007 10:23 AM > > Subject: Re: [HSF] Coronary Case > > > > > > Ani, > > Before you wade into a possibly elective, ineffective, CABG nightmare, > I would > > insist that the lady absolutely undergo a trial of smoking cessation. If > necessary, this > > should be confirmed by urine screening for nicotine metabolites. It could > be that > > heavy smoking is producing disabling spasm. I am usually not that tough > on patients > > about smoking (though I should be), but this is possibly the exception. > Tough case. > > Hal > > > > > > -----Original Message----- > > From: > prasannasimha@gmail.com a@gmail.com> > > To: OpenHeart-L@lists.hsforum.com L@lists.hsforum.com L@lists.hsforum.com>> > > Sent: Tue, 30 Jan 2007 6:42 AM > > Subject: Re: [HSF] Coronary Case > > > > > > Could you dig out the IVUS report ?? > > > > I agree that angiography could underestimate the disease but you also > > say there is no inducible Ischemia on Thallium (that doesn't go hand in > > hand) > > Assuming that the lesion is the cause of Ischemia, I would have to graft > > LAD with all the diagonals and probably the RCA. It still seems like we > > are being "tricked" into saying graft. That makes me suspicious. > > I am still curious of the possibility of the open highway and blocked > > side roads.If that is really the case what you need to do then is stent > > endartrectomy, open up side branches and place a large patch over all of > > this and place an IMA or distal IMA and grafts (sequentialize the IMA to > > all the involved diagonals) > > No arterial graft on the RCA would use an SVG. > > Could probably consider partial cardiac denervation (though I am not > > sure if if the blessed thing works). > > > > 12 caths over 36 months still is a bit too much - one cath every 3 > > months on the average for 3 years still is a pincushion situation !! > > I strongly suspect that she will not have good relief of symptoms post > > surgery unless there is some objective evidence of Ischemia. Is the gun > > at our heads because she has become a pincushion and someone is trying > > to finally dump a problem on you ?? > > Prasanna > > Ani Anyanwu wrote: > > > Thanks for responses. > > > > > > I specifically had said to assume you will operate on the patient just > to > > > divert the discussion away from indications of surgery but as I > expected > > > that is where everyone decides to focus! > > > > > > The 12 caths were over 3 years not 18 months. She has been > investigated for > > > non-cardiac chest pain but it keeps coming back to the heart. Clearly > there > > > is a suspicion that something is not right with the stent or that some > > > disease is being missed, which is why they keep re-imaging it. Had > IVUS > > > after second stent so they were clearly concerned about placement. > Symptoms > > > are almost certainly anginal and are relieved by nitrates (I know so > can > > > esophageal pain but that is rarely triggered by exertion). She did > have an > > > objective coronary lesion and ECG changes on first presentation and > also a > > > thallium that showed apical ischemia so the patient definitely has had > > > symptomatic coronary disease. Has been worked up by cardiologists in > two > > > separate cities both of which come to same conclusion (coronary pain) > and > > > she has been managed on medical therapy. She shouldn't be smoking but > does > > > (again that's life - actually says she 'stopped' a month ago). > > > > > > Indication for CABG is intractable angina with angiographic (LAD) > disease. > > > Angiography can and does underestimate luminal narrowing so the > presumption > > > has to be that 40% ISR within a 5 cm of stent counts for more than > that (in > > > the absence of alternative explanations). The RCA spasm can be > debated. In > > > my view I suspect there may be a real lesion; I do not know if she had > pain > > > during the cath (I suspect many of them do if you watch what happens > in the > > > lab). She also has (minor) disease in her ramus. I am not sure if > stent has > > > pinched diagonals - will go back and have a look. I have not said I > would > > > graft any vessel - I was just presenting options of what is surgically > > > graftable (the six vessels I listed) not what should be grafted (which > some > > > would say is