[?]Re: [HSF] Posterior Post-Infarction VSD, SAM, and other M...

Sat Jul 14 16:08:45 EDT 2007

Combining your replies as to drawing conclusions from volume alone and the need for high volume centers, I will take the challenge that was fairly predictable from your number query and my guarded answer.

The challenge is akin to the "mine is bigger than yours" argument of adolescence, except everyone already knows and I have already acquiesced to the fact that yours is bigger. While this argument is always a source of fascination, I am betting that much of our jury (HSF) is more sophisticated and realizes while the size fascination is a factor it is not in and of itself likely to be a source of either enlightenment or persuasion. That it is continually espoused by parts of the medical community, many with dogs in the fight, as a reliable source of superiority is a symptom of intellectual laziness at best and self promotion at worst. If you do an excellent valve repair, your work will speak for itself, or at least your transparent results will. To further insist on high volume, while a choice for those selecting, in my opinion degrades the primary argument for quality.

The large number argument is an ever popular and usually passable but not nearly a reliable one. Just because one approach is used extensively and overwhelmingly does not make it best or even appropriate in some settings. Over whelming experience has been used as appeal to superiority for On verses OFF pump, PCI vs CABG (by both sides at different times),  slogans for Xerox and likely certain kinds of buggy whips. It was clearly used against the use of mitral valve repair in its early stages.

The numbers you wish to quote, while not irrelevant, are not suitable for clear decision analysis. Neither you nor I know the necessary or actual details concerning which failed, which were chosen and which were not, clear follow up, or the exact etiologies so gross numbers while "fascinating"  may be misleading. Further I think you also have, at least on occasion, changed your technique based on other technical "needs" such as "mine (incision) is much smaller than yours". What conclusion should we draw from that?

Lastly neither you who state that you use a ring for every case or I who state that I don't use a ring for any case can say anything about whether or when a ring  is or is not  necessary for a particular case. I have had the experience of watching a repair fall apart intraop after what seemed a good result, but I cannot say it was due to a lack of ring since I ultimately chose to replace rather than use a ring. This would have been the perfect experiment. If a repair was my overwhelming concern, probably could have revised this patient (as I remember a third time), but seldom is repair the only factor important to the patient. If it is that too should be noted to the patient. However, this case  might have been satisfactory with a sliding repair instead of too large an old style quad resection or perhaps selecting a neochord repair initially. Many factors will contribute to failure some perhaps mitigated by the ring, but others perhaps not. By the same token you have no way
 of knowing if your selected ring of the week or year prevented problems for successes or was superfluous. Clearly it does not prevent any failures which you may or may not experience.

My contention has never been that no one should use a ring, but only that a ring is not always a necessity. If I have even one patient with a stable repair that trumps a thousand with rings. It does not prove to a surgeon that he should abandon rings, just that he sometimes may. And thus sometimes he may avoid the errors inherent in the same. I doubt that many who currently use rings routinely will suddenly stop doing so. I do hope that there are no patients who do not get a chance at an easy repair for lack of an industry manufactured ring. I think that rings are oversold. I will stop short of calling them overpriced since everyone seems to be willing to buy them.

The problem with not knowing whether a ring is necessary, or conversely, relying on a ring as the solution for every situation, is that it begets a crutch mentality and engenders progressively faulty thinking. As per many of our HSF discussions the ring size, placement, or physical qualities can and will produce its own source of errors. I think it also leads to trying to correct non-annular problems with annular solutions, which I imagine is a mistake particularly in ischemic ventricles which may have better options. To try to force a ring to make up for problems that can not be corrected at the leaflet level or at the annular level seems to be likely a mistake even if it "allows" one to do a repair. The heart is, after all, more than a competent valve repair that looks good on TEE.

If we submitted to "big experience" wins as a "best" idea, we would not know VATS,  OFF pump surgery, aortic stenting or likely mitral valve repair. As you may know I am very concerned that we avoid errors of faulty thinking whenever possible. Faulty thinking is inherent in the human condition, but it must be overcome to avoid stagnation and ultimately obsolescence. This probably is why programmed death is a universal biologic principle: it clears the way for new "ideas".

By the way, I guess that I have done about 50 mitral repairs of varying techniques allowing for an error of a factor of two either way. Maybe I should look up my experience and track down the follow up, but what difference would that make to you even if it were good? What would be the right number to change your mind? What would be the right number to allow me to continue to do repairs by decree from the high volume centers? As it is I don't see many young myxomatous valves or see the point of robotic repair of the same, but I feel comfortable with a routine adult practice which should include some ability with mitral valve disease. They must all be looking or sent less where. I have some patients that don't want to go 5 miles to the next hospital I usually use much less a different city. 

The fault may be with my training. I trained as a trauma surgeon in Parkland. I fixed almost anything they could shoot or stab, but never did 50 of anything that I remember except AV fistula since I was interested in transplants. You probably did the same at Cook. Nothing much has changed except that I have done a whole lot of CAB eventually many different ways. If we were to practice twenty more years, I imagine that you and I will both be doing both some completely new things and some old things differently. But not if we set up and define the only one known best and universal way to do it something based on volume and the ideas of the few in a volume center alone...

tea

----- Original Message ----
From: "Hgrmd at aol.com" <Hgrmd at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Friday, July 13, 2007 6:17:01 AM
Subject: Re: [??????????????]Re: [HSF] Posterior Post-Infarction VSD, SAM, and other M...

Tea,
  I figured you wouldn't give me a straight answer.  With that,  the readers 
of HSF should draw their own conclusions about your  recommendation.

Hal

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