From prasannasimha at gmail.com Thu Mar 1 07:28:59 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Wed Feb 28 20:59:40 2007 Subject: [HSF] Lupus and MR In-Reply-To: <783E0FFA8DFA684496D51E349BD28D3801B66A13@e2kb32.ad.uky.edu> References: <048301c758e4$aa9d48ba$07091fac@ad.uky.edu> <8C9275880FCF2DE-758-142C@WEBMAIL-DF18.sysops.aol.com> <783E0FFA8DFA684496D51E349BD28D3801B66A13@e2kb32.ad.uky.edu> Message-ID: <45E63363.8020100@gmail.com> The crux of the issue is that you said the leaflets look like Barlow's with no leaflet restriction. Libman Sack verrucous vegetations will be found in varying degrees on every SBE case and do not cause "valvular damage" per se unless they get secondarily infected. If the leaflets are thin on inspection intraop go for it. I would also ask the blood bank to check the cross match of the patient and also look for auto and warm + cold agglutinins. Prasanna Ramaiah, Chandrashekar wrote: > Hal, Ani, and Prasanna- > There is not much in the literature on this subject, only case reports. > Most of them justify replacing with a mechanical valve as Lupus can > destroy the bioprosthesis and repaired valve (again 1 or 2 cases). I > could only find one by Carpentier where he replaced with a homograft. > > This patient has proven SLE with renal involvement (Class III lupus > nephritis), and heart involvement. Had thrombocytopenia in the past > responded to Immunosuppression with Steroids and Imuran. > > Her valve "looks like Barlow's" but it has features of Libman Sach's > endocarditis. This is probably the reason the cardiologist did not refer > her for replacement (thinking that she will get a mechanical Valve) for > nearly 3 years and did when she became a NYHA IV. > What other problems do you expect in post op period and how to handle > it? > > Chand > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com > [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of > hgrmd@aol.com > Sent: Sunday, February 25, 2007 7:59 PM > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] Lupus and MR > > Chand, > I'm not aware of any contraindication to repairing a Barlow's valve in > an SLE patient. Whenever I've had a cardiologist refer the patient with > orders to replace, I tell him to just let me do my job. I then repair > the valve if it is feasible. I find that kind of presumptive behavior > by the cardiologist quite annoying. As for the SLE, I have had 2 > patients with SLE develop fatal postop mediastinitis. They account for > 1/2 of the fatal mediastinitis occuring in my private practice over the > last 17 years. > Hal > > -----Original Message----- > From: crama01@email.uky.edu > To: OpenHeart-L@lists.hsforum.com > Sent: Sun, 25 Feb 2007 8:54 AM > Subject: [HSF] Lupus and MR > > > 30 y/o has severe bileaflet prolapse and looks as if it is a severe case > of > myxomatous degeneration. Patient and the referring cardiologist is > requesting a > mechanical valve and I think it can be repaired easily. > Any concerns with the durability of repair in a patient with SLE. > Chand > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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@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 > ----------------------------------------- > > > From prasannasimha at gmail.com Thu Mar 1 07:32:02 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Wed Feb 28 21:02:34 2007 Subject: [HSF] Continuous venovenous haemofiltration In-Reply-To: <2068.71875.qm@web35906.mail.mud.yahoo.com> References: <2068.71875.qm@web35906.mail.mud.yahoo.com> Message-ID: <45E6341A.3080803@gmail.com> If you are using CVH- CAVH will not work without a driving pressure (it will cause the membrane to keep clotting) and the driving pressure will not be that good once pressures are below 80) and you will require pump assisted CVVH. Any way you have to also improve hemodynamics because the flux of fluids etc also has to be managed and tolerated. Prasabba john pj wrote: > > > Our nephrologists are not willing to offer CVH for patients whose BP is less than 90 systolic. > I wish to know the experience in other centres > > --------------------------------- > Check out the all-new Yahoo! Mail beta - Fire up a more powerful email and get things done faster. > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > > From prasannasimha at gmail.com Thu Mar 1 07:34:06 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Wed Feb 28 21:11:26 2007 Subject: [HSF] On pump beating heart In-Reply-To: <00cf01c75b97$9cca2030$4ab6e818@GUSTAVOABUIN> References: <45E419E4.2030402@gmail.com> <00cf01c75b97$9cca2030$4ab6e818@GUSTAVOABUIN> Message-ID: <45E63496.20500@gmail.com> Mumbai - I do not have his exact address but he is practicing (One of the sites where he operates) in Breach Candy Hospital. Prasanna gustavo abuin wrote: > Dear Prasanna. > Where does Doctor Bhattacharya is? It would be very interesting to > play a visit. > Thanks > ----- Original Message ----- From: "prasannasimha" > > To: > Sent: Tuesday, February 27, 2007 8:45 AM > Subject: Re: [HSF] On pump beating heart > > >> The worst possible scenario is a person wanting to complete a 100 % >> OPCAB experience in time for a conference etc and refusing to go on >> pump or at least institute an IABP while the heart is demanding it >> !!. Saying this, in isolated CABG's not in cardiogenic shock, >> inability to displace the heart during OPCAB is more often an >> expression of failure of the surgeon - anesthesiologist team to >> understand what is going on. >> You should see Dr Bhattacharya doing a multivessel total arterial >> revascularization on a 10 - 15 % EF heart being done effortlessly to >> believe it. He has probably the worlds largest "individual surgeon" >> series of OPCAB's and unfortunately the blessed man doesn't publish. >> Watching him do an OPCAB is like seeing an orchestra play. >> Prasanna >> >> Ani Anyanwu wrote: >>> Off-pump surgery is sometimes also a crime against the human - I >>> have seen several cases where the heart, or the entire patient, has >>> suffered because of reluctance and refusal of the surgeon to accept >>> conversion to CPB. It cuts both ways (some patients also suffer by >>> having on-pump CABG). We should not be evangelists for a technique >>> but for the patient. The patient couldn't care less whether we used >>> CPB or not - all they want is a lasting operation at low risk so our >>> primary aim should be to deliver this goal. >>> >>> Ani >>> ----- Original Message ----- From: >>> NielsB@aol.com To: >>> OpenHeart-L@lists.hsforum.com >>> Sent: Tuesday, February 27, 2007 3:09 AM >>> Subject: Re: [HSF] On pump beating heart >>> >>> >>> Who said it is?. It is not a crime against humanity but in some >>> cases it is a crime against a human. The heart lung machine is a >>> tool among many others, very frequently a very important one. But it >>> is not some holy grail either. We use it when we need it, for CABG >>> this is not so common, then the stabilizer is a better tool in my >>> humble opinion. >>> >>> >>> Jacob Bergsland >>> >>> >>> ************************************** >>> AOL now offers free email to everyone. Find out more about >>> what's free from AOL at http://www.aol.com. >>> _______________________________________________ >>> OpenHeart-L mailing list >>> >>> Send postings to: >>> OpenHeart-L@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@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@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@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 > ----------------------------------------- > > From donross at bigpond.com Thu Mar 1 16:20:08 2007 From: donross at bigpond.com (Donald Ross) Date: Thu Mar 1 00:20:41 2007 Subject: [HSF] On pump beating heart {OT} In-Reply-To: <8C9298B1915F9D3-1E4-1B5B@webmail-md12.sysops.aol.com> References: <8C928EA3F703A1E-1724-80AC@MBLK-M22.sysops.aol.com> <7D3C5DEA-8356-43AE-97A0-019A26D51B77@bigpond.com> <8C9298B1915F9D3-1E4-1B5B@webmail-md12.sysops.aol.com> Message-ID: <78F38C5F-68F5-42D2-9DE7-CFD233B6C13A@bigpond.com> Hal, I think Oz could accommodate you...just. I know bugger all about rock music but I am sure my daughter could find somewhere to get your ears ringing again. My piano need a work out so you would have to stay with us in Sydney. Don On 01/03/2007, at 7:06 AM, hgrmd@aol.com wrote: > Don, > When I finally make to Oz, I want to see Bon Scott's resting > place. I recently saw an old video of a live performance with him > fronting AC/DC. I love that band. About 4 years ago, I saw them > 3rd row center. Even wearing earplugs, my ears rang for about a > day afterwards. > Hal > > -----Original Message----- > From: donross@bigpond.com > To: OpenHeart-L@lists.hsforum.com > Sent: Wed, 28 Feb 2007 4:07 AM > Subject: Re: [HSF] On pump beating heart > > > For the rest of the forum, Billy T was an old Oz rocker who just > died from a large infarct. > Ben, It was George G. > Don > On 28/02/2007, at 7:17 PM, Ben Bidstrup wrote: > >> Glad it wasn't Billy T >> >> >>>> Though Don Ross does them by using his long shunts, he is in a >>>> >>> tiny minority. Perhaps the naysayers of endarterectomy who >>>> are >>> 100% OPCAB'ers would rethink their position if they >>>> tried it on >>> pump. Believe me, it works well. >>> They sure do. >>> When I was a young fella I did three long endos on an >> >>> "inoperable" Jazz guitarist. 25 years on he is still playing and >>> >> angina free despite his vile vein grafts. >>> Don >>>> >>>> Thanks Hal. >>>> >>>> Yes, I do endarterectomy, and I will not do this off >>>> pump. We only get the occasional patient who needs it. >>>> I have thought of taking out stents but have not been >>>> brave enough! We sometimes get those calcific horrors >>>> where there is no place to open the vessel. The last >>>> one needed 2 `traditional` long incision >>>> endarterectomies, with long patch anastomoses. >>>> >>>> Us `opcabbers` get enthusiastic when we can safely do >>>> a full revascularisation the same way we would do it >>>> on pump, we enjoy the operation more so approaching >>>> 100% makes us feel better! We still know it is better >>>> for the patient, even if marginally. But would not >>>> hesitate to go on, and not hesitate to decide go on >>>> pump pre-op if we think it safer. Just like you, I am >>>> sure, would like to repair 100% of the valves you >>>> tackle, but also would not spend too much time mucking >>>> about when it becomes clear that the valve should >>>> rather be cut out and replaced. >>>> Dave >>>> --- hgrmd@aol.com wrote: >>>> >>>>> Dave, >>>>> Thanks for the clarification. Just make sure that >>>>> you aren't finessing too vessels just so you can do >>>>> the case off pump. Like Mark, I believe extensive >>>>> endarterectomies should have a definite place in >>>>> your quiver as we continue to get patients with more >>>>> diffuse disease. Anyway, good luck with your policy >>>>> and let us know how it goes. >>>>> Hal >>>>> >>>>> -----Original Message----- >>>>> From: drdharris@yahoo.co.uk >>>>> To: OpenHeart-L@lists.hsforum.com >>>>> Sent: Mon, 26 Feb 2007 3:51 PM >>>>> Subject: Re: [HSF] On pump beating heart >>>>> >>>>> >>>>> HA HA, I knew I would get you guys going! What I >>>>> meant >>>>> was I RECENTLY started to do 100% off pump! That was >>>>> the last 20 consecutive cases! Have not hit any >>>>> rough >>>>> ones since then! I`ll keep you posted! >>>>> >>>>> Seriously though, of course I agree there are >>>>> `IMPOSSIBLE` cases! And these are probably done best >>>>> beating on the pump. But I still am convinced the >>>>> results will be better if you do 90% off pump, which >>>>> I >>>>> will generally aim for....however after recently see >>>>> patients trash their legs and their bowel after >>>>> being >>>>> on the pump I vowed I`ll try to do 100% off! >>>>> >>>>> >>>>> --- hgrmd@aol.com wrote: >>>>> >>>>>> Tea, >>>>>> Coming from a guy who does a very high >>>>> percentage >>>>>> of cases off pump, your comment about 100% >>>>> OPCAB'ers >>>>>> is well taken. Having been an avid follower of >>>>> HSF >>>>>> for a few years, I've definitely seen my share of >>>>>> breathless hyperbole (and no, I don't believe I've >>>>>> been a part of it). >>>>>> Hal >>>>>> >>>>>> -----Original Message----- >>>>>> From: tacuff@swbell.net >>>>>> To: OpenHeart-L@lists.hsforum.com >>>>>> Sent: Sun, 25 Feb 2007 10:33 PM >>>>>> Subject: Re: [HSF] On pump beating heart >>>>>> >>>>>> >>>>>> I would put froth coming out of the ET under the >>>>>> category of "potential >>>>>> problem". In reference to Chand's earlier patient >>>>>> with portal venous air, froth >>>>>> in the ET would also qualify as "unstable" even if >>>>>> the BP was 100 on pressors. >>>>>> One might not have to go on CPB, but it should be >>>>> a >>>>>> consideration and available. >>>>>> It would be hard to object in retrospect to CPB >>>>> even >>>>>> if you go below 100% on >>>>>> this one. >>>>>> >>>>>> I actually looked up my rate for 2004 and 2005 for >>>>>> "CABG with no CPB" at my >>>>>> primary hospital. The trend of cases is down and >>>>> the >>>>>> trend of "CAB and valve or >>>>>> other" is up. In two years I did 3 cases of CAB >>>>>> alone with CPB (including >>>>>> redo's) in 150 cases. This is a 98% rate, I think. >>>>>> Next year could be 90% or >>>>>> 100%, but it won't be 10% or 50%. >>>>>> >>>>>> Here is what I hear when surgeons tell me their >>>>> rate >>>>>> of off pump surgery. >>>>>> Although the most common thing they now say is >>>>> that >>>>>> they stopped or it is >>>>>> rountine. It is just a guess, as always I could be >>>>>> wrong, but when I check a >>>>>> reference that visits the surgeon or see what they >>>>>> do year after year I think I >>>>>> may be more right than not: >>>>>> I tried a few but wasn't comfortable.