AW: AW: [HSF] New crazy operations and solutions at HZL

Tea Acuff tacuff at swbell.net
Fri Apr 25 19:00:12 EDT 2008 

May I suggest that part of the problem is a "devaluation" of our medical services because of the insulation that social responsiblilty and other third parties "provide". It is the same respect and devaluation that over indulgent parents see from adolesent and adult children that expect "rountine" family benefits without being independent. We can ignore this and I sure i am way out of line politically (imagine that!), but I am not blind and only sometimes silent. How many of us would want to spend $100,000 for this for ourselves, instead of leaving it for other things. It is a near absolute loss of perspective of the nature of things. I could go on, but the social perspective is so perverted it makes my mere suggestion to reflect seem the preversion.

tea



----- Original Message ----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Friday, April 25, 2008 3:24:07 PM
Subject: Re: AW: AW: [HSF] New crazy operations and solutions at HZL

Ed,
I do not disagree at all - which is part of the problem that we have gotten
oursleves into.  Everyone wants to live forever, no one wants to say no,
there is always a surgical solution to a problem.  I can easily see,
regardless of the outcome - which will be great in your hands - everytime he
hiccups funny they will call you.  We dont say NO to much either and often
families and referring physicians have no problem sending granny to a
nursing home PEGed and Trach'ed never to get out of bed again........ There
are tough cases - such as this one, but an interesting and possibly lower
risk solution - and there are tough problems.


