[HSF] Too scared to touch.....

[Mark Levinson]

On May 1, 2007, at 7:04 AM, Hgrmd at aol.com wrote:

> Ajit,
>   I invested the time it took to read all of Prasanna's   
> abstracts.  I'm
> still not convinced that medical therapy with beta-blockers  is the  
> way to go for
> nearly every case.  Again, if a stress test in an  asymptomatic  
> patient shows
> a lot of myocardium with reversible ischemia, it  would be potentially
> foolhardy not to cath that patient.  Over the years,  we've been  
> referred lots of
> patients with left mains or critical 3vd that were  cathed prior to  
> an elective
> noncardiac procedure (usually carotid, ischemic leg,  or AAA).  We  
> did the
> CABG, they eventually got the vascular procedure, and  they did  
> fine.  I've yet to
> recall "graft closure" while the subsequent  case was done.  In  
> light of the
> problems with DES, the cardiologists are  much more likely to use  
> bare metal
> stents in such scenarios.
>   I do agree that beta blockade, possible Swan, and a competent   
> cardiac
> anesthesiologist suffice for the vast majority of cardiac patients   
> getting
> noncardiac surgery.  However, there are plenty of asymptomatic   
> cardiac time bombs
> waiting to explode for those that never cath and treat  preemptively.
> Hal
>
>

Hal:

I agree with you.   This past week, I did a CABG on a patient that  
another surgeon did
a fem-tib bypass for limb salvage.   Prior to her vascular surgery,  
she had
an adenosine thallium, which was normal.   She had no prior cardiac  
symptoms
and a normal EKG.      Two days after her fem-tib, she developed CHF  
and this
prompted cath.    A 95% left main and 70% right main was found.

The anesthesia provider who did her fem-tib was visibly upset when he  
found
out that he had done the original case on a patient with an  
undiagnosed LM.
The anesthesia societies are training their members to insist on risk  
control
and we are now seeing them refuse patients until the cardiac  
situation has been
clarified and there is a note by cardiology that it is OK to  
proceed.   Even so,
many times the vasculopath will still have something underneath the  
surface.

In my hospital, one of the general surgeons had a death on the table  
from
acute MI during a carotid (before the carotid was even clamped).   This
patient also had a negative preop thallium.  This case still haunts  
him...

There was a malpractice case in my state (not at my hospital) decided  
against
the surgeon for a death from MI after a carotid...for "failure to  
diagnose".

This is the playing field we are on.     Even with some papers saying  
there is no
difference between groups, there is a difference if something happens  
to your patient
and the critics ask you why you did not investigate.    It is very,  
very hard to explain
a statistical analysis of comparative groups to a jury.      Forget  
it.   They just
want to know if you did everything you could to make the operation  
safe.     If not....

I continue to request cardiology screening, cath, and/or  
interventions for symptomatic
patients or those with high risk factors, EKG findings, etc. prior to  
undergoing
a major vascular case.

Mark



Mark M. Levinson, MD
Founder, Editor-in-Chief,
The Heart Surgery Forum
WWW: <http://www.hsforum.com>
Email: <mmLevinson at hsforum.com>