=we had some >>>>>> bad results in the first ten >>>>>> (I mean another surgeon obviously) so I stopped. >>>>>> I do 10-20%=I tried it once or twice but didn't >>>>> like >>>>>> it. I might try it again if >>>>>> I have too. >>>>>> I do 30-40%. =I do half of my single and double >>>>>> bypasses. >>>>>> I do 50%.= I almost always do single and double >>>>>> bypasses and some easy PL or >>>>>> PDAs. >>>>>> I do all of mine OPCAB.= I try do do most of mine >>>>>> off pump (work in progress) or >>>>>> perhaps it is actually my rountine. >>>>>> I do 100% off pump.= Either I am FOS or I forgot >>>>>> about the couple of problem >>>>>> patients last year. If he writes a lot of papers >>>>> it >>>>>> is even money the former. >>>>>> >>>>>> I have no one in mind when I wrote this. Promise. >>>>>> Almost. >>>>>> tea >>>>>> >>>>>> >>>>>> ----- Original Message ---- >>>>>> From: David Harris >>>>>> To: OpenHeart-L@lists.hsforum.com >>>>>> Sent: Sunday, February 25, 2007 5:08:30 PM >>>>>> Subject: Re: [HSF] On pump beating heart >>>>>> >>>>>> >>>>>> I can`t remember when I last saw a patient in >>>>>> cardiogenic shock referred for surgery....we have >>>>>> excellent cardiologists who intervene >>>>>> percutaneously, >>>>>> and they do`nt turf the patient to us if half the >>>>>> ventricle has been wiped out already. >>>>>> >>>>>> --- hgrmd@aol.com wrote: >>>>>> >>>>>>> When my group does OPCAB, they don't prime the >>>>>> pump, >>>>>>> either. However, they do have a perfusionist >>>>> and >>>>>> a >>>>>>> pump in the room ready to go if the need arises. >>>>> >>>>>>> One hundred per cent OPCAB? You apparently >>>>> don't >>>>>>> offer surgery to patients in cardiogenic shock >>>>> and >>>>>>> froth coming out the ET tube. I have and do. >>>>>>> However, no way would I consider doing that type >>>>>> of >>>>>>> patient off pump. >>>>>>> >>>>>>> Hal >>>>>>> >>>>>>> >>>>>>> -----Original Message----- >>>>>>> From: drdharris@yahoo.co.uk >>>>>>> To: OpenHeart-L@lists.hsforum.com >>>>>>> Sent: Wed, 21 Feb 2007 4:48 PM >>>>>>> Subject: Re: [HSF] On pump beating heart >>>>>>> >>>>>>> >>>>>>> I agree fully with Tea: there is no need to have >>>>>> the >>>>>>> pump primed for an OPCAB, unless it is a >>>>> potential >>>>>>> problem. Similarly, with increased experience, >>>>> the >>>>>>> cardiologists never ask for standby for PTCA. >>>>>> Those >>>>>>> nasty earlier conversions were during the >>>>> learning >>>>>>> curve, when we did not know the limits. We know >>>>>>> where >>>>>>> the limits are now, and it will be safe: limited >>>>>>> traction for first graft (LAD), with a few >>>>> sutures >>>>>>> just above phrenic nerve, use of shunts always, >>>>>> not >>>>>>> accepting any extrasystole, (and sorting out >>>>> what >>>>>> is >>>>>>> causing them immediately), careful manipulation >>>>>> for >>>>>>> last grafts by verticalisation only, and not >>>>>>> accepting >>>>>>> ANY hypotension before carrying on. >>>>>>> I have recently changed to 100% OPCAB, and you >>>>> can >>>>>>> immediately see the difference, and the major >>>>>>> difference is seen not only in hospital, but >>>>>> during >>>>>>> the first 3 months. >>>>>>> >>>>>>> >>>>>>> --- hgrmd@aol.com wrote: >>>>>>> >>>>>>>> Tea, >>>>>>>> Knowing you as I do, I've no doubt that you >>>>>>> speak >>>>>>>> the truth about your OPCAB experience (For >>>>> once, >>>>>>> I'm >>>>> >>>> === message truncated === >>>> >>>> >>>> Dr. David G. Harris, FCS, MMED, >>>> Cardiothoracic Surgeon >>>> Suite A2 >>>> Tygerberg Hospital, 7505 >>>> Cape Town, South Africa. >>>> Tel +27-21-9762347 >>>> Fax +27-21-9761157 Mobile +27-83-3309587 >>>> _______________________________________________ >>>> OpenHeart-L mailing list >>>> >>>> Send postings to: >>>> OpenHeart-L@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@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@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 anddisclaimers posted at: >>> http://www.hsforum.com/listdisclaim >>> ----------------------------------------- >> >> >> --> Ben Bidstrup FRACS FRCSEd FEBCTS >> Consultant Cardiothoracic Surgeon >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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@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 anddisclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > ______________________________________________________________________ > __ > AOL now offers free email to everyone. Find out more about what's > free from AOL at AOL.com. > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From donross at bigpond.com Thu Mar 1 16:32:49 2007 From: donross at bigpond.com (Donald Ross) Date: Thu Mar 1 00:34:18 2007 Subject: [HSF] Ischaemic cardiomapathy In-Reply-To: <414479.5003.qm@web26714.mail.ukl.yahoo.com> References: <414479.5003.qm@web26714.mail.ukl.yahoo.com> Message-ID: <056A4583-9894-45D7-B5A3-742EED1651D6@bigpond.com> David, That is good advice. I had done 6 or so very low EF patients bhop with no problems, but as you push your luck further some more help is needed as my last two case illustrated. I will give the overnight balloon consideration for the next one. Thanks, Don On 01/03/2007, at 7:56 AM, David Harris wrote: > I agree with pre-op balloon in all these patients with > EF around 20. I think you have only one chance with > these patients. Then you can see if you can do them > off pump, and if not, do them beating on pump. The > timing of the balloon is important, they need at least > overnight, but no longer. Some low dose dobutamine > also helps, and by the time the operation time comes > around, the heart has decreased in size. Another > choice for all left side vessels is to do it all > through a thoracotomy, so you need not displace the > heart and cause hemodynamic chaos. Proximal grafts > onto the left subclavian can also classify this as an > `anaortic` CABG > > > --- Donald Ross wrote: > >> Ben, >> Can't agree; if that was the case the problem would >> come on earlier. >> The lad grafts take ~ 5min including placement of >> shunt. Check out >> the "real time lima to LAD "at "movies " at >> beating-heart.com hardly long enough to bother a >> myocyte. Can't do >> much about the anaesthetic unless you practice in >> India where >> epidurals suffice. >> I think the diastolic augmentation of the balloon >> helps to belt >> blood down spasmy imas. >> Don >> On 28/02/2007, at 7:21 PM, Ben Bidstrup wrote: >> >>> I think it is more than that. In poor LVs even a >> small amount of >>> depression by transient ischaemia to the LAD >> despite shunts can >>> lead to the need for more support. There is likely >> to be some >>> oedema after revascularisation, and the impact of >> anaesthesia needs >>> consideration also. >>> >>> >>>> Prasanna, >>>> I did talk to Dr Bhattacharya at the meeting in >> Mumbai, I now know >>>> since my registrar confirmed his distinguished >> appearance. >>>> He must be slick to use the RIMA exclusively for >> his T graft . >>>> He did, however mention that he uses the balloon >> for sick hearts >>>> which perhaps is the reason for his 100% record. >>>> Now that I am reminded of this I will do the same >> for my next <20% >>>> EF patient since the last two done bh on pump >> needed post op >>>> balloons... not immediately but after a few >> hours. I suspect the >>>> reason relates to transient ima hypoperfusion >> which intolerant >>>> of the low mean pressure of some low EF hearts. >>>> Don >>>> On 27/02/2007, at 11:49 PM, prasannasimha wrote: >>>> >>>>> He practices in Mumbai.(He visits multiple >> hospitals including >>>>> Breach Candy hospital etc) >>>>> Prasanna >>>>> Donald Ross wrote: >>>>>> Prasanna, >>>>>> Who publishes series of individual cases no >> matter how pretty >>>>>> the clinical results? >>>>>> Even if they are put into print many wont >> believe them ( Hal et >>>>>> al ) or take any notice unless there has been >> some some attempt >>>>>> at science, some hypothesis formulated , some >> conclusion to be >>>>>> elucidated. >>>>>> This wonderful surgeon/orchestral conductor >> can't publish his >>>>>> beautiful playing. >>>>>> All one can do is to take your advice and visit >> the man. >>>>>> So, where does he work? >>>>>> Don >>>>>> PS I thought he used a balloon instead of >> bypass in crook cases >>>>>> which I believe is probably more morbid than >> cpb. >>>>>> >>>>>> On 27/02/2007, at 10:45 PM, prasannasimha >> wrote: >>>>>> >>>>>>> The worst possible scenario is a person >> wanting to complete a >>>>>>> 100 % OPCAB experience in time for a >> conference etc and >>>>>>> refusing to go on pump or at least institute >> an IABP while the >>>>>>> heart is demanding it !!. Saying this, in >> isolated CABG's not >>>>>>> in cardiogenic shock, inability to displace >> the heart during >>>>>>> OPCAB is more often an expression of failure >> of the surgeon - >>>>>>> anesthesiologist team to understand what is >> going on. >>>>>>> You should see Dr Bhattacharya doing a >> multivessel total >>>>>>> arterial revascularization on a 10 - 15 % EF >> heart being done >>>>>>> effortlessly to believe it. He has probably >> the worlds largest >>>>>>> "individual surgeon" series of OPCAB's and >> unfortunately the >>>>>>> blessed man doesn't publish. Watching him do >> an OPCAB is like >>>>>>> seeing an orchestra play. >>>>>>> Prasanna >>>>>>> >>>>>>> Ani Anyanwu wrote: >>>>>>>> Off-pump surgery is sometimes also a crime >> against the human - >>>>>>>> I have seen several cases where the heart, or >> the entire >>>>>>>> patient, has suffered because of reluctance >> and refusal of the >>>>>>>> surgeon to accept conversion to CPB. It cuts >> both ways (some >>>>>>>> patients also suffer by having on-pump CABG). >> We should not be >>>>>>>> evangelists for a technique but for the >> patient. The patient >>>>>>>> couldn't care less whether we used CPB or not >> - all they want >>>>>>>> is a lasting operation at low risk so our >> primary aim should >>>>>>>> be to deliver this goal. >>>>>>>> >>>>>>>> Ani >>>>>>>> ----- Original Message ----- From: >>>>>>>> NielsB@aol.com To: >> OpenHeart- >>>>>>>> >> > L@lists.hsforum.com >> >>>>>>>> Sent: Tuesday, February 27, 2007 3:09 AM >>>>>>>> Subject: Re: [HSF] On pump beating heart >>>>>>>> >>>>>>>> >>>>>>>> Who said it is?. It is not a crime against >> humanity but in >>>>>>>> some cases it is a crime against a human. >> The heart lung >>>>>>>> machine is a tool among many others, very >> frequently a very >>>>>>>> important one. But it is not some holy grail >> either. We use >>>>>>>> it when we need it, for CABG this is not so >> common, then the >>>>>>>> stabilizer is a better tool in my humble >> opinion. >>>>>>>> >>>>>>>> >>>>>>>> Jacob Bergsland >>>>>>>> >>>>>>>> >>>>>>>> ************************************** >>>>>>>> AOL now offers free email to everyone. >> Find out more >>>>>>>> about what's free from AOL at >> http://www.aol.com>>>>>>> www.aol.com/>. >>>>>>>> >> _______________________________________________ >>>>>>>> OpenHeart-L mailing list >>>>>>>> >>>>>>>> Send postings to: >>>>>>>> >> OpenHeart-L@lists.hsforum.com>>>>>>> L@lists.hsforum.com> >>>>>>>> >>>>>>>> To UNSUBSCRIBE, to CHANGE email address, or >> to view archives: >>>>>>>> >> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >>>>>>>> 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> >>>>>>>> listdisclaim> >>>>>>>> ----------------------------------------- >>>>>>>> >> _______________________________________________ >>>>>>>> OpenHeart-L mailing list >>>>>>>> >>>>>>>> Send postings to: >>>>>>>> OpenHeart-L@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 >> > === message truncated === > > > Dr. David G. Harris, FCS, MMED, > Cardiothoracic Surgeon > Suite A2 > Tygerberg Hospital, 7505 > Cape Town, South Africa. > Tel +27-21-9762347 > Fax +27-21-9761157 Mobile +27-83-3309587 > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From donross at bigpond.com Thu Mar 1 16:53:42 2007 From: donross at bigpond.com (Donald Ross) Date: Thu Mar 1 00:55:14 2007 Subject: [HSF] On pump beating heart In-Reply-To: References: <414479.5003.qm@web26714.mail.ukl.yahoo.com> Message-ID: <6CFCFE6D-6640-4243-9723-22C800925D01@bigpond.com> Hey, Ani , look at the thread: "On pump beating heart" If there is an aneurysm or localised dead heart or MR opcabers quickly become oncabers. Don On 01/03/2007, at 1:59 PM, Ani Anyanwu wrote: > One problem I see with advocating aggressive regimes for > accomplishing Off-pump revascularization in the sick ventricle with > low EF is that it diverts this away from surgery for heart failure > (which it is) to surgery for angina or MI prophylaxis (which it > isn't). > > The drive to do OPCAB in these patients results in a new group of > under-treated heart failure patients. The treatment of these > patients is often multimodal and not infrequently should include > mitral valve repair and sometimes LV remodeling or tricuspid valve > repair even. By pursuing OPCAB with zeal in this group I suspect > some surgeons are under-treating the associated lesions. As a > transplant surgeon, I see patients now and then who have had CABG > (on or off) and had the mitral neglected and progressed in heart > failure, with essentially a wasted operation. My view is if a > patient needs an IABP overnight to accomplish an OPCAB then he is > probably having the wrong operation. > > Ani > ----- Original Message ----- > From: David Harris > To: OpenHeart-L@lists.hsforum.com L@lists.hsforum.com> > Sent: Wednesday, February 28, 2007 3:56 PM > Subject: Re: [HSF] On pump beating heart > > > I agree with pre-op balloon in all these patients with > EF around 20. I think you have only one chance with > these patients. Then you can see if you can do them > off pump, and if not, do them beating on pump. The > timing of the balloon is important, they need at least > overnight, but no longer. Some low dose dobutamine > also helps, and by the time the operation time comes > around, the heart has decreased in size. Another > choice for all left side vessels is to do it all > through a thoracotomy, so you need not displace the > heart and cause hemodynamic chaos. Proximal grafts > onto the left subclavian can also classify this as an > `anaortic` CABG > > > --- Donald Ross > > wrote: > >> Ben, >> Can't agree; if that was the case the problem would >> come on earlier. >> The lad grafts take ~ 5min including placement of >> shunt. Check out >> the "real time lima to LAD "at "movies " at >> beating-heart.com hardly long enough to bother a >> myocyte. Can't do >> much about the anaesthetic unless you practice in >> India where >> epidurals suffice. >> I think the diastolic augmentation of the balloon >> helps to belt >> blood down spasmy imas. >> Don >> On 28/02/2007, at 7:21 PM, Ben Bidstrup wrote: >> >>> I think it is more than that. In poor LVs even a >> small amount of >>> depression by transient ischaemia to the LAD >> despite shunts can >>> lead to the need for more support. There is likely >> to be some >>> oedema after revascularisation, and the impact of >> anaesthesia needs >>> consideration also. >>> >>> >>>> Prasanna, >>>> I did talk to Dr Bhattacharya at the meeting in >> Mumbai, I now know >>>> since my registrar confirmed his distinguished >> appearance. >>>> He must be slick to use the RIMA exclusively for >> his T graft . >>>> He did, however mention that he uses the balloon >> for sick hearts >>>> which perhaps is the reason for his 100% record. >>>> Now that I am reminded of this I will do the same >> for my next <20% >>>> EF patient since the last two done bh on pump >> needed post op >>>> balloons... not immediately but after a few >> hours. I suspect the >>>> reason relates to transient ima hypoperfusion >> which intolerant >>>> of the low mean pressure of some low EF hearts. >>>> Don >>>> On 27/02/2007, at 11:49 PM, prasannasimha wrote: >>>> >>>>> He practices in Mumbai.(He visits multiple >> hospitals including >>>>> Breach Candy hospital etc) >>>>> Prasanna >>>>> Donald Ross wrote: >>>>>> Prasanna, >>>>>> Who publishes series of individual cases no >> matter how pretty >>>>>> the clinical results? >>>>>> Even if they are put into print many wont >> believe them ( Hal et >>>>>> al ) or take any notice unless there has been >> some some attempt >>>>>> at science, some hypothesis formulated , some >> conclusion to be >>>>>> elucidated. >>>>>> This wonderful surgeon/orchestral conductor >> can't publish his >>>>>> beautiful playing. >>>>>> All one can do is to take your advice and visit >> the man. >>>>>> So, where does he work? >>>>>> Don >>>>>> PS I thought he used a balloon instead of >> bypass in crook cases >>>>>> which I believe is probably more morbid than >> cpb. >>>>>> >>>>>> On 27/02/2007, at 10:45 PM, prasannasimha >> wrote: >>>>>> >>>>>>> The worst possible scenario is a person >> wanting to complete a >>>>>>> 100 % OPCAB experience in time for a >> conference etc and >>>>>>> refusing to go on pump or at least institute >> an IABP while the >>>>>>> heart is demanding it !!. Saying this, in >> isolated CABG's not >>>>>>> in cardiogenic shock, inability to displace >> the heart during >>>>>>> OPCAB is more often an expression of failure >> of the surgeon - >>>>>>> anesthesiologist team to understand what is >> going on. >>>>>>> You should see Dr Bhattacharya doing a >> multivessel total >>>>>>> arterial revascularization on a 10 - 15 % EF >> heart being done >>>>>>> effortlessly to believe it. He has probably >> the worlds largest >>>>>>> "individual surgeon" series of OPCAB's and >> unfortunately the >>>>>>> blessed man doesn't publish. Watching him do >> an OPCAB is like >>>>>>> seeing an orchestra play. >>>>>>> Prasanna >>>>>>> >>>>>>> Ani Anyanwu wrote: >>>>>>>> Off-pump surgery is sometimes also a crime >> against the human - >>>>>>>> I have seen several cases where the heart, or >> the entire >>>>>>>> patient, has suffered because of reluctance >> and refusal of the >>>>>>>> surgeon to accept conversion to CPB. It cuts >> both ways (some >>>>>>>> patients also suffer by having on-pump CABG). >> We should not be >>>>>>>> evangelists for a technique but for the >> patient. The patient >>>>>>>> couldn't care less whether we used CPB or not >> - all they want >>>>>>>> is a lasting operation at low risk so our >> primary aim should >>>>>>>> be to deliver this goal. >>>>>>>> >>>>>>>> Ani >>>>>>>> ----- Original Message ----- From: >>>>>>>> NielsB@aol.com>>>>>>> to:NielsB@aol.com>> To: >> OpenHeart- >>>>>>>> >> > L@lists.hsforum.com L@lists.hsforum.com L@lists.hsforum.com>> >> >>>>>>>> Sent: Tuesday, February 27, 2007 3:09 AM >>>>>>>> Subject: Re: [HSF] On pump beating heart >>>>>>>> >>>>>>>> >>>>>>>> Who said it is?. It is not a crime against >> humanity but in >>>>>>>> some cases it is a crime against a human. >> The heart lung >>>>>>>> machine is a tool among many others, very >> frequently a very >>>>>>>> important one. But it is not some holy grail >> either. We use >>>>>>>> it when we need it, for CABG this is not so >> common, then the >>>>>>>> stabilizer is a better tool in my humble >> opinion. >>>>>>>> >>>>>>>> >>>>>>>> Jacob Bergsland >>>>>>>> >>>>>>>> >>>>>>>> ************************************** >>>>>>>> AOL now offers free email to everyone. >> Find out more >>>>>>>> about what's free from AOL at >> http://www.aol.com >>>>>>>> www.aol.com/>. >>>>>>>> >> _______________________________________________ >>>>>>>> OpenHeart-L mailing list >>>>>>>> >>>>>>>> Send postings to: >>>>>>>> >> OpenHeart-L@lists.hsforum.com> L@lists.hsforum.com- >>>>>>>> L@lists.hsforum.com> >>>>>>>> >>>>>>>> To UNSUBSCRIBE, to CHANGE email address, or >> to view archives: >>>>>>>> >> > http://mmp.cjp.com/mailman/listinfo/openheart-l mmp.cjp.com/mailman/listinfo/openheart-l >> >>>>>>>> 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 >> >>>>>>>> listdisclaim> >>>>>>>> ----------------------------------------- >>>>>>>> >> _______________________________________________ >>>>>>>> OpenHeart-L mailing list >>>>>>>> >>>>>>>> Send postings to: >>>>>>>> OpenHeart-L@lists.hsforum.com>>>>>>> L@lists.hsforum.com> >>>>>>>> >>>>>>>> To UNSUBSCRIBE, to CHANGE email address, or >> to view archives: >>>>>>>> >> http://mmp.cjp.com/mailman/listinfo/openheart-l> 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>>>>>>> listdisclaim> >> > === message truncated === > > > Dr. David G. Harris, FCS, MMED, > Cardiothoracic Surgeon > Suite A2 > Tygerberg Hospital, 7505 > Cape Town, South Africa. > Tel +27-21-9762347 > Fax +27-21-9761157 Mobile +27-83-3309587 > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l 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 listdisclaim> > ----------------------------------------- > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From donross at bigpond.com Thu Mar 1 17:08:59 2007 From: donross at bigpond.com (Donald Ross) Date: Thu Mar 1 01:09:28 2007 Subject: [HSF] Tricuspid repair w/pulmonary hypertension In-Reply-To: <002801c75bb8$b52947c0$6601a8c0@JGAMMIEHOMEXP> References: <414479.5003.qm@web26714.mail.ukl.yahoo.com> <8C929CDC83E218A-17F4-2C51@mblk-r41.sysops.aol.com> <002801c75bb8$b52947c0$6601a8c0@JGAMMIEHOMEXP> Message-ID: <9049D603-1242-4DDE-AC71-2E3E4BD18945@bigpond.com> I think TR in this setting is a symptom of an inoperable disease and repair only hastens inevitable demise. I speak from bitter experience by the way! Don On 01/03/2007, at 3:18 PM, James S Gammie wrote: > HSF: > elderly male 3vCAD, ef 50 %, severe mr (type I-dilated annulus), > severe TR, PA pressures systolic 90. > > operation: > CABGx4, 28 physio for mitral, 26 mc3 for tricuspid; > > postpump tee: no mr, no tr, good lv function. RV sick; unable to > wean cpb despite usual measures: RVAD outcome uncertain. > > Qs: any reservations about correcting TR in face of near systemic > pulm htn? > any role for assessing "reversibility" of pulmonary vascular > resistance, like we do in transplant? > what is forum's experience with outcomes for mv/tv ops in > patients with similar PA pressures? Literature suggests up front > mort of 10-15 percent but fairly old experience... > > jsg > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From donross at bigpond.com Thu Mar 1 17:16:58 2007 From: donross at bigpond.com (Donald Ross) Date: Thu Mar 1 01:18:32 2007 Subject: [HSF] On pump beating heart In-Reply-To: <8C929CDC83E218A-17F4-2C51@mblk-r41.sysops.aol.com> References: <414479.5003.qm@web26714.mail.ukl.yahoo.com> <8C929CDC83E218A-17F4-2C51@mblk-r41.sysops.aol.com> Message-ID: Jees, Hal, how do you define a down and dirty opcab? BTW all these down and dirty opcabs get an ICD and an LV lead. Don On 01/03/2007, at 3:04 PM, hgrmd@aol.com wrote: > Damn right, Ani!! You are absolutely right. In my experience, it > is uncommon for a patient with an EF of 20% to not have at least > moderate MR. Unless the patient has a hostile aorta, that should > be fixed. Don't forget to repair LV aneurysms. Finally, add > permanent epicardial LV leads for eventual bi-v ICD. A "down and > dirty" OPCAB in this scenario is definitely undertreating the > patient in most instances. > Hal > > -----Original Message----- > From: anianyanwu@hotmail.com > To: OpenHeart-L@lists.hsforum.com > Sent: Wed, 28 Feb 2007 9:59 PM > Subject: Re: [HSF] On pump beating heart > > > One problem I see with advocating aggressive regimes for > accomplishing Off-pump > revascularization in the sick ventricle with low EF is that it > diverts this away > from surgery for heart failure (which it is) to surgery for angina > or MI > prophylaxis (which it isn't). > > The drive to do OPCAB in these patients results in a new group of > under-treated > heart failure patients. The treatment of these patients is often > multimodal and > not infrequently should include mitral valve repair and sometimes > LV remodeling > or tricuspid valve repair even. By pursuing OPCAB with zeal in this > group I > suspect some surgeons are under-treating the associated lesions. As > a transplant > surgeon, I see patients now and then who have had CABG (on or off) > and had the > mitral neglected and progressed in heart failure, with essentially > a wasted > operation. My view is if a patient needs an IABP overnight to > accomplish an > OPCAB then he is probably having the wrong operation. > > Ani > ----- Original Message ----- > From: David Harris > To: OpenHeart-L@lists.hsforum.com L@lists.hsforum.com> > Sent: Wednesday, February 28, 2007 3:56 PM > Subject: Re: [HSF] On pump beating heart > > > I agree with pre-op balloon in all these patients with > EF around 20. I think you have only one chance with > these patients. Then you can see if you can do them > off pump, and if not, do them beating on pump. The > timing of the balloon is important, they need at least > overnight, but no longer. Some low dose dobutamine > also helps, and by the time the operation time comes > around, the heart has decreased in size. Another > choice for all left side vessels is to do it all > through a thoracotomy, so you need not displace the > heart and cause hemodynamic chaos. Proximal grafts > onto the left subclavian can also classify this as an > `anaortic` CABG > > > --- Donald Ross > > wrote: > >> Ben, >> Can't agree; if that was the case the problem would >> come on earlier. >> The lad grafts take ~ 5min including placement of >> shunt. Check out >> the "real time lima to LAD "at "movies " at >> beating-heart.com hardly long enough to bother a >> myocyte. Can't do >> much about the anaesthetic unless you practice in >> India where >> epidurals suffice. >> I think the diastolic augmentation of the balloon >> helps to belt >> blood down spasmy imas. >> Don >> On 28/02/2007, at 7:21 PM, Ben Bidstrup wrote: >> >>> I think it is more than that. In poor LVs even a >> small amount of >>> depression by transient ischaemia to the LAD >> despite shunts can >>> lead to the need for more support. There is likely >> to be some >>> oedema after revascularisation, and the impact of >> anaesthesia needs >>> consideration also. >>> >>> >>>> Prasanna, >>>> I did talk to Dr Bhattacharya at the meeting in >> Mumbai, I now know >>>> since my registrar confirmed his distinguished >> appearance. >>>> He must be slick to use the RIMA exclusively for >> his T graft . >>>> He did, however mention that he uses the balloon >> for sick hearts >>>> which perhaps is the reason for his 100% record. >>>> Now that I am reminded of this I will do the same >> for my next <20% >>>> EF patient since the last two done bh on pump >> needed post op >>>> balloons... not immediately but after a few >> hours. I suspect the >>>> reason relates to transient ima hypoperfusion >> which intolerant >>>> of the low mean pressure of some low EF hearts. >>>> Don >>>> On 27/02/2007, at 11:49 PM, prasannasimha wrote: >>>> >>>>> He practices in Mumbai.(He visits multiple >> hospitals including >>>>> Breach Candy hospital etc) >>>>> Prasanna >>>>> Donald Ross wrote: >>>>>> Prasanna, >>>>>> Who publishes series of individual cases no >> matter how pretty >>>>>> the clinical results? >>>>>> Even if they are put into print many wont >> believe them ( Hal et >>>>>> al ) or take any notice unless there has been >> some some attempt >>>>>> at science, some hypothesis formulated , some >> conclusion to be >>>>>> elucidated. >>>>>> This wonderful surgeon/orchestral conductor >> can't publish his >>>>>> beautiful playing. >>>>>> All one can do is to take your advice and visit >> the man. >>>>>> So, where does he work? >>>>>> Don >>>>>> PS I thought he used a balloon instead of >> bypass in crook cases >>>>>> which I believe is probably more morbid than >> cpb. >>>>>> >>>>>> On 27/02/2007, at 10:45 PM, prasannasimha >> wrote: >>>>>> >>>>>>> The worst possible scenario is a person >> wanting to complete a >>>>>>> 100 % OPCAB experience in time for a >> conference etc and >>>>>>> refusing to go on pump or at least institute >> an IABP while the >>>>>>> heart is demanding it !!. Saying this, in >> isolated CABG's not >>>>>>> in cardiogenic shock, inability to displace >> the heart during >>>>>>> OPCAB is more often an expression of failure >> of the surgeon - >>>>>>> anesthesiologist team to understand what is >> going on. >>>>>>> You should see Dr Bhattacharya doing a >> multivessel total >>>>>>> arterial revascularization on a 10 - 15 % EF >> heart being done >>>>>>> effortlessly to believe it. He has probably >> the worlds largest >>>>>>> "individual surgeon" series of OPCAB's and >> unfortunately the >>>>>>> blessed man doesn't publish. Watching him do >> an OPCAB is like >>>>>>> seeing an orchestra play. >>>>>>> Prasanna >>>>>>> >>>>>>> Ani Anyanwu wrote: >>>>>>>> Off-pump surgery is sometimes also a crime >> against the human - >>>>>>>> I have seen several cases where the heart, or >> the entire >>>>>>>> patient, has suffered because of reluctance >> and refusal of the >>>>>>>> surgeon to accept conversion to CPB. It cuts >> both ways (some >>>>>>>> patients also suffer by having on-pump CABG). >> We should not be >>>>>>>> evangelists for a technique but for the >> patient. The patient >>>>>>>> couldn't care less whether we used CPB or not >> - all they want >>>>>>>> is a lasting operation at low risk so our >> primary aim should >>>>>>>> be to deliver this goal. >>>>>>>> >>>>>>>> Ani >>>>>>>> ----- Original Message ----- From: >>>>>>>> NielsB@aol.com>>>>>>> to:NielsB@aol.com>> > To: >> OpenHeart- >>>>>>>> >> > L@lists.hsforum.com L@lists.hsforum.com L@lists.hsforum.com>> >> >>>>>>>> Sent: Tuesday, February 27, 2007 3:09 AM >>>>>>>> Subject: Re: [HSF] On pump beating heart >>>>>>>> >>>>>>>> >>>>>>>> Who said it is?. It is not a crime against >> humanity but in >>>>>>>> some cases it is a crime against a human. >> The heart lung >>>>>>>> machine is a tool among many others, very >> frequently a very >>>>>>>> important one. But it is not some holy grail >> either. We use >>>>>>>> it when we need it, for CABG this is not so >> common, then the >>>>>>>> stabilizer is a better tool in my humble >> opinion. >>>>>>>> >>>>>>>> >>>>>>>> Jacob Bergsland >>>>>>>> >>>>>>>> >>>>>>>> ************************************** >>>>>>>> AOL now offers free email to everyone. >> Find out more >>>>>>>> about what's free from AOL at >> http://www.aol.com >>>>>>>> www.aol.com/>. >>>>>>>> >> _______________________________________________ >>>>>>>> OpenHeart-L mailing list >>>>>>>> >>>>>>>> Send postings to: >>>>>>>> >> OpenHeart-L@lists.hsforum.com> L@lists.hsforum.com- > >>>>>>>> L@lists.hsforum.com> >>>>>>>> >>>>>>>> To UNSUBSCRIBE, to CHANGE email address, or >> to view archives: >>>>>>>> >> > http://mmp.cjp.com/mailman/listinfo/openheart-l mmp.cjp.com/mailman/listinfo/openheart-l >> >>>>>>>> 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 >> >>>>>>>> listdisclaim> >>>>>>>> ----------------------------------------- >>>>>>>> >> _______________________________________________ >>>>>>>> OpenHeart-L mailing list >>>>>>>> >>>>>>>> Send postings to: >>>>>>>> OpenHeart-L@lists.hsforum.com>>>>>>> L@lists.hsforum.com> >>>>>>>> >>>>>>>> To UNSUBSCRIBE, to CHANGE email address, or >> to view archives: >>>>>>>> >> http://mmp.cjp.com/mailman/listinfo/openheart-l> 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>>>>>>> listdisclaim> >> > === message truncated === > > > Dr. David G. Harris, FCS, MMED, > Cardiothoracic Surgeon > Suite A2 > Tygerberg Hospital, 7505 > Cape Town, South Africa. > Tel +27-21-9762347 > Fax +27-21-9761157 Mobile +27-83-3309587 > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l 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 listdisclaim> > ----------------------------------------- > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > ______________________________________________________________________ > __ > AOL now offers free email to everyone. Find out more about what's > free from AOL at AOL.com. > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From hgrmd at aol.com Thu Mar 1 01:20:25 2007 From: hgrmd at aol.com (hgrmd@aol.com) Date: Thu Mar 1 01:20:58 2007 Subject: [HSF] On pump beating heart In-Reply-To: <188785.55049.qm@web81614.mail.mud.yahoo.com> References: <188785.55049.qm@web81614.mail.mud.yahoo.com> Message-ID: <8C929E0D5B28467-724-3221@MBLK-M06.sysops.aol.com> Tea, You must have only been half listening during my talk on ischemic MR. Elefteriades used to write that those fancy Yale vein grafts alone were uniformly effective in resolving significant preop ischemic MR. Though I haven't seen it in print, I did notice that he was recently a pro debater for repairing ischemic MR at the time of surgery. The spotty results seen with ischemic MR repair are more historic in my view and personal experience. I've implanted over 200 ETlogix rings the past 3 years with only one reop. Though the data isn't completely worked up, I believe the results are quite acceptable. You can go on and think that you're doing a great job just revascularizing a sick ventricle, off pump, while ignoring significant MR. I do believe that your views on this subject are, thankfully, becoming the minority. Do OPCAB when CABG alone is indicated. Learn to recognize that the majority of bad LV's from ischemia have clinically significant MR that will not resolve with CABG alone. Hal -----Original Message----- From: tacuff@swbell.net To: OpenHeart-L@lists.hsforum.com Sent: Wed, 28 Feb 2007 11:13 PM Subject: Re: [HSF] On pump beating heart Interesting argument here, too. I think it is pretty hard to blame the OPCABers for poor treatment for ischemic related CHF. We were pretty bad at it long before off pump was a baby. You even are following the old, and incorrect dictums, concerning the role of revascularization for CHF. CHF, at least in the states, is mostly ischemic disease. Many patients will get better with revascularization alone, if properly evaluated. I do agree with your point that we do a very poor job of evaluating these patients, however. You point dismissing CABG is likely wrong and lacking in self awareness if you think that many of the poor ventricles that had CABG and mitral repairs don't also come back with worse ventricles and recurrent MR a couple of years later. You are again right in that CHF is complex disease and requires many considerations leaving some patients with good options and others with none. As a young pup who may have always been at the source of knowledge, I would encourage you to reflect upon and, if you get chance, be that laggard, the local MD , to see what you would do with a different set of resources. Logically the wrong diagnosis usually leads to the wrong operation. You are suggesting that our technical limitation of operations is leading to poor treatment. This is a more complex interaction, but it is my impression that (based on the surgical options you listed) our problems are more related to the former problem (complete diagnosis of pathophysiology) and lack of seeing the benefit of other techniques than our fixation of technique that is lacking. Surely habit makes your argument important, however. I think that you are barking up the wrong tree, but agree with the barking. Incidentally, I find the IABP for OPCAB almost always unnecessary (and much less necessary than any arrest technique) , and perhaps logically the wrong support for the dilated heart, but as you see it has a strong contingent. I find it quite unproductive to do other than point to other contrary experiences. Yours, tea ----- Original Message ---- From: Ani Anyanwu To: OpenHeart-L@lists.hsforum.com Sent: Wednesday, February 28, 2007 8:59:57 PM Subject: Re: [HSF] On pump beating heart One problem I see with advocating aggressive regimes for accomplishing Off-pump revascularization in the sick ventricle with low EF is that it diverts this