[HSF] Honest discussion-Hybrid Coronary Revascularization

Wed Nov 28 19:29:16 EST 2007

Ani,
This well descibes the actual situation under which we labor. I further largely agree with your "less" (on some things) is "more" for the patient. Having been an early adapter to many thoracic incisions in the pursuit of that holy grail, minimally invasive surgery, I am perhaps a little more equiposed than you in the value of that particular parameter.  Almost every incision can be done more adroitly and gently by some compared to others. 

It does seem that your description flies in face of your "universal quidelines". To just pick the top ten percent or large city surgeons obviously has nothing to do with "universal" guides. Bill Novick has noted that 90% of the world has no or little access to even simple surgical care. Never does he advocate inferior care, even if he wisely avoids treating everything everywhere. The same problems exist in the USA even if the slope(s) of the curves of access and results may be different. Top down regulation is very tricky at its best.

Your critisim that I live ideologically "far in the future" in the problem of patient subgroups, is, I think, just the inverse of the problem that you describe. In one setting we hold the patient group stable (surgeon variance), in the other we hold the surgeon group stable with the patient being the variance. Neither you our I desire planned harm to the patient by prior selection. That is why our abstraction to universals in the continuous possible mismatch of patient and surgeon is death to the system even if it seems to "protect" some individual patients...usually the ones the experts did not get to see but some else did.  Surgery, like in the stock market, is easy pickin's based on last years results. 

tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Saturday, November 24, 2007 9:27:59 PM
Subject: RE: [HSF] Honest discussion-Hybrid Coronary Revascularization

Hal

The reason I want to do side mitral surgery is that I do believe in reducing the trauma of surgery. I also don't mind struggling and have the patience to do so. I am by no means against minimally invasive surgery and even though my posts might suggest otherwise, I am very keen on all varieties of minimally invasive surgery  excluding for now the robot (for reasons we have debated before). If I had a coronary practice I would be very keen to investigate Dr Levison's sub-xiphoid approach. I personally believe that properly done OPCAB is superior to ONCAB but agree there is no evidence that this is the case. Indeed today I just placed a Heartmate XVE LVAD in a post-MI cardiogenic shock patient without use of cardiopulmonary bypass, something most VAD surgeons would regard as unnecesary and dangerous. My own believe is to only cut what is necessary to do the operation. The emphasis though is *the operation*. If I can do the operation through a 3 inch rather
 than 5 inch incision then I will do that. I think the opposite of mini-surgery, the maxi-invasive 6 inch sternotomy and aggressive retraction, division of all the fat down to the innominate, and wide incision of the pericardium down to the heart apex etc just to do a mitral repair is a disregard for the patient we operate on. Just violating tissues because we can. So my belief is that we respect the human body - it belongs to someone else not to us - and just cut what we need to to do the operation. Same philosophy extends to why I skeletonize the IMA and dont take it down with half the chest wall. We should not cut for our convenience. Surgery should IMHO be about doing best for the patient and respecting the patient and not doing the best or easiest for ourselves. 

You are right that we underestimate the impact of sternotomy. If there is an operation I can safely do without a full sternotomy, I will. We do quite a few mitrals via 8 to 10 cm hemisternotomy for example. I am quite keen to look into Dr Zhou's thoracotomy approach to AVR. If there is an operation I can safely do without CPB I also will. When I have the courage and I see the data I will like to also do the operation without cardiac ischemia. However, I must not compromise on the surgery itself - partly why I do not agree with endoscopic vein harvest because I suspect it is compromising on the goal of the operation which is to harvest vein with minimal endothelial damage.

It is however important we do not mix our personal views or practice with facts and evidence and that we do not force our views on others without supporting data.  There is no evidence of the superiority of most mini-invasive techniques. While it seems logical that less trauma is good, this good can only be achieved if we do no harm. It is the harm we (as a speciality) do during these mini approaches, or the inability to deliver operation of similar quality, that prevents mini approaches having a net benefit. Every surgeon must individually assess 1) his ability to minimize harm during mini approaches and 2) his ability to perform *the operation* (and not an incomplete or watered down version) through limited access. Both require skill and patience. I have been one of few to call a spade a spade in this discussion. The reality is that all cardiac surgeons cannot do mini-invasive surgery because we do not have the skills and patience to do so. Lets not
 kid ourselves, doing an LAD graft on a beating heart without sternotomy is more difficult than doing it on CPB with sternotomy. Those that do mini-invasive stuff with good results are as a general rule more skilled than those who don't do mini-invasive. The problems arise when for various reasons surgeons jump on the bandwagon of mini-invasiveness without the patience, knowledge, expertise or the skill to do so. Such bandwagon effect is for example why OPCAB got a bad name. For these reasons I believe there must be restraint in pushing these techniques as either the future for individual surgeons  or for the speciality. 

Ani

> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Honest discussion-Hybrid Coronary Revascularization> From: hgrmd at aol.com> Date: Sat, 24 Nov 2007 14:08:53 +0000> CC: > > Ani,> Well said, but why are you guys planning side mitral surgery? Also, don't underestimate the risk of sternotomy in certain populations. More later... I'm on my way to a meeting in Costa Rica.> > Hal> Sent from my Verizon Wireless BlackBerry> > -----Original Message-----> From: Ani Anyanwu <anianyanwu at hotmail.com>> > Date: Sat, 24 Nov 2007 13:03:06 > To:<openheart-l at lists.hsforum.com>> Subject: RE: [HSF] Honest discussion-Hybrid Coronary Revascularization> > > > 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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