From benjamin.bidstrup at bigpond.com Tue May 1 09:28:51 2007 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Mon Apr 30 18:41:18 2007 Subject: [HSF] Server Outage In-Reply-To: References: <8311B6B3-F237-48C4-AECD-9C06F2652E26@boxg.com> Message-ID: In Australia we have the pedal wireless. This kept many people in contact from the outback or many years until transistorised radios etc took over. Maybe we can dig one of these up for you Jon. Then you can keep fit at the same time as keeping the addicts connected. >WHAT! >No excuse - not hooked up to a backup generator? > No hand crank? > (what about mice on a wheel) > Did you not call the Electric Co and plan this according to our schedule? > >This is an outrage - give me something to throw..... > who is to blame - get them here now! > > better yet, get their Boss on the phone...... heads will role! > > >-michael > >(ps - you know us, gotta rant and rave about something - thanks for the >notice.......) > > > > > > > > >On 4/30/07, Jon Golden wrote: >> >>Dear List, >> >>The local Electric company is pulling our power tonight (scheduled >>issues in area) and although we have 4-5 hours of UPS power available >>I would expect the list to be offline for a bit tonight - The outage >>will occur between 1730 (GMT-0400) - 2330 (GMT-0400) - The server >>will remain up as long as I have battery power. >> >>Thanks for your understanding. >> >>Jon >>_______________________________________________ >>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 >----------------------------------------- -- Ben Bidstrup FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon From drdharris at yahoo.co.uk Tue May 1 01:02:10 2007 From: drdharris at yahoo.co.uk (David Harris) Date: Mon Apr 30 19:02:40 2007 Subject: [HSF] Possible infected Freestyle In-Reply-To: Message-ID: <602612.53431.qm@web26706.mail.ukl.yahoo.com> I agree totally with Ani. Maybe the situation is not so bad, at any rate I would not go back in so soon, and not after trying to identify the microbiology. At worst he may need only local drainage, antibiotics and wrapping the graft with omentum. That is what is suggested by Coselli and Safi and co in Houston for infected aortic grafts. Send off fluid for fungal cultures, do CRP serially, and see if it goes down spontaneously first, then with antibiotics, and if still remaining slightly elevated start impirical antifungals. If the CRP continues to go up then you know you have a problem needing surgery. At this stage all you have is sterile pus, and no proof of infection. you will need to do a few blood cultures as well (just in case) Dave Harris --- Ani Anyanwu wrote: > A reoperative root replacement 2 months postop in an > 80 year old with patent grafts is a difficult > operation with high mortality so not one to > undertake unless absolutely indicated (to save > life). Even surgery just to drain the collection is > not straightforward. > Have you checked for fungus? Presentations like this > are typical for fungal abscess. Also did you have > any post-operative imaging - was there a known > collection before? Did he have a lot of > post-operative bleeding? I presume the CT was done > with contrast and there is no pseudoaneurysm? > > When you say though that radiologist sampled > substernal fluid, is the collection round aorta > contiguous with a substernal collection or does he > have two separate collections? Not an easy case but > I suspect you may be dealing with a fungus or a less > fastidious bacterium especially if he is > immunosuppressed or debilitated. While it is nice to > hope that this is not an infection I agree with you > that this has to be the assumption until proven > otherwise (which is near impossible to prove). > > Personally in this patient (assuming no > pseudoaneurysm) I would favor opening up and > draining the abscess, leave open for a few days with > vacuum dressing and then when clean get plastic > colleague to transpose a pectoral muscle over the > root then close sternum. We have used this method > successfully for abscess around dacron grafts > (without root rereplacement). Doing a homograft may > be ideal but you need a live patient at the end. > > Welcome to the forum - I am quite junior too and > have learnt a lot here, I am sure you will too. Best > of luck! > > Ani > ----- Original Message ----- > From: john streitman > To: > OpenHeart-L@lists.hsforum.com > > Sent: Monday, April 30, 2007 12:39 AM > Subject: [HSF] Possible infected Freestyle > > > HS forum members: > > I am new to the forum (recent grad from UF-2006 > (hi > Tom) but have been reading many of the threads and > finally have a case I would like some input on. > Three > months ago I performed a Freestyle root (25mm)/ 4V > CABG on an 80 y/o male with severe AS/ASCAD. I > started out doing an AVR/CABG and could not get a > 25 > mosaic to sit appopriately and in trying to do so > tore > the aorta b/t the left main ostium and the > annulus. > Instead of trying to repair this and downsize the > valve choice or enlarge an injured root, I elected > to > proceed with a 25-Freestyle and he did amazingly > well > (solid 80 y/o protoplasm). He was seen at 4 weeks > and > was d/c back to his cardiologist. Now 8 weeks out > he > came to my office with a small midsternal abscess > (less that 1 cm) which I thought was just a suture > abscess. I proceeded with CT scan which showed > fluid > around his root/asc aorta. The sternum appears > well > healed and is clinically stable. No fever, normal > WBC > and feels well. I opened the abscess to find pus > and > on GS there was no bact with many WBC's. Culture > neg > for >72 hrs on no abx prior. I was able to get a > radiologist to sample the substernal fluid and > this > too had many WBC's w/o bacteria and so far (48 > hrs) > has been culture negative. He remains afebrile > with a > normal WBC. He will get a TEE tomorrow. ID has > seen > him and feels he needs root replacement and I have > several homografts coming in. I am prepared to > replace this root but is this the right answer? > Any > other ideas about how to determine what to do? > Look > forward to your input. > > John > > John E Streitman, M.D. > Cardiovascular Surgeon > Pinehurst Surgical > streitman@yahoo.com > > __________________________________________________ > Do You Yahoo!? > Tired of spam? Yahoo! Mail has the best spam > protection around > http://mail.yahoo.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 > ----------------------------------------- > Dr. David G. Harris, FCS, MMED, Cardiothoracic Surgeon Suite 207 Kuils River Private Hospital, PO Box 1200, Kuils River, 7579, Cape Town, South Africa. Tel +27-21-9006411 Fax +27-21-9006412 Mobile +27-83-3309587 From drdharris at yahoo.co.uk Tue May 1 01:11:36 2007 From: drdharris at yahoo.co.uk (David Harris) Date: Mon Apr 30 23:12:06 2007 Subject: [HSF] Bicuspid aortic valve and dilated ascending aorta In-Reply-To: <17df8996.b4b7.461e.b760.357bdcd20420@aol.com> Message-ID: <20070430231136.2284.qmail@web26703.mail.ukl.yahoo.com> Another indication, I have found, in borderline cases is a thin aorta, which will often give you problems with closure. If I see I am possibly going to have problems closing the aortotomy, or on the rare occasion where there is inadequate hemostasis, I will replace the ascending. This does not add much more time to the procedure, but there is obviously the increased risk of infection. Having worked in a teaching hospital for a while, I have seen disasters where surgeons could not close the aortotomy nicely, (in dilated aortas), got it closed eventually, only to have the patient bleed to death later. Dave Harris --- Tdmartin2000 wrote: > I think the indications for an asymptomatic (i.e. > one that has not ruptured or dissected as those are > usually the only symptoms of ascendings) ascending > repair depends a lot on the pt. How old are they, > what are their comorbidities etc. For any non Marfan > pt that has a tricuspid valve and an ascending > aneurysm of 5cm or more I will spend at least 45min > to 1 hr with them drawing pictures and expaining to > them the natural history of the disease and it's > risks. I will also explain to them the operation > necessary to repair their problem along with all the > risks and benefits. In the end the pt and I will > review the expected risks and benefits of both > treatment plans (including the % risk of morbidity > and mortality of both) and then I let the patient > make the final decision. > > Tom Martin > U of Florida > Gainesville > > > In a message dated 04/28/07 16:43:52 Eastern > Daylight Time, Hgrmd writes: > Mitch, > The classic indication for asymptomatic ascending > aortic aneurysm is 6 cm. > However, people seem to be getting progressively > more aggressive. Among > others, we need to hear from Drs. Bachet and > Martin. > Hal > > > > ************************************** See what's > free 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 > ----------------------------------------- > Dr. David G. Harris, FCS, MMED, Cardiothoracic Surgeon Suite 207 Kuils River Private Hospital, PO Box 1200, Kuils River, 7579, Cape Town, South Africa. Tel +27-21-9006411 Fax +27-21-9006412 Mobile +27-83-3309587 From tdmartin2000 at aol.com Tue May 1 01:22:06 2007 From: tdmartin2000 at aol.com (Tdmartin2000) Date: Tue May 1 00:23:08 2007 Subject: [HSF] Possible infected Freestyle In-Reply-To: <69105.73212.qm@web50902.mail.re2.yahoo.com> References: <69105.73212.qm@web50902.mail.re2.yahoo.com> Message-ID: <5fef6461.fa15.48ee.95c6.0b0913b91f43@aol.com> John Great case- this is what you get for getting the CT scan. It doesn't surprise me to have fluid around the graft. If you were to CT all pts with a root ascending repair at 8 wks I would expect a large number to have fluid around their graft. If you have no bacteria on gram stain and no growth and no evidence of any suture line breakdown, I would do nothing and repeat the CT scan in 2 to 4 wks. If it is infected he will declare himself. If you are forced to do anything surgically then at this point in time I would only explore his mediastinum, pulse lavage, and if there is any question of infection then put some omentum over/around the root. I would not redo his root unless there was some type of breakdown/pseudoaneurysm. I am assuming from your post that there was no direct communication between the substernal and subcu fluid collections. Let us know what you decide. Tom Martin U of Florida Gainesville In a message dated 04/30/07 00:42:39 Eastern Daylight Time, streitman@yahoo.com writes: HS forum members: I am new to the forum (recent grad from UF-2006 (hi Tom) but have been reading many of the threads and finally have a case I would like some input on. Three months ago I performed a Freestyle root (25mm)/ 4V CABG on an 80 y/o male with severe AS/ASCAD. I started out doing an AVR/CABG and could not get a 25 mosaic to sit appopriately and in trying to do so tore the aorta b/t the left main ostium and the annulus. Instead of trying to repair this and downsize the valve choice or enlarge an injured root, I elected to proceed with a 25-Freestyle and he did amazingly well (solid 80 y/o protoplasm). He was seen at 4 weeks and was d/c back to his cardiologist. Now 8 weeks out he came to my office with a small midsternal abscess (less that 1 cm) which I thought was just a suture abscess. I proceeded with CT scan which showed fluid around his root/asc aorta. The sternum appears well healed and is clinically stable. No fever, normal WBC and feels well. I opened the abscess to find pus and on GS there was no bact with many WBC's. Culture neg for >72 hrs on no abx prior. I was able to get a radiologist to sample the substernal fluid and this too had many WBC's w/o bacteria and so far (48 hrs) has been culture negative. He remains afebrile with a normal WBC. He will get a TEE tomorrow. ID has seen him and feels he needs root replacement and I have several homografts coming in. I am prepared to replace this root but is this the right answer? Any other ideas about how to determine what to do? Look forward to your input. John John E Streitman, M.D. Cardiovascular Surgeon Pinehurst Surgical streitman@yahoo.com __________________________________________________ Do You Yahoo!? Tired of spam? Yahoo! Mail has the best spam protection around http://mail.yahoo.