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

[Nasser F. Abou'Seada]

Dear Ani
Very well said and summed up.

NFA

On 5/16/07, Ani Anyanwu <anianyanwu at hotmail.com> 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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-- 
Nasser  F.  Abou'Seada,
MB,ChB,MD,FRCSEd,ChM,ChD C/Th,
FICS,FISCVS,FSSRCTS,FHMS,MESC