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

Thu May 17 12:30:35 EDT 2007

Are you saying the whole left ventricle is thinned or just more than the anterior wall? What evidence do you have that (some) thinning can not ever be recovered?
Instead of just focusing on the class 4 patient, how do you see, as a doctor not just a transplanter, the care of Michael's patient with say two to three vessel disease status post large recent MI managing before progressing if possible to the point of no return, a completely dilated LV. 

We hopefully can be more than buzzards, but one might wonder,
tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Thursday, May 17, 2007 5:34:30 AM
Subject: Re: [HSF] Another on vs off pump question......

It is unusual that patients with endstage cardiomyopathy have only LAD disease except if LAD wraps around apex to supply inferior wall. Most isolated LAD infarcts will not progress to end-stage myopathy. 3 vessel disease is more typical in cardiomyopathy.

We do not always do a viability study in patients referred for transplant as sometimes it is obvious that the ventricle has little recovery potential (patients typically have several years history of heart failure with very low EF, the ventricle has now dilated globally, LVEDD>70mm and myocardium thinned out on echo. No sort of CABG and SVR can restore these to life). 

The setting in Michael's patient is different though - he does not have advanced cardiomyopathy and does not need transplant evaluation. The question is whether he should be managed medically or whether he will benefit from revascularization.

Ani
----- Original Message ----- 
  From: Tea Acuff<mailto:tacuff at swbell.net> 
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
  Sent: Wednesday, May 16, 2007 11:56 PM
  Subject: Re: [HSF] Another on vs off pump question......

  Ani,
  You mistake me for, perhaps, an academic. I have enough trouble keeping my own balls out of a crack to worry about yours. I while I am personally pleased with agreement, I seldom argue for consensus. Our future depends on the failure of current consensus. I personally have a too small a grasp on the truth to predict which of the facts that are clear to me now are to be shown to be nonsense in the near future. In fact we are all dependent on dreamers, skeptics, and just the lucky but brave observer to find a new way for us. All I try to do is identify patterns that work in one spot that are not used in the next to see if there is a common fundamental truth at work. 

   On the other hand, it does seem hard to subject people to surgery and not to belive that LIMA to LAD is a very useful tool in experienced hands despite the universal appeal of PCI to many lesions.

  I am curious. Do you get an MR on all the "large Lad" infarcts that you transplant. That is certainly rich soil for SVR. There are undoubtedly many CHF patients with less favorable patterns of ischemic dysfunction to fill those slots.

  The data is pretty good that late revascularization is of much less benefit and still high risk for patients without reversible ischemia. Do you take any test as proof of that state or only the best availble and do you test all patients with dysfunction?

  tea

  ----- Original Message ----
  From: Ani Anyanwu <anianyanwu at hotmail.com<mailto:anianyanwu at hotmail.com>>
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
  Sent: Tuesday, May 15, 2007 10:55:24 PM
  Subject: Re: [HSF] Another on vs off pump question......

  Tea since you provoke me to say what you know I am saying I will say it and will await your castration. I tell people though that my balls are safely in a jar on Yacoub's (my first chief) table since 1999 so doubt you can do me much harm now as my balls are long gone. Yes I am actually saying that an isolated lesion of the LAD alone cannot be an indication for surgery - otherwise we become like our cath lab colleagues who treat the anatomy and not the patient. 

  There has to be an additional indication other than the presence of stenosis in the LAD vessel. Certainly there is no evidence that surgery provides better survival than angioplasty or even medical therapy in the setting of proximal LAD disease, so there has to be an additional qualification that indicates (any) revascularization. A huge MI in the LAD territory is certainly not an indication for surgery - indeed some would argue that the occurrence of a huge MI can make LAD grafting a worthless exercise. Most of the ischemic patients I transplant have had huge anterior MIs. Few have LIMAs on their LADs.

  Ani
    ----- Original Message ----- 
    From: Tea Acuff<mailto:tacuff at swbell.net<mailto:tacuff at swbell.net>> 
    To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com%3Cmailto:OpenHeart-L at lists.hsforum.com>> 
    Sent: Tuesday, May 15, 2007 11:19 PM
    Subject: Re: [HSF] Another on vs off pump question......

    Words are funny constructs. A huge infarct salvaged by lytics is an ambiguous paradox. Something for everyone, but likely somewhere in between. Surely you, Ani, are not saying a LIMA is inappropiate for an isolated LAD, however?
    tea

    ----- Original Message ----
    From: Ani Anyanwu <anianyanwu at hotmail.com<mailto:anianyanwu at hotmail.com<mailto:anianyanwu at hotmail.com%3Cmailto:anianyanwu at hotmail.com>>>
    To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com%3Cmailto:OpenHeart-L at lists.hsforum.com>>
    Sent: Tuesday, May 15, 2007 7:53:09 PM
    Subject: Re: [HSF] Another on vs off pump question......

    Michael

    Surely this is not an indication for coronary artery bypass surgery? 

    Indeed this is the situation where you require collaborating evidence (such as angina or imaging viability) to even show that surgery will be of any value at all.

    Ani
      ----- Original Message ----- 
      From: Michael Firstenberg<mailto:msfirst at gmail.com<mailto:msfirst at gmail.com<mailto:msfirst at gmail.com%3Cmailto:msfirst at gmail.com>>> 
      To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com%3Cmailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com%3Cmailto:OpenHeart-L at lists.hsforum.com%3Cmailto:OpenHeart-L at lists.hsforum.com%3Cmailto:OpenHeart-L at lists.hsforumcom>>> 
      Sent: Tuesday, May 15, 2007 2:20 PM
      Subject: Re: [HSF] Another on vs off pump question......

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

      -michael

      On 5/15/07, Nasser F. Abou'Seada <nfaabouseada at gmail.com<mailto:nfaabouseada at gmail.com<mailto:nfaabouseada at gmail.com%3Cmailto:nfaabouseada at gmail.com<mailto:nfaabouseada at gmail.com%3Cmailto:nfaabouseada at gmail.com%3Cmailto:nfaabouseada at gmail.com%3Cmailto:nfaabouseada at gmail.com>>>> wrote:
      >
      > in a 72 yo, what is the indication of surgery? any reason why not PCI
      > / BMS, and PFO device closure? is it really Plavix ? what is the
      > nature of the lung mass?  any S&S ?
      >
      > NFA
      >
      > On 5/14/07, Michael Firstenberg <msfirst at gmail.com<mailto:msfirst at gmail.com<mailto:msfirst at gmail.com%3Cmailto:msfirst at gmail.com<mailto:msfirst at gmail.com%3Cmailto:msfirst at gmail.com%3Cmailto:msfirst at gmail.com%3Cmailto:msfirst at gmail.com>>>> wrote:
      > > Just got a call from my friendly interventionalist.
      > >
      > > 72 year/old, multiple medical problems (nothing too bad), but has a
      > "lung
      > > mass" which may need work-up and treatment - so he really does not want
      > to
      > > put a proximal LAD stent in and keep her on Plavix forever.  He asked me
      > to
      > > do an off-pump LIMA to LAD.  Sounds good.  However, since her admission
      > > diagnosis was a anterior wall MI, we are letting her "cool down" (peak
      > > troponin 500 - yikes).  So we got an echo to eval function.  EF~30%,
      > little
      > > AI, little MR, moderate TR, elevated pulmonary pressures..... ok nothing
      > too
      > > bad.  Small PFO.
      > >
      > > Question: 1)  Off-pump LIMA-LAD and ignore the PFO
      > >               2)  On-pump LIMA-LAD and close the PFO
      > >               3)  Would anyone touch the tricuspid (sorry dont have the
      > > sizes)
      > >               4)   Let him put in a BMS and a clam-shell to the PFO and
      > > walk away..........
      > >
      > >
      > > Hate to go on pump just to fix a PFO - but she may get a lung resection
      > at
      > > some point and she already does have some pulm hypertension.
      > >
      > > ----thoughts/comments?
      > >
      > >
      > >
      > > -michael
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      > Nasser  F.  Abou'Seada,
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