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 tdmartin2000 at aol.com Tue May 1 01:26:08 2007 From: tdmartin2000 at aol.com (Tdmartin2000) Date: Tue May 1 00:30:55 2007 Subject: [HSF] Bicuspid aortic valve and dilated ascending aorta In-Reply-To: References: Message-ID: Great point Hal. We do take size into consideration although we do not have an "index" per say. For true Marfans pts I would seriously start dialogue about surgery somewhere between 4 and 4.5cm. Bicuspids I would say 5 to 5.5cm. Tom In a message dated 04/30/07 07:09:20 Eastern Daylight Time, Hgrmd writes: Tom, Thanks for the reply. Do you ever take a patient's size in consideration as well? To me, a 5 ft, 85 lb lady with a 5 cm ascending aorta is a lot more concerning than a 6 ft 2 in, 200 lb man with the same. I remember the Cleveland Clinic proposed indexing. I think the size they chose was 2.5cm/m2. Also, what is the minimum size you recommend aortic replacement for Marfan's or bicuspid aorta? Hal ************************************** See what's free 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 ----------------------------------------- From rudi at kbd.hr Tue May 1 10:25:04 2007 From: rudi at kbd.hr (Igor Rudez) Date: Tue May 1 03:28:56 2007 Subject: [HSF] Ascending Aortic Aneurysm In-Reply-To: <24fa2966cc4b9ad0cd77dc6a3627e56d@mac.com> Message-ID: <000601c78bc1$ee71c190$1d23a8c0@kbd.hr> Steve, I would definitively deal with the valve as well. If not, very soon you might find yourself in a position that you have to do a re-do surgery to replace the valve because it will deteriorate! And I would go for bio-valve! Igor Rudez -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Steven Schwartz Sent: Tuesday, May 01, 2007 5:29 AM To: OpenHeart-L@lists.hsforum.com Subject: [HSF] Ascending Aortic Aneurysm 59 yo male with "atypical chest pain" had CT scan of chest done. 6 cm ascending aortic aneurysm identified, reportedly ends at level of innominate artery. My question centers around a recent echo which showed an aortic valve area of 1.4 cm2. Should the valve be addressed? Just a "tube graft"? Steve Schwartz _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From damle at cableone.net Tue May 1 04:08:21 2007 From: damle at cableone.net (Ajit Damle) Date: Tue May 1 04:08:34 2007 Subject: [HSF] Mitral Valve In-Reply-To: Message-ID: <001301c78bc7$e321e2b0$0201a8c0@yourg8he5gjrox> For your comments, gentlemen. Ajit Damle ULTRA MINIMALLY INVASIVE MITRAL VALVE SURGERY WITHOUT AORTIC CROSS CLAMP Authors: Kumar, S.; Ahmad, R.; Greelish, J.; Petracek, M.; Balaguer, J.; Byrne, J. Source: ANZ Journal of Surgery, Volume 77, Supplement 1, May 2007, pp. A8-A8(1) Publisher: Blackwell Publishing Abstract: Objective? We developed a technique for mitral valve surgery through an ultra small (5?cm) right lateral thoracotomy without aortic cross clamp. This study reports our combined ST. Thomas and Vanderbilt Heart Institutes five years experience with this technique. ? Methods Six hundred and twenty five (316 M /309 F; aged 22-75 mean of 62 years) underwent ultra minimally invasive mitral valve surgery between August 2000 and June 2006. Through a 5 centimeter right lateral thoracotomy along the 4th intercostal space access to the pericardium and the left atrium was gained. Cardiopulmonary bypass was instituted through femoral cannulation. Under cold fibrillatory arrest (28?C) without aortic cross clamp, mitral valve repair (n?=?196) or replacement (n?=?380), in addition to mitral valve procedure we performed tricuspid valve repair (n?=?69), ASD/PFO closure (n?=?201) and Maze (n?=?156). Mean pre operative New York Heart Association function class was 2.2???0.9. Twenty eight patients had ejection fraction less than 20%. Results? Thirty-day mortality was 1.28% (n?=?8), Operating time, bypass time operating averaged 189???52, 113???35 minutes, respectively. Three patients had conversion to sternotomy. Fifteen patients (2.4%) underwent reexploration for bleeding. Average length of hospital stay from surgery to discharge was 6.85???3 days. Ten patients (1.6%) had neurological events. Renal failure required hemodialysis in 5 patients (0.81%). Long term follow-up results are awaited. Conclusions? This study demonstrate that this simplified technique of ultra minimally invasive mitral valve surgery is reproducible and provides the least invasive operative approach with low mortality and morbidity with good cosmetic results. From bbiocina at kbd.hr Tue May 1 11:40:38 2007 From: bbiocina at kbd.hr (bbiocina@kbd.hr) Date: Tue May 1 05:48:19 2007 Subject: [HSF] Ascending Aortic Aneurysm In-Reply-To: <24fa2966cc4b9ad0cd77dc6a3627e56d@mac.com> Message-ID: Steve , some data from ECHO is missing ; how big the transvalvular gradient is? is there any calcifications of leaflets? any hypertrophy of the LV? the lower origin of the aneurysm-sinuses or sinotubular junction? -all that should be taken into account. As the stenosis is mild by definition , you should have in mind that mild stenosis in younger patients might be slowly progressing. In a study of 142 patients with "mild" stenosis (catheterization-proven AVA >1.5 cm2), the rate of progression to severe stenosis was 8 percent in 10 years, 22 percent in 20 years, and 38 percent in 25 years. Rahimtoola,S.H.,Aortic Valve Disease,Hurst's Diseases of The Heart,10th Edition,Vol.2,Pp.1682-1695 Also , the type of operation you plan should be considered if you opt for valve replacement- Bentall or valve + tube graft. Of course you can apply the "why not" principle , but in that case a natural history of various tissue valves ( advantages and disadvantages of mechanical valves have been better defined) shoud be taken into account. Bojan On 5/1/2007, "Steven Schwartz" wrote: 59 yo male with "atypical chest pain" had CT scan of chest done. 6 cm >ascending aortic aneurysm identified, reportedly ends at level of >innominate artery. >My question centers around a recent echo which showed an aortic valve >area of 1.4 cm2. >Should the valve be addressed? Just a "tube graft"? >Steve Schwartz > >_______________________________________________ >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 damle at cableone.net Tue May 1 05:54:45 2007 From: damle at cableone.net (Ajit Damle) Date: Tue May 1 06:01:13 2007 Subject: [HSF] Too scared to touch..... In-Reply-To: <46354C58.8030005@gmail.com> Message-ID: <006801c78bd6$bf89cd90$0201a8c0@yourg8he5gjrox> Great posting, Prasanna! I know medical practice is based (somewhat loosely) on science, but I wish our practices were a tad more rigorous. We commonly form our opinions from our own personal experiences. Of course, life in trenches is a little different, but still..... Perhaps medical societies could take lead in this. I fantasize about a day when all the patient parameters are inputed in a computer and the treatment options are displayed with scientific validity of each, at least what class of evidence is their for each treatment. The best way , I think, would be to try and figure out how this can be done, rather than think of all the (currently good) reasons why it can not. Am I just dreaming? Ajit Damle -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of prasannasimha Sent: Sunday, April 29, 2007 8:55 PM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Too scared to touch..... Hal, Assumptions about certain things does not often mean we are right. The articles after 2004 have shifted and this is specifically after the 2002 recommendations of maximal beta blockade peri-surgery which caused a paradigm shift in perioperative outcomes after noncardiac surgery in IHD patients. Here are some references. In fact the new AHA guidelines (for what they are worth) have shifted recommendations from revascularization to beta blockade since that actually has given a better outcome than both PCI and CABG. Just because we do these does not mean we are actually reducing the event rate !! Most periop MI's in recently revascularized patients have been due to enhanced mortality due to stent/ graft closure produced by a combination of withdrawal of platelets inhibitors, hemodynamic perturberations that have actually increased graft closure (compared to native coronary disease) and new events in non revascularized areas. As far as current practice in US that you speak of ,see the heterogeneity of practice in ref 5 !! Prasanna 1: Acta Chir Belg. 2006 Jul-Aug;106(4):361-6. Perioperative cardiac risk stratification and modification in abdominal aortic aneurysm repair. Dunkelgrun M, Schouten O, Feringa HH, Noordzij PG, Hoeks S, Boersma E, Bax JJ, Poldermans D. Vascular Surgery, Erasmus Medical Center, Rotterdam, The Netherlands. Cardiovascular complications are important causes of morbidity and mortality following vascular surgery. Adequate preoperative risk assessment and perioperative management may modify postoperative mortality and morbidity and improve long-term prognosis. The objective of this review is to examine the present day knowledge regarding the preoperative evaluation and perioperative management of patients undergoing noncardiac surgery, focusing specifically on abdominal aortic aneurysm (AAA) repair. Clinical markers combined with ECG and surgical risk assessment can effectively divide patients in a truly low-risk, intermediate and high-risk population. Low-risk patients can probably be operated on without additional cardiac testing. Notably, due to the surgical risk, AAA patients are never low-risk patients. Intermediate-risk and high-risk patients are referred for cardiac testing to exclude extensive stress induced myocardial ischemia, as beta-blockers provide insufficient myocardial protection in this case and preoperative coronary revascularization might be considered. Whether patients at intermediate risk without ischemic heart disease should be treated with statins and/or beta-blockers is still controversial._* In high-risk patients, it is strongly advised to administer beta-blockers with heart rate determined dose adjustment, while the effects of preoperative revascularization remain subject to debate.*_ Publication Types: Review PMID: 17017685 [PubMed - indexed for MEDLINE] 2: Curr Treat Options Cardiovasc Med. 2006 Feb;8(1):59-66. Preoperative evaluation and treatment of stable CAD in patients scheduled for major elective vascular surgery. Kelly RF, McFalls EO. Division of Cardiology, VA Medical Center, University of Minnesota, 1 Veterans Drive, 111C, Minneapolis, MN 55414, USA. One of the most controversial topics in clinical cardiology is the extent of preoperative studies that is required among patients scheduled for major elective noncardiac operations. Patients in need of an elective operation for either an expanding aortic aneurysm or lower limb ischemia have the highest risk of postoperative cardiac complications because of the high prevalence of coronary artery disease and the hemodynamic stresses associated with the vascular procedures. The decision to perform preoperative coronary angiography should be reserved for only those patients who are deemed clinically unstable or are functionally limited by cardiac symptoms. _*Among patients with minimal symptoms, preoperative coronary artery revascularization with either coronary artery bypass graft surgery or percutaneous coronary interventions delays the needed operation and does not improve short-term outcomes or long-term survival. *_ PMID: 16401384 [PubMed] 3: CMAJ. 2005 Sep 27;173(7):779-88. Surveillance and prevention of major perioperative ischemic cardiac events in patients undergoing noncardiac surgery: a review. Devereaux PJ, Goldman L, Yusuf S, Gilbert K, Leslie K, Guyatt GH. Department of Medicine, McMaster University, Hamilton, Ont. philipj@mcmaster.ca This is the second of 2 articles evaluating cardiac events in patients undergoing noncardiac surgery. Unrecognized myocardial infarctions (MIs) are common, and up to 50% of perioperative MIs may go unrecognized if physicians rely only on clinical signs or symptoms. In this article, we summarize the evidence regarding monitoring strategies for perioperative MI in patients undergoing noncardiac surgery. Perioperative troponin measurements and 12-lead electrocardiograms can detect clinically silent MIs and provide independent prognostic information. Currently, there are no standard diagnostic criteria for perioperative MIs in patients undergoing noncardiac surgery. We propose diagnostic criteria that reflect the unique features of perioperative MIs. Finally, we review the evidence for perioperative prophylactic cardiac interventions. There is encouraging evidence that some perioperative interventions (e.g., beta-blockers, alpha2-adrenergic agonists, statins) may prevent major cardiac ischemic events, but firm conclusions await the results of large definitive trials./* */_*/The best evidence /does not support a management strategy of preoperative coronary revascularization before noncardiac surgery.