away from surgery for heart failure (which it is) to surgery for angina or MI prophylaxis (which it isn't). The drive to do OPCAB in these patients results in a new group of under-treated heart failure patients. The treatment of these patients is often multimodal and not infrequently should include mitral valve repair and sometimes LV remodeling or tricuspid valve repair even. By pursuing OPCAB with zeal in this group I suspect some surgeons are under-treating the associated lesions. As a transplant surgeon, I see patients now and then who have had CABG (on or off) and had the mitral neglected and progressed in heart failure, with essentially a wasted operation. My view is if a patient needs an IABP overnight to accomplish an OPCAB then he is probably having the wrong operation. Ani ----- Original Message ----- From: David Harris To: OpenHeart-L@lists.hsforum.com Sent: Wednesday, February 28, 2007 3:56 PM Subject: Re: [HSF] On pump beating heart I agree with pre-op balloon in all these patients with EF around 20. I think you have only one chance with these patients. Then you can see if you can do them off pump, and if not, do them beating on pump. The timing of the balloon is important, they need at least overnight, but no longer. Some low dose dobutamine also helps, and by the time the operation time comes around, the heart has decreased in size. Another choice for all left side vessels is to do it all through a thoracotomy, so you need not displace the heart and cause hemodynamic chaos. Proximal grafts onto the left subclavian can also classify this as an `anaortic` CABG --- Donald Ross > wrote: > Ben, > Can't agree; if that was the case the problem would > come on earlier. > The lad grafts take ~ 5min including placement of > shunt. Check out > the "real time lima to LAD "at "movies " at > beating-heart.com hardly long enough to bother a > myocyte. Can't do > much about the anaesthetic unless you practice in > India where > epidurals suffice. > I think the diastolic augmentation of the balloon > helps to belt > blood down spasmy imas. > Don > On 28/02/2007, at 7:21 PM, Ben Bidstrup wrote: > > > I think it is more than that. In poor LVs even a > small amount of > > depression by transient ischaemia to the LAD > despite shunts can > > lead to the need for more support. There is likely > to be some > > oedema after revascularisation, and the impact of > anaesthesia needs > > consideration also. > > > > > >> Prasanna, > >> I did talk to Dr Bhattacharya at the meeting in > Mumbai, I now know > >> since my registrar confirmed his distinguished > appearance. > >> He must be slick to use the RIMA exclusively for > his T graft . > >> He did, however mention that he uses the balloon > for sick hearts > >> which perhaps is the reason for his 100% record. > >> Now that I am reminded of this I will do the same > for my next <20% > >> EF patient since the last two done bh on pump > needed post op > >> balloons... not immediately but after a few > hours. I suspect the > >> reason relates to transient ima hypoperfusion > which intolerant > >> of the low mean pressure of some low EF hearts. > >> Don > >> On 27/02/2007, at 11:49 PM, prasannasimha wrote: > >> > >>> He practices in Mumbai.(He visits multiple > hospitals including > >>> Breach Candy hospital etc) > >>> Prasanna > >>> Donald Ross wrote: > >>>> Prasanna, > >>>> Who publishes series of individual cases no > matter how pretty > >>>> the clinical results? > >>>> Even if they are put into print many wont > believe them ( Hal et > >>>> al ) or take any notice unless there has been > some some attempt > >>>> at science, some hypothesis formulated , some > conclusion to be > >>>> elucidated. > >>>> This wonderful surgeon/orchestral conductor > can't publish his > >>>> beautiful playing. > >>>> All one can do is to take your advice and visit > the man. > >>>> So, where does he work? > >>>> Don > >>>> PS I thought he used a balloon instead of > bypass in crook cases > >>>> which I believe is probably more morbid than > cpb. > >>>> > >>>> On 27/02/2007, at 10:45 PM, prasannasimha > wrote: > >>>> > >>>>> The worst possible scenario is a person > wanting to complete a > >>>>> 100 % OPCAB experience in time for a > conference etc and > >>>>> refusing to go on pump or at least institute > an IABP while the > >>>>> heart is demanding it !!. Saying this, in > isolated CABG's not > >>>>> in cardiogenic shock, inability to displace > the heart during > >>>>> OPCAB is more often an expression of failure > of the surgeon - > >>>>> anesthesiologist team to understand what is > going on. > >>>>> You should see Dr Bhattacharya doing a > multivessel total > >>>>> arterial revascularization on a 10 - 15 % EF > heart being done > >>>>> effortlessly to believe it. He has probably > the worlds largest > >>>>> "individual surgeon" series of OPCAB's and > unfortunately the > >>>>> blessed man doesn't publish. Watching him do > an OPCAB is like > >>>>> seeing an orchestra play. > >>>>> Prasanna > >>>>> > >>>>> Ani Anyanwu wrote: > >>>>>> Off-pump surgery is sometimes also a crime > against the human - > >>>>>> I have seen several cases where the heart, or > the entire > >>>>>> patient, has suffered because of reluctance > and refusal of the > >>>>>> surgeon to accept conversion to CPB. It cuts > both ways (some > >>>>>> patients also suffer by having on-pump CABG). > We should not be > >>>>>> evangelists for a technique but for the > patient. The patient > >>>>>> couldn't care less whether we used CPB or not > - all they want > >>>>>> is a lasting operation at low risk so our > primary aim should > >>>>>> be to deliver this goal. > >>>>>> > >>>>>> Ani > >>>>>> ----- Original Message ----- From: > >>>>>> NielsB@aol.com> To: > OpenHeart- > >>>>>> > L@lists.hsforum.com> > > >>>>>> Sent: Tuesday, February 27, 2007 3:09 AM > >>>>>> Subject: Re: [HSF] On pump beating heart > >>>>>> > >>>>>> > >>>>>> Who said it is?. It is not a crime against > humanity but in > >>>>>> some cases it is a crime against a human. > The heart lung > >>>>>> machine is a tool among many others, very > frequently a very > >>>>>> important one. But it is not some holy grail > either. We use > >>>>>> it when we need it, for CABG this is not so > common, then the > >>>>>> stabilizer is a better tool in my humble > opinion. > >>>>>> > >>>>>> > >>>>>> Jacob Bergsland > >>>>>> > >>>>>> > >>>>>> ************************************** > >>>>>> AOL now offers free email to everyone. > Find out more > >>>>>> about what's free from AOL at > http://www.aol.com > >>>>>> www.aol.com/>. > >>>>>> > _______________________________________________ > >>>>>> OpenHeart-L mailing list > >>>>>> > >>>>>> Send postings to: > >>>>>> > OpenHeart-L@lists.hsforum.com- > >>>>>> L@lists.hsforum.com> > >>>>>> > >>>>>> To UNSUBSCRIBE, to CHANGE email address, or > to view archives: > >>>>>> > http://mmp.cjp.com/mailman/listinfo/openheart-l > > >>>>>> 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 > > >>>>>> listdisclaim> > >>>>>> ----------------------------------------- > >>>>>> > _______________________________________________ > >>>>>> OpenHeart-L mailing list > >>>>>> > >>>>>> Send postings to: > >>>>>> OpenHeart-L@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 > === message truncated === Dr. David G. Harris, FCS, MMED, Cardiothoracic Surgeon Suite A2 Tygerberg Hospital, 7505 Cape Town, South Africa. Tel +27-21-9762347 Fax +27-21-9761157 Mobile +27-83-3309587 _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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@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@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 ----------------------------------------- ________________________________________________________________________ AOL now offers free email to everyone. Find out more about what's free from AOL at AOL.com. From hgrmd at aol.com Thu Mar 1 01:25:06 2007 From: hgrmd at aol.com (hgrmd@aol.com) Date: Thu Mar 1 01:25:41 2007 Subject: [HSF] Tricuspid repair w/pulmonary hypertension In-Reply-To: <002801c75bb8$b52947c0$6601a8c0@JGAMMIEHOMEXP> References: <414479.5003.qm@web26714.mail.ukl.yahoo.com> <8C929CDC83E218A-17F4-2C51@mblk-r41.sysops.aol.com> <002801c75bb8$b52947c0$6601a8c0@JGAMMIEHOMEXP> Message-ID: <8C929E17CD8C9CF-724-322E@MBLK-M06.sysops.aol.com> Jim, Tough case. The cardiologists generally give NTG during the right heart cath to see if the PA HTN is reversible. I've done lots of cases like you describe. Some of them don't do well. I assume you have or will try milrinone, nitric oxide, prostaglandins, or Viagra. Hal -----Original Message----- From: gammie@comcast.net To: OpenHeart-L@lists.hsforum.com Sent: Wed, 28 Feb 2007 11:18 PM Subject: [HSF] Tricuspid repair w/pulmonary hypertension HSF: elderly male 3vCAD, ef 50 %, severe mr (type I-dilated annulus), severe TR, PA pressures systolic 90. operation: CABGx4, 28 physio for mitral, 26 mc3 for tricuspid; postpump tee: no mr, no tr, good lv function. RV sick; unable to wean cpb despite usual measures: RVAD outcome uncertain. Qs: any reservations about correcting TR in face of near systemic pulm htn? any role for assessing "reversibility" of pulmonary vascular resistance, like we do in transplant? what is forum's experience with outcomes for mv/tv ops in patients with similar PA pressures? Literature suggests up front mort of 10-15 percent but fairly old experience... jsg _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- ________________________________________________________________________ AOL now offers free email to everyone. Find out more about what's free from AOL at AOL.com. From hgrmd at aol.com Thu Mar 1 01:27:14 2007 From: hgrmd at aol.com (hgrmd@aol.com) Date: Thu Mar 1 01:27:49 2007 Subject: [HSF] On pump beating heart {OT} In-Reply-To: <78F38C5F-68F5-42D2-9DE7-CFD233B6C13A@bigpond.com> References: <8C928EA3F703A1E-1724-80AC@MBLK-M22.sysops.aol.com> <7D3C5DEA-8356-43AE-97A0-019A26D51B77@bigpond.com> <8C9298B1915F9D3-1E4-1B5B@webmail-md12.sysops.aol.com> <78F38C5F-68F5-42D2-9DE7-CFD233B6C13A@bigpond.com> Message-ID: <8C929E1C925EC25-724-3235@MBLK-M06.sysops.aol.com> Don, That's a deal. Don't worry, my performance tastes are generally baroque, classical, and romantic. Hal -----Original Message----- From: donross@bigpond.com To: OpenHeart-L@lists.hsforum.com Sent: Thu, 1 Mar 2007 12:20 AM Subject: Re: [HSF] On pump beating heart {OT} Hal, I think Oz could accommodate you...just. I know bugger all about rock music but I am sure my daughter could find somewhere to get your ears ringing again. My piano need a work out so you would have to stay with us in Sydney. Don On 01/03/2007, at 7:06 AM, hgrmd@aol.com wrote: > Don, > When I finally make to Oz, I want to see Bon Scott's resting > place. I recently saw an old video of a live performance with him > fronting AC/DC. I love that band. About 4 years ago, I saw them > 3rd row center. Even wearing earplugs, my ears rang for about a > day afterwards. > Hal > > -----Original Message----- > From: donross@bigpond.com > To: OpenHeart-L@lists.hsforum.com > Sent: Wed, 28 Feb 2007 4:07 AM > Subject: Re: [HSF] On pump beating heart > > > For the rest of the forum, Billy T was an old Oz rocker who just > died from a large infarct. > Ben, It was George G. > Don > On 28/02/2007, at 7:17 PM, Ben Bidstrup wrote: > >> Glad it wasn't Billy T >> >> >>>> Though Don Ross does them by using his long shunts, he is in a >>>> >>> tiny minority. Perhaps the naysayers of endarterectomy who >>>> are >>> 100% OPCAB'ers would rethink their position if they >>>> tried it on >>> pump. Believe me, it works well. >>> They sure do. >>> When I was a young fella I did three long endos on an >> >>> "inoperable" Jazz guitarist. 