none). > > > > > > Still waiting for operative suggestions - what if you had a gun to > your head > > > in the OR, what would you do for this lady! > > > > > > Ani > > > ----- Original Message ----- > > > From: > > > prasannasimha > > m>> > > > To: OpenHeart-L@lists.hsforum.com L@lists.hsforum.com- > > L@lists.hsforum.com L@lists.hsforum.com art-L@lists.hsforum.com- > > L@lists.hsforum.com>> > > > Sent: Tuesday, January 30, 2007 3:45 AM > > > Subject: Re: [HSF] Coronary Case > > > > > > > > > I still remember an elegant expose given by Unique pharma on cause > of > > > chest pain !! > > > I would also check for an esophageal motility disorder (cork screw > > > esophagus) and gall bladder dysfunction which can mimic angina in > all > > > aspects including relief with nitroglycerine. Especially in a > smoker. > > > Prasanna > > > > > > Tohru Asai wrote: > > > > Dear Ani > > > > > > > > What is the indication for CABG? I don't think bypass will help > this > > > > patient. Coronary spasm may complicate the procedure. > > > > > > > > What is pulmonary status? I experienced a case with giant bulla, > causing > > > > angina-like symptom. It is rare but was writen in Shields' > textbook of > > > > General Thoracic Surgery. > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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 > ----------------------------------------- From prasannasimha at gmail.com Thu Feb 1 13:42:11 2007 From: prasannasimha at gmail.com (psimha) Date: Thu Feb 1 03:19:44 2007 Subject: [HSF] [Fwd: Image of the Week - Fixing a tube :)] In-Reply-To: <1BEC53E4-790A-4E06-91B2-C3840CF5FAD2@bigpond.com> References: <000c01c745c5$c3a40a50$0401a8c0@OEM> <89c4ed2d0701312205r1395c607ke668aca77d636c41@mail.gmail.com> <1BEC53E4-790A-4E06-91B2-C3840CF5FAD2@bigpond.com> Message-ID: <45C1A0DB.8040001@sify.com> Probably Prasanna Donald Ross wrote: > Prasanna, > I bet they give some purchasing officer a warm glow but the land fill > engineers a headache. > Don > On 01/02/2007, at 5:05 PM, Prasanna Simha M wrote: > >> Nope they are all waering the same thing that I wear . If we use a >> disposable set it contains enough gowns for the entire team + drapes etc >> etc. >> Prasanna >> >> On 2/1/07, Nasser F. Abou'Seada wrote: >>> >>> good observation Don, also note the normal gowns of the assisting team >>> !!!! >>> >>> NFA >>> >>> > -----Original Message----- >>> > From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l- >>> > bounces@lists.hsforum.com] On Behalf Of Donald Ross >>> > Sent: Wednesday, January 31, 2007 1:18 PM >>> > To: OpenHeart-L@lists.hsforum.com >>> > Subject: Re: [HSF] [Fwd: Image of the Week - Fixing a tube :)] >>> > >>> > Prasanna, >>> > I note that your manly form is stylishly clad in a disposable gown. >>> > I thought only we in the "first world" had to suffer such an >>> > environmentally unfriendly, industry driven foolishness! >>> > Here, they argue that is is too costly to launder and re-sterilise >>> > linen but surely that is not the case in India? >>> > Don >>> > On 01/02/2007, at 4:30 AM, prasannasimha wrote: >>> > >>> > > Resent >>> > > Prasanna >>> > > >>> > > -------- Original Message -------- >>> > > >>> > > Pictures of Vicryl thread fixing of a tube. Last picture is of me >>> > > desperately pulling on the tube to demonstrate that it holds well >>> > > (To address Hal's concern about its holding property - I am my the >>> > > toes and falling backwards to demonstrate its load bearing >>> > > capacity !!! >>> > > Picture 1 is showing th stitch as placed in Dr Levinson's video - >>> > > when tied it allows good edge to edge approximation of the skin >>> > > edges compared to a classical purse string. >>> > > I bet some will think it is much ado about nothing but it does help >>> > > and avoids "minor irritants" and at the end of it all that is what >>> > > the patient sees even if you have spent hours doing some wonderful >>> > > things inside him / her !! >>> > > Prasanna >>> > > >>> > > >>> > > >>> > > _______________________________________________ >>> > > OpenHeart-L mailing list >>> > > >>> > > Send postings to: >>> > > OpenHeart-L@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@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@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 >>> ----------------------------------------- >>> >> >> >> >> --Prasanna Simha M >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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@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 > ----------------------------------------- > From nfaabouseada at gmail.com Thu Feb 1 00:22:19 2007 From: nfaabouseada at gmail.com (Nasser F. Abou'Seada) Date: Thu Feb 1 03:22:59 2007 Subject: [HSF] Coronary Case In-Reply-To: Message-ID: <000501c745da$19592c50$0401a8c0@OEM> Thanks Ani, I take that as a compliment !! .."was it??" .. I do totally concur with your concepts and agree that the most important point is that "we are prepared to backtrack if it becomes obvious the> decision is the wrong one." Nothing is ever dogmatic after all . I do accept that we both agree about the basic rules underlying the decision making process. I would agree that the advice of the chief of the cath lab would be a major variable in the decision making process. though I would still argue against smoking, as a negative variable in the setup of the final formula, yet still I do recognize the logic in your thinking and the flexibility you certainly allow, though taking the risk on your shoulders ..!! NFA > From: Ani Anyanwu > NFA > Words of wisdom as always! > You summate it very well. More like one has decided to operate, and the patient has > decided she wants surgery, and one looking is for justification. I would argue with > your POV and in some ways it is correct. Like I said in response to the chest drain > issue, not all the decisions we make as physicians are logical. Sometimes we first > make a decision (or the decision is made for us) and then seek the explanation. What > is important though is that we are prepared to backtrack if it becomes obvious the > decision is the wrong one. > > The thallium which showed ischemia was before the first PCI. > > The 40% ISR was based on the report. If you recall I said I believed it was more. > Sometimes it is difficult to judge a long tubular stenosis. I went to the chief of our > cath lab as an independent opinion to appraise the case, open to suggestions > including a recath and IVUS, without any prompting he said that would count to at > least 70% stenosis. I am technologically na?ve or would post pictures online for you. > Mind you he recommended surgery and is rarely known to do so (in our institution last > year the ratio of PCI to CABG was 19:1). > > Regarding smoking, all the things you say are true. But though remember you are > comparing a non-smoker to a smoker. A smoker with LAD stenosis who has CABG will > deliver more O2 to the myocardium compared to a smoker who has a stenosis with no > bypass. For that patient CABG still offers a better outcome (even though less than the > combination of smoking cessation and CABG). We do actually offer surgery to IV drug > users with endocarditis, though admittedly the recidivism is high; if they come back > with prosthetic valve endocarditis then usually will not offer a second chance. Like I > said transplantation is the only scenario in cardiac surgery in my institution that we > explicitly deny patients therapy based on their habits. > > Thanks > > Ani > > > ----- Original Message ----- > From: Nasser F. Abou'Seada > To: OpenHeart-L@lists.hsforum.com > Sent: Wednesday, January 31, 2007 12:44 AM > Subject: RE: [HSF] Coronary Case > > > Ani > I thought Isotope study did not show any area of ischaemia ???? > you then mentioned that " She had a thallium that showed apical ischemia so > the patient definitely has had symptomatic coronary disease." > ???? > > also the cath you reported as > > Most recent catheter shows about 40% tubular stenosis (ISR) within 5cm > > of stented LAD. Unobstructed large Cx which gives rise to PDA, 30% > > ramus lesion. On this instance there was 80% proximal narrowing of the > > non-dominant RCA which resolved with nitroglycerin confirming spasm in > > this vessel. Normal LV function. > > however the interpretation of your chief of lab of the catheter seems more > impressive, as an indication for surgery. !!!!! > > IMHO the point is to be sure of one's strategy, and FORMULATION OF THE > PROBLEM whether there is an indication for Surgery ??? based on adopted > concepts - mine is exclusive of