*_ Publication Types: Research Support, Non-U.S. Gov't Review PMID: 16186585 [PubMed - indexed for MEDLINE] 4: Mt Sinai J Med. 2005 May;72(3):185-92. Preoperative cardiovascular evaluation for noncardiac surgery. Maddox TM. Zena and Michael A. Wiener Cardiovascular Institute, Box 1030, Mount Sinai School of Medicine, One East 100th Street, New York, NY 10029-6574, USA. tmaddox@alumni.rice.edu Cardiovascular complications following noncardiac surgery constitute an enormous burden of perioperative morbidity and mortality. Annually, more than one million operations are complicated by adverse cardiovascular events, such as perioperative myocardial infarction or death from cardiac causes. In order to combat this problem, cardiac evaluation prior to noncardiac surgery should ask two questions about the patient: What is the risk of cardiac complications during and after surgery? How can that risk be reduced or eliminated? Risk assessment evaluates patients' co-morbidities and exercise tolerance, as well as the type of surgery to be performed, to determine the overall risk of perioperative cardiac complications. Previous or current cardiac disease, diabetes and renal insufficiency all confer higher risks for perioperative cardiac complications. Poor exercise tolerance and high-risk surgical procedures (e.g., vascular, prolonged thoracic or abdominal operations) also predict worse perioperative outcomes. Noninvasive stress testing is widely used to help predict risk of perioperative complications, but the poor predictive power of these tests hampers their usefulness. After estimating the risk of cardiac complications, one should take measures to reduce it. Beta blockade has shown clear benefits in risk reduction. At this time, there are no data suggesting benefits of percutaneous coronary intervention or coronary artery bypass grafting in reducing noncardiac surgical risk. In addition, angioplasty with stenting and its attendant need for anticoagulation can expose patients to increased risk of perioperative bleeding. Thus, the use of coronary revascularization prior to noncardiac surgery should be reserved for those patients with an independent cardiac need for the procedure, such as unstable angina or stable angina refractory to medical therapy. In summary, patients with low clinical risk factors and good functional status, undergoing a low or intermediate risk surgery, have an excellent prognosis and may proceed to surgery without further delay. In addition, stable patients who have previously undergone coronary revascularization may also safely undergo surgery. Patients requiring urgent surgery should proceed immediately, since the consequences of delay usually outweigh the benefits of preoperative risk assessment. However, elective surgery should be indefinitely deferred for those patients with unstable coronary syndromes, since consequences of the cardiac disease usually negate the benefits of surgery. Controversy involves the intermediate or high clinical risk patient considering high-risk, but elective, surgery. Noninvasive testing offers only limited assistance in estimating risk for these patients. _*The best risk reduction strategy for these patients is perioperative beta blockade use. The role of coronary revascularization specifically to reduce perioperative cardiac complications remains unproven.*_ Publication Types: Review PMID: 15915313 [PubMed - indexed for MEDLINE] 5: Am J Cardiol. 2004 Nov 1;94(9):1124-8. Disparate opinions regarding indications for coronary artery revascularization before elective vascular surgery. Pierpont GL, Moritz TE, Goldman S, Krupski WC, Littooy F, Ward HB, McFalls EO; Current Opinion On Revascularization Study Investigators. Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota 55417, USA. pierp002@umn.edu Despite consensus guidelines, the optimal strategy for preoperative cardiac risk management among patients scheduled for major noncardiac surgery remains controversial. This study assesses current opinion about the role of preoperative coronary revascularization for patients with coronary artery disease scheduled for elective vascular surgery. Thirty-one practicing cardiologists recruited from 4 different regions reviewed case records, imaging tests, and coronary angiograms of 12 patients with coronary artery disease participating in the Coronary Artery Revascularization Prophylaxis (CARP) trial. The need for preoperative coronary revascularization was determined and results summarized using 3 categories: favoring conservative management, neutral, or recommending revascularization (either by percutaneous intervention or bypass surgery). We found recommendations were frequently disparate and often deviated from published guidelines (40% of the time). The likelihood of discordance between 2 cardiologists was 54%, with a 26% chance that recommendations for revascularization would be directly contradictory. Opinions were more often conservative (43%) or aggressive (40%) than neutral (17%). Similar inconsistency was found as to the preferred method of revascularization, with only 1 patient having complete agreement. _*Thus, this study reveals substantial differences of opinion among cardiologists across the country about the role of preoperative coronary artery revascularization for patients scheduled for elective vascular operations. Deviations from published guidelines are common, suggesting that current consensus statements need additional data to support their recommendations.*_ Publication Types: Clinical Trial Comparative Study Randomized Controlled Trial Research Support, U.S. Gov't, Non-P.H.S. PMID: 15518605 [PubMed - indexed for MEDLINE] 6: J Vasc Surg. 2004 Oct;40(4):752-60. Long-term survival after vascular surgery: specific influence of cardiac factors and implications for preoperative evaluation. Back MR, Leo F, Cuthbertson D, Johnson BL, Shamesmd ML, Bandyk DF. Division of Vascular & Endovascular Surgery, University of South Florida College of Medicine, the Surgical Service, James A. Haley Veterans Hospital, Tampa, FL, USA. mback@hsc.usf.edu OBJECTIVE: We sought to identify specific determinants of long-term cardiac events and survival in patients undergoing major arterial operations after preoperative cardiac risk stratification by American College of Cardiology/American Heart Association guidelines. A secondary goal was to define the potential long-term protective effect of previous coronary revascularization (coronary artery bypass grafting [CABG] or percutaneous coronary intervention [PCI]) in patients with vascular disease. METHODS: Four hundred fifty-nine patients underwent risk stratification (high, intermediate, low) before 534 consecutive elective or urgent (<24 hours after presentation) open cerebrovascular, aortic, or lower limb reconstruction procedures between August 1996 and January 2000. Long-term follow-up (mean, 56 +/- 14 months) was possible in 97% of patients. The Kaplan-Meier method was used for survival data. Long-term prognostic variables were identified with the multivariate Cox proportional hazards model and contingency table analysis censoring early (<30 days) perioperative deaths. RESULTS: While 5-year survival was 72% for the overall cohort, cardiac causes accounted for only 24% of all deaths, and new cardiac events (myocardial infarction, congestive heart failure, arrhythmia, unstable angina, new coronary angiography, new CABG or PCI, cardiac death) affected only 4.6% of patients per year during follow-up. High cardiac risk stratification level (hazards ratio [HR], 2.2, 95% confidence interval [CI], 1.4-3.4), adverse perioperative cardiac events (myocardial infarction, congestive heart failure, ventricular arrhythmia; HR, 2.2; 95% CI, 1.2-4.1), and age (HR, 0.33; 95% CI, 0.2-0.6) were independently prognostic for latemortality. Preoperative cardiac risk levels also correlated with new cardiac event rates ( P < .01) and late cardiac mortality ( P = .02). Modestly improved survival in patients who had undergone CABG or PCI less than 5 years before vascular operations compared with those who had undergone revascularization 5 or more years previously and those at high risk without previous coronary intervention (73% vs 58% vs 62% 5-year survival; P = .02) could be demonstrated with univariate testing, but not with multivariate analysis. Type of operation, urgency, noncardiac complications, and presence of diabetes did not affect long-term survival. CONCLUSION: Despite cardiac events being a less common cause of late mortality after vascular surgery, perioperative cardiac factors (age, preoperative risk level, early cardiac complications) are the primary determinants of patient longevity._/* Patients undergoing more recent (<5 years) CABG or PCI before vascular surgery do not have an obvious survival advantage compared with patients at high cardiac risk without previous coronary*/_ /_*interventions.*_/ Publication Types: Comparative Study PMID: 15472605 [PubMed - indexed for MEDLINE] Hgrmd@aol.com wrote: > Ben, > You seem to be mixing apples and oranges a bit. I thought we were > discussing whether coronary revascularization makes noncardiac surgery less risky, > not whether Mike's patient should get a CABG. Not withstanding the 2002 > Circulation article reportedly showing no benefit of CABG and PCI in lowering the > risk of noncardiac surgery, go ahead and repair an AAA on a patient with a > critical left main. See how they do, and see how long it takes you to end up > in court. I can tell you that patients and families get pretty upset when the > patient has a perioperative MI. Furthermore, I don't know of any reputable > general, orthopedic, or vascular surgeon, or anesthesiologist for that > matter, who will take a patient to surgery with a stress test showing a lot of > myocardium at risk. > Hal > > > > ************************************** See what's free 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 ----------------------------------------- From benjamin.bidstrup at bigpond.com Tue May 1 21:14:54 2007 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Tue May 1 06:15:55 2007 Subject: [HSF] Too scared to touch..... In-Reply-To: <006801c78bd6$bf89cd90$0201a8c0@yourg8he5gjrox> References: <006801c78bd6$bf89cd90$0201a8c0@yourg8he5gjrox> Message-ID: Ajit, In a way that is what we do every time we look at something. How did you arrive at your protocol for cardioplegia, sorry Tomas, myocardial preservation? What about CPB management? Temp etc. We have done a fair bit of what you describe already. However, we must combine what we would get from the computer with what we can do. It is no good having teh Ross operation come up as a clear winner if we don't do it. Sure we can send them off somewhere which at times I would do. For example in a small program seeing 1 or 2 dissections a year and doing them not well, I have advocated sending them to a busy unit 1 hour up the road. Our team does not get enough practice at them but some at the hospital think that this not in the patients best interests. So into your program you need to factor in your own experience. What you are asking about are the guidelines now produced for some conditions. Trouble is in rarer conditions there is usually not enough solid evidence even with meta-analysis. >Great posting, Prasanna! > >I know medical practice is based (somewhat loosely) on science, but I wish >our practices were a tad more rigorous. > >We commonly form our opinions from our own personal experiences. Of course, >life in trenches is a little different, but still..... > >Perhaps medical societies could take lead in this. I fantasize about a day >when all the patient parameters are inputed in a computer and the treatment >options are displayed with scientific validity of each, at least what class >of evidence is their for each treatment. > >The best way , I think, would be to try and figure out how this can be done, >rather than think of all the (currently good) reasons why it can not. > >Am I just dreaming? > >Ajit Damle > > > > > >-----Original Message----- >From: openheart-l-bounces@lists.hsforum.com >[mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of prasannasimha >Sent: Sunday, April 29, 2007 8:55 PM >To: OpenHeart-L@lists.hsforum.com >Subject: Re: [HSF] Too scared to touch..... > >Hal, >Assumptions about certain things does not often mean we are right. > >The articles after 2004 have shifted and this is specifically after the 2002 >recommendations of maximal beta blockade peri-surgery >which caused a paradigm shift in perioperative outcomes after noncardiac >surgery in IHD patients. >Here are some references. In fact the new AHA guidelines (for what they are >worth) have shifted recommendations from revascularization > to beta blockade since that actually has given a better outcome than both >PCI and CABG. Just because we do these does not mean > we are actually reducing the event rate !! Most periop MI's in recently >revascularized patients have been due to enhanced mortality >due to stent/ graft closure produced by a combination of withdrawal of >platelets inhibitors, hemodynamic perturberations that have actually > increased graft closure (compared to native coronary disease) and new >events in non revascularized areas. >As far as current practice in US that you speak of ,see the heterogeneity >of practice in ref 5 !! > >Prasanna > >1: Acta Chir Belg. 2006 Jul-Aug;106(4):361-6. > >Perioperative cardiac risk stratification and modification in abdominal >aortic >aneurysm repair. > >Dunkelgrun M, Schouten O, Feringa HH, Noordzij PG, Hoeks S, Boersma E, Bax >JJ, >Poldermans D. > >Vascular Surgery, Erasmus Medical Center, Rotterdam, The Netherlands. > >Cardiovascular complications are important causes of morbidity and mortality >following vascular surgery. Adequate preoperative risk assessment and >perioperative management may modify postoperative mortality and morbidity >and >improve long-term prognosis. The objective of this review is to examine the >present day knowledge regarding the preoperative evaluation and >perioperative >management of patients undergoing noncardiac surgery, focusing specifically >on >abdominal aortic aneurysm (AAA) repair. Clinical markers combined with ECG >and >surgical risk assessment can effectively divide patients in a truly >low-risk, >intermediate and high-risk population. Low-risk patients can probably be >operated on without additional cardiac testing. Notably, due to the surgical >risk, AAA patients are never low-risk patients. Intermediate-risk and >high-risk >patients are referred for cardiac testing to exclude extensive stress >induced >myocardial ischemia, as beta-blockers provide insufficient myocardial >protection >in this case and preoperative coronary revascularization might be >considered. >Whether patients at intermediate risk without ischemic heart disease should >be >treated with statins and/or beta-blockers is still controversial._* In >high-risk >patients, it is strongly advised to administer beta-blockers with heart rate >determined dose adjustment, while the effects of preoperative >revascularization >remain subject to debate.