25 years on he is still playing and >>> >> angina free despite his vile vein grafts. >>> Don >>>> >>>> Thanks Hal. >>>> >>>> Yes, I do endarterectomy, and I will not do this off >>>> pump. We only get the occasional patient who needs it. >>>> I have thought of taking out stents but have not been >>>> brave enough! We sometimes get those calcific horrors >>>> where there is no place to open the vessel. The last >>>> one needed 2 `traditional` long incision >>>> endarterectomies, with long patch anastomoses. >>>> >>>> Us `opcabbers` get enthusiastic when we can safely do >>>> a full revascularisation the same way we would do it >>>> on pump, we enjoy the operation more so approaching >>>> 100% makes us feel better! We still know it is better >>>> for the patient, even if marginally. But would not >>>> hesitate to go on, and not hesitate to decide go on >>>> pump pre-op if we think it safer. Just like you, I am >>>> sure, would like to repair 100% of the valves you >>>> tackle, but also would not spend too much time mucking >>>> about when it becomes clear that the valve should >>>> rather be cut out and replaced. >>>> Dave >>>> --- hgrmd@aol.com wrote: >>>> >>>>> Dave, >>>>> Thanks for the clarification. Just make sure that >>>>> you aren't finessing too vessels just so you can do >>>>> the case off pump. Like Mark, I believe extensive >>>>> endarterectomies should have a definite place in >>>>> your quiver as we continue to get patients with more >>>>> diffuse disease. Anyway, good luck with your policy >>>>> and let us know how it goes. >>>>> Hal >>>>> >>>>> -----Original Message----- >>>>> From: drdharris@yahoo.co.uk >>>>> To: OpenHeart-L@lists.hsforum.com >>>>> Sent: Mon, 26 Feb 2007 3:51 PM >>>>> Subject: Re: [HSF] On pump beating heart >>>>> >>>>> >>>>> HA HA, I knew I would get you guys going! What I >>>>> meant >>>>> was I RECENTLY started to do 100% off pump! That was >>>>> the last 20 consecutive cases! Have not hit any >>>>> rough >>>>> ones since then! I`ll keep you posted! >>>>> >>>>> Seriously though, of course I agree there are >>>>> `IMPOSSIBLE` cases! And these are probably done best >>>>> beating on the pump. But I still am convinced the >>>>> results will be better if you do 90% off pump, which >>>>> I >>>>> will generally aim for....however after recently see >>>>> patients trash their legs and their bowel after >>>>> being >>>>> on the pump I vowed I`ll try to do 100% off! >>>>> >>>>> >>>>> --- hgrmd@aol.com wrote: >>>>> >>>>>> Tea, >>>>>> Coming from a guy who does a very high >>>>> percentage >>>>>> of cases off pump, your comment about 100% >>>>> OPCAB'ers >>>>>> is well taken. Having been an avid follower of >>>>> HSF >>>>>> for a few years, I've definitely seen my share of >>>>>> breathless hyperbole (and no, I don't believe I've >>>>>> been a part of it). >>>>>> Hal >>>>>> >>>>>> -----Original Message----- >>>>>> From: tacuff@swbell.net >>>>>> To: OpenHeart-L@lists.hsforum.com >>>>>> Sent: Sun, 25 Feb 2007 10:33 PM >>>>>> Subject: Re: [HSF] On pump beating heart >>>>>> >>>>>> >>>>>> I would put froth coming out of the ET under the >>>>>> category of "potential >>>>>> problem". In reference to Chand's earlier patient >>>>>> with portal venous air, froth >>>>>> in the ET would also qualify as "unstable" even if >>>>>> the BP was 100 on pressors. >>>>>> One might not have to go on CPB, but it should be >>>>> a >>>>>> consideration and available. >>>>>> It would be hard to object in retrospect to CPB >>>>> even >>>>>> if you go below 100% on >>>>>> this one. >>>>>> >>>>>> I actually looked up my rate for 2004 and 2005 for >>>>>> "CABG with no CPB" at my >>>>>> primary hospital. The trend of cases is down and >>>>> the >>>>>> trend of "CAB and valve or >>>>>> other" is up. In two years I did 3 cases of CAB >>>>>> alone with CPB (including >>>>>> redo's) in 150 cases. This is a 98% rate, I think. >>>>>> Next year could be 90% or >>>>>> 100%, but it won't be 10% or 50%. >>>>>> >>>>>> Here is what I hear when surgeons tell me their >>>>> rate >>>>>> of off pump surgery. >>>>>> Although the most common thing they now say is >>>>> that >>>>>> they stopped or it is >>>>>> rountine. It is just a guess, as always I could be >>>>>> wrong, but when I check a >>>>>> reference that visits the surgeon or see what they >>>>>> do year after year I think I >>>>>> may be more right than not: >>>>>> I tried a few but wasn't comfortable.=we had some >>>>>> bad results in the first ten >>>>>> (I mean another surgeon obviously) so I stopped. >>>>>> I do 10-20%=I tried it once or twice but didn't >>>>> like >>>>>> it. I might try it again if >>>>>> I have too. >>>>>> I do 30-40%. =I do half of my single and double >>>>>> bypasses. >>>>>> I do 50%.= I almost always do single and double >>>>>> bypasses and some easy PL or >>>>>> PDAs. >>>>>> I do all of mine OPCAB.= I try do do most of mine >>>>>> off pump (work in progress) or >>>>>> perhaps it is actually my rountine. >>>>>> I do 100% off pump.= Either I am FOS or I forgot >>>>>> about the couple of problem >>>>>> patients last year. If he writes a lot of papers >>>>> it >>>>>> is even money the former. >>>>>> >>>>>> I have no one in mind when I wrote this. Promise. >>>>>> Almost. >>>>>> tea >>>>>> >>>>>> >>>>>> ----- Original Message ---- >>>>>> From: David Harris >>>>>> To: OpenHeart-L@lists.hsforum.com >>>>>> Sent: Sunday, February 25, 2007 5:08:30 PM >>>>>> Subject: Re: [HSF] On pump beating heart >>>>>> >>>>>> >>>>>> I can`t remember when I last saw a patient in >>>>>> cardiogenic shock referred for surgery....we have >>>>>> excellent cardiologists who intervene >>>>>> percutaneously, >>>>>> and they do`nt turf the patient to us if half the >>>>>> ventricle has been wiped out already. >>>>>> >>>>>> --- hgrmd@aol.com wrote: >>>>>> >>>>>>> When my group does OPCAB, they don't prime the >>>>>> pump, >>>>>>> either. However, they do have a perfusionist >>>>> and >>>>>> a >>>>>>> pump in the room ready to go if the need arises. >>>>> >>>>>>> One hundred per cent OPCAB? You apparently >>>>> don't >>>>>>> offer surgery to patients in cardiogenic shock >>>>> and >>>>>>> froth coming out the ET tube. I have and do. >>>>>>> However, no way would I consider doing that type >>>>>> of >>>>>>> patient off pump. >>>>>>> >>>>>>> Hal >>>>>>> >>>>>>> >>>>>>> -----Original Message----- >>>>>>> From: drdharris@yahoo.co.uk >>>>>>> To: OpenHeart-L@lists.hsforum.com >>>>>>> Sent: Wed, 21 Feb 2007 4:48 PM >>>>>>> Subject: Re: [HSF] On pump beating heart >>>>>>> >>>>>>> >>>>>>> I agree fully with Tea: there is no need to have >>>>>> the >>>>>>> pump primed for an OPCAB, unless it is a >>>>> potential >>>>>>> problem. Similarly, with increased experience, >>>>> the >>>>>>> cardiologists never ask for standby for PTCA. >>>>>> Those >>>>>>> nasty earlier conversions were during the >>>>> learning >>>>>>> curve, when we did not know the limits. We know >>>>>>> where >>>>>>> the limits are now, and it will be safe: limited >>>>>>> traction for first graft (LAD), with a few >>>>> sutures >>>>>>> just above phrenic nerve, use of shunts always, >>>>>> not >>>>>>> accepting any extrasystole, (and sorting out >>>>> what >>>>>> is >>>>>>> causing them immediately), careful manipulation >>>>>> for >>>>>>> last grafts by verticalisation only, and not >>>>>>> accepting >>>>>>> ANY hypotension before carrying on. >>>>>>> I have recently changed to 100% OPCAB, and you >>>>> can >>>>>>> immediately see the difference, and the major >>>>>>> difference is seen not only in hospital, but >>>>>> during >>>>>>> the first 3 months. >>>>>>> >>>>>>> >>>>>>> --- hgrmd@aol.com wrote: >>>>>>> >>>>>>>> Tea, >>>>>>>> Knowing you as I do, I've no doubt that you >>>>>>> speak >>>>>>>> the truth about your OPCAB experience (For >>>>> once, >>>>>>> I'm >>>>> >>>> === message truncated === >>>> >>>> >>>> Dr. David G. Harris, FCS, MMED, >>>> Cardiothoracic Surgeon >>>> Suite A2 >>>> Tygerberg Hospital, 7505 >>>> Cape Town, South Africa. >>>> Tel +27-21-9762347 >>>> Fax +27-21-9761157 Mobile +27-83-3309587 >>>> _______________________________________________ >>>> OpenHeart-L mailing list >>>> >>>> Send postings to: >>>> OpenHeart-L@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@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@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 anddisclaimers posted at: >>> http://www.hsforum.com/listdisclaim >>> ----------------------------------------- >> >> >> --> Ben Bidstrup FRACS FRCSEd FEBCTS >> Consultant Cardiothoracic Surgeon >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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@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 anddisclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > ______________________________________________________________________> __ > AOL now offers free email to everyone. Find out more about what's > free from AOL at AOL.com. > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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 anddisclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- ________________________________________________________________________ AOL now offers free email to everyone. Find out more about what's free from AOL at AOL.com. From enaseri at hotmail.com.tr Thu Mar 1 11:04:30 2007 From: enaseri at hotmail.com.tr (=?iso-8859-9?B?ZXJkaW7nIG5hc2VyaQ==?=) Date: Thu Mar 1 06:05:22 2007 Subject: [HSF] Tricuspid repair w/pulmonary hypertension In-Reply-To: <9049D603-1242-4DDE-AC71-2E3E4BD18945@bigpond.com> Message-ID: completely agree with Don.TR + PAP 90 mmhg in CAD is an absolute contraindication for CABG.It will not improve survival and QOL and it will risk the patient for a high operative mortality. erdinc >From: Donald Ross >Reply-To: OpenHeart-L@lists.hsforum.com >To: OpenHeart-L@lists.hsforum.com >Subject: Re: [HSF] Tricuspid repair w/pulmonary hypertension >Date: Thu, 1 Mar 2007 17:08:59 +1100 > >I think TR in this setting is a symptom of an inoperable disease and >repair only hastens inevitable demise. >I speak from bitter experience by the way! >Don >On 01/03/2007, at 3:18 PM, James S Gammie wrote: > >>HSF: >>elderly male 3vCAD, ef 50 %, severe mr (type I-dilated annulus), severe >>TR, PA pressures systolic 90. >> >>operation: >>CABGx4, 28 physio for mitral, 26 mc3 for tricuspid; >> >>postpump tee: no mr, no tr, good lv function. RV sick; unable to wean >>cpb despite usual measures: RVAD outcome uncertain. >> >>Qs: any reservations about correcting TR in face of near systemic pulm >>htn? >> any role for assessing "reversibility" of pulmonary vascular >>resistance, like we do in transplant? >> what is forum's experience with outcomes for mv/tv ops in >>patients with similar PA pressures? Literature suggests up front mort of >>10-15 percent but fairly old experience... >> >>jsg >> >>_______________________________________________ >>OpenHeart-L mailing list >> >>Send postings to: >>OpenHeart-L@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@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 >----------------------------------------- From anianyanwu at hotmail.com Thu Mar 1 06:42:17 2007 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Thu Mar 1 06:42:54 2007 Subject: [HSF] On pump beating heart References: <414479.5003.qm@web26714.mail.ukl.yahoo.com> <6CFCFE6D-6640-4243-9723-22C800925D01@bigpond.com> Message-ID: Actually I did look at the thread - "On-pump beating heart" it did not say "off-pump" - somewhere however the thread dot derailed by the OPCAB movement to discuss OPCAB in the poor LV! On-pump beating heart is indeed a modality for treating the poor LV and also lends itself to adjunctive procedures, as a Dor, mitral and trcuspid could also be done this way. Ani ----- Original Message ----- From: Donald Ross To: OpenHeart-L@lists.hsforum.com Sent: Thursday, March 01, 2007 12:53 AM Subject: Re: [HSF] On pump beating heart Hey, Ani , look at the thread: "On pump beating heart" If there is an aneurysm or localised dead heart or MR opcabers quickly become oncabers. Don On 01/03/2007, at 1:59 PM, Ani Anyanwu wrote: > One problem I see with advocating aggressive regimes for > accomplishing Off-pump revascularization in the sick ventricle with > low EF is that it diverts this away from surgery for heart failure > (which it is) to surgery for angina or MI prophylaxis (which it > isn't). > > The drive to do OPCAB in these patients results in a new group of > under-treated heart failure patients. The treatment of these > patients is often multimodal and not infrequently should include > mitral valve repair and sometimes LV remodeling or tricuspid valve > repair even. By pursuing OPCAB with zeal in this group I suspect > some surgeons are under-treating the associated lesions. As a > transplant surgeon, I see patients now and then who have had CABG > (on or off) and had the mitral neglected and progressed in heart > failure, with essentially a wasted operation. My view is if a > patient needs an IABP overnight to accomplish an OPCAB then