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

[psimha]

Viability is the issue and the open artery hypothesis has been disproved
in trials. Dead muscle is dead unless some saint will make the dead rise up.
Hibernating / mixed infarcts etc are a different story.
Prasanna
Ani Anyanwu wrote:
> 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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