*_ > >Publication Types: > Review > >PMID: 17017685 [PubMed - indexed for MEDLINE] > >2: Curr Treat Options Cardiovasc Med. 2006 Feb;8(1):59-66. > >Preoperative evaluation and treatment of stable CAD in patients scheduled >for >major elective vascular surgery. > >Kelly RF, McFalls EO. > >Division of Cardiology, VA Medical Center, University of Minnesota, 1 >Veterans >Drive, 111C, Minneapolis, MN 55414, USA. > >One of the most controversial topics in clinical cardiology is the extent of >preoperative studies that is required among patients scheduled for major >elective noncardiac operations. Patients in need of an elective operation >for >either an expanding aortic aneurysm or lower limb ischemia have the highest >risk >of postoperative cardiac complications because of the high prevalence of >coronary artery disease and the hemodynamic stresses associated with the >vascular procedures. The decision to perform preoperative coronary >angiography >should be reserved for only those patients who are deemed clinically >unstable or >are functionally limited by cardiac symptoms. _*Among patients with minimal >symptoms, preoperative coronary artery revascularization with either >coronary >artery bypass graft surgery or percutaneous coronary interventions delays >the >needed operation and does not improve short-term outcomes or long-term >survival. >*_ >PMID: 16401384 [PubMed] > >3: CMAJ. 2005 Sep 27;173(7):779-88. > >Surveillance and prevention of major perioperative ischemic cardiac events >in >patients undergoing noncardiac surgery: a review. > >Devereaux PJ, Goldman L, Yusuf S, Gilbert K, Leslie K, Guyatt GH. > >Department of Medicine, McMaster University, Hamilton, Ont. >philipj@mcmaster.ca > >This is the second of 2 articles evaluating cardiac events in patients >undergoing noncardiac surgery. Unrecognized myocardial infarctions (MIs) are >common, and up to 50% of perioperative MIs may go unrecognized if physicians >rely only on clinical signs or symptoms. In this article, we summarize the >evidence regarding monitoring strategies for perioperative MI in patients >undergoing noncardiac surgery. Perioperative troponin measurements and >12-lead >electrocardiograms can detect clinically silent MIs and provide independent >prognostic information. Currently, there are no standard diagnostic criteria >for >perioperative MIs in patients undergoing noncardiac surgery. We propose >diagnostic criteria that reflect the unique features of perioperative MIs. >Finally, we review the evidence for perioperative prophylactic cardiac >interventions. There is encouraging evidence that some perioperative >interventions (e.g., beta-blockers, alpha2-adrenergic agonists, statins) may >prevent major cardiac ischemic events, but firm conclusions await the >results of >large definitive trials./* */_*/The best evidence /does not support a >management >strategy of preoperative coronary revascularization before noncardiac >surgery.*_ > >Publication Types: > Research Support, Non-U.S. Gov't > Review > >PMID: 16186585 [PubMed - indexed for MEDLINE] > >4: Mt Sinai J Med. 2005 May;72(3):185-92. > >Preoperative cardiovascular evaluation for noncardiac surgery. > >Maddox TM. > >Zena and Michael A. Wiener Cardiovascular Institute, Box 1030, Mount Sinai >School of Medicine, One East 100th Street, New York, NY 10029-6574, USA. >tmaddox@alumni.rice.edu > >Cardiovascular complications following noncardiac surgery constitute an >enormous >burden of perioperative morbidity and mortality. Annually, more than one >million >operations are complicated by adverse cardiovascular events, such as >perioperative myocardial infarction or death from cardiac causes. In order >to >combat this problem, cardiac evaluation prior to noncardiac surgery should >ask >two questions about the patient: What is the risk of cardiac complications >during and after surgery? How can that risk be reduced or eliminated? Risk >assessment evaluates patients' co-morbidities and exercise tolerance, as >well as >the type of surgery to be performed, to determine the overall risk of >perioperative cardiac complications. Previous or current cardiac disease, >diabetes and renal insufficiency all confer higher risks for perioperative >cardiac complications. Poor exercise tolerance and high-risk surgical >procedures >(e.g., vascular, prolonged thoracic or abdominal operations) also predict >worse >perioperative outcomes. Noninvasive stress testing is widely used to help >predict risk of perioperative complications, but the poor predictive power >of >these tests hampers their usefulness. After estimating the risk of cardiac >complications, one should take measures to reduce it. Beta blockade has >shown >clear benefits in risk reduction. At this time, there are no data suggesting >benefits of percutaneous coronary intervention or coronary artery bypass >grafting in reducing noncardiac surgical risk. In addition, angioplasty with >stenting and its attendant need for anticoagulation can expose patients to >increased risk of perioperative bleeding. Thus, the use of coronary >revascularization prior to noncardiac surgery should be reserved for those >patients with an independent cardiac need for the procedure, such as >unstable >angina or stable angina refractory to medical therapy. In summary, patients >with >low clinical risk factors and good functional status, undergoing a low or >intermediate risk surgery, have an excellent prognosis and may proceed to >surgery without further delay. In addition, stable patients who have >previously >undergone coronary revascularization may also safely undergo surgery. >Patients >requiring urgent surgery should proceed immediately, since the consequences >of >delay usually outweigh the benefits of preoperative risk assessment. >However, >elective surgery should be indefinitely deferred for those patients with >unstable coronary syndromes, since consequences of the cardiac disease >usually >negate the benefits of surgery. Controversy involves the intermediate or >high >clinical risk patient considering high-risk, but elective, surgery. >Noninvasive >testing offers only limited assistance in estimating risk for these >patients. >_*The best risk reduction strategy for these patients is perioperative beta >blockade use. The role of coronary revascularization specifically to reduce >perioperative cardiac complications remains unproven.*_ > >Publication Types: > Review > >PMID: 15915313 [PubMed - indexed for MEDLINE] > >5: Am J Cardiol. 2004 Nov 1;94(9):1124-8. > >Disparate opinions regarding indications for coronary artery >revascularization >before elective vascular surgery. > >Pierpont GL, Moritz TE, Goldman S, Krupski WC, Littooy F, Ward HB, McFalls >EO; >Current Opinion On Revascularization Study Investigators. > >Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota 55417, >USA. >pierp002@umn.edu > >Despite consensus guidelines, the optimal strategy for preoperative cardiac >risk >management among patients scheduled for major noncardiac surgery remains >controversial. This study assesses current opinion about the role of >preoperative coronary revascularization for patients with coronary artery >disease scheduled for elective vascular surgery. Thirty-one practicing >cardiologists recruited from 4 different regions reviewed case records, >imaging >tests, and coronary angiograms of 12 patients with coronary artery disease >participating in the Coronary Artery Revascularization Prophylaxis (CARP) >trial. >The need for preoperative coronary revascularization was determined and >results >summarized using 3 categories: favoring conservative management, neutral, or >recommending revascularization (either by percutaneous intervention or >bypass >surgery). We found recommendations were frequently disparate and often >deviated >from published guidelines (40% of the time). The likelihood of discordance >between 2 cardiologists was 54%, with a 26% chance that recommendations for >revascularization would be directly contradictory. Opinions were more often >conservative (43%) or aggressive (40%) than neutral (17%). Similar >inconsistency >was found as to the preferred method of revascularization, with only 1 >patient >having complete agreement. _*Thus, this study reveals substantial >differences of >opinion among cardiologists across the country about the role of >preoperative >coronary artery revascularization for patients scheduled for elective >vascular >operations. Deviations from published guidelines are common, suggesting that >current consensus statements need additional data to support their >recommendations.*_ > >Publication Types: > Clinical Trial > Comparative Study > Randomized Controlled Trial > Research Support, U.S. Gov't, Non-P.H.S. > >PMID: 15518605 [PubMed - indexed for MEDLINE] > >6: J Vasc Surg. 2004 Oct;40(4):752-60. > >Long-term survival after vascular surgery: specific influence of cardiac >factors >and implications for preoperative evaluation. > >Back MR, Leo F, Cuthbertson D, Johnson BL, Shamesmd ML, Bandyk DF. > >Division of Vascular & Endovascular Surgery, University of South Florida >College >of Medicine, the Surgical Service, James A. Haley Veterans Hospital, Tampa, >FL, >USA. mback@hsc.usf.edu > >OBJECTIVE: We sought to identify specific determinants of long-term cardiac >events and survival in patients undergoing major arterial operations after >preoperative cardiac risk stratification by American College of >Cardiology/American Heart Association guidelines. A secondary goal was to >define >the potential long-term protective effect of previous coronary >revascularization >(coronary artery bypass grafting [CABG] or percutaneous coronary >intervention >[PCI]) in patients with vascular disease. METHODS: Four hundred fifty-nine >patients underwent risk stratification (high, intermediate, low) before 534 >consecutive elective or urgent (<24 hours after presentation) open >cerebrovascular, aortic, or lower limb reconstruction procedures between >August >1996 and January 2000. Long-term follow-up (mean, 56 +/- 14 months) was >possible >in 97% of patients. The Kaplan-Meier method was used for survival data. >Long-term prognostic variables were identified with the multivariate Cox >proportional hazards model and contingency table analysis censoring early >(<30 >days) perioperative deaths. RESULTS: While 5-year survival was 72% for the >overall cohort, cardiac causes accounted for only 24% of all deaths, and new >cardiac events (myocardial infarction, congestive heart failure, arrhythmia, >unstable angina, new coronary angiography, new CABG or PCI, cardiac death) >affected only 4.6% of patients per year during follow-up. High cardiac risk >stratification level (hazards ratio [HR], 2.2, 95% confidence interval [CI], >1.4-3.4), adverse perioperative cardiac events (myocardial infarction, >congestive heart failure, ventricular arrhythmia; HR, 2.2; 95% CI, 1.2-4.1), >and >age (HR, 0.33; 95% CI, 0.2-0.6) were independently prognostic for >latemortality. >Preoperative cardiac risk levels also correlated with new cardiac event >rates ( >P < .01) and late cardiac mortality ( P = .02). Modestly improved survival >in >patients who had undergone CABG or PCI less than 5 years before vascular >operations compared with those who had undergone revascularization 5 or more >years previously and those at high risk without previous coronary >intervention >(73% vs 58% vs 62% 5-year survival; P = .02) could be demonstrated with >univariate testing, but not with multivariate analysis. Type of operation, >urgency, noncardiac complications, and presence of diabetes did not affect >long-term survival. CONCLUSION: Despite cardiac events being a less common >cause >of late mortality after vascular surgery, perioperative cardiac factors >(age, >preoperative risk level, early cardiac complications) are the primary >determinants of patient longevity._/* Patients undergoing more recent (<5 >years) >CABG or PCI before vascular surgery do not have an obvious survival >advantage >compared with patients at high cardiac risk without previous coronary*/_ >/_*interventions.