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

[Edward Bender]

I never ask for cardiology clearance prior to major vascular  
surgery.  I always refer the patient for cardiac cath plus  
appropriate arteriogram (aorta, legs, etc.).
Ed Bender, MD

On May 16, 2007, at 8:53 PM, Mark Levinson wrote:

>
> 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>
>
>
>
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