payment, though I admit it is important, yet > not in decision making- or at least this was the way I was taught. > > second point if it is agreed that the patient has got anginal pain due to > defective coronary bed, being SURE of INTERPRETATION of preop workup, is to > be sure to provide for the BEST OPTIMAL circumstances before embarking on an > intervention. this is for sure to optimize Oxygen carrying capacity, > unloading, delivery, Glycaemic control, hormonal milieu, ....etc. > > For sure I would not trust Nicotine, CO shifting the Oxygen carrying > capacity curve, CO occupation of the Haemoglobin, Hormonal disturbance with > stress induced rise of anti- Insulin hormones, raised Cortisol, ACTH, Growth > Hormone, Thyroxine levels, disturbances of Plasma protein binding .... etc > .... to mention but a few of the effects of more than 34 chemical substances > in cigarettes. let apart the effects on gastic mucosa ....etc ..... > Believing that a technically complicated and demanding cardiac procedure > should be offered to a patient who is refusing to give up - or try > enthusiastically to- just for whatever purposes, or else denying > self-responsibility blaming the society, is just like offering a cardiac > procedure for a tricuspid valve surgery for a drug induced endocarditis for > a patient who refuses to give it up. > I believe we as surgeons are representing the society in our judgment as to > the best preoperative situations that we should allow our patients to get > before a designated interference. claiming otherwise would to my mind > deprive us of the faculty of being "physicians" and in fact risk being > detrimental to the rank of a manual worker .... however expert we might be > ...!!!! .... > > NFA > > > -----Original Message----- > > From: openheart-l-bounces@lists.hsforum.com bounces@lists.hsforum.com> [mailto:openheart-l- > > bounces@lists.hsforum.com] On Behalf Of > Ani Anyanwu > > Sent: Tuesday, January 30, 2007 5:55 PM > > To: OpenHeart-L@lists.hsforum.com > > > > Subject: Re: [HSF] Coronary Case > > > > I reviewed the cath with the chief of our lab today regarding whether IVUS > would be > > helpful (none of the caths or interventions had been done in our center). > He felt that > > the ISR was up to 70% and that was more than enough indication to operate. > Without > > knowing the history he said that the stent must have been across a > myocardial bridge > > (it was) and that was the likely reason for the early failure of a DES in > that manner. > > He says he has known debilitating angina to arise from a myocardial bridge > and a > > LIMA to LAD may cure her. > > > > Talking of competitive flow, I had a lady last week obese (BMI 38) > diabetic 45 years > > old who had three prior PCI to LAD with new stenosis around DES each time. > > Presented with acute coronary syndrome but now had 95% circ lesion not > previously > > present but adjacent to LAD stent which has now converged on Left Main. > Stents to > > proximal LAD were open (10% maybe stenosed). Cardiologist felt that > because of her > > predilection to stenosing stents best to go ahead with CABG. In this > situation would > > you just bypass the OM? Most recent stent was 3 months prior. I put a LIMA > on the > > OM and a RIMA on the LAD. I suppose my hope is when the stent does go down > the > > RIMA would open up and that is preferable to a reop when the LAD stent > goes down in > > a few months as has been the case with her in the past - is that wishful > thinking? > > > > Ani > > ----- Original Message ----- > > From: > hgrmd@aol.com .com>> > > To: OpenHeart-L@lists.hsforum.com L@lists.hsforum.com L@lists.hsforum.com>> > > Sent: Tuesday, January 30, 2007 10:28 AM > > Subject: Re: [HSF] Coronary Case > > > > > > Ani, > > Even with a gun to my head, I would insist on an IVUS of the LAD and > the RCA > > before laying the blade. You do the patient no favor if you graft > hemodynamically > > unimportant lesions at this point in her life. I'm sure there's little > question that she > > will eventually require surgery. However, grafting the vessels before > competitive flow > > is compromised is a sure recipe for early graft closure and a very unhappy > patient. > > Hal > > > > > > -----Original Message----- > > From: > anianyanwu@hotmail.com