*_/ > >Publication Types: > Comparative Study > >PMID: 15472605 [PubMed - indexed for MEDLINE] > > >Hgrmd@aol.com wrote: >> Ben, >> You seem to be mixing apples and oranges a bit. I thought we were >> discussing whether coronary revascularization makes noncardiac surgery >less risky, >> not whether Mike's patient should get a CABG. Not withstanding the 2002 >> Circulation article reportedly showing no benefit of CABG and PCI in >lowering the >> risk of noncardiac surgery, go ahead and repair an AAA on a patient with >a >> critical left main. See how they do, and see how long it takes you to >end up >> in court. I can tell you that patients and families get pretty upset >when the >> patient has a perioperative MI. Furthermore, I don't know of any >reputable >> general, orthopedic, or vascular surgeon, or anesthesiologist for that >> matter, who will take a patient to surgery with a stress test showing a >lot of >> myocardium at risk. >> Hal >> >> >> >> ************************************** See what's free 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 >----------------------------------------- -- Ben Bidstrup FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon From anianyanwu at hotmail.com Tue May 1 07:34:03 2007 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Tue May 1 06:35:00 2007 Subject: [HSF] Possible infected Freestyle References: <69105.73212.qm@web50902.mail.re2.yahoo.com> <5fef6461.fa15.48ee.95c6.0b0913b91f43@aol.com> Message-ID: Dear Dr Martin But he did have pus coming out the wound in patient with bioprosthetic root- wound that not (at least relatively) indicate a CT scan? With pus streaming out subcutaneously and a substernal collection contiguous with the aorta is it not just wishful thinking if we conclude the two are unrelated? Usually as surgeons we tend to know when there is a problem. From the way the email is structured and reading between the lines in john's email, I would be surprised if this turns out to be nothing. We can hope but hope never takes problems away, they will come back to haunt us. It is unlikely that any surgeon would be contemplating a homograft for a patient who is not even infected so I would give John the benefit of the doubt - there may be something in the story which John either knows or feels but we are not privy to, hence his concern. It is also interesting though that several have suggested empriric antibiotics for this on one hand while in the other hand they insist it is not an infection. Either we treat it as an infection or we don't. If we chose to assume it is an infection then it needs surgical debridement. No amount of antibiotics can resolve it; indeed they may make situation worse by inducing chronicity and resistance. So to me either he is re-explored if John thinks he is septic or stop all antibiotics and observe if we don't think it is septic. There is little middle ground here. Ani ----- Original Message ----- From: Tdmartin2000 To: OpenHeart-L@lists.hsforum.com Sent: Tuesday, May 01, 2007 12:22 AM Subject: Re: [HSF] Possible infected Freestyle John Great case- this is what you get for getting the CT scan. It doesn't surprise me to have fluid around the graft. If you were to CT all pts with a root ascending repair at 8 wks I would expect a large number to have fluid around their graft. If you have no bacteria on gram stain and no growth and no evidence of any suture line breakdown, I would do nothing and repeat the CT scan in 2 to 4 wks. If it is infected he will declare himself. If you are forced to do anything surgically then at this point in time I would only explore his mediastinum, pulse lavage, and if there is any question of infection then put some omentum over/around the root. I would not redo his root unless there was some type of breakdown/pseudoaneurysm. I am assuming from your post that there was no direct communication between the substernal and subcu fluid collections. Let us know what you decide. Tom Martin U of Florida Gainesville In a message dated 04/30/07 00:42:39 Eastern Daylight Time, streitman@yahoo.com writes: HS forum members: I am new to the forum (recent grad from UF-2006 (hi Tom) but have been reading many of the threads and finally have a case I would like some input on. Three months ago I performed a Freestyle root (25mm)/ 4V CABG on an 80 y/o male with severe AS/ASCAD. I started out doing an AVR/CABG and could not get a 25 mosaic to sit appopriately and in trying to do so tore the aorta b/t the left main ostium and the annulus. Instead of trying to repair this and downsize the valve choice or enlarge an injured root, I elected to proceed with a 25-Freestyle and he did amazingly well (solid 80 y/o protoplasm). He was seen at 4 weeks and was d/c back to his cardiologist. Now 8 weeks out he came to my office with a small midsternal abscess (less that 1 cm) which I thought was just a suture abscess. I proceeded with CT scan which showed fluid around his root/asc aorta. The sternum appears well healed and is clinically stable. No fever, normal WBC and feels well. I opened the abscess to find pus and on GS there was no bact with many WBC's. Culture neg for >72 hrs on no abx prior. I was able to get a radiologist to sample the substernal fluid and this too had many WBC's w/o bacteria and so far (48 hrs) has been culture negative. He remains afebrile with a normal WBC. He will get a TEE tomorrow. ID has seen him and feels he needs root replacement and I have several homografts coming in. I am prepared to replace this root but is this the right answer? Any other ideas about how to determine what to do? Look forward to your input. John John E Streitman, M.D. Cardiovascular Surgeon Pinehurst Surgical streitman@yahoo.com __________________________________________________ Do You Yahoo!? Tired of spam? Yahoo! Mail has the best spam protection around http://mail.yahoo.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 Hgrmd at aol.com Tue May 1 08:30:55 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Tue May 1 07:31:31 2007 Subject: [HSF] Possible infected Freestyle Message-ID: John, Welcome to our club. I hope one of the principles you learn from this case is that less is often more. I don't know of many 80 yo patients who would truly benefit from the hassle of a 25 mm stented prosthesis. If you had placed a 23 mm C-E Magna, you would have gotten the same effective orifice area, and presumably not had this terrible complication. I'm not sure what Tea was implying about the use of pledgets on the aortotomy, but I recommend you use them liberally. Losing control of an aortotomy is a very lonely feeling. Hal ************************************** See what's free at http://www.aol.com. From Hgrmd at aol.com Tue May 1 08:37:12 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Tue May 1 07:41:32 2007 Subject: [HSF] Ascending Aortic Aneurysm Message-ID: Steve, With a 1.4 cm area, what is the diameter of the annulus on TEE? If it appears that you could get a 25 mm valve in, then it might be reasonable to replace the valve. Conversely, if he has a small annulus, whatever you use to replace the valve is unlikely to have an EOA much larger than with what you started. Hal ************************************** See what's free at http://www.aol.com. From Hgrmd at aol.com Tue May 1 08:45:04 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Tue May 1 07:45:40 2007 Subject: [HSF] Mitral Valve Message-ID: Ajit, Interesting paper that covers no new ground. I know John Byrne (one of my interns when I was a fellow) and Pitracek recently joined forces at Vanderbilt. I suspect the vast majority of cases are Pitracek's when he was at St. Thomas. Notice that most are replacements, rather than repairs. Is that due to patient selection, or lack of reparative skill? Also, notice they call this "ultra minimimally invasive". I guess my robotic approach with a 20 mm working port is "ultra, ultra minimally invasive". Hal ************************************** See what's free at http://www.aol.com. From prasannasimha at gmail.com Tue May 1 18:20:35 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Tue May 1 07:52:03 2007 Subject: [HSF] Mitral Valve In-Reply-To: <001301c78bc7$e321e2b0$0201a8c0@yourg8he5gjrox> References: <001301c78bc7$e321e2b0$0201a8c0@yourg8he5gjrox> Message-ID: <4637298B.9090809@gmail.com> Isn't this what Fredrick Mohr is doing ? My one worry with all these methods is the replacement of the safer aortic cannulation with a riskier femoral cannulation. Also non cross clamp continuous fibrillation while being old hat is a pain even with minimal AR. Prasanna Ajit Damle wrote: > For your comments, gentlemen. > > > > Ajit Damle > > > > > > > > ULTRA MINIMALLY INVASIVE MITRAL VALVE SURGERY WITHOUT AORTIC CROSS CLAMP > > Authors: Kumar, S.; Ahmad, R.; Greelish, J.; Petracek, M.; Balaguer, J.; Byrne, J. Source: ANZ Journal of Surgery, Volume 77, Supplement 1, May 2007, pp. A8-A8(1) Publisher: Blackwell Publishing > > > > Abstract: > > > > Objective? > > > > We developed a technique for mitral valve surgery through an ultra small (5?cm) right lateral thoracotomy without aortic cross clamp. This study reports our combined ST. Thomas and Vanderbilt Heart Institutes five years experience with this technique. > > ? > > Methods > > > > Six hundred and twenty five (316 M /309 F; aged 22-75 mean of 62 years) underwent ultra minimally invasive mitral valve surgery between August 2000 and June 2006. Through a 5 centimeter right lateral thoracotomy along the 4th intercostal space access to the pericardium and the left atrium was gained. Cardiopulmonary bypass was instituted through femoral cannulation. Under cold fibrillatory arrest (28?C) without aortic cross clamp, mitral valve repair (n?=?196) or replacement (n?=?380), in addition to mitral valve procedure we performed tricuspid valve repair (n?=?69), ASD/PFO closure (n?=?201) and Maze (n?=?156). Mean pre operative New York Heart Association function class was 2.2???0.9. Twenty eight patients had ejection fraction less than 20%. > > > > Results? > > > > Thirty-day mortality was 1.28% (n?=?8), Operating time, bypass time operating averaged 189???52, 113???35 minutes, respectively. Three patients had conversion to sternotomy. Fifteen patients (2.4%) underwent reexploration for bleeding. Average length of hospital stay from surgery to discharge was 6.85???3 days. Ten patients (1.6%) had neurological events. Renal failure required hemodialysis in 5 patients (0.81%). Long term follow-up results are awaited. > > > > Conclusions? > > > > This study demonstrate that this simplified technique of ultra minimally invasive mitral valve surgery is reproducible and provides the least invasive operative approach with low mortality and morbidity with good cosmetic results. > > _______________________________________________ > 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 Tue May 1 09:04:25 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Tue May 1 08:05:00 2007 Subject: [HSF] Too scared to touch..... Message-ID: Ajit, I invested the time it took to read all of Prasanna's abstracts. I'm still not convinced that medical therapy with beta-blockers is the way to go for nearly every case. Again, if a stress test in an asymptomatic patient shows a lot of myocardium with reversible ischemia, it would be potentially foolhardy not to cath that patient. Over the years, we've been referred lots of patients with left mains or critical 3vd that were cathed prior to an elective noncardiac procedure (usually carotid, ischemic leg, or AAA). We did the CABG, they eventually got the vascular procedure, and they did fine. I've yet to recall "graft closure" while the subsequent case was done. In light of the problems with DES, the cardiologists are much more likely to use bare metal stents in such scenarios. I do agree that beta blockade, possible Swan, and a competent cardiac anesthesiologist suffice for the vast majority of cardiac patients getting noncardiac surgery. However, there are plenty of asymptomatic cardiac time bombs waiting to explode for those that never cath and treat preemptively. Hal ************************************** See what's free at http://www.aol.com. From enaseri at hotmail.com.tr Tue May 1 13:14:17 2007 From: enaseri at hotmail.com.tr (=?iso-8859-9?B?ZXJkaW7nIG5hc2VyaQ==?