AW: [HSF] redo mitral video nope

Fri Oct 26 22:01:00 EDT 2007

As usual any time I push to go in a direction that seems unique to me, there are others like you way ahead of me. I would very much like your critique of how I set up the question. I also agree that if one feels that the compounded "interest" (interesting dual meaning is it not) analogy is applicable, it is difficult to assail the conclusion. We don't practice in a test tube, but all of us are constantly making these same simplified answers to protect our experiment while the world makes our test tube obsolete. The desire to control "undesired" exuberances is over whelming to those with the power to regulate or the ear of those that do. Unfortunately the prescience of these same actors is under whelming in breadth if not also depth. 

As to your question as to why I do not practice pediatrics presently, it is hard to come up with a simple or single answer as to why I gave up pediatric surgery. The most compeling answer is that the volume was small in the program that I set up, and another surgeon from the pediatric hospital came over to try to steal my practice or at least its location. I was also setting up an adult program 30 miles away (Denton) and my other adult partners did not want to leave to help me so I had to run both programs. I gave the pediatric practice to the competing surgeon, and helped him cover and scrubbed with him on some cases. We became good friends. I eventually left my group who did not want to leave the "big" hospital even after I built up a volume for two (but not quite three) in Denton. The other pedisurgeon eventually left, the hospital helped refund and reorganize the program, and a surgeon who is content to make the practice his life and do everything
 himself is quite busy and sucessful at least by volume criterion.

With that background let my say that I think the single most destructive thing to happen to the future of cardiac surgey is the success of CABG. I personally think like a "team player" (football being my first love, but I being a slow white guy). If someone wants to do exactly what I am doing, and particularly if everyone wants to do what I am doing, I try to find something else to do. Something else may be to build new access (a factor that most experts in big institutions and big cities seem to diminish). The most simple new access is to build a parallel service or program add on like off pump or valve program where an adult program is operative or rebuild the pieces. Next hardest is to set up a new service whether pediatric in an adult hospital or a new program in a hospital without intensive services. We set up a research organization in our private (and "big") hospital which was a similar "new" task, although Mack wore the mantle for that one. I
 think, however, the most difficult task is to develop a new field. Thoracscopy was one that mostly required a new tool and was ready, at least for a few who now practice it heavily. Off pump was a knock off, its advantages to some patients are real but still under valued. What we currently are discussing, the use of cardiac imaging and particularly applying it to a new field such as ventricular remodeling (few think it is field, rather a flower pot, perhaps), is both the most simple yet difficult task. Most of the pieces are lying around and are familar which is a huge disability. To do this one has to rethink all your biases and create a different intrinsic story. The final step of a new field is almost impossible: get others to rethink with you. The history of science, Poppers' view at least suggests it is more likely that the other story just dies off.
 Few will change their mind. How long has valve repair been a topic?

Why I don't return to pediatrics? Twenty more years of medical liability in the USA does not appeal to me at my age. I might eventually help Dr. Novick in a different country in some way. The legal arm of regulation, which is the battlefield of regulation, is a potent deterrent to participation. In my opinion the public looses more than it gains by looking to us to regulate medicine. Whether we better or worsen the publics plight compared to government regulation alone is unclear to me.

Think about all of these competing factors for a while. I am sure that I have barely touched the surface, but they have influenced me. The delivery of medical care is much more complicated than finding a surgeon on the internet or magazine that can repair valves to match with a valve that needs repair.

I would be interesting to get Bob's take on all of this, since he has seen this develop from what we consider the beginning. Of course this was not the beginning either, but it was the beginning of the tool that (re)defined our specialty. Perhaps we should not call ourselves cardiac surgeons, but cardiopulmonary bypass surgeons, which is now shortened to just "bypass surgeons". Should we redefine who we are? I think so. Again I would do it by expansion of the many not limitation of the many. We need badly to rethink our specialty. Do we specialize and credential everything? Is cardiothoracic surgery where general surgery was when I was finishing, the leftovers that no one at the moment wants?

Frankly I would say on subject if I knew where the lines were.

tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Thursday, October 25, 2007 9:51:24 PM
Subject: RE: AW: [HSF] redo mitral video nope

Tea,

In the way you have asked the questions, the answers are self evident so I wont go into detail in my response.

One way or the other though, we need to restrict surgery for mitral valvar regurgitation to valve repair to surgeons interested in valve repair. Those who have interest in it will seek appropriate training and continuing education. Every center or cluster of centers should designate a surgeon(s) to fulfil this role. Trainees seeking to take up valve repair should do fellowships in a high volume center. 

