[HSF] Coronary Case (OT)
Ramaiah, Chandrashekar
crama01 at email.uky.edu
Thu Feb 1 09:28:34 EST 2007
Dear NFA,
I sincerely apologize for the grammatical errors and if I insulted you
in any way. I was responding to your posting from my phone waiting for
my flight from San Diego to take off (I should have gone through it
before sending it).
I was trying respond to your comments (Try to read your original mail to
which I responded again to see if someone could get annoyed reading it).
I do not think we should continue this thread further and waste the
precious time of others on the forum. Please feel free to contact me on
my personal email if you would like continue the discussion.
Thanks again for your insightful comments.
Sincerely,
Chand
-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Nasser F.
Abou'Seada
Sent: Thursday, February 01, 2007 1:18 AM
To: OpenHeart-L at lists.hsforum.com
Subject: RE: [HSF] Coronary Case
Dear Chand
appreciating your educative attitude, I am hoping I'd receive your
comments
and SCIENTIFIC OBJECTIVE arguments as to the subject of pathophysiology
in
performing a coronary bed revascularization procedure in a heavily
smoking
patient on a non-urgent non emergency basis.
Kindly do accept my sincere humble regards
Yours
NFA
> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
> bounces at lists.hsforum.com] On Behalf Of Ramaiah, Chandrashekar
> Sent: Wednesday, January 31, 2007 10:47 AM
> To: OpenHeart-L at lists.hsforum.com
> Subject: RE: [HSF] Coronary Case
>
> 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" <nfaabouseada at gmail.com>
> To: "OpenHeart-L at lists.hsforum.com" <OpenHeart-L at 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" <nfaabouseada at gmail.com>
> > To: "OpenHeart-L at lists.hsforum.com" <OpenHeart-L at 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 at lists.hsforum.com [mailto:openheart-l-
> > > bounces at lists.hsforum.com] On Behalf Of prasannasimha
> > > Sent: Tuesday, January 30, 2007 7:36 AM
> > > To: OpenHeart-L at 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 at 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 at gmail.com
> > > > To: OpenHeart-L at 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<mailto:prasannasimha at gmail.com>
> > > >> To:
> > OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-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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