=) Date: Tue May 1 08:15:14 2007 Subject: [HSF] Mitral Valve In-Reply-To: Message-ID: Hal, wish someday I will have the opportunity to see mitral repair through a 2 cm hole by you. erdinc >From: Hgrmd@aol.com >Reply-To: OpenHeart-L@lists.hsforum.com >To: OpenHeart-L@lists.hsforum.com >Subject: Re: [HSF] Mitral Valve >Date: Tue, 1 May 2007 07:45:04 EDT > >Ajit, > Interesting paper that covers no new ground. I know John Byrne (one of >my >interns when I was a fellow) and Pitracek recently joined forces at >Vanderbilt. I suspect the vast majority of cases are Pitracek's when he >was at St. >Thomas. Notice that most are replacements, rather than repairs. Is that >due >to patient selection, or lack of reparative skill? Also, notice they call >this >"ultra minimimally invasive". I guess my robotic approach with a 20 mm >working port is "ultra, ultra minimally invasive". > >Hal > > > >************************************** See what's free 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 >----------------------------------------- From Hgrmd at aol.com Tue May 1 09:11:30 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Tue May 1 08:15:52 2007 Subject: [HSF] Possible infected Freestyle Message-ID: Ani, You are even more binary and concrete than yours truly!! Though I'm the first to profess that I'm not an aortic expert, I have seen and read of instances where conservative therapy has worked well for mediastinal infections in the presence of aortic grafts. Coselli and others have written for years about treating some of these cases with omentum and life long antibiotics. As long as the patient is closely watched, the risk of waiting is not that great. Also, exchanging a Free Style for a homograft in an 80 yo by a new surgeon carries a hell of a lot of risk no matter how you slice it. Hal ************************************** See what's free at http://www.aol.com. From Hgrmd at aol.com Tue May 1 09:19:15 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Tue May 1 08:23:36 2007 Subject: [HSF] Mitral Valve Message-ID: Erdinc, When you make it to Florida, you have to come visit me, and I'll show you. Hal ************************************** See what's free at http://www.aol.com. From prasannasimha at gmail.com Tue May 1 18:56:50 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Tue May 1 08:28:12 2007 Subject: [HSF] Mitral Valve In-Reply-To: References: Message-ID: <4637320A.7090501@gmail.com> Count me in if I ever manage to get to Florida !! (Now that is called an unabashed self invitation ;-) ) Prasanna Hgrmd@aol.com wrote: > Erdinc, > When you make it to Florida, you have to come visit me, and I'll show you. > Hal > > > > ************************************** See what's free 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 > ----------------------------------------- > > > From prasannasimha at gmail.com Tue May 1 19:19:05 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Tue May 1 08:50:33 2007 Subject: [HSF] Too scared to touch..... In-Reply-To: References: Message-ID: <46373741.8030603@gmail.com> Hal, The reason I have shifted in my approach is after seeing the reverse happening too. In fact I had teamed up many years back with a cardiologist and we used to implant a BMS for say a circ lesion or CABG the patient and do some major vascular work and found our event rate was higher and then I shifted to selective treatment with vascular surgery first and sos stenting /CABG which had a far better result. I also had a bunch of aortic surgeries in inoperable CAD and they were managed very well with aggressive beta blockade , additional epidural for pain relief etc etc. In fact what triggered it all was a patient with inoperable CAD who had limb threatening ischemia and I did his aortobifemoral and when he started getting postop Ischemia ,I did a literature search and he improved dramatically with IV beta blockade and other measures and then this started me thinking. Obviously you have to be careful and every case would not qualify especially if the CAD is unstable but for stable CAD I really think we may be doing a disservice by treating the angio and not the patient.Obviously all of this requires good periop management, good pain relief and judicious fluid management. Prasanna Hgrmd@aol.com wrote: > Ajit, > I invested the time it took to read all of Prasanna's abstracts. I'm > still not convinced that medical therapy with beta-blockers is the way to go for > nearly every case. Again, if a stress test in an asymptomatic patient shows > a lot of myocardium with reversible ischemia, it would be potentially > foolhardy not to cath that patient. Over the years, we've been referred lots of > patients with left mains or critical 3vd that were cathed prior to an elective > noncardiac procedure (usually carotid, ischemic leg, or AAA). We did the > CABG, they eventually got the vascular procedure, and they did fine. I've yet to > recall "graft closure" while the subsequent case was done. In light of the > problems with DES, the cardiologists are much more likely to use bare metal > stents in such scenarios. > I do agree that beta blockade, possible Swan, and a competent cardiac > anesthesiologist suffice for the vast majority of cardiac patients getting > noncardiac surgery. However, there are plenty of asymptomatic cardiac time bombs > waiting to explode for those that never cath and treat preemptively. > Hal > > > > ************************************** See what's free 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 > ----------------------------------------- > > > From tdmartin2000 at aol.com Tue May 1 11:22:17 2007 From: tdmartin2000 at aol.com (tdmartin2000@aol.com) Date: Tue May 1 10:22:56 2007 Subject: [HSF] Possible infected Freestyle In-Reply-To: References: Message-ID: <8C95A1341CA37E2-4B8-9EC@WEBMAIL-MA11.sysops.aol.com> Hal A 25 Mosaic will easily fit in the same annulus as a 23 magna. So, if he were to have tried to place a 23 magna the same problem would have occured. The question to John would be if he thought he oversized. If so he should have tried a 23 Mosaic to begin with. What do you think John? Tom -----Original Message----- From: Hgrmd@aol.com To: OpenHeart-L@lists.hsforum.com Sent: Tue, 1 May 2007 7:30 AM Subject: Re: [HSF] Possible infected Freestyle John, Welcome to our club. I hope one of the principles you learn from this case is that less is often more. I don't know of many 80 yo patients who would truly benefit from the hassle of a 25 mm stented prosthesis. If you had placed a 23 mm C-E Magna, you would have gotten the same effective orifice area, and presumably not had this terrible complication. I'm not sure what Tea was implying about the use of pledgets on the aortotomy, but I recommend you use them liberally. Losing control of an aortotomy is a very lonely feeling. Hal ************************************** See what's free 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. From tdmartin2000 at aol.com Tue May 1 11:24:17 2007 From: tdmartin2000 at aol.com (tdmartin2000@aol.com) Date: Tue May 1 10:24:54 2007 Subject: [HSF] Possible infected Freestyle In-Reply-To: References: Message-ID: <8C95A138910467F-4B8-A18@WEBMAIL-MA11.sysops.aol.com> Just for discussion sake- has anyone ever heard of a "sterile " abscess where there are multiple wbc's but no bacteria? Tom Martin U of Florida Gainesville -----Original Message----- From: Hgrmd@aol.com To: OpenHeart-L@lists.hsforum.com Sent: Tue, 1 May 2007 8:11 AM Subject: Re: [HSF] Possible infected Freestyle Ani, You are even more binary and concrete than yours truly!! Though I'm the first to profess that I'm not an aortic expert, I have seen and read of instances where conservative therapy has worked well for mediastinal infections in the presence of aortic grafts. Coselli and others have written for years about treating some of these cases with omentum and life long antibiotics. As long as the patient is closely watched, the risk of waiting is not that great. Also, exchanging a Free Style for a homograft in an 80 yo by a new surgeon carries a hell of a lot of risk no matter how you slice it. Hal ************************************** See what's free 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. From prasannasimha at gmail.com Tue May 1 21:07:36 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Tue May 1 10:39:00 2007 Subject: [HSF] Possible infected Freestyle In-Reply-To: <8C95A1341CA37E2-4B8-9EC@WEBMAIL-MA11.sysops.aol.com> References: <8C95A1341CA37E2-4B8-9EC@WEBMAIL-MA11.sysops.aol.com> Message-ID: <463750B0.4050302@gmail.com> One of the worse mistakes to do is to try to shove too large a prosthesis into an aorta. This seems to be compounded in bioprosthesis with their struts. I think if you have had the misfortune of doing it ,augmentation of the aortotomy needs to be doe to prevent the aorta tearing and also to prevent sleeving of the aorta over the bioprosthesis compromising coronary flow. As far as pledgets on thin aortae, I think the best thing is to avoid bleeding in the first place by using a finer suture and closer bites and more importantly to "decompress" the aorta with CPB or SNP flushes and to take any subsequent bites on a non "pressurized" aorta.One more thing is to clear the aorta of adventitia or reverse flap the adventitia to act as an autopledget that seems to work well. (I think I sent the photo once some time back). I also prefer pericardial pledgets compared to Teflon as far as possible especially the U pledgets that act as both local tamponade in addition to pledgets. http://ctsurgcomplications.wikia.com/wiki/Image:Hemostasis_aorta1.jpg http://ctsurgcomplications.wikia.com/wiki/Complications_related_to_Arterial_cannulation (Have to restart reediting the Wiki - having too much of Kitty (veterinary) problems of late with my kitten !!) Prasanna tdmartin2000@aol.com wrote: > Hal > A 25 Mosaic will easily fit in the same annulus as a 23 magna. So, if he were to have tried to place a 23 magna the same problem would have occured. The question to John would be if he thought he oversized. If so he should have tried a 23 Mosaic to begin with. > What do you think John? > Tom > > -----Original Message----- > From: Hgrmd@aol.com > To: OpenHeart-L@lists.hsforum.com > Sent: Tue, 1 May 2007 7:30 AM > Subject: Re: [HSF] Possible infected Freestyle > > > John, > Welcome to our club. I hope one of the principles you learn from this > case is that less is often more. I don't know of many 80 yo patients who would > > truly benefit from the hassle of a 25 mm stented prosthesis. If you had > placed a 23 mm C-E Magna, you would have gotten the same effective orifice > area, > and presumably not had this terrible complication. I'm not sure what Tea was > implying about the use of pledgets on the aortotomy, but I recommend you use > them liberally. Losing control of an aortotomy is a very lonely feeling. > Hal > > > > ************************************** See what's free 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 > ----------------------------------------- > > > From Hgrmd at aol.com Tue May 1 11:39:19 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Tue May 1 10:43:43 2007 Subject: [HSF] Possible infected Freestyle Message-ID: Sorry, Tom. I'm not following your logic. What makes you think a 25 Mosaic will fit as well as a 23 Magna? Unless there are sizing discrepancies between the 2 companies valves (which I've seen), the smaller valve should fit more easily than the larger one. Parenthetically, though I'm sure you are aware, the Magna is designed such that it's 19mm valve has the same EOA as its 21mm Perimount. They do this by thinning out the stent and sewing ring. I've been using them for about a year, and have been pleased with their performance so far. In the larger annuli, it probably doesn't make much difference. However, for the smaller roots the hemodynamic data I've seen (company provided, of course) appear favorable. Hal ************************************** See what's free at http://www.aol.com. From prasannasimha at gmail.com Tue May 1 21:18:08 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Tue May 1 10:49:33 2007 Subject: [HSF] Possible infected Freestyle In-Reply-To: References: Message-ID: <46375328.7040404@gmail.com> Not sure about ring sizes in large sizes as ring trimming is typically only done for size 19 by most companies.(It was actually started by Medtronic who started the 20 size valve which had a trimmed 19 ring) Prasanna Hgrmd@aol.com wrote: > Sorry, Tom. I'm not following your logic. What makes you think a 25 Mosaic > will fit as well as a 23 Magna? Unless there are sizing discrepancies > between the 2 companies valves (which I've seen), the smaller valve should fit > more easily than the larger one. Parenthetically, though I'm sure you are > aware, the Magna is designed such that it's 19mm valve has the same EOA as its > 21mm Perimount. They do this by thinning out the stent and sewing ring. I've > been using them for about a year, and have been pleased with their performance > so far. In the larger annuli, it probably doesn't make much difference. > However, for the smaller roots the hemodynamic data I've seen (company > provided, of course) appear favorable. > > Hal > > > > ************************************** See what's free 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 > ----------------------------------------- > > From nfaabouseada at gmail.com Tue May 1 11:20:04 2007 From: nfaabouseada at gmail.com (Nasser F. Abou'Seada) Date: Tue May 1 11:26:57 2007 Subject: [HSF] Too scared to touch..... In-Reply-To: <517121.47043.qm@web26701.mail.ukl.yahoo.com> References: <517121.47043.qm@web26701.mail.ukl.yahoo.com> Message-ID: You've got the guts to do such case dave. I'd follow Hal's opinion by all means. NFA On 4/28/07, David Harris wrote: > > This would be the ideal patient for a hybrid / MIDCAB > approach. No risk from the sternotomy in obese > patient. If the MIDCAB is done properly, and I am sure > your cardiologist is aware of this, the risk will be > minimal. This is a typical kind of patient we see > thesedays......we become our worst enemies if we do > not accept these cases for surgery. The > (liberal)indications for the CABG in this patient > should be the same as any other patient. If you do > this one well via a MIDCAB, the cardiologist will take > notice and may think twice before stenting the LAD > next time. > > Dave Harris > > > --- Ani Anyanwu wrote: > > > Actually in this case Michael you do