I have just written a paper for a cardiology journal which attempts to idealize your test tube by matching the echocardiographic lesions with the least skilled surgeon able to fix the problem. For example a P2 prolapse with ruptured chords can go to most cardiac surgeons, an A2 prolapse with ruptured chords can go to a local or regional surgeon with an interest in valve surgery who has a track record of fixing such valves, and a bileaflet Barlow would go to a suuperspecialist. So the scenarios where a valve would be open in front of a surgeon who cannot repair it will be minimized. This method has worked in areas such as pediatric cardiac surgery (incidentally why did you give it up? Maybe your answer might fit in the test-tube model of specialization!).

The reality is that most valves can be repaired with relative ease but surgeons, for various reasons chose not to put in the effort to do it. For one why bother when in the USA surgeons are paid more to replace a valve than to repair a valve? Certainly though the solution does not lie in every surgeon doing valve repair as the vast majority of surgeons will not acquire specialists skills beyond that which they obtained during training for various reasons including the low volume, lack of interest to acquire new skills and lack of a structured method of on the job training for those who would like to develop new skills. 

Ani

> Date: Thu, 25 Oct 2007 16:43:01 -0700> From: tacuff at swbell.net> Subject: Re: AW: [HSF] redo mitral video nope> To: OpenHeart-L at lists.hsforum.com> CC: > > Good. > > I believe that at for the moment (we can talk about looking at images later) you, Prasanna, and I (puts a community surgeon like me in pretty good company) agree about the need for emphasis on proper diagnosis. We "gave" that away (did we ever have it, Bob?), but the emphasis is SURGICAL diagnosis, not "MR", "bad ventricle with EF 30%, etc. We would never(?) argue to operate on just a description of 3 vessel disease.> > But the point I wish to take up with you, Ani, was your comment to the effect: it is not the right surgeon for the patient, but the right patient for the surgeon. This to me seems nonsense in our usual "test tube surgery" limitations of appropriate conversation. (WARNING! Here goes tea again and pretty soon we will have to pull Mitch and Bill off each other again.)> > In the
 surgery test tube we mix valve surgeon and patient with valve. Which ever goes in first and however it goes in we get repaired valve. For the sake of argument we all now agree that this is better than the tube with nonvalve surgeon and valve patient. (Forget my subpopulation dissent, and other possible ingredients.)> > My question for you, and we are now completely out of our safe experimental and artifical test tube, is how do we best get to that mixture in the test tube? Without getting "personal and ideological" (even if in actuality it is the only way we get there so I will talk in formalisms) do we restrict the options for surgeons and likely in parallel patients to prohibit bad mixtures, or do we seek to open up and incent the likelyhood that more surgeons will meet the valve that they can fix?> > When I hear the name Stark or listen to you and Hal talk about "limiting" those that would do valves, I get the sense that you push for "pure
 ingredients" hoping for better mixtures even if it may mean less suitable but workable mixtures might be denied. Or do we "incent" low volume surgeons and perhaps low volume programs with better diagnosis to aim over time for ultimately more total numbers of repaired valves? My favorite option is the latter. Both of us would have all kind of qualifiers, exceptions, etc, to our model, but which way is it? Do we limit or expand? It seems a simple choice on the surface. It may, however, be a choice for destiny. (Did I say we create our craft more than discover it?)> > As you know I like analogies from other areas so I propose two different ones for thought. Over time would you have more money (or repaired valves) if you charged a nominally higher flat interest rate, or would it be better to accept a lower rate up front that can be compounded? If that seems difficult to rethink would you rather have a higher inital rate of valve repair or more surgeons
 trying to repair valves?> > Secondly, historically monoarchy and communism seem to argue for completely opposite mechanisms for a benevolent society. One wanted to direct the "just" from above, the other secure the "just" from below. (One, perhaps both, were a lie, but I give the benefit of the doubt when at all possible. Don, you pick the liar.) Either of these systems at times and circumstances could have or did suceed just like the choice of a good and not bad flat interest rate. Both, however, seem to have failed. Why? I think because both lagged over time from other imperfect systems that leveraged the small compounds of the many.> > tea> > > ----- Original Message ----> From: Ani Anyanwu <anianyanwu at hotmail.com>> To: openheart-l at lists.hsforum.com> Sent: Wednesday, October 24, 2007 10:15:39 PM> Subject: RE: AW: [HSF] redo mitral video nope> > > Tea> > My chief's (Dr Adams) main focus is not intraoperative differentiation but pre-operative
 differentiation of disease based on history and imaging. We wrote a paper on this in the current issue of seminars. We would *never* counsel a patient referred for mitral surgery without first reviewing the echocardiographic image usually we review these images with the patients as I am sure you do with CMR. Only after review of these images do we make a statement about repairability, choice of procedure, incisions, potential durability of repair and alternative therapies. It is not enough - indeed it is hardly helpful - to look at an echo report.> > I do agree with your focus on pre-operative imaging. I spend more and more time reviewing cardiac CTs and MR images with our imaging cardiologist - it surprises me more or more what one can see. It is also important as you say for master surgeons to demistify their disciplines - part of the problem with low uptake of mitral repair, aortic valve repair etc comes I believe because those who thrive in it often