he is > probably having the wrong operation. > > Ani > ----- Original Message ----- > From: David Harris> > To: OpenHeart-L@lists.hsforum.com- > L@lists.hsforum.com> > Sent: Wednesday, February 28, 2007 3:56 PM > Subject: Re: [HSF] On pump beating heart > > > I agree with pre-op balloon in all these patients with > EF around 20. I think you have only one chance with > these patients. Then you can see if you can do them > off pump, and if not, do them beating on pump. The > timing of the balloon is important, they need at least > overnight, but no longer. Some low dose dobutamine > also helps, and by the time the operation time comes > around, the heart has decreased in size. Another > choice for all left side vessels is to do it all > through a thoracotomy, so you need not displace the > heart and cause hemodynamic chaos. Proximal grafts > onto the left subclavian can also classify this as an > `anaortic` CABG > > > --- Donald Ross >> > wrote: > >> Ben, >> Can't agree; if that was the case the problem would >> come on earlier. >> The lad grafts take ~ 5min including placement of >> shunt. Check out >> the "real time lima to LAD "at "movies " at >> beating-heart.com hardly long enough to bother a >> myocyte. Can't do >> much about the anaesthetic unless you practice in >> India where >> epidurals suffice. >> I think the diastolic augmentation of the balloon >> helps to belt >> blood down spasmy imas. >> Don >> On 28/02/2007, at 7:21 PM, Ben Bidstrup wrote: >> >>> I think it is more than that. In poor LVs even a >> small amount of >>> depression by transient ischaemia to the LAD >> despite shunts can >>> lead to the need for more support. There is likely >> to be some >>> oedema after revascularisation, and the impact of >> anaesthesia needs >>> consideration also. >>> >>> >>>> Prasanna, >>>> I did talk to Dr Bhattacharya at the meeting in >> Mumbai, I now know >>>> since my registrar confirmed his distinguished >> appearance. >>>> He must be slick to use the RIMA exclusively for >> his T graft . >>>> He did, however mention that he uses the balloon >> for sick hearts >>>> which perhaps is the reason for his 100% record. >>>> Now that I am reminded of this I will do the same >> for my next <20% >>>> EF patient since the last two done bh on pump >> needed post op >>>> balloons... not immediately but after a few >> hours. I suspect the >>>> reason relates to transient ima hypoperfusion >> which intolerant >>>> of the low mean pressure of some low EF hearts. >>>> Don >>>> On 27/02/2007, at 11:49 PM, prasannasimha wrote: >>>> >>>>> He practices in Mumbai.(He visits multiple >> hospitals including >>>>> Breach Candy hospital etc) >>>>> Prasanna >>>>> Donald Ross wrote: >>>>>> Prasanna, >>>>>> Who publishes series of individual cases no >> matter how pretty >>>>>> the clinical results? >>>>>> Even if they are put into print many wont >> believe them ( Hal et >>>>>> al ) or take any notice unless there has been >> some some attempt >>>>>> at science, some hypothesis formulated , some >> conclusion to be >>>>>> elucidated. >>>>>> This wonderful surgeon/orchestral conductor >> can't publish his >>>>>> beautiful playing. >>>>>> All one can do is to take your advice and visit >> the man. >>>>>> So, where does he work? >>>>>> Don >>>>>> PS I thought he used a balloon instead of >> bypass in crook cases >>>>>> which I believe is probably more morbid than >> cpb. >>>>>> >>>>>> On 27/02/2007, at 10:45 PM, prasannasimha >> wrote: >>>>>> >>>>>>> The worst possible scenario is a person >> wanting to complete a >>>>>>> 100 % OPCAB experience in time for a >> conference etc and >>>>>>> refusing to go on pump or at least institute >> an IABP while the >>>>>>> heart is demanding it !!. Saying this, in >> isolated CABG's not >>>>>>> in cardiogenic shock, inability to displace >> the heart during >>>>>>> OPCAB is more often an expression of failure >> of the surgeon - >>>>>>> anesthesiologist team to understand what is >> going on. >>>>>>> You should see Dr Bhattacharya doing a >> multivessel total >>>>>>> arterial revascularization on a 10 - 15 % EF >> heart being done >>>>>>> effortlessly to believe it. He has probably >> the worlds largest >>>>>>> "individual surgeon" series of OPCAB's and >> unfortunately the >>>>>>> blessed man doesn't publish. Watching him do >> an OPCAB is like >>>>>>> seeing an orchestra play. >>>>>>> Prasanna >>>>>>> >>>>>>> Ani Anyanwu wrote: >>>>>>>> Off-pump surgery is sometimes also a crime >> against the human - >>>>>>>> I have seen several cases where the heart, or >> the entire >>>>>>>> patient, has suffered because of reluctance >> and refusal of the >>>>>>>> surgeon to accept conversion to CPB. It cuts >> both ways (some >>>>>>>> patients also suffer by having on-pump CABG). >> We should not be >>>>>>>> evangelists for a technique but for the >> patient. The patient >>>>>>>> couldn't care less whether we used CPB or not >> - all they want >>>>>>>> is a lasting operation at low risk so our >> primary aim should >>>>>>>> be to deliver this goal. >>>>>>>> >>>>>>>> Ani >>>>>>>> ----- Original Message ----- From: >>>>>>>> NielsB@aol.com >>>>>>>> to:NielsB@aol.com>> To: >> OpenHeart- >>>>>>>> >> > L@lists.hsforum.com- > L@lists.hsforum.com- > L@lists.hsforum.com>> >> >>>>>>>> Sent: Tuesday, February 27, 2007 3:09 AM >>>>>>>> Subject: Re: [HSF] On pump beating heart >>>>>>>> >>>>>>>> >>>>>>>> Who said it is?. It is not a crime against >> humanity but in >>>>>>>> some cases it is a crime against a human. >> The heart lung >>>>>>>> machine is a tool among many others, very >> frequently a very >>>>>>>> important one. But it is not some holy grail >> either. We use >>>>>>>> it when we need it, for CABG this is not so >> common, then the >>>>>>>> stabilizer is a better tool in my humble >> opinion. >>>>>>>> >>>>>>>> >>>>>>>> Jacob Bergsland >>>>>>>> >>>>>>>> >>>>>>>> ************************************** >>>>>>>> AOL now offers free email to everyone. >> Find out more >>>>>>>> about what's free from AOL at >> http://www.aol.com> >>>>>>>> www.aol.com/>>. >>>>>>>> >> _______________________________________________ >>>>>>>> OpenHeart-L mailing list >>>>>>>> >>>>>>>> Send postings to: >>>>>>>> >> OpenHeart-L@lists.hsforum.com- >> L@lists.hsforum.com>- >>>>>>>> L@lists.hsforum.com>> >>>>>>>> >>>>>>>> To UNSUBSCRIBE, to CHANGE email address, or >> to view archives: >>>>>>>> >> > http://mmp.cjp.com/mailman/listinfo/openheart-l > mmp.cjp.com/mailman/listinfo/openheart-l >> >>>>>>>> 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 > > >> >>>>>>>> listdisclaim> >>>>>>>> ----------------------------------------- >>>>>>>> >> _______________________________________________ >>>>>>>> OpenHeart-L mailing list >>>>>>>> >>>>>>>> Send postings to: >>>>>>>> OpenHeart-L@lists.hsforum.com- >>>>>>>> L@lists.hsforum.com> >>>>>>>> >>>>>>>> To UNSUBSCRIBE, to CHANGE email address, or >> to view archives: >>>>>>>> >> http://mmp.cjp.com/mailman/listinfo/openheart-l >> 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 >>>>>>>> listdisclaim> >> > === message truncated === > > > Dr. David G. Harris, FCS, MMED, > Cardiothoracic Surgeon > Suite A2 > Tygerberg Hospital, 7505 > Cape Town, South Africa. > Tel +27-21-9762347 > Fax +27-21-9761157 Mobile +27-83-3309587 > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com> > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > 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 > listdisclaim> > ----------------------------------------- > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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 ----------------------------------------- From anianyanwu at hotmail.com Thu Mar 1 06:45:21 2007 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Thu Mar 1 06:46:20 2007 Subject: [HSF] Re: Follow up to the New York Times article Stents vs. CABG References: <46A395F05A07E84F9EADEE48E66FFF07017849E2@server.starrwood.com> Message-ID: This raises again the debate as to whether the stented vessel should have been bypassed initially. Ani ----- Original Message ----- From: Tony Furnary To: OpenHeart-L@lists.hsforum.com Sent: Thursday, March 01, 2007 1:24 AM Subject: RE: [HSF] Re: Follow up to the New York Times article Stents vs. CABG Similar story... 48yo male smoker 6 months s/p successful DES to RCA for 90% lesion. Presented again with recurrent angina from 70% LMT, 50% LAD and 65% OM (that were all there in August when DES was placed); RCA DES now widely patent. Sent for surgery to LAD/OM. Held Pavix for 4 days. Then LIMA >LAD & SVG > OM (because of lower grade lesion, despite age). Bled a bit post-op, got 1 pack of platlets which stopped bleeding. Next day bradycardia, ST depression in I, III, and AVF followed by VT / VF. Shocked back -- low BP; high PAp's ; cardiogenic shock. Took immediatly back to OR.... RV akinetic with Acute RV infarct. Opened PDA and RPL -- no flow in either as DES had thrombosed. Emergent CABG with SVG's to both. RV recovered & so did patient. Now at one month and feeling fine with 4 grafts. Off Plavix for life. -----Original Message----- From: hgrmd@aol.com [mailto:hgrmd@aol.com] Sent: Wed 2/28/2007 6:35 PM To: OpenHeart-L@lists.hsforum.com Cc: Subject: Re: [HSF] Re: Follow up to the New York Times article Stents vs. CABG Ed, I can't wait to use your term "Plavix junkies" the next time I'm talking to an interventionalist. In certain aspects, it's probably worse than having a mechanical valve. Using heparin or Lovenox overlap, the unprotected window for a procedure is only about 24 hours. In contrast, the Plavix junkie must stop at least 5 days in order to get the procedure done. I'm thinking about selling my J&J stock in anticipation of it being "Mercked". Hal -----Original Message----- From: ebender001@charter.net To: OpenHeart-L@lists.hsforum.com Sent: Wed, 28 Feb 2007 6:55 PM Subject: Re: [HSF] Re: Follow up to the New York Times article Stents vs. CABG Let me also add a case. 75 year old male with previous CABG and subsequent DES to RCA vein graft feeding a hyperdominant RCA. He has a small skin cancer from his arm that needs to be removed. Plavix stopped for 5 days, gets a skin cancer about the size of a dime removed, and has a huge infarct immediately after surgery. He required redo CABG, but did well after prolonged hospital stay. We have hundreds of thousands of Plavix "junkies" out there. I smell multiple class action lawsuits in the making. Ed Bender, MD On Feb 28, 2007, at 5:26 PM, hgrmd@aol.com wrote: > Cary, > Thanks for sharing this unfortunate case. I've heard and seen > similar. It's slowly dawning on the interventionalists that they > really screwed up, and that these DES patients are analogous to > those with mechanical valves. The lawyers will soon be in another > feeding frenzy. > Hal > > -----Original Message----- > From: CSPassik@aol.com > To: OpenHeart-L@lists.hsforum.com > Sent: Wed, 28 Feb 2007 5:26 PM > Subject: [HSF] Re: Follow up to the New York Times article Stents > vs. CABG > > > HSF'ers, > > I would like to share for your mutual interest an unfortunate case > I saw > yesterday. 51 yo man, active, skinny in good shape. He presented > with an MI > 7/05 and underwent multiple drug-eluting stents to his LAD and CX > for 2-v CAD. > > Big vessels, good angiographic result and good residual LV > function. Newly > diagnosed with early stage prostate CA and was scheduled for a > robotic > Davinci prostatectomy. His Plavix and ASA was thus stopped two > weeks ago. > Cardiology workup included stress testing which was somewhat > equivocal so he > was > cathed last Friday. Stents all looked widely patent. Cardiologist > thus said > "low risk for heart problems"-start his antiplatelet meds ASAP > post-op. He was > > about 2/3 of the way through his port access prostate yesterday > when he had > ST segment changes and therafter coded/CPR. Operation aborted-with > an open > bladder leaking into the belly and a cath lab visit-- occluded > stents in both > vessels-successfully opened but poor reflow and expired. > In summary, these drug coated stents are, IMHO, going to turn out > to be a > disaster for the patients who ever need anything done at any time > in the > future that will require stopping their Plavix. They have created a > new > disease! I > suspect we will all be seeing and hearing more of these cases, > and I also > suspect the stent manufacturer's will try to tell us that this is > just one > case,not reaching statistical significance, blah, blah blah. Too > bad this poor > man didn't have a nice 2V CABG in 05. > Cary Passik >


