[HSF] (no subject)

Sat May 12 20:27:10 EDT 2007

virtual operation
virtual patient
virtual results
progress in medicine, priceless

tea

----- Original Message ----
From: Ben Bidstrup <benjamin.bidstrup at bigpond.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Saturday, May 12, 2007 6:19:14 PM
Subject: Re: [HSF] (no subject)

He could have
1. BiV pacemaker and Defib - to reduce risk of sudden death and increase EF
2. Perc AVR and perc MV "repair"
3. Optimize med therapy.
4. PCI to suitable vessels.

All 'low risk ' stuff for a high risk patient. And it won't screw up 
your figures.

I suspect a long discussion with the patient and a few responsible 
members of the family with the real risks - surviving an operation 
with say 3 months in hospital, and an undefined period in a rehab 
facility, with a 30% chance of brain failure (memory loss or worse), 
will come up with the right answer.

This man shows the natural history of CV disease. In the 21st 
century, we look harder at them for various reasons (or the 
cardiologists do for ??). We are starting to learn why the survival 
curves diverge somewhat. We of course do not know the medical 
conditions of all of those who die of natural causes as there is 
usually no acceptable entry on a death certificate for natural causes 
(JPFROG does not go down well).

With his calcified aorta, calcified valve and calcified coronaries 
and probably calcified mitral annulus, he represents what I learnt in 
pathology a long time ago that calcification is one end stage of 
wearing out.

The LV is secondary to that. What was his LV like 12 months ago? Or 
at the original operation or at any time point postoperatively?

If he were my (now late) father, I would say "come home Dad with the 
tablets." (He threatened me with worse than the 4th Horseman if I had 
anything extraordinary done when he got unwell in his mid 80s.)

>Ahhh, fun case.....
>
>Perc. AVR?
>
>While I have no doubt you could get him thru whatever operation you 
>choose (did they use ice slush the first time?  could make for a fun 
>redo?  or could be a "cake walk"....hmmmm).  But, sounds like a job 
>for true informed consent - there was a recent report in Annals 
>about how few of these patients (who survive there operation) 
>actually ever leave a nursing home.  While you may not refuse 
>surgery, potentially convincing him that medical management may be 
>his best option.  If he "currently" feels well it may be hard to 
>improve on that.......
>
>-michael
>
>
>>I don't think I would. I would certainly try medicine first and 
>>pray for the 4th horseman. Supposedly the onset of CHF carries a 
>>50% two year survival. His age alone carries a 4 year 50% survival. 
>>It is not going to be easy in and out.
>>tea
>>
>>
>>----- Original Message ----
>>From: prasannasimha <prasannasimha at gmail.com>
>>To: OpenHeart-L at lists.hsforum.com
>>Sent: Saturday, May 12, 2007 11:25:23 AM
>>Subject: Re: [HSF] (no subject)
>>
>>
>>Somewhere along the line I missed out the fact that this was a redo (pig
>>valve in place).Now that adds to the fun.
>>Prasanna
>>Douville, Chuck wrote:
>>>Hal, in our program in Portland, we would not offer this 86 yo man 
>>>with extensive aortic calcification and that level of lv 
>>>dysfunction reoperative surgery.
>>>
>>>-----Original Message-----
>>>From: "Hgrmd at aol.com" <Hgrmd at aol.com>
>>>To: "OpenHeart-L at lists.hsforum.com" <OpenHeart-L at lists.hsforum.com>
>>>Sent: 5/12/07 6:32 AM
>>>Subject: [HSF] (no subject)
>>>
>>>Dear Members,
>>>   I need an opinion. We've got an 86 yo man referred to our  
>>>service who
>>>presented with CHF not requiring intubation.  He's currently on  
>>>telemetry.  Cath
>>>revealed severe 3VD.  The EF was 15%.  There was  a 27 mm gradient across a
>>>19yo pig valve that appeared heavily calcified and  stenotic on 
>>>TEE.  The root
>>>and arch showed extensive calcification, but the  distal aorta was OK.  He
>>>currently feels pretty well.   Surgery?
>>>Hal
>>>
>>>
>>>
>>>************************************** See what's free at 
>>>http://www.aol.com.
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>>
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-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon
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