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

[Ani Anyanwu]

Tohru,

I think we actually do agree except that I disagree that LV dysfunction 
means that surgery is indicated. While early trials did show benefit of CABG 
in patients with LMS or 3VD with impaired LV function we have moved on to 
identifying which patients in that subset would benefit from surgery and 
which would not.

A high grade proximal LAD stenosis with a large anterior MI is not a clear 
indication for surgery.

A high grade proximal LAD stenosis in a patient with a prior MI who is in 
heart failure with evidence of viability is an indication for surgery.

Having previously suffered a huge MI is not necessarily an indication for 
CABG.

By the way maybe it is possible that some patients could have been saved a 
transplant by a LIMA to LAD after an acute MI, but I seriously doubt it. 
Unless they had subsequent infarcts later that could have been prevented by 
the CABG. These patients are screened for viability prior to transplant and 
are generally found to have extensive transmural infarction.

The scenario I see more frequently is patients who did undergo CABG after an 
acute MI only to present for transplantation or VAD therapy 6 to 12 months 
later having had a futile and wasted operation. The prior surgery places 
them at unnecessarily increased risk for what should have been the 
definitive therapy in the first place (transplantation). Sometimes 
complications from an unnecessary CABG procedure make patients ineligible 
for subsequent transplant.

In the present era I am not sure it is excusable to undertake CABG in the 
SEVERELY dysfunctional ventricle post MI without evidence of viability 
(ongoing ischemia, angina or imaging evidence).

Ani
  ----- Original Message ----- 
  From: Tohru Asai<about:blank>
  To: OpenHeart-L at lists.hsforum.com<about:blank>
  Sent: Wednesday, May 16, 2007 7:35 AM
  Subject: Re: [HSF] Another on vs off pump question......


  Michael

  What is "lytics"? Thrombolytics like TPA?
  I personally do not agree with Ani. Your patient clearly has LV 
dysfunction
  with significant large LAD territory. Most cases have some hibernated
  myocardium to be saved by bypass and improve LV function.

  I am just wondering whether it is common to have PET study to evaluate
  viability of myocardium in such cases in US?

  Another questions: Are there any severe lung diease like advanced 
emphysema
  or fibrosis?

  Without watching cath film, I can not be certain. But I would "cool down"
  for a month,find inducible ischemia and/or viable myocardium, then accept
  for bypass surgery maybe with excisional biopsy of lung mass, if 
respiratory
  med guys agree with me. If closing device is available and reliable, no 
need
  to open RA during OPCAB.
  -- 
  Tohru Asai
  Shiga University of Medical Science
  Otsu, Japan





  > Indications for surgery - proximal high grade LAD lesion and a huge 
infarct
  > salvaged by lytics.
  >
  > -michael


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