know the other > > devil. Easy to work out likely scenario if you did > > operate. How obese is obese here anyway? > > > > Ani > > ----- Original Message ----- > > From: Michael > > Firstenberg > > To: > > > OpenHeart-L@lists.hsforum.com > > > > Sent: Saturday, April 28, 2007 11:01 AM > > Subject: Re: [HSF] Too scared to touch..... > > > > > > That is a major part of our argument not to > > operate. > > She came in with a RCA/RV problem - and that was > > taken care of. > > Everyone is just "scared" of the LAD/Cx disease > > (not that bad though) > > and thinks that CABG will save everything...... > > > > > > resisting the oculo-graft reflex (i.e see > > blockage - needs graft) > > > > the devil you know vs the devil you dont. > > > > she needs medical management (I dont even think > > she came in on beta- > > blockers/statin/etc) > > > > > > -michael > > > > > > > > On Apr 28, 2007, at 10:51 AM, Ani Anyanwu wrote: > > > > > Michael, > > > > > > What would be the indication for surgery at the > > present time? > > > > > > Ani > > > ----- Original Message ----- > > > From: Michael > > > Firstenberg> > > > To: > > > OpenHeart-L@lists.hsforum.com OpenHeart-L@lists.hsforum.com%3Cmailto:OpenHeart>- > > > > > L@lists.hsforum.com> > > > Sent: Saturday, April 28, 2007 10:36 AM > > > Subject: [HSF] Too scared to touch..... > > > > > > > > > Would anyone do anything different? > > > > > > 52 year/old, multiple medical problems (poorly > > controlled diabetes, > > > hypertension, high lipids of course - and dont > > forget obese). Known > > > brain AVM, cryptogenic cirrhosis with history > > of varices/bleeding/ > > > blakemore tube (the works, but nothing recent > > and LFTs/proteins not > > > too bad) - treated with mesocaval shunt for > > portal vein > > > thrombosis in > > > 1999. Splenic embolization also. Chronic > > anemia and renal > > > insufficiency. CT scan of abdomen "suggests > > carcinomatosis" - > > > slightly worse over past "couple of years" - > > but no primary (CA125 > > > elevated to ~60 baseline in our hospital > > 0-40, already had TAH-BSO > > > years ago). About six months ago, fell and > > got a "hairline" > > > fracture > > > of left hip - no intervention, but developed a > > DVT in right leg. > > > Recently, fell again (may have been near > > syncope) and broke right > > > ankle in several places. Admitted to outside > > hospital after fall, > > > hypotensive, found to have a troponin of ~20 > > with a moderate RV > > > infarct. Taken to cath lab for PCI (BMS to > > occluded right - > > > interesting as she was on coumadin) - opened > > up, but also has > > > significant LAD/Cx disease. Good targets. > > Cardiology asking for > > > off- > > > pump LIMA-LAD and they will do a protected > > left main stent. > > > Anesthesia and Ortho doesnt want to fix her > > ankle until her heart is > > > taken care of. > > > > > > Would anyone operate? > > > > > > Cardiology somewhat understanding of our > > reluctance to "take the > > > high > > > potential operative mortality hit" and in fact > > they are not sure > > > they > > > even want to "take the PCI hit". To be > > honest, we all want to try > > > and help (not sure of the long term benefit as > > no one has any > > > idea of > > > her long-term prognosis), but no one wants to > > have a potential CABG > > > mortality. > > > > > > Hal - can I send her to you? > > > > > > > > > -michael > > > > > _______________________________________________ > > > OpenHeart-L mailing list > > > > > > Send postings to: > > > > > > OpenHeart-L@lists.hsforum.com OpenHeart-L@lists.hsforum.com%3Cmailto:OpenHeart-L@lists.hsforum.com>> > > > > > > To UNSUBSCRIBE, to CHANGE email address, or to > > view archives: > > > > > > http://mmp.cjp.com/mailman/listinfo/openheart-l http://mmp.cjp.com/mailman/listinfo/openheart-l%3Chttp://> > > > > > 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 http://www.hsforum.com/listdisclaim%3Chttp://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< > 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< > 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 > > ----------------------------------------- > > > === message truncated === > > > Dr. David G. Harris, FCS, MMED, > Cardiothoracic Surgeon > Suite 207 > Kuils River Private Hospital, > PO Box 1200, Kuils River, 7579, Cape Town, South Africa. > Tel +27-21-9006411 > Fax +27-21-9006412 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 > ----------------------------------------- > -- Nasser F. Abou'Seada, MB,ChB,MD,FRCSEd,ChM,ChD C/Th, FICS,FISCVS,FSSRCTS,FHMS,MESC From prasannasimha at gmail.com Tue May 1 21:03:11 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Tue May 1 11:33:34 2007 Subject: [HSF] Possible infected Freestyle In-Reply-To: <8C95A138910467F-4B8-A18@WEBMAIL-MA11.sysops.aol.com> References: <8C95A138910467F-4B8-A18@WEBMAIL-MA11.sysops.aol.com> Message-ID: <46374FA7.3040609@gmail.com> Incidentally if the net result is sterile collection the CT scan would make him a victim of VOMIT http://ctsurgcomplications.wikia.com/wiki/VOMIT:_victim_of_medical_%28or_modern%29_imaging_%28or_investigational%29_technology Prasanna tdmartin2000@aol.com wrote: > Just for discussion sake- has anyone ever heard of a "sterile " abscess where there are multiple wbc's but no bacteria? > > Tom Martin > U of Florida > Gainesville > > -----Original Message----- > From: Hgrmd@aol.com > To: OpenHeart-L@lists.hsforum.com > Sent: Tue, 1 May 2007 8:11 AM > Subject: Re: [HSF] Possible infected Freestyle > > > Ani, > You are even more binary and concrete than yours truly!! Though I'm the > first to profess that I'm not an aortic expert, I have seen and read of > instances where conservative therapy has worked well for mediastinal infections > in > the presence of aortic grafts. Coselli and others have written for years > about treating some of these cases with omentum and life long antibiotics. As > long as the patient is closely watched, the risk of waiting is not that great. > > Also, exchanging a Free Style for a homograft in an 80 yo by a new surgeon > carries a hell of a lot of risk no matter how you slice it. > Hal > > > > ************************************** See what's free 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 > ----------------------------------------- > > > From enaseri at hotmail.com.tr Tue May 1 17:09:24 2007 From: enaseri at hotmail.com.tr (=?iso-8859-9?B?ZXJkaW7nIG5hc2VyaQ==?=) Date: Tue May 1 12:10:16 2007 Subject: [HSF] Possible infected Freestyle In-Reply-To: Message-ID: Ani, Agree with you completely.Considering that there is a prosthetic material with a collection of fluid composed mainly of wbc albeit sterile any treatment short of removal of the graft will only prolog the problem with no change in the ultimate prognosis. erdinc. >From: "Ani Anyanwu" >Reply-To: OpenHeart-L@lists.hsforum.com >To: >Subject: Re: [HSF] Possible infected Freestyle >Date: Tue, 1 May 2007 06:34:03 -0400 > >Dear Dr Martin > >But he did have pus coming out the wound in patient with bioprosthetic >root- wound that not (at least relatively) indicate a CT scan? > >With pus streaming out subcutaneously and a substernal collection >contiguous with the aorta is it not just wishful thinking if we conclude >the two are unrelated? Usually as surgeons we tend to know when there is a >problem. From the way the email is structured and reading between the lines >in john's email, I would be surprised if this turns out to be nothing. We >can hope but hope never takes problems away, they will come back to haunt >us. It is unlikely that any surgeon would be contemplating a homograft for >a patient who is not even infected so I would give John the benefit of the >doubt - there may be something in the story which John either knows or >feels but we are not privy to, hence his concern. > >It is also interesting though that several have suggested empriric >antibiotics for this on one hand while in the other hand they insist it is >not an infection. Either we treat it as an infection or we don't. If we >chose to assume it is an infection then it needs surgical debridement. No >amount of antibiotics can resolve it; indeed they may make situation worse >by inducing chronicity and resistance. So to me either he is re-explored if >John thinks he is septic or stop all antibiotics and observe if we don't >think it is septic. There is little middle ground here. > >Ani > ----- Original Message ----- > From: Tdmartin2000 > To: OpenHeart-L@lists.hsforum.com > Sent: Tuesday, May 01, 2007 12:22 AM > Subject: Re: [HSF] Possible infected Freestyle > > > John > Great case- this is what you get for getting the CT scan. It doesn't >surprise me to have fluid around the graft. If you were to CT all pts with >a root ascending repair at 8 wks I would expect a large number to have >fluid around their graft. > If you have no bacteria on gram stain and no growth and no evidence of >any suture line breakdown, I would do nothing and repeat the CT scan in 2 >to 4 wks. If it is infected he will declare himself. > If you are forced to do anything surgically then at this point in time I >would only explore his mediastinum, pulse lavage, and if there is any >question of infection then put some omentum over/around the root. I would >not redo his root unless there was some type of breakdown/pseudoaneurysm. > I am assuming from your post that there was no direct communication >between the substernal and subcu fluid collections. > Let us know what you decide. > > Tom Martin > U of Florida > Gainesville > > > > > In a message dated 04/30/07 00:42:39 Eastern Daylight Time, >streitman@yahoo.com writes: > HS forum members: > > I am new to the forum (recent grad from UF-2006 (hi > Tom) but have been reading many of the threads and > finally have a case I would like some input on. Three > months ago I performed a Freestyle root (25mm)/ 4V > CABG on an 80 y/o male with severe AS/ASCAD. I > started out doing an AVR/CABG and could not get a 25 > mosaic to sit appopriately and in trying to do so tore > the aorta b/t the left main ostium and the annulus. > Instead of trying to repair this and downsize the > valve choice or enlarge an injured root, I elected to > proceed with a 25-Freestyle and he did amazingly well > (solid 80 y/o protoplasm). He was seen at 4 weeks and > was d/c back to his cardiologist. Now 8 weeks out he > came to my office with a small midsternal abscess > (less that 1 cm) which I thought was just a suture > abscess. I proceeded with CT scan which showed fluid > around his root/asc aorta. The sternum appears well > healed and is clinically stable. No fever, normal WBC > and feels well. I opened the abscess to find pus and > on GS there was no bact with many WBC's. Culture neg > for >72 hrs on no abx prior. I was able to get a > radiologist to sample the substernal fluid and this > too had many WBC's w/o bacteria and so far (48 hrs) > has been culture negative. He remains afebrile with a > normal WBC. He will get a TEE tomorrow. ID has seen > him and feels he needs root replacement and I have > several homografts coming in. I am prepared to > replace this root but is this the right answer? Any > other ideas about how to determine what to do? Look > forward to your input. > > John > > John E Streitman, M.D. > Cardiovascular Surgeon > Pinehurst Surgical > streitman@yahoo.com > > __________________________________________________ > Do You Yahoo!? > Tired of spam? Yahoo! Mail has the best spam protection around > http://mail.yahoo.