tmail.com> > > To: OpenHeart-L@lists.hsforum.com L@lists.hsforum.com L@lists.hsforum.com>> > > Sent: Tue, 30 Jan 2007 6:06 AM > > Subject: Re: [HSF] Coronary Case > > > > > > Thanks for responses. > > > > I specifically had said to assume you will operate on the patient just > to > > divert the discussion away from indications of surgery but as I expected > > that is where everyone decides to focus! > > > > The 12 caths were over 3 years not 18 months. She has been investigated > for > > non-cardiac chest pain but it keeps coming back to the heart. Clearly > there > > is a suspicion that something is not right with the stent or that some > > disease is being missed, which is why they keep re-imaging it. Had IVUS > > after second stent so they were clearly concerned about placement. > Symptoms > > are almost certainly anginal and are relieved by nitrates (I know so can > > esophageal pain but that is rarely triggered by exertion). She did have > an > > objective coronary lesion and ECG changes on first presentation and also > a > > thallium that showed apical ischemia so the patient definitely has had > > symptomatic coronary disease. Has been worked up by cardiologists in two > > separate cities both of which come to same conclusion (coronary pain) > and > > she has been managed on medical therapy. She shouldn't be smoking but > does > > (again that's life - actually says she 'stopped' a month ago). > > > > Indication for CABG is intractable angina with angiographic (LAD) > disease. > > Angiography can and does underestimate luminal narrowing so the > presumption > > has to be that 40% ISR within a 5 cm of stent counts for more than that > (in > > the absence of alternative explanations). The RCA spasm can be debated. > In > > my view I suspect there may be a real lesion; I do not know if she had > pain > > during the cath (I suspect many of them do if you watch what happens in > the > > lab). She also has (minor) disease in her ramus. I am not sure if stent > has > > pinched diagonals - will go back and have a look. I have not said I > would > > graft any vessel - I was just presenting options of what is surgically > > graftable (the six vessels I listed) not what should be grafted (which > some > > would say is none). > > > > Still waiting for operative suggestions - what if you had a gun to your > head > > in the OR, what would you do for this lady! > > > > Ani > > ----- Original Message ----- > > From: > > > prasannasimha > > m>> > > To: OpenHeart-L@lists.hsforum.com L@lists.hsforum.com- > > L@lists.hsforum.com L@lists.hsforum.com art-L@lists.hsforum.com- > > L@lists.hsforum.com>> > > Sent: Tuesday, January 30, 2007 3:45 AM > > Subject: Re: [HSF] Coronary Case > > > > > > I still remember an elegant expose given by Unique pharma on cause of > > chest pain !! > > I would also check for an esophageal motility disorder (cork screw > > esophagus) and gall bladder dysfunction which can mimic angina in all > > aspects including relief with nitroglycerine. Especially in a smoker. > > Prasanna > > > > Tohru Asai wrote: > > > Dear Ani > > > > > > What is the indication for CABG? I don't think bypass will help this > > > patient. Coronary spasm may complicate the procedure. > > > > > > What is pulmonary status? I experienced a case with giant bulla, > causing > > > angina-like symptom. It is rare but was writen in Shields' textbook > of > > > General Thoracic Surgery. From nfaabouseada at gmail.com Thu Feb 1 00:26:03 2007 From: nfaabouseada at gmail.com (Nasser F. Abou'Seada) Date: Thu Feb 1 05:12:41 2007 Subject: [HSF] Gibbon Paper In-Reply-To: <020120070723.11236.45C1956D000E31F100002BE422135285730E9001010D9C9D@comcast.net> Message-ID: <000601c745da$9ee1be50$0401a8c0@OEM> Dear Robert Thank you very much indeed for your kind courtesy. should there be any problems please do send it to my personal email, can always reduce its size and re-send it back again. or post to my web for downloading ... thank you again Kindest Regards NFA > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l- > bounces@lists.hsforum.com] On Behalf Of rsboova@comcast.net > Sent: Wednesday, January 31, 2007 11:23 PM > To: OpenHeart-L@lists.hsforum.com > Subject: RE: [HSF] Gibbon Paper > > copy sent , undergoing review by HSF due to size of file sorry for delay RSB > > -------------- Original message -------------- > From: "Nasser F. Abou'Seada" > > > Dear Robert > > can you post a copy ? > > should you have a digital copy "scanned" ... would you send me a copy please > > > > > > NFA > > > > > -----Original Message----- > > > From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l- > > > bounces@lists.hsforum.com] On Behalf Of rsboova@comcast.net > > > Sent: Sunday, January 07, 2007 9:08 AM > > > To: OpenHeart-L@lists.hsforum.com > > > Subject: Re: [HSF] Gibbon Paper > > > > > > I have a copy of Dr. Gibbon's operative summary from the first successful > > open heart > > > procedure ( ASD repair ) performed at Jefferson Medical College . It is > > of historic note > > > , and remarkably similar to our operative dictations today . > > > RSB > > > > > > -------------- Original message -------------- > > > From: prasannasimha > > > > > > > Victor Aldrete got the PDF file of Gibbon's [paper from Minnesota > > > > medical. It is copyright free. Anyone who wants it tell me I will send > > > > it directly. Incidentally am trying to convert into JPEG so that it can > > > > be transmitted to the HSF but it is proving more difficult than I > > imagined. > > > > Prasanna > > > > _______________________________________________ > > > > OpenHeart-L mailing list > > > > > > > > Send postings to: > > > > OpenHeart-L@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@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@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@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 > ----------------------------------------- From gauze at brturbo.com.br Thu Feb 1 05:49:45 2007 From: gauze at brturbo.com.br (Theofilo) Date: Thu Feb 1 06:26:32 2007 Subject: RES: [HSF] Re: [HSF ] OPCAB pitfall In-Reply-To: References: <003601c744fe$e333c030$0401a8c0@OEM> Message-ID: Dear Ani, Totally agree with you Theofilo Gauze From Hgrmd at aol.com Thu Feb 1 07:37:07 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Thu Feb 1 07:41:28 2007 Subject: [HSF] Image of the Week - Fixing a tube :)(OT) Message-ID: Prasanna, I've got quite a few physician friends who are substantially shorter than 5" 6", and I hope you weren't slighted by what I said. The picture of you with the bright, mischevious eyes tugging on the chest tubes reminded me of a kid having fun. Hal From Hgrmd at aol.com Thu Feb 1 07:43:11 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Thu Feb 1 07:43:46 2007 Subject: [HSF] Coronary Case Message-ID: BTW, who was the surgeon who operated on DeBackey? Hal From TSalerno at med.miami.edu Thu Feb 1 07:50:07 2007 From: TSalerno at med.miami.edu (Salerno, Tomas) Date: Thu Feb 1 07:51:33 2007 Subject: [HSF] Re: [HSF ] OPCAB pitfall References: <003601c744fe$e333c030$0401a8c0@OEM><96EC413E-B4C5-41CD-9831-EB92EF10A37A@bigpond.com> Message-ID: hi Fon, yes. flows measurements before and after protomine. Tomas ________________________________ From: openheart-l-bounces@lists.hsforum.com on behalf of Donald Ross Sent: Thu 2/1/2007 12:25 AM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Re: [HSF ] OPCAB pitfall Thomas, I expect that is so but you didn't say whether you tested flow before and after protamine. I am interested as such a protocol would give some insight to graft closure which could be prevented by anticoagulant measures Don On 01/02/2007, at 9:24 AM, Salerno, Tomas wrote: > in my experience unless one confirms graft patency via flowmetry or > spy, one runs the risk of closing the patient with grafts (vein or > artery) already occluded, regardless of how easy the anastomoses > were, and whether the patient was done on or off pump. Therefore, > any study that assesses graft patency postoperatively must have > documentation of flow patency at time of closure. > > Tomas > > ________________________________ > > From: openheart-l-bounces@lists.hsforum.com on behalf of Donald Ross > Sent: Wed 1/31/2007 4:04 PM > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] Re: [HSF ] OPCAB pitfall > > > > Dear Thomas, > As you know we don't own a flow probe so can not answer that question. > Do you routinely measure flows in all grafts before and after heparin? > It would, indeed, be interesting to know exactly when the graft goes > down and I think you have previously