[HSF] STS
Ramaiah, Chandrashekar
crama01 at email.uky.edu
Thu Feb 1 10:48:55 EST 2007
Overall I was disappointed with the meeting but had fun meeting old
friends and meeting several HSF friends. Thanks to Hal, Tea (and
Edwards) for organizing the Dinner and "Teat Party".
David Taggart's talk this year had some more updated studies and was
the highlight. The debate about the Mitral Repairs especially Prof.
Carpantier's comments were good. Very disappointed with afib stuff.
I attended all of Tech-Con but only a few STS talks.
Chand
-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of
prasannasimha
Sent: Thursday, February 01, 2007 9:36 AM
To: OpenHeart-L at lists.hsforum.com
Subject: [HSF] STS
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.
>>>>>> >
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