[HSF] Too scared to touch.....

[Ben Bidstrup]

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 at lists.hsforum.com
>[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of prasannasimha
>Sent: Sunday, April 29, 2007 8:55 PM
>To: OpenHeart-L at 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 at 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 at 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 at 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 at 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 at 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 at lists.hsforum.com
>>
>>  To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>>  http://mmp.cjp.com/mailman/listinfo/openheart-l
>>
>>  All messages transmitted by the OpenHeart-L are subject to the policies
>and
>>  disclaimers posted at:
>>  http://www.hsforum.com/listdisclaim
>>  -----------------------------------------
>>
>>
>
>_______________________________________________
>OpenHeart-L mailing list
>
>Send postings to:
>  OpenHeart-L at lists.hsforum.com
>
>To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>http://mmp.cjp.com/mailman/listinfo/openheart-l
>
>All messages transmitted by the OpenHeart-L are subject to the policies and
>disclaimers posted at:
>http://www.hsforum.com/listdisclaim
>-----------------------------------------
>
>_______________________________________________
>OpenHeart-L mailing list
>
>Send postings to:
>  OpenHeart-L at lists.hsforum.com
>
>To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>http://mmp.cjp.com/mailman/listinfo/openheart-l
>
>All messages transmitted by the OpenHeart-L are subject to the policies and
>disclaimers posted at:
>http://www.hsforum.com/listdisclaim
>-----------------------------------------


-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon