[HSF] RCA osteal lesion-osteal reconstruction

Sun Apr 27 13:41:33 EDT 2008

But Ed what about the other patients on whom you performed this operation 10 or 20 years ago - how have they fared? How do you know what will happen in the eleventh year of this vein graft? How do you even know the patients lack of symptoms is a product of your operation? What if he had a cath today in preparation for an AVR and they found the graft is occluded - would that finding surprise you?

It is true probabilistic statistics and population medicine will never (by definition) represent the truth for all patients, so  i agree we do not give the absolute truth, as Tea often reminds us, but in many ways these data represent the best we have. For your patient, a vein graft may have been the ideal procedure and it certainly worked very well, but on a more global scale, if we wish to provide patients a surgical option to PCI for single vessel disease that stands even an occasional chance of being chosen by the patient and cardiologist, it cannot be with a vein graft: patients may not want to rely on chance to be, like your patient, among the lucky minority that will have a vein graft that lasts 10 to 20 years. 

I certainly do not agree with prasanna's argument of keeping the RIMA for the left side - firstly how many surgeons use the RIMA for the left routinely in even primary cases, talk less reoperations - very few (less than 15% CABG in US done with two mammaries), and secondly why do we believe a patient with a pristine LAD and CX, now on aggressive secondary prevention strategy will develop new left disease and that this will require surgery. Thirdly, how are we to know the RIMA will be an ideal conduit (mainly for technical constraints) for this hypothetical future reoperation? Maybe next one will be isolated Cx disease and the excuse now will be avoiding a resternotomy and the patient will get a vein to the descending aorta. 

In my opinion, an ostial right lesion provides an ideal scenario for a pedicled RIMA graft. This can be performed by MIDCAB (r ant thoracotomy or lower sternotomy) with direct or robotic IMA take down, and i do not see that one can critically look at the data and truly say this is an inferior or less durable operation than a SVG.

Ani

> From: ebender001 at charter.net> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] RCA osteal lesion-osteal reconstruction> Date: Sat, 26 Apr 2008 22:40:14 -0500> CC: > > Ten years ago I did a single SVG to a PDA after the patient had > recurrent symptomatic re-stenosis 2 times after stenting. He has had > no symptoms and normal stress tests since. I am rarely asked to do > this type of procedure, but I have no issue with the results when I > have done it. Your opinions are well thought out, but do not > represent an absolute truth.> Ed Bender, MD> > > On Apr 26, 2008, at 4:45 PM, Ani Anyanwu wrote:> > > No arterial graft has been shown to be better than a> saphenous vein > > on the right side (In fact radials have been found to be> worse if > > the lesion is less than 80 %). There is no survival benefit of a> > > precrux arterial RCA graft and the RIMA is better preserved for the > > left> system where there is a possible shred of an evidence that a > > second IMA may> be better.> Prasanna> >> > Prasanna> >> > I think we are misrepresenting the data to prove a point here.> >> > Firstly, we chose to interpret the data how we like, and pick the > > studies we wish to emphasize to justify our practice, but a critical > > study of the literature will not reach the conclusion that arteries > > and veins are equivalent on the right system, or indeed any coronary > > artery, if one starts comparing apples with apples and oranges with > > oranges. True the benefit of an arterial graft may not be as > > pronounced on the RCA as the LAD but the same biological arguments > > exist. I have often said (and I have done this in public forum) that > > i can argue logically from the literature that a vein and mammary > > are also equivalent on the LAD distribution - something I certainly > > do not believe.> >> > Secondly, single vessel CAB with right coronary grafts are not done > > for survival benefit, so saying there is no 'survival benefit of a > > precrux arterial graft' really does not have significant implication > > as there is no survival benefit of majority of isolated RCA grafts > > either.> >> > Having been to my cath lab several times I have seen numerous > > interventions of diseased vein grafts to the RCA - i have never seen > > one to a diseased arterial graft. Maybe they do not exist, but I for > > one have put quite a few. One think is clear - the vast majority of > > vein grafts have a limited life expectancy but the same cannot be > > said of any arterial graft. I know Buxtons group will present data > > at the AATS in few weeks that arteries and veins are equivalent in > > latest analysis from their RCT but that too has heavy flaws.> >> > One thing is certain is I would never have my chest opened for a > > single venous bypass (but would consider so for a single arterial > > graft). It is such dated operations (vein grafts for single vessel > > disease) by surgeons - who will often use flawed data to justify > > their practice - that mark the death of our speciality. With veins > > for single vessel disease, how can we compete with the high > > technology modern PCI options? To be fair you do say PCI is the > > first choice here but we should uniformly be able to offer a viable > > alternative (arterial grafting to the RCA).> >> > Ani> >> >> >> >> >> Date: Sat, 26 Apr 2008 21:02:12 +0530> From: > >> prasannasimha at gmail.com> To: OpenHeart-L at lists.hsforum.com> > >> Subject: Re: [HSF] RCA osteal lesion-osteal reconstruction> CC: > > > >> A single RCA lesion should receive a PCI if possible. If not then > >> it can> receive any graft. No arterial graft has been shown to be > >> better than a> saphenous vein on the right side (In fact radials > >> have been found to be> worse if the lesion is less than 80 %). > >> There is no survival benefit of a> precrux arterial RCA graft and > >> the RIMA is better preserved for the left> system where there is a > >> possible shred of an evidence that a second IMA may> be better.> > >> Prasanna> On Sat, Apr 26, 2008 at 8:47 AM, yadav del <yadavluck at yahoo.com > >> > wrote:> > >> > We have a 60 yr old female patient admitted with > >> acute inferior MI with> > RV extension . At admission she was in > >> shock and complete heart block,severe> > MR and severe TR.She > >> improved with temporary pacemaking.> > Repeat echo after 3 weeks > >> shwoed mild mr mild tr, EF 60% and coronoro> > angiogram showed RCA > >> [large and dominant] with 98% osteal lesion .> > Dobutamine echo > >> showed viable RCA territory.> >> > What is the optimal surgical > >> treatment? RCA graft or osteal> > reconstruction?> >> >> > > >> ---------------------------------> > Be a better friend, newshound, > >> and know-it-all with Yahoo! Mobile. Try it> > now.> > > >> _______________________________________________> > 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 > >> > > -----------------------------------------> >> > > > -- > > >> Prasanna Simha M> _______________________________________________> > >> 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 > >> > -----------------------------------------> > _________________________________________________________________> > Bag extra points with the Walkers Brit Trip Game> > http://www.walkersbrittrips.co.uk/game_______________________________________________> > 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> -----------------------------------------
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