[HSF] Re: [HSF ] OPCAB pitfall

Thu Feb 1 00:07:16 EST 2007

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<mailto:donross at bigpond.com> 
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at 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
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