 over-mystify it.> > Ani> > > > > Date: Wed, 24 Oct 2007 16:51:10 -0700> From: tacuff at swbell.net> Subject: Re: AW: [HSF] redo mitral video nope> To: OpenHeart-L at lists.hsforum.com> CC: > > All the more reason to take those valves out of the hands (brains) of the mysterious master surgeons and into careful, thoughtful and particularly organized preoperative imaging programs. and exactly why surgeons need to be the ones organizing these TTE, TEE, CT and CMR programs. And exactly why our societies are so remiss deferring to our masters. > > Your chief is making some movement in this direction (ie out of the mysterious) but it is only intraoperative analysis which is too late for what you propose unless your goal is purely self serving (official referring).> > See my editorial already out in Innovations this year on Cardiac Imaging: A Hunterian Perspective if we are playing the editorial game.> > tea > > > ----- Original Message ----> From: Ani Anyanwu
 <anianyanwu at hotmail.com>> To:> openheart-l at lists.hsforum.com> Sent: Wednesday, October 24, 2007 10:23:26 AM> Subject: RE: AW: [HSF] redo mitral video nope> > > Roberto> > I think we have to take this to the next level and move on from advocating the right operation for the right surgeon to advocating the right surgeon for the right patient. > > Prasanna made this quite clear - as a surgeon you should be able to tell with near certainty on examining a pre-op TTE whether you can repair a mitral valve. If the surgeon studies the echo and is not sure he can repair it, he is the wrong surgeon for the patient. That patient should seek a surgeon who looking at the echo stands a good chance of repairing it. The days of 'discovering' in the operating room that a valve is not repairable should be over - this assertion should have been made on the pre-operative echo and either the patient told by the surgeon *preoperatively* that the best he or she can do is
 replace the valve or the patient> should be sent to another surgeon with expertise in valve reconstruction. I have seen many patients with Barlow's during my training scheduled for a 'mitral valve repair' and yet predictably (because the entire team knows the surgeon would never repair such valves) end up with a replacement with a long story to the> cardiologist on how tough a valve it was and how it cannot be repaired. > > We should not be making intuitive decisions in front of mitral insufficiency in the OR anymore - these should be made pre-operative on the transthoracic (or transesophageal if done) echocardiogram. In this era it should no longer be an excuse for a mitral valve replacement that the surgeon thought a replacement was the best approach 'in his hands' - those were the wrong hands for this patient and the patient should never have got there in the first place. In an elective case, if a valve is indeed to be deemed irreparable, that final
 determination should ideally only> be made by valve experts like Hal and Prassana, or at least by the most experienced valve surgeon assessible to that patient, to give patients the maximum probability of achieving a repair.> > We have an editorial coming out soon in JTCVS discussing this.> > Ani> > > > > > From: battr at medizin.uni-leipzig.de> To: OpenHeart-L at lists.hsforum.com> Subject: AW: [HSF] redo mitral video nope> Date: Wed, 24 Oct 2007 11:33:10 +0200> CC: > > Ani,> You theorized all the points, also Tea, but do not forget that moving the> instruments there is a SURGEON with more or less experience E.g. In mitral> reconstruction, and a possible re-reconstruction for Hal should be a valve> replacement for others. In front of a mitral insufficiency, we all must> intuitive make a decision based in our previous experience, and go on. Bob> once gave a talk in a European meeting Leipzig about the right operation for> the right surgeon, I´ll never forget
 it.> Roberto> >> -----Ursprüngliche Nachricht-----> Von: openheart-l-bounces at lists.hsforum.com> [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Ani Anyanwu> Gesendet: Dienstag, 23. Oktober 2007 13:33> An: openheart-l at lists.hsforum.com> Betreff: RE: [HSF] redo mitral video nope> > Tea> > You> are moving things way into the future. We are struggling now to deliver> *effective* population based therapies and you are suggesting we move to> sub-population or sub-sub population based therapies. While the latter> strategies will ultimately provide the best healthcare, they should only be> sought when we have achieved the former effectively.> > Take three strategies for treating severe MR with LV dysfunction> > Mitral Valve Repair> > Mitral Valve replacement> > Medical therapy> > The best healthcare will arise if everybody was treated with mitral valve> repair. It does not follow as you say that everyone will benefit from the> 'superior'
 treatment (indeed some> suffer harm) but in population based> medicine you treat many to benefit a few. If everyone got a valve> replacement or medical therapy, the loss of health or life would be more.> > Then moving to the next step, which is where you seem to come from (seem> because we can usually never> understand where you come from), within the> entire cohort there are those that medical therapy is best (mainly those who> die of complications of surgery) and those for whom replacement is best> (such as those who need early replacement for repair failure). But that will> not on its own justify widespread use of medical therapy or replacement.> Your suggestion that we go on to identify these subpopulations is good but> first I think we have to attack the mass delivery of inferior and> ineffective care as still exists for many diseases. When we have reached> acceptable uptake levels (such as for immunization or LIMA use) we can now> settle down to a