indicated that it can occur > soon after the heparin is given? > If that is the case then my anti-thrombosis protocol may have some > merit. > Don > On 01/02/2007, at 4:23 AM, Salerno, Tomas wrote: > >> would like to know if flows were measured prior to closure of this >> patient. It is possible that all grafts were already occluded at >> the end of the operation... >> >> Tomas >> >> ________________________________ >> >> From: openheart-l-bounces@lists.hsforum.com on behalf of Donald Ross >> Sent: Wed 1/31/2007 4:52 AM >> To: OpenHeart-L@lists.hsforum.com >> Subject: [HSF] Re: [HSF ] OPCAB pitfall >> >> >> >> This is a cautionary tale about a case done for a colleague who is a >> dedicated opcaber but has not yet developed a respect for the >> dangers of hypercoagulation. >> A routine off pump cabg X3 was done on his service with lima to Lad >> and SVG to Cx,Pda ( T-graft from lima, vein used because radial >> unavailable) >> Pre-op TEG was slightly hypercoagulable but this result was ignored >> and all the heparin was reversed and early post-op aspirin given. >> Next day the patient looked okay but there was a small troponin leak >> which triggered a re-cath. >> This showed complete thrombosis of the SVG which obviously required >> re-op. >> >> Because I have been similarly burnt I use a different protocol which >> so far has been effective. >> 1. Only reverse half heparin in all cases >> 2. Give clopidogrel as well as aspirin within 30 min of returning to >> recovery . ( clopidogrel ceased at 6 weeks) >> 3. If TEG is suspicious don't reverse heparin and give intra-op >> aspirin and clopidogrel >> >> A final observation is that the SVG is more prone to this annoying >> complication than the IMA. Hopefully the radial is also protected. >> Don >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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@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@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@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@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 ----------------------------------------- From prasannasimha at gmail.com Thu Feb 1 18:21:24 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Thu Feb 1 07:51:56 2007 Subject: [HSF] Image of the Week - Fixing a tube :)(OT) In-Reply-To: References: Message-ID: <45C1E24C.6000305@gmail.com> No I wasn't. We are closing our OT for repairs and also because we will all being to go to Jaipur for our annual conference so we wanted to combine repairs and the conference so that the OR down time could be used "constructively". So this was my last case and my "break" starts so there was a bit of tomfoolery going around too !! In anticipation of lazing around and doing nothing - so I went to the Hospital today and finished rounds , helped my librarian install an anti virus and clean our one of our libraries computer which was loaded with viruses and then sat down not knowing what to do !!!! (We have installed a broad band connection in our library lately). I also tested the Wifi connection that was set up in the library for him. tomorrow will probably be a marathon lecture series for my perfusion students !! Prasanna Hgrmd@aol.com wrote: > Prasanna, > I've got quite a few physician friends who are substantially shorter than > 5" 6", and I hope you weren't slighted by what I said. The picture of you > with the bright, mischevious eyes tugging on the chest tubes reminded me of a > kid having fun. > Hal > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > From TSalerno at med.miami.edu Thu Feb 1 07:51:23 2007 From: TSalerno at med.miami.edu (Salerno, Tomas) Date: Thu Feb 1 07:52:47 2007 Subject: [HSF] Re: [HSF ] OPCAB pitfall References: <003601c744fe$e333c030$0401a8c0@OEM> <96EC413E-B4C5-41CD-9831-EB92EF10A37A@bigpond.com> <45C141BD.4090604@gmail.com> Message-ID: no, this has not occurred yet. However. I might be criticized if flows were not measured and something bad occurred, although flow measurements is not stand of care in USA Tomas ________________________________ From: openheart-l-bounces@lists.hsforum.com on behalf of prasannasimha Sent: Wed 1/31/2007 8:26 PM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Re: [HSF ] OPCAB pitfall I am not being cheeky but if the graft requires