[HSF] STS (OT)
Tea Acuff
tacuff at swbell.net
Thu Feb 1 20:05:48 EST 2007
I think "teat" pretty much sums up the lurkers contribution to the effort.
You are now "off" on your own, Chand.
tea
----- Original Message ----
From: psimha <prasannasimha at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Thursday, February 1, 2007 10:02:28 AM
Subject: Re: [HSF] STS (OT)
We pardon you for your "Freudian slip" ;-)
Prasanna
Ramaiah, Chandrashekar wrote:
> Sorry...It was supposed to be "Tea Party"
> Chand
>
>
>
> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com
> [mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Ramaiah,
> Chandrashekar
> Sent: Thursday, February 01, 2007 10:49 AM
> To: OpenHeart-L at lists.hsforum.com
> Subject: RE: [HSF] STS
>
> 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.
>>>>>>> >
>>>>>>> _______________________________________________
>>>>>>> OpenHeart-L mailing list
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