[HSF] Coronary Case
Nasser F. Abou'Seada
nfaabouseada at gmail.com
Thu Feb 1 00:22:19 EST 2007
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 naïve 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<mailto:nfaabouseada at gmail.com>
> To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at 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 at lists.hsforum.com<mailto:openheart-l-
> bounces at lists.hsforum.com> [mailto:openheart-l-
> > bounces at lists.hsforum.com<mailto:bounces at lists.hsforum.com>] On Behalf
Of
> Ani Anyanwu
> > Sent: Tuesday, January 30, 2007 5:55 PM
> > To:
OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at 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 at aol.com<mailto:hgrmd at aol.com<mailto:hgrmd at aol.com<mailto:hgrmd at aol
> .com>>
> > To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-
> L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-
> L at 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 at hotmail.com<mailto:anianyanwu at hotmail.com<mailto:anianyanwu at ho
> tmail.com<mailto:anianyanwu at hotmail.com>>
> > To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-
> L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-
> L at 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<mailto:prasannasimha at gmail.com<mailto:prasannasimha at gmail.co
> <mailto:prasannasimha at gmail.com<mailto:prasannasimha at gmail.co>
> > m>>
> > To:
OpenHeart-L at lists.hsforum.com<mailto:OpenHeart<mailto:OpenHeart-
> L at lists.hsforum.com<mailto:OpenHeart>-
> > L at lists.hsforum.com<mailto:OpenHeart-
>
L at lists.hsforum.com<mailto:OpenHeart<mailto:L at lists.hsforum.com<mailto:OpenH
e
> art-L at lists.hsforum.com<mailto:OpenHeart>-
> > L at lists.hsforum.com<mailto:L at 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.
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