-michael


On 4/25/08, DukeB60 at aol.com <DukeB60 at aol.com> wrote:
>
> Michael,
>    Herein lies the dilemma.  If we  declare him to be non-operative he then
> potentially goes on to get a  transfemoral or a transapical valve and we as
> surgeons are criticized for not  operating on "high risk" patients and
> giving
> away what we do.  Is he really  non operative?  Without question he is high
> risk.  He was seen a year  ago and now reappears with chest pain so the
> cards and
> family want something  done so he doesn't keep coming back to the ER.
>    In my mind it is reasonable to suggest  the apico-aortic conduit to keep
> him out of the ER with a significantly lower  risk than traditional aortic
> surgery but the decision is ultimately up to him  and the family.  The
> patient
> and family are not ready to "cash in his  chips" and I specifically asked
> him
> that question and suggested that doing  nothing was not an unreasonable
> point of
> view.  He is, after all, a "beat  up old high mileage Buick" but he and the
> family don't think he is ready for the  junk yard, realizing, nevertheless,
> that he is very old, new valve or  not..
>    I don't think I am very interested in a  redo sternotomy as it
> guarantees
> a significant pump run, the risk of hypotension  if I get into the RIMA
> graft
> then necessitating dissecting out the whole heart  for a CAB, the risk of
> myocardial dysfunction as a result of cardioplegia  and isoelectric arrest
> (albeit a very small risk) and the risk of  cerebral emboli from aortic
> manipulation
> and cross clamping which in this man  with CNS dysfunction already will not
> be at all tolerated.
>    So, do I simply turn him down (which is  easy to do and I have done
> already) or offer a solution that entails only a  general anesthetic with
> none of
> the other risks associated with a traditional  redo sternotomy?  Or do I
> yield
> to the percutaneous alternatives or  the "do nothing" opinion?  I realize
> doing nothing is certainly a  reasonable alternative and actually was my
> recommendation previously but here he  is again looking for help with his
> valve with
> an area of 0.5 cm2 with a gradient  of 30 mmHg.  - probably somewhat low
> due to
> his LV dysfunction.
>    I very much enjoy redos. and challenging  cases and get plenty but try
> to
> be realistic and open minded about the best  option for each patient and
> certainly am very in tune to the desires and wishes  of the patient and
> family as
> long as they are realistic.  What is  realistic?
>    In my mind, perhaps wrongly which is why I  posted the case, offering
> this man the apical alternative is reasonable not only  for this patient in
> particular but also for our specialty in general instead of  being
> criticized for
> not doing tough cases and handing them over to the cards.  and percutaneous
> approaches.
>    In some respects it follows a previous  line of discussion on the Forum
> about not doing redo CAB and instead  suggesting stents would be better,
> not
> because they really are but because a  surgeon doesn't want to do a tough
> case.
> If surgical revascularization is  the best alternative it should be so
> whether it is a redo or not within a  reasonable assessment of objective
> co-morbidities.
>    We can't turn our back on hard cases  because they are hard if there is
> distinct potential benefit to the  patient.  The benefit to some degree is
> in
> the eye of the beholder and  sometimes the decision is troublingly
> difficult
> and grasping what is  "right" from many perspectives problematic.
>
>
>                      Ed
>
> Edward P. Raines, M.D., J.D.
> BryanLGH  Cardiothoracic Surgery
> BryanLGH Medical Center East
> 1600 South 48th  Str.
> Lincoln, Nebraska 68506
> Office: 402-481-8430
> Cell:  402-730-9242
> Fax: 402-481-8429iv
>
>
>
> In a message dated 4/24/2008 8:50:31 A.M. Central Daylight Time,
> msfirst at gmail.com writes:
>
> Ed,
>
> 85 with severe dementia?
>
> Granted this may be a low  flow problem (which people always talk about,
> but
> I have never seen get  better) - has he had a CT/MRI?
>
> With impaired neuro status, how can you  be sure about his symptoms?
>
> Objectively, what are his  gradients?
>
> Not to be too critical (since I seem to be doing these kind  of cases
> lately)
> - but what are your goals for this  patient?
>
>
> -michael
>
>
>
> On 4/24/08, DukeB60 at aol.com  <DukeB60 at aol.com> wrote:
> >
> > I was re-consulted yesterday on  an 85 yo.  male with severe AS admitted
> > with
> > chest  pain.  I had consulted on him a  year ago and thought him to be  a
> > poor
> > surgical candidate because he had previous  CAB  with Bilateral IMA's
> with
> > the
> > RIMA crossing the midline  anterior to the  aorta, LIMA to the LAD and a
> > couple
> > of  veins.  His EF is 30% - not  that bad.  He has, however,
> pretty  severe
> > dementia which played a  significant role in my decision  not to operate
> > then.
> > Renal function is  okay.
> >    I reconsidered doing him now because of my  experience with the
> > apico-aortic conduit which I think would be much  better  tolerated and
> > safer than a
> > traditional  redo.  I would think it  has a high likelihood of
> giving  this
> > man
> > symptomatic relief and keep him  out of the  hospital for a while, but
> like
> > AVI,
> > maybe I am avoiding a  tough redo  for the sake of an inferior but easier
> >  alternative.  The family has looked  into percutaneous  valves.
> >    In my mind the apico-aortic conduit makes a  non-operative case an
> > operative one in this patient but perhaps it is  not a  viable
> alternative
> > and he
> > should be done through a  traditional sternotomy.  Any  thoughts?
> >
> >
> >            Ed
> >
> > Edward P. Raines,  M.D.
> > BryanLGH Cardiothoracic  Surgery
> > BryanLGH Medical  Center East
> > 1600 South 48th Str.
> > Lincoln,  Nebraska  68506
> > Office: 402-481-8430
> > Cell: 402-730-9242
> >  Fax:  402-481-8429
> >
> >
> >
> > In a message dated  4/24/2008 5:20:10 A.M. Central Daylight Time,
> > Hgrmd at aol.com  writes:
> >
> > Roberto,
> > Of course we are not better surgeons  than the guys  at HZL!  As  you
> must
> > know by now, HZL  is widely considered one  of the top heart  programs in
> >  the
> > world.  However, I do think  it's a fact that there  is  little known
> about
> > the long
> > term  performance of  transapical AVI, particularly  the durability of
> the
> >  prosthesis.  That is why I caution surgeons in  thinking that  most
> aortic
> > valve
> > cases should be done in this fashion.  Indeed, that may eventually be
> the
> > case,
> > but for now,  we just don't  know.  The fact remains that most aortic
> valve
> > cases can be  done conventionally with  excellent  immediate and long
> term
> > results.
> >
> >  Hal
> >
> >
> >
> > **************Need a new ride? Check  out  the largest site for U.S. used
> > car
> > listings at AOL  Autos.
> > (http://autos.aol.com/used?NCID=aolcmp00300000002851)
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