[HSF] RCA osteal lesion-osteal reconstruction

Mon Apr 28 15:01:31 EDT 2008

You do good teaspeak, Michael. I particularly like the religious similes at the end.

tea

----- Original Message ----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Sunday, April 27, 2008 12:01:16 PM
Subject: Re: [HSF] RCA osteal lesion-osteal reconstruction

I think we often forget the basics of "bypass"
1)  Good inflow
2)  Good outflow
3)  Good conduit

I am sure there are more finer points - but if you put anything to a crappy
target then it is not going to stay open.  That is why I rarely use RIMAs to
the right - I am not going to waste a good arterial (2nd best?) conduit on a
target that, in a word, sucks - sure there is a lot of bias in these kinds
of things and to lump everything together as we often do in these large
studies looking at graft patencies then is it easy to come to fuzzy
conclusions.

Prasanna -
Right, we dont know - but we think we are doing the right thing based on
principles, some science/data/extrapolations, luck/voodoo, and so on - so if
we dont do it, then we will never know and the Cardiologists will continue
to take more and more of what we give them.  Do you think they have any long
term data on these kinds of problems - probably not - but hey, it is just a
stick in the groin and a little pill that you have to take for a while - I
agree with their logic is much of what they do and their data is just as
sound (if not better than ours).  If you continue to look for excuses not to
operate, then dont we surprised if you dont have any cases - isnt that
negative "reinventing"?

Using Tea-speak, it is hard to think of this as a binary solution - right vs
wrong.  Afterall, what is the data that suggests that it is the wrong thing
to do?  The more common situation - like Hal's recent case - you are
"already in there" doing an AVR/MVR/TVR/whatever - so we get our pre-op
cath's and graft whatever needs grafting.  Using the logic of this case, why
not just do the AVR and have the cardiologist put a stent to the RCA post-op
(or even pre-op)?  It obviously becomes risks/benefits - and everyone is
saying they "would not have their chest opened for a single IMA/SVG to the
RCA" - but you, even as a surgeon, would have a PCI/BMS/DES/Plavix?  Excuse
me, but look at some of the data from larger centers - such as the CCF
(available online) - their PCI mortality, as published for all comers - is
not all that different than their CABG (for all comers).  I dont want a
sternotomy either, but if I need one, I need one.  We need to avoid drinking
the same cool-aid that our cardiology friends are drinking - they have their
perspectives (right or wrong) and we must continue to have our.  In fact,
they are starting to see things a little bit our way these days.  The other
day I did a CABGx2 - SVG to a crappy right and a LIMA to a large DIAG - the
LAD was fine.  The cardiologist (a very well respected and experienced doc)
and the interventionalist (also extremely experienced) both known for their
good judgement wanted this done - I reviewed the case and thought that
everything made sense.  What?  No LIMA-LAD??  OMG!!!  Lightning strike me
down

-michael

On 4/27/08, Prasanna Simha M <prasannasimha at gmail.com> wrote:
>
> yes but without it you don't know whether you are really doing the right
> thing or working on a "wrong " footing.
> Prasanna
>
> On Sun, Apr 27, 2008 at 8:55 PM, Michael Firstenberg <msfirst at gmail.com>
> wrote:
>
> > Just because there is not a huge double blind randomized study with a
> > nejm-circulation meta analysis or cochrane ebm report that does mean it
> is
> > not a good idea or that it will not work.
> >
> > Michael Firstenberg <msfirst at gmail.com>
> >
> > -----Original Message-----
> > From: "Edward Bender" <ebender001 at charter.net>
> > To: OpenHeart-L at lists.hsforum.com
> > Sent: 4/26/2008 11:40 PM
> > Subject: Re: [HSF] RCA osteal lesion-osteal reconstruction
> >
> > 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.> >
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