 more selective> strategy. In your world there would be no> inferior or superior therapy but *appropriate* therapies matched to> individual patient sub-groups.> > Your observation of LIMA failure in your case illustrates this - in the> population this patient belongs to, a saphenous vein may have been more>> beneficial first time. Does that then mean we waver from our message that> LIMA should be used in almost all settings? Until we can relaibly identify> that subgroup, continued use of LIMA or mitral repair remains the best> epidemiological strategy.> > Ani> PS - talking of failed repair, we yesterday did a patient not too dissimilar> to yours, except younger, who had a reprolapse 3 years after repair due to> chordal elongation. We treated simply by limited triangular resectionand one> goretex chord - actually a much simpler, safer and faster procedure than a> valve replacement. Of course which is better in the long term I cannot say> (as how can one
 tell chords won't> elongate again).> > > > > Date: Mon, 22 Oct 2007 21:36:10 -0700> From: tacuff at swbell.net> To:> OpenHeart-L at lists.hsforum.com> CC: > Subject: [HSF] redo mitral video nope>> > I apologize for my ineptness in transferring images with my text. In> trying to review them I am not satisfied with> the resolution or my ability> to get a single cardiac cycle to loop. I probably can get single a picture,> but it will require some different software and a little time.> > The point> of the case (quixotic) is that I did a Lima to the Lad which failed and a> mitral repair posterior resection which did not seem to fail by my suture> annuloplasty, but by obvious reprolapse of the posterior leaflet. There was> perhaps some mild anterior prolapse and thickening of the valve leaflets in> general. The annuloplasty suture and most of the few pledgets that I use for> that were nicely covered in scar, I am reasonably sure that a complex repair> could have
 been accomplished,> but I choose a more expedient replacement> associated with tricuspid ring and RSV to the Lad in this 75 year old. > >> Admittedly I could have just made a series of errors in the first operation,> but I would suggest despite the implications of our "guidelines" or expert> opinion, the> behavior of populations on the average at least requires both> good results and bad results with the "preferred" therapy. Ani described a> variety of ways that repairs fail, but most discussions emphasize the data> that suggests one technique is preferred ignoring the distribution of> failure in both or competing techniques. The unaddressed question in all of> this is in which sub groups of patients that can undergo the "preferred"> therapy is the inferior therapy actually better.> > One example of this> effect that I recently read about was a finding that was called "reverse> epidemiology". (I am not sure this moniker makes sense, however.) The>
 observation was that in> sub groups of chronic disease patients that live,> the "lucky unlucky", such as ESRD or very elderly, traditional risk factors> like obesity and hyperlipidemia seem protective. Further, therapeutic> modification to reduce these risk factors do not help the longevity of these> lucky> unlucky groups. Thus these patients are in some sense harmed by best> therapy for the many.> > I can imagine in our rush to make larger and more> inclusive studies to "universalize" therapy we are losing more and more> ability to discriminate "among" patients. (I think that I am still talking> about medicine and not politics, colleagues, both of which suffer> immeasurably by political correctness if not hyperbole.) Further in our rush> to proscribe guidelines we will subject some to harm by commission. The more> successful our efforts toward universalization, the more of these minorities> (all nonmajority) we will either not help or hurt.> > I will
 keep working on> my> pictures so you can believe your own lying eyes, not just my contrarian> thinking.> > tea> _______________________________________________>> 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>> -----------------------------------------> _________________________________________________________________> Get free emoticon packs and customisation from Windows Live. > http://www.pimpmylive.co.uk_______________________________________________> 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> -----------------------------------------> > _______________________________________________> 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> -----------------------------------------> _________________________________________________________________> 100’s of Music vouchers to be won with MSN Music> https://www.musicmashup.co.uk_______________________________________________> 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> -----------------------------------------> _______________________________________________> 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> -----------------------------------------> _________________________________________________________________> The next generation of MSN Hotmail has arrived - Windows Live Hotmail> http://www.newhotmail.co.uk_______________________________________________> 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> -----------------------------------------> _______________________________________________> 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> -----------------------------------------
_________________________________________________________________
Celeb spotting – Play CelebMashup and win cool prizes
https://www.celebmashup.com_______________________________________________
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
-----------------------------------------