[HSF] RCA osteal lesion-osteal reconstruction

[Ani Anyanwu]

> Tea,> I think you may have been somewhere between Saturn and Jupiter when you > wrote that one. However, I do "get it". My > minimally invasive AVR, via a 6 cm upper sternal split, yields the same result > as an open sternotomy. So far, my robotic mitrals have yielded similar > results. > > Hal> > 
 
 
Hal
 
With respect I am not sure you do "get it". It is rarely possible or true that two different interventions yield the same result. This is why clinical trialists insist on randomized trials of new interventions because what we conceive to be the same (or superior or inferior) may not be so. There are numerous such examples of therapies we think to be beneficial (or harmful or equivalent) that are shown not to be so. Aprotinin for example (regardless of which side of the fence one stands on this). As Hunter said "when I did the experiment, the result was different (from what I conceived)". For the same reason health economists frown at the "cost-minimization" approach where two health interventions are considered the same (mini-AVR vs conventional for example) so to work out the better one you just pick the cheaper one (in terms of cost or less morbidity) as the better one. Health economists will generally insist on actually measuring benefits (outcomes)  as when this is done, it is almost unknown to get two interventions (e.g robotic vs open mitral) that truly have the same benefit.
 
Back to your examples, it is NOT possible that a robotic mitral and open mitral or mini-AVR and open AVR yield the same results. Indeed the mini-approaches could paradoxically (for various reasons) yield results superior to an open operation as we see for example with the prostate robotic excisions. Similarly PCI could conceivably give results superior to CABG (and most likely someday will). Even if you take aside the human and system based influences on either approach, the operations  of robot vs open are different so cannot be the same. That both end up with no MR does not mean they are the same. Its like saying all airlines and classes of travel between new york and london are the same because they all usually get you to london without crashing. There is a difference, there has to be a difference. That is why we conduct studies to find what this difference is. Just this morning on rounds we saw a patient who had a VATS esophagectomy with an epidural - I was surprised because I was told in the past the whole point of lot of this mini-invasive stuff is that they suffer less pain, sounds intuitive alright but when studied objectively then they these lesser degrees of pain were not observed and they all end up with epidurals. 
 
I do not know the difference between a robotic mitral cf sternotomy- it may be superior, it may be inferior but certainly isn't the same. Whether the risks and resources necessary justify the incremental benefit, and not which offers more benefit per se, is however what (should) guide choice of approach on a population basis. This is also the reason why each procedure - AVI, AVR, valvulopasty; MVR, robotic MVR, evalve; ONCAB, OPCAB, PCI should each be considered on their own merit, with different considerations and different standards and choices made between either based on such data. Mind you that a procedure has superior results does not mean it is the superior technique or that it should be the procedure of choice for a given patient a concept Tea often indirectly hints at...
 
Ani
 



> From: Hgrmd at aol.com> Date: Wed, 30 Apr 2008 08:06:19 -0400> Subject: Re: [HSF] RCA osteal lesion-osteal reconstruction> To: OpenHeart-L at lists.hsforum.com> CC: > > Tea,> I think you may have been somewhere between Saturn and Jupiter when you > wrote that one. However, I do "get it". Less invasive approaches may be less > efficacious. However, not all of them are inferior to open techniques. My > minimally invasive AVR, via a 6 cm upper sternal split, yields the same result > as an open sternotomy. So far, my robotic mitrals have yielded similar > results. In fact, I'm beginning to think I can do even more complex repairs > robotically than open if a patient is particularly deep. The robot doesn't give > a hoot about how big or deep a person is. As for AVI, I think those will > always give inferior results to a standard AVR. There is some AI on virtually > every case, according to personal communication I've had with surgeons > experienced in the technique. Hopefully, AVI will open up a new population of > patients that would otherwise be treated medically.> > 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)> _______________________________________________> 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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