[HSF] STS
prasannasimha
prasannasimha at gmail.com
Thu Feb 1 20:05:35 EST 2007
Chand,
What impressed you in the STS meet ?
All those who attended - what did you all like ?
Prasanna
Ramaiah, Chandrashekar wrote:
> 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.
>>>>>> >
>>>>>> _______________________________________________
>>>>>> OpenHeart-L mailing list
>>>>>>
>>>>>> Send postings to:
>>>>>>
>>>>>>
>> OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
>>
>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>>>>>> http://mmp.cjp.com/mailman/listinfo/openheart-
>>>>>>
>>>> l<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<http://www.hsforum.com/listdisclaim>
>
>>>>>> -----------------------------------------
>>>>>> _______________________________________________
>>>>>> OpenHeart-L mailing list
>>>>>>
>>>>>> Send postings to:
>>>>>> OpenHeart-L at 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 at 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 at 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 at 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 at 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 at 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 at 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 at 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 at 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 at 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
> -----------------------------------------
>
>
More information about the OpenHeart-L
mailing list