[HSF] STS

[Tea Acuff]

There has never been a better straight man than Hal. He does all the talking and cites all the data, and I just point out a 
discrepancy or two. Me thinks that many base judgment by volume of data.
 
It was interesting to hear everyone presenting at STS supporting their positions with part of the story.
 
As did HalI thought the percutaneous side to side repair of the mitral and Billy Cohn's percutaneous annuloplasty talks verses Alain's talk of twenty five years of mitral repair putting both together (annuloplasty and valvuloplasty) was interesting. Not surprisingly I had a slightly different take of it. Everyone ignored their own weaknesses. You all might remember I recently raised the issue of separating the procedures for some patients for strictly "a priori" reasons. How this will ultimately work out remains to be seen. The "lessors" will not quit at a single attempt.
 
I think that we surgeons labor under a dual and tremendous bais, and perhaps not an inappropiate one from our perspective, of seeing the worse cases and seeing them only once. The population of MR (or whatever disease) is much larger than we ever see. As I have stated before, changing the population for which a test or procedure is used can have drastic consequences. A cure of 90% with a mortality of 5% may be spectular for end stage and largely fatal disease, but it may be draconian for earlier or less morbid diease of high prevalence. One man fudge the numbers a little, but the concept remains. We suffer under the belief that what we see and what we do are normative. It is for us, but we will have to see about larger populations.
 
I also heard several discussions about the "evidence" of results and information, both for regulation, eg FDA, and renumeration with coming P4P. There is a lot of both general scepticism and arrogance on this problem, again, not much different from the frequent discussions which we have on HSF concerning the use of evidence. I continue to be amazed at those that advocate in public a clamp down by regulators on others for "excess" profit or extension of  "off label" use as a solution to "our" problems. This, too, we see come up in our discussions. Many will reflect that we make a "seemingly pretty good profit" or use most things "off label"  from others' perspective. For myself, I noted that I learned that lesson in the second grade (even if I occasionally relearn it), when I reported to the teacher that one of my classmates had his eyes open during the prayer. When asked for the evidence, it made an impression upon me. The rope we eagerly make for others will surely also
 hang us. The French never quite figured out their revolution.
 
Tea
 
----- Original Message ----
From: "Hgrmd at aol.com" <Hgrmd at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Thursday, February 1, 2007 7:11:28 AM
Subject: [HSF] STS


I got home from San Diego last night.  The STS was fairly  enlightening, 
though I didn't attend listen to as many papers as I should,  because I was really 
tied up with industry examining my ring ideas.  Last  Saturday, I attended 
George Lawrie's mitral repair course.  He has a system  that relies exclusively 
on resuspending all prolapsed segments with Goretex  chords.  He also only 
uses a fully flexible band or ring for all types of  MR.  He secures these 
prostheses with a running 2-0 Prolene.  There  exists tons of recent literature 
revealing that this is a flawed approach for MR  secondary to myopathic 
ventricles. He also has plenty of snide remarks about  Carpentier that really irritate 
me so much that I flatly told him so in front of  the whole group of surgeons.  
I've reached the point in my career where I  don't really care what guys like 
him think of me.  Disagreeing with a giant  like Carpentier is OK and a 
natural progression to our field (I now  substantially deviate from what I learned 
from Carpentier).  However, to  belittle him makes that surgeon look small and 
detracts from his  credibility.
  A guy named Taggert from Oxford gave a one hour lecture on CABG vs  PCI at 
Tech-Con.  It was quite enlightening.  He examined several  large data bases 
and came to the convincing conclusion that there is a 30%  survival benefit at 
2 years if CABG rather than PCI is used for multivessel  disease.  Try telling 
that to a patient on the table while the cardiologist  is listening!  
  There was a lot of talk about percutaneous valve procedures.   The 
transapical AVI (aortic valve insertion) looks the most promising.  Ted  Feldman 
presented his study comparing E-valve to open repair.  A "success"  is when there 
is a 2 grade improvement in the severity of MR.  In other  words, from severe 
to moderate would be considered a success.  I've never  let anyone out of the 
OR with a repair that had moderate residual MR.   Ample data exists that such 
repairs do the patient no favor.  The way this  charlatan's study is 
constructed, he would be happy to enroll a 24 yo lady with  severe MR from a flail P2, 
even though he knows that she would end up with a  likely replacment if surgery 
was required more than 18 months after deployment  of the clip.  Apparently, 
the scarring from A2 to P2 from this clip Alfieri  makes subsequent repair 
nearly impossible.  In mine and many other  competent repair surgeons hands, 
repairing surch a lesion would be essentially  curative and make her survival the 
same as the general public.  In  contrast, should she eventually require a 
mechanical prosthesis, the odds of her  living stroke free to Medicare would be 
unlikely.
Hal
_______________________________________________
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
-----------------------------------------