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 >----------------------------------------- From otto at iafrica.com Tue May 1 19:13:32 2007 From: otto at iafrica.com (Otto Thaning) Date: Tue May 1 12:14:11 2007 Subject: [HSF] Sterna-Band chest closure References: <268361.844.qm@web26715.mail.ukl.yahoo.com> Message-ID: <000801c78c0b$aa9a5b40$0200a8c0@your35b02f5053> Yes I use them often in obese patients but in addition to the usual sternal wire closure routines. I will get the details of the suppliers to you. Otto Thaning CBMH Cape Town ----- Original Message ----- From: "David Harris" To: Sent: Monday, April 30, 2007 12:31 AM Subject: [HSF] Sterna-Band chest closure > Are any members using above for augmenting chest > closure. > > I am keen to use it in obese patients. > > Does anyone have contact details of distributors? I > cannot track them down, even on the internet > > Dr. David G. Harris, FCS, MMED, > Cardiothoracic Surgeon > Suite 207 > Kuils River Private Hospital, > PO Box 1200, Kuils River, 7579, Cape Town, South Africa. > Tel +27-21-9006411 > Fax +27-21-9006412 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 johnschor at mac.com Tue May 1 11:40:29 2007 From: johnschor at mac.com (John Schor) Date: Tue May 1 13:41:14 2007 Subject: [HSF] Ascending Aortic Aneurysm In-Reply-To: References: Message-ID: <5D9EB8E2-7712-4318-82CC-9BBAA16CAC7B@mac.com> If the valve is bicuspid, AVR + Root. If not, it's a judgement call.......I would tend to replace in an older person or one with otherwise limited lifespan who would be a high risk redo. John John Schor, MD PO Box 4445 Cottonwood, AZ 86326 On May 1, 2007, at 4:37 AM, Hgrmd@aol.com wrote: > Steve, > With a 1.4 cm area, what is the diameter of the annulus on TEE? > If it > appears that you could get a 25 mm valve in, then it might be > reasonable to > replace the valve. Conversely, if he has a small annulus, > whatever you use to > replace the valve is unlikely to have an EOA much larger than with > what you > started. > Hal > > > > ************************************** See what's free 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 > ----------------------------------------- From mdavalle at aol.com Tue May 1 16:28:06 2007 From: mdavalle at aol.com (mdavalle@aol.com) Date: Tue May 1 15:28:51 2007 Subject: [HSF] Ascending Aortic Aneurysm In-Reply-To: <24fa2966cc4b9ad0cd77dc6a3627e56d@mac.com> References: <24fa2966cc4b9ad0cd77dc6a3627e56d@mac.com> Message-ID: <8C95A3DFAB9BB73-3D4-1C60@WEBMAIL-RB15.sysops.aol.com> Exactly where is the proper leval to measure the ascending aorta? Sinotubular junction? coronary sinuses? There is often 1 to 1.5 cm difference at these levels so I am not sure where they are referring when it comes to the size that requires replacement. -----Original Message----- From: smschwartz@mac.com To: OpenHeart-L@lists.hsforum.com Sent: Mon, 30 Apr 2007 10:28 PM Subject: [HSF] Ascending Aortic Aneurysm 59 yo male with "atypical chest pain" had CT scan of chest done. 6 cm ascending aortic aneurysm identified, reportedly ends at level of innominate artery. My question centers around a recent echo which showed an aortic valve area of 1.4 cm2. Should the valve be addressed? Just a "tube graft"? Steve Schwartz _______________________________________________ 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 streitman at yahoo.com Tue May 1 14:49:25 2007 From: streitman at yahoo.com (john streitman) Date: Tue May 1 16:50:56 2007 Subject: [HSF] Possible infected Freestyle In-Reply-To: Message-ID: <9649.99036.qm@web50909.mail.re2.yahoo.com> Hal, Unfortunately at the time the only valve on the shelf was Medtronic. I am new here but have finally gotten Edwards valves on the shelf. I have spent the past several months trying to sort out the propoganda regarding tissue aortic valve data. I have found several things interesting. Specifically comparing the Mosaic Ultra to the Perimount Magna, I have found that the sizers for these valves are not the same. If you look at the barrel end of both sets, the Magna is true to size (ie 25 is 25) and the Ultra barrel end is smaller than stated ( a 25 is really 23mm in diameter). What this does in my opinion is make you think you are getting a bigger Medtronic valve in the same sized hole. I think the EOA size for size b/t the two is better in the Edwards valve. I guess what I am getting at is I believe that the Magna is a better choice from an EOA/gradient standpoint and now have that available. John --- Hgrmd@aol.com wrote: > John, > Welcome to our club. I hope one of the principles > you learn from this > case is that less is often more. I don't know of > many 80 yo patients who would > truly benefit from the hassle of a 25 mm stented > prosthesis. If you had > placed a 23 mm C-E Magna, you would have gotten the > same effective orifice area, > and presumably not had this terrible complication. > I'm not sure what Tea was > implying about the use of pledgets on the > aortotomy, but I recommend you use > them liberally. Losing control of an aortotomy is > a very lonely feeling. > Hal > > > > ************************************** See what's > free 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 > ----------------------------------------- > John E Streitman, M.D. Cardiovascular Surgeon Pinehurst Surgical streitman@yahoo.com __________________________________________________ Do You Yahoo!? Tired of spam? Yahoo! Mail has the best spam protection around http://mail.yahoo.com From donross at bigpond.com Wed May 2 07:56:31 2007 From: donross at bigpond.com (Donald Ross) Date: Tue May 1 16:58:03 2007 Subject: [HSF] Too scared to touch..... In-Reply-To: References: Message-ID: <34B8F55A-C67F-4ECF-B571-420173412656@bigpond.com> Also, one wonders about the not infrequent peri-op AMIs during non- cardiac surgery that come our way for revascularisation prior to discharge. Is this unnecessary surgery as well, given it carries the same indications as regular coronary surgery? Don On 01/05/2007, at 10:04 PM, Hgrmd@aol.com wrote: > Ajit, > I invested the time it took to read all of Prasanna's > abstracts. I'm > still not convinced that medical therapy with beta-blockers is the > way to go for > nearly every case. Again, if a stress test in an asymptomatic > patient shows > a lot of myocardium with reversible ischemia, it would be potentially > foolhardy not to cath that patient. Over the years, we've been > referred lots of > patients with left mains or critical 3vd that were cathed prior to > an elective > noncardiac procedure (usually carotid, ischemic leg, or AAA). We > did the > CABG, they eventually got the vascular procedure, and they did > fine. I've yet to > recall "graft closure" while the subsequent case was done. In > light of the > problems with DES, the cardiologists are much more likely to use > bare metal > stents in such scenarios. > I do agree that beta blockade, possible Swan, and a competent > cardiac > anesthesiologist suffice for the vast majority of cardiac patients > getting > noncardiac surgery. However, there are plenty of asymptomatic > cardiac time bombs > waiting to explode for those that never cath and treat preemptively. > Hal > > > > ************************************** See what's free 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 > ----------------------------------------- From tacuff at swbell.net Tue May 1 17:24:29 2007 From: tacuff at swbell.net (Tea Acuff) Date: Tue May 1 19:24:58 2007 Subject: [HSF] To Treat the Dead Message-ID: <989822.10501.qm@web81611.mail.mud.yahoo.com> I wondered it anyone has been doing any study in this space...the putative dead. Some of this would make sense with the gap I am seeing on cardiac MR between live but "hybernating" muscle that responds (eventually) to revascularization and old scar. The stuff in the gap is thinned out muscle without scarrring, which is what one expect to see if apoptosis is the cause. I don't think this article is referring to the anoxic brain, but maybe that is a space for work also. Tomas, any comments on the heart? tea See article below: http://www.msnbc.msn.com/id/18368186/site/newsweek?GT1=9951 From hgrmd at aol.com Tue May 1 21:03:37 2007 From: hgrmd at aol.com (hgrmd@aol.com) Date: Tue May 1 20:08:00 2007 Subject: [HSF] Possible infected Freestyle In-Reply-To: <9649.99036.qm@web50909.mail.re2.yahoo.com> Message-ID: <8C95A64777F8107-19D4-28E9@mblk-d15.sysops.aol.com> John, Obviously, I agree with your choice. BTW, since this was a recent hot topic, I have absolutely no vested interest in what valve or ring anyone uses. I do firmly believe that the Magna is currently the best aortic bioprosthesis available for the average case. I know of some other valves in testing that may eventually change my opinion. Hal -----Original Message----- From: streitman@yahoo.com To: OpenHeart-L@lists.hsforum.com Sent: Tue, 1 May 2007 4:49 PM Subject: Re: [HSF] Possible infected Freestyle Hal, Unfortunately at the time the only valve on the shelf was Medtronic. I am new here but have finally gotten Edwards valves on the shelf. I have spent the past several months trying to sort out the propoganda regarding tissue aortic valve data. I have found several things interesting. Specifically comparing the Mosaic Ultra to the Perimount Magna, I have found that the sizers for these valves are not the same. If you look at the barrel end of both sets, the Magna is true to size (ie 25 is 25) and the Ultra barrel end is smaller than stated ( a 25 is really 23mm in diameter). What this does in my opinion is make you think you are getting a bigger Medtronic valve in the same sized hole. I think the EOA size for size b/t the two is better in the Edwards valve. I guess what I am getting at is I believe that the Magna is a better choice from an EOA/gradient standpoint and now have that available. John --- Hgrmd@aol.com wrote: > John, > Welcome to our club. I hope one of the principles > you learn from this > case is that less is often more. I don't know of > many 80 yo patients who would > truly benefit from the hassle of a 25 mm stented > prosthesis. If you had > placed a 23 mm C-E Magna, you would have gotten the > same effective orifice area, > and presumably not had this terrible complication. > I'm not sure what Tea was > implying about the use of pledgets on the > aortotomy, but I recommend you use > them liberally. Losing control of an aortotomy is > a very lonely feeling. > Hal > > > > ************************************** See what's > free 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 > ----------------------------------------- > John E Streitman, M.D. Cardiovascular Surgeon Pinehurst Surgical streitman@yahoo.com __________________________________________________ Do You Yahoo!? Tired of spam? Yahoo! Mail has the best spam protection around http://mail.yahoo.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. From prasannasimha at gmail.com Wed May 2 07:23:59 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Tue May 1 20:55:25 2007 Subject: [HSF] Too scared to touch..... In-Reply-To: <34B8F55A-C67F-4ECF-B571-420173412656@bigpond.com> References: <34B8F55A-C67F-4ECF-B571-420173412656@bigpond.com> Message-ID: <4637E127.9000503@gmail.com> Where in literature has it been shown that a patient who is stable after an MI benefits from urgent in house revascularization ? Prasanna Donald Ross wrote: > Also, one wonders about the not infrequent peri-op AMIs during > non-cardiac surgery that come our way for revascularisation prior to > discharge. > Is this unnecessary surgery as well, given it carries the same > indications as regular coronary surgery? > Don > On 01/05/2007, at 10:04 PM, Hgrmd@aol.com wrote: > >> Ajit, >> I invested the time it took to read all of Prasanna's abstracts. I'm >> still not convinced that medical therapy with beta-blockers is the >> way to go for >> nearly every case. Again, if a stress test in an asymptomatic >> patient shows >> a lot of myocardium with reversible ischemia, it would be potentially >> foolhardy not to cath that patient. Over the years, we've been >> referred lots of >> patients with left mains or critical 3vd that were cathed prior to >> an elective >> noncardiac procedure (usually carotid, ischemic leg, or AAA). We >> did the >> CABG, they eventually got the vascular procedure, and they did >> fine. I've yet to >> recall "graft closure" while the subsequent case was done. In light >> of the >> problems with DES, the cardiologists are much more likely to use >> bare metal >> stents in such scenarios. >> I do agree that beta blockade, possible Swan, and a competent cardiac >> anesthesiologist suffice for the vast majority of cardiac patients >> getting >> noncardiac surgery. However, there are plenty of asymptomatic >> cardiac time bombs >> waiting to explode for those that never cath and treat preemptively. >> Hal >> >> >> >> ************************************** See what's free 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 anddisclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > From prasannasimha at gmail.com Wed May 2 07:28:54 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Tue May 1 22:01:14 2007 Subject: [HSF] To Treat the Dead In-Reply-To: <989822.10501.qm@web81611.mail.mud.yahoo.com> References: <989822.10501.qm@web81611.mail.mud.yahoo.com> Message-ID: <4637E24E.1080108@gmail.com> That was what the science of Cryonics is all about. Prasanna Tea Acuff wrote: > I wondered it anyone has been doing any study in this space...the putative dead. Some of this would make sense with the gap I am seeing on cardiac MR between live but "hybernating" muscle that responds (eventually) to revascularization and old scar. The stuff in the gap is thinned out muscle without scarrring, which is what one expect to see if apoptosis is the cause. I don't think this article is referring to the anoxic brain, but maybe that is a space for work also. > Tomas, any comments on the heart? > tea > > See article below: > http://www.msnbc.msn.com/id/18368186/site/newsweek?GT1=9951 > _______________________________________________ > 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 tdmartin2000 at aol.com Tue May 1 23:32:02 2007 From: tdmartin2000 at aol.com (Tdmartin2000) Date: Tue May 1 22:36:43 2007 Subject: [HSF] Valve sizing F/U to infected freestyle In-Reply-To: References: Message-ID: <028d9d70.abf5.4ee5.9cd2.ec5dfd2be8d4@aol.com> Hal It's all marketing smoke and mirrors. I have used every valve and valve sizer possible and have put them all to the test by getting sizers from each company and then trying them in the same annulus. I guarantee you that in any annulus you size to a 21 Magna you will size it to a 23 Mosaic. The sizers are completely different. That is why Edwards always says that "size for size" their valve is significantly better in terms of GOA and EOA. That statement is technically true if you use the labeled sizes. But again, they are not the same and you can