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AOL now > offers free > email to everyone. Find out more about what's free from AOL at > http://www.aol.com. > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > ______________________________________________________________________> __ > AOL now offers free email to everyone. Find out more about what's > free from AOL at AOL.com. > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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 anddisclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- ________________________________________________________________________ AOL now offers free email to everyone. Find out more about what's free from AOL at AOL.com. _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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@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 ----------------------------------------- From enaseri at hotmail.com.tr Thu Mar 1 11:52:11 2007 From: enaseri at hotmail.com.tr (=?iso-8859-9?B?ZXJkaW7nIG5hc2VyaQ==?=) Date: Thu Mar 1 06:52:47 2007 Subject: [HSF] On pump beating heart In-Reply-To: Message-ID: Dear Don, In your practice what myocardial reserve invesdtigations are done for the patients with EF of 20-25 which are candidates for OPCAB . erdinc >From: Donald Ross >Reply-To: OpenHeart-L@lists.hsforum.com >To: OpenHeart-L@lists.hsforum.com >Subject: Re: [HSF] On pump beating heart >Date: Wed, 28 Feb 2007 18:29:52 +1100 > >Prasanna, >I did talk to Dr Bhattacharya at the meeting in Mumbai, I now know since >my registrar confirmed his distinguished appearance. >He must be slick to use the RIMA exclusively for his T graft . >He did, however mention that he uses the balloon for sick hearts which >perhaps is the reason for his 100% record. >Now that I am reminded of this I will do the same for my next <20% EF >patient since the last two done bh on pump needed post op balloons... not >immediately but after a few hours. I suspect the reason relates to >transient ima hypoperfusion which intolerant of the low mean pressure of >some low EF hearts. >Don >On 27/02/2007, at 11:49 PM, prasannasimha wrote: > >>He practices in Mumbai.(He visits multiple hospitals including Breach >>Candy hospital etc) >>Prasanna >>Donald Ross wrote: >>>Prasanna, >>>Who publishes series of individual cases no matter how pretty the >>>clinical results? >>>Even if they are put into print many wont believe them ( Hal et al ) or >>>take any notice unless there has been some some attempt at science, some >>>hypothesis formulated , some conclusion to be elucidated. >>>This wonderful surgeon/orchestral conductor can't publish his beautiful >>>playing. >>>All one can do is to take your advice and visit the man. >>>So, where does he work? >>>Don >>>PS I thought he used a balloon instead of bypass in crook cases which I >>>believe is probably more morbid than cpb. >>> >>>On 27/02/2007, at 10:45 PM, prasannasimha wrote: >>> >>>>The worst possible scenario is a person wanting to complete a 100 % >>>>OPCAB experience in time for a conference etc and refusing to go on >>>>pump or at least institute an IABP while the heart is demanding it !!. >>>>Saying this, in isolated CABG's not in cardiogenic shock, inability to >>>>displace the heart during OPCAB is more often an expression of failure >>>>of the surgeon - anesthesiologist team to understand what is going on. >>>>You should see Dr Bhattacharya doing a multivessel total arterial >>>>revascularization on a 10 - 15 % EF heart being done effortlessly to >>>>believe it. He has probably the worlds largest "individual surgeon" >>>>series of OPCAB's and unfortunately the blessed man doesn't publish. >>>>Watching him do an OPCAB is like seeing an orchestra play. >>>>Prasanna >>>> >>>>Ani Anyanwu wrote: >>>>>Off-pump surgery is sometimes also a crime against the human - I have >>>>>seen several cases where the heart, or the entire patient, has >>>>>suffered because of reluctance and refusal of the surgeon to accept >>>>>conversion to CPB. It cuts both ways (some patients also suffer by >>>>>having on-pump CABG). We should not be evangelists for a technique but >>>>>for the patient. The patient couldn't care less whether we used CPB or >>>>>not - all they want is a lasting operation at low risk so our primary >>>>>aim should be to deliver this goal. >>>>> >>>>>Ani >>>>> ----- Original Message ----- From: >>>>>NielsB@aol.com To: OpenHeart- >>>>>L@lists.hsforum.com Sent: >>>>>Tuesday, February 27, 2007 3:09 AM >>>>> Subject: Re: [HSF] On pump beating heart >>>>> >>>>> >>>>> Who said it is?. It is not a crime against humanity but in some >>>>>cases it is a crime against a human. The heart lung machine is a >>>>>tool among many others, very frequently a very important one. But it >>>>>is not some holy grail either. We use it when we need it, for CABG >>>>>this is not so common, then the stabilizer is a better tool in my >>>>>humble opinion. >>>>> >>>>> >>>>> Jacob Bergsland >>>>> >>>>> >>>>> ************************************** >>>>> AOL now offers free email to everyone. Find out more about >>>>>what's free from AOL at http://www.aol.com. >>>>> _______________________________________________ >>>>> OpenHeart-L mailing list >>>>> >>>>> Send postings to: >>>>> OpenHeart-L@lists.hsforum.com>>>>L@lists.hsforum.com> >>>>> >>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>> http://mmp.cjp.com/mailman/listinfo/openheart-l>>>>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>>>>listdisclaim> >>>>> ----------------------------------------- >>>>>_______________________________________________ >>>>>OpenHeart-L mailing list >>>>> >>>>>Send postings to: >>>>> OpenHeart-L@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@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@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 >>>anddisclaimers posted at: >>>http://www.hsforum.com/listdisclaim >>>----------------------------------------- >>> >>> >>>--No virus found in this incoming message. >>>Checked by AVG Free Edition. >>>Version: 7.5.446 / Virus Database: 268.18.4/703 - Release Date: >>>2/26/2007 2:56 PM >>> >>> >> >>_______________________________________________ >>OpenHeart-L mailing list >> >>Send postings to: >>OpenHeart-L@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@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 >----------------------------------------- From jbflegejr at aol.com Thu Mar 1 07:32:38 2007 From: jbflegejr at aol.com (jbflegejr@aol.com) Date: Thu Mar 1 07:33:17 2007 Subject: [HSF] Re: Follow up to the New York Times article Stents vs. CABG In-Reply-To: References: <46A395F05A07E84F9EADEE48E66FFF07017849E2@server.starrwood.com> Message-ID: <8C92A14D5548806-1180-3317@webmail-da02.sysops.aol.com> I have no doubts that the stented vessels should be bypassed in this setting and with SVG. I have seen disaster from clotted stents postop and apparently so have many of this forum's participants. (Maybe I am one of those never in doubt, often wrong). There is an immense number of patients, and more every day, with DES and at risk. Most of those dying of MI following stoppping of Plavix for some operation or some other reason just get buried and no connection is made. Now that some are getting publicity, more will be identified correctly. John Flege -----Original Message----- From: anianyanwu@hotmail.com To: OpenHeart-L@lists.hsforum.com Sent: Thu, 1 Mar 2007 6:45 AM Subject: Re: [HSF] Re: Follow up to the New York Times article Stents vs. CABG This raises again the debate as to whether the stented vessel should have been bypassed initially. Ani ----- Original Message ----- From: Tony Furnary To: OpenHeart-L@lists.hsforum.com Sent: Thursday, March 01, 2007 1:24 AM Subject: RE: [HSF] Re: Follow up to the New York Times article Stents vs. CABG Similar story... 48yo male smoker 6 months s/p successful DES to RCA for 90% lesion. Presented again with recurrent angina from 70% LMT, 50% LAD and 65% OM (that were all there in August when DES was placed); RCA DES now widely patent. Sent for surgery to LAD/OM. Held Pavix for 4 days. Then LIMA >LAD & SVG > OM (because of lower grade lesion, despite age). Bled a bit post-op, got 1 pack of platlets which stopped bleeding. Next day bradycardia, ST depression in I, III, and AVF followed by VT / VF. Shocked back -- low BP; high PAp's ; cardiogenic shock. Took immediatly back to OR.... RV akinetic with Acute RV infarct. Opened PDA and RPL -- no flow in either as DES had thrombosed. Emergent CABG with SVG's to both. RV recovered & so did patient. Now at one month and feeling fine with 4 grafts. Off Plavix for life. -----Original Message----- From: hgrmd@aol.com [mailto:hgrmd@aol.com] Sent: Wed 2/28/2007 6:35 PM To: OpenHeart-L@lists.hsforum.com Cc: Subject: Re: [HSF] Re: Follow up to the New York Times article Stents vs. CABG Ed, I can't wait to use your term "Plavix junkies" the next time I'm talking to an interventionalist. In certain aspects, it's probably worse than having a mechanical valve. Using heparin or Lovenox overlap, the unprotected window for a procedure is only about 24 hours. In contrast, the Plavix junkie must stop at least 5 days in order to get the procedure done. I'm thinking about selling my J&J stock in anticipation of it being "Mercked". Hal -----Original Message----- From: ebender001@charter.net To: OpenHeart-L@lists.hsforum.com Sent: Wed, 28 Feb 2007 6:55 PM Subject: Re: [HSF] Re: Follow up to the New York Times article Stents vs. CABG Let me also add a case. 75 year old male with previous CABG and subsequent DES to RCA vein graft feeding a hyperdominant RCA. He has a small skin cancer from his arm that needs to be removed. Plavix stopped for 5 days, gets a skin cancer about the size of a dime removed, and has a huge infarct immediately after surgery. He required redo CABG, but did well after prolonged hospital stay. We have hundreds of thousands of Plavix "junkies" out there. I smell multiple class action lawsuits in the making. Ed Bender, MD On Feb 28, 2007, at 5:26 PM, hgrmd@aol.com wrote: > Cary, > Thanks for sharing this unfortunate case. I've heard and seen > similar. It's slowly dawning on the interventionalists that they > really screwed up, and that these DES patients are analogous to > those with mechanical valves. The lawyers will soon be in another > feeding frenzy. > Hal > > -----Original Message----- > From: CSPassik@aol.com > To: OpenHeart-L@lists.hsforum.com > Sent: Wed, 28 Feb 2007 5:26 PM > Subject: [HSF] Re: Follow up to the New York Times article Stents > vs. CABG > > > HSF'ers, > > I would like to share for your mutual interest an unfortunate case > I saw > yesterday. 51 yo man, active, skinny in good shape. He presented > with an MI > 7/05 and underwent multiple drug-eluting stents to his LAD and CX > for 2-v CAD. > > Big vessels, good angiographic result and good residual LV > function. Newly > diagnosed with early stage prostate CA and was scheduled for a > robotic > Davinci prostatectomy. His Plavix and ASA was thus stopped two > weeks ago. > Cardiology workup included stress testing which was somewhat > equivocal so he > was > cathed last Friday. Stents all looked widely patent. Cardiologist > thus said > "low risk for heart problems"-start his antiplatelet meds ASAP > post-op. He was > > about 2/3 of the way through his port access prostate yesterday > when he had > ST segment changes and therafter coded/CPR. Operation aborted-with > an open > bladder leaking into the belly and a cath lab visit-- occluded > stents in both > vessels-successfully opened but poor reflow and expired. > In summary, these drug coated stents are, IMHO, going to turn out > to be a > disaster for the patients who ever need anything done at any time > in the > future that will require stopping their Plavix. They have created a > new > disease! I > suspect we will all be seeing and hearing more of these cases, > and I also > suspect the stent manufacturer's will try to tell us that this is > just one > case,not reaching statistical significance, blah, blah blah. Too > bad this poor > man didn't have a nice 2V CABG in 05. > Cary Passik >


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