a redo if the flows are inadequate / blocked are you "reportable" Prasanna Salerno, Tomas wrote: > in my experience unless one confirms graft patency via flowmetry or spy, one runs the risk of closing the patient with grafts (vein or artery) already occluded, regardless of how easy the anastomoses were, and whether the patient was done on or off pump. Therefore, any study that assesses graft patency postoperatively must have documentation of flow patency at time of closure. > > Tomas > > ________________________________ > > From: openheart-l-bounces@lists.hsforum.com on behalf of Donald Ross > Sent: Wed 1/31/2007 4:04 PM > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] Re: [HSF ] OPCAB pitfall > > > > Dear Thomas, > As you know we don't own a flow probe so can not answer that question. > Do you routinely measure flows in all grafts before and after heparin? > It would, indeed, be interesting to know exactly when the graft goes > down and I think you have previously indicated that it can occur > soon after the heparin is given? > If that is the case then my anti-thrombosis protocol may have some > merit. > Don > On 01/02/2007, at 4:23 AM, Salerno, Tomas wrote: > > >> would like to know if flows were measured prior to closure of this >> patient. It is possible that all grafts were already occluded at >> the end of the operation... >> >> Tomas >> >> ________________________________ >> >> From: openheart-l-bounces@lists.hsforum.com on behalf of Donald Ross >> Sent: Wed 1/31/2007 4:52 AM >> To: OpenHeart-L@lists.hsforum.com >> Subject: [HSF] Re: [HSF ] OPCAB pitfall >> >> >> >> This is a cautionary tale about a case done for a colleague who is a >> dedicated opcaber but has not yet developed a respect for the >> dangers of hypercoagulation. >> A routine off pump cabg X3 was done on his service with lima to Lad >> and SVG to Cx,Pda ( T-graft from lima, vein used because radial >> unavailable) >> Pre-op TEG was slightly hypercoagulable but this result was ignored >> and all the heparin was reversed and early post-op aspirin given. >> Next day the patient looked okay but there was a small troponin leak >> which triggered a re-cath. >> This showed complete thrombosis of the SVG which obviously required >> re-op. >> >> Because I have been similarly burnt I use a different protocol which >> so far has been effective. >> 1. Only reverse half heparin in all cases >> 2. Give clopidogrel as well as aspirin within 30 min of returning to >> recovery . ( clopidogrel ceased at 6 weeks) >> 3. If TEG is suspicious don't reverse heparin and give intra-op >> aspirin and clopidogrel >> >> A final observation is that the SVG is more prone to this annoying >> complication than the IMA. Hopefully the radial is also protected. >> Don >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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@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@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@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@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 ----------------------------------------- From prasannasimha at gmail.com Thu Feb 1 18:23:24 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Thu Feb 1 08:00:53 2007 Subject: [HSF] Image of the Week - Fixing a tube :)(OT) In-Reply-To: References: Message-ID: <45C1E2C4.3040402@gmail.com> ps - not a bit slighted all of you tall guys have to bow down to us to hear us :-) !!! We short guys "rule" !! (From someone having suddenly too much of free time at hand) Prasanna Hgrmd@aol.com wrote: > Prasanna, > I've got quite a few physician friends who are substantially shorter than > 5" 6", and I hope you weren't slighted by what I said. The picture of you > with the bright, mischevious eyes tugging on the chest tubes reminded me of a > kid having fun. > Hal > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > From prasannasimha at gmail.com Thu Feb 1 18:31:16 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Thu Feb 1 08:01:47 2007 Subject: [HSF] Coronary Case In-Reply-To: References: Message-ID: <45C1E49C.8030009@gmail.com> I think it was Dr Noon. See this discussion on ethics at an ethics web site. Prasanna DeBakey's surgery It is sometimes said you should be able to teach an entire Bioethics cour