[HSF] Honest discussion-Hybrid Coronary Revascularization

Sun Nov 25 06:52:21 EST 2007

Tom,

I think that you raise very valid questions which get to my interest as to what exactly is surgery specifically and medical care in general. 

As to hybrid procedures one way to think about this (and there are several if not many and one or a hundred trials will not solve these multiple interactions) is to think of it as both planned sequential and "team" therapy. This would be opposed to more discrete single intervention and subsequent "new" need for reintervention. I wonder if it is because I am a "cowboy" or "lone ranger", but I argue against this approach in other settings. I certainly dislike it when it happens by "accident" in a short time frame as it increases the uncertainties and thus makes your personal outcomes less predictable. Clearly multiple caregivers can effect outcomes in multiple ways. This is a major problem that modern medicine seems particularly unable to address. We may need to rethink all of medicine as we become both rapidly more specialized yet interdependent.

It is not fair for you to criticise "miminally invasive" therapy solely because you have to do further intervention on them. You frequently do the same for "maximally invasive" therapies as well. You may however have special (not necessarily synomonous with retarded) insight to the conflict between best present pallition and problems with later need for intervention to which I alluded on a different thread.

Minimally invasive therapy is a poorly described phenomena, if not idea. As a practioner I have no particular problem with partaking. It is actually one the primary tenets of surgical thinking, that is to apply appropriate, but appropiately limited, mechanical stress to the patient. To me it is similar to, say,  bloodless surgery "invented" for Jehovah Witnesses. To do it well and appropiately, one must be both diligent and explict about rules and both expectations and lack of expectations. This is hard to do if it is largely a "marketing" exercise. 

In some respects "valve sparing" procedures could be considered minimally invasive. And one with which I would agree depending on the above rules, explict and diligent in application and expectations.

tea

----- Original Message ----
From: "tdmartin2000 at aol.com" <tdmartin2000 at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Thursday, November 22, 2007 2:17:25 PM
Subject: Re: [HSF] Honest discussion-Hybrid Coronary Revascularization

Mark

?I hear what you are saying. However I am going to take this opportunity and this forum to vent a little. I have no problem with people offering minimally invasive type of procedures- hybrids, midcabs, robotic valves/cabg, minii maze?etc. as long as they honestly discuss with the pt and their families the real data and even their own data. To my knowledge and understanding most surgeons do not do that. What they tell pts is that they are candidates for the latest and greatest minimally invasive procedure and they equate minimally invasive to "better" and I am really getting irritated at that. I have even seen websites and videos etc that either come out and say "minimally invasive" is better for the pt or they imply it when we all know that at the moment this is outright falsehood. There is no data to support any of this. As long as this is explained to the pt and they understand, great, but if the surgeon is not explaining all of this to the pt- I have
 a real problem with th
at.
I get pts that come to me and ask about "minimally invasive" procedures and I tell them that yes we can offer that to them but they need to understand the data and the options. When I tell them that at best the results are equal in very selected cases and that there in fact may be an increase in complications with no real advantage in morbidity, mortality,hospital stay or pain, most all pts opt for a standard approach. Maybe it is being in the University setting where I get to see the failed "minimally invasive" procedure or the complications of such procedures in pts that if they had had a standard approach would most likely be home working etc with a great long term outlook. Yes I am in a setting where I do not have to placate cardiologists, but I think we all need to take a step back and ask ourselves the real question-- What is the best for the pt and make sure they understand what that is. We also need to be more aggressive in educating the? public.
 They need to understa
nd that minimally invasive is not equal to or?better than a tried and true proven procedure - at least at the moment. I could go on and on because I really feel stongly about this subject. I am all for innovation and improvement but I think we need to be totally honest with our pts. If you are not it will come back to haunt you. 

Tom Martin
U of Florida
Gainesville

-----Original Message-----
From: Mark Levinson <mmlevinson at hsforum.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Thu, 22 Nov 2007 1:20 am
Subject: Re: [HSF] Hybrid Coronary Revascularization

On Oct 26, 2007, at 6:40 AM, alsadd wrote:?
?
> Dear Forum Members:?
>?
>?
>?
> We are currently entertaining the hybrid coronary revascularization > approach?
> at our institution. Any thoughts suggestions are greatly welcomed. > Any one?
> who has used this approach is invited to give his/her opinion. This > is a?
> very new thing for us and we want to benefit from other members of the?
> Forum.?
>?
> Thank you very much in advance?
>?
?
Tom Martin is correct in that there is no data to support a superior outcome of hyrbrid when compared with multivessel CABG.?
And there was at least one paper I saw that implied a higher re-intervention rate with hybrids than with standard CABG, but?
I don't have the reference in front of me.?
?
However, if you don't offer hybrid, you do not get consulted on many patients who could be revascularized surgically, and this?
includes some patients who you would otherwise end up recommending a multivessel approach. For example, patients?
with a long complex LAD stenosis and a 70% small OM1 are just stented, despite the poor results with a long stent jacket?
in the prox LAD. With hybrid and minimally invasive CABG, I am now seeing these patients again.?
?
I have taken the approach that if I can get a LIMA-LAD and the cardiologists are left with a minor branch to dilate, then I?
respect the patients desire not to have a full sternotomy just to do a LIMA and a minor branch, such as a small OM or?
small PDA. So, in those cases I suggest a hybrid, using a subxiphoid approach (I don't like thoracotomies for CABG)?
?
The numbers of hybrids are small, but my cardiologists are very appreciative that they now have this as an option,?
and for them, it makes it easy to request a surgical consultation knowing that a minimally invasive approach might?
be more attractive than a long series of stents in the LAD followed by repeat procedures. Such patients would otherwise?
opt for a handful of stents just to avoid a "big operation" and, in my experience,?
readily accept a small non-sternotomy approach with a hybrid to a minor vessel.?
?
The results of my subxiphoid series are posted at URL:?
?
http://www.newoptionsinheartsurgery.com/subxiphoid-multi-arterial-bypass-grafting-.current-re.html?
?
Mark Levinson, MD?
?
?
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