[HSF] Honest discussion-Hybrid Coronary Revascularization

[Ani Anyanwu]

> In the final analysis, bad results are going to occasionally occur, > whether open or closed.> > Hal
 
This is true Hal but does not remove from the likely fact that far more patients suffer from mini-invasive procedures than do from sternotomy. Aside from the major wound infections it is difficult to see how a patient can suffer for sternotomy. However, several undoubtedly suffer from mini-invasive approach as rather than tailor the operation to suit the patient, minimally invasive surgeons often tailor the patient to suit the operation, forcing the patient to fit in a mini-invasive construct. I presented a case last year who had side surgery and ended on a BiVAD because the surgeon  then death for a scenario that would not have occured open. Mark raises the issue of coronary disease and I bet that many of his patients who he grafted with the mitral would have had coronary disease ignored and side-surgery in other centers - occasionally such patients will suffer. The case I mentioned from Europe had moderate AI which was ignored and the mitral fixed from the side, even though clamp-time was less than an hour the heart suffered from no protection as the AI was too severe - something that could not have happened via sternotomy. Then there is the issue of complications of femoral artery annulations in young patients with no collaterals. Even OPCAB has killed is share. I had a video once of one of my mentors persisting in an OPCAB with the heart barely moving and trying best to stretch a short RIMA to the LAD, heart defibrillated 4 times, massaged and PA and systemic pressures equalized - still kept going off-pump, the rest being history. The problem here is that many mini-invasive surgeons are not offering the patients choice (of a non-mini-invasive approach). The goal becomes to complete a mini-invasive operation rather than to complete a repair of the patients cardiac condition. Last year we rerepaired three mitrals done via mini-invasive thoracotomy and I am sure you have seen your fair share.
 
I am not against mini-invasive surgery and we will start offering side mitral surgery soon but we have to be honest with ourselves that this is NOT a better or even equivalent operation. Some patients will suffer because of the mini approach. We change the rules just to satisfy our mini-invasive desire - for example, complete revascularization no longer matters with OPCAB (but suddenly does if patient done on pump), complete rings dont matter with a robot (but suddenly do for open cases), leaflet height in Barlow's doesn't matter with a nip and tuck mitral via side approach (but suddenly does with a Carpentier sternotomy approach), moderate MR doesnt matter for AVR via thoracotomy (but suddenly does if done via sternotomy). As I heard Sugabaker say once, as a surgeon we have to believe in the knife. All of a sudden we believe cutting is not good for patients. Fine if we believe so for all our patients (as with cholecystectomy) but we cant have different rules when we do mini and different when we do sternotomy. Mini approaches can only be equivalent to sternotomy approach if you can do via mini-invasive exactly what you can do open (not the case) and if the incremental risk of the mini approach becomes negligible. So far we cannot say we (we being the speciality and not a handful of individual surgeons) have reached that point for any cardiac surgical operation.
 
Ani



> From: Hgrmd at aol.com> Date: Fri, 23 Nov 2007 18:40:44 -0500> Subject: Re: [HSF] Honest discussion-Hybrid Coronary Revascularization> To: OpenHeart-L at lists.hsforum.com> CC: > > Ani,> Appreciate your usual insightful response. As long as the results from > minimally invasive surgery are roughly equivalent to a sternotomy approach, the > patient will take the small incision nearly every time. The responsibility > lies with the surgeon to make sure that the case selection is proper.> I think you are right that only a few experienced surgeons should do small > incision valve surgery. For one thing, I believe it is imperative that the > surgeon have lots of open experience before trying to do small incision > surgery. It is naive and misguided that a surgeon with a small valve practice to > try to become a minimally invasive valve repair expert.> In the final analysis, bad results are going to occasionally occur, > whether open or closed. It is our job to make sure that the patient's outcome is > not compromised because of the approach.> > Hal> > > > **************************************Check out AOL's list of 2007's hottest > products.> (http://money.aol.com/special/hot-products-2007?NCID=aoltop00030000000001)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
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