[HSF] Another on vs off pump question......

[Ani Anyanwu]

Michael

You interventionalist must be very friendly indeed to call you about such a patient - single vessel revascularization - a rarity these days.

As presented though, I am not clear as to the indication for surgery. Why does this patient need an operation? Does the patient have disease in the other two coronary distributions or isolated LAD disease? If isolated LAD why does she need revascularization now (and how come she did not have primary angioplasty during the MI - an angioplasty only or BMS would have been options if they were concerned about lifelong plavix)?

Also why do you reckon the patient has pulmonary hypertension? 



Ani

----- Original Message ----- 
  From: Michael Firstenberg<mailto:msfirst at gmail.com> 
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
  Sent: Monday, May 14, 2007 8:30 PM
  Subject: [HSF] Another on vs off pump question......


  Just got a call from my friendly interventionalist.

  72 year/old, multiple medical problems (nothing too bad), but has a "lung
  mass" which may need work-up and treatment - so he really does not want to
  put a proximal LAD stent in and keep her on Plavix forever.  He asked me to
  do an off-pump LIMA to LAD.  Sounds good.  However, since her admission
  diagnosis was a anterior wall MI, we are letting her "cool down" (peak
  troponin 500 - yikes).  So we got an echo to eval function.  EF~30%, little
  AI, little MR, moderate TR, elevated pulmonary pressures..... ok nothing too
  bad.  Small PFO.

  Question: 1)  Off-pump LIMA-LAD and ignore the PFO
                 2)  On-pump LIMA-LAD and close the PFO
                 3)  Would anyone touch the tricuspid (sorry dont have the
  sizes)
                 4)   Let him put in a BMS and a clam-shell to the PFO and
  walk away..........


  Hate to go on pump just to fix a PFO - but she may get a lung resection at
  some point and she already does have some pulm hypertension.

  ----thoughts/comments?



  -michael
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