[HSF] Intimal Tears

[Edward Bender]

I see nothing conflicting in operating on your renal transplant  
patient.  I remember a patient I had in 1982 who had undergone a renal  
transplant, that came in with a fever and no other symptoms until he  
arrested and died 6 hours later.  I attended the autopsy and was  
aghast to see a transmural anterior MI probably 4 days old.  Important  
coronary disease can be asymptomatic and eventually fatal, and the  
fatality can be aborted by CABG.

Ed Bender, MD


On Feb 4, 2008, at 7:17 PM, Ani Anyanwu wrote:

> Ed
>
> Not really. Surgery is my job and I would just do my job whatever it  
> is. Whether what I do or what we do is the 'right' thing is another  
> question which is what I raised in the earlier discussion. LVAD  
> therapy is no different from any other and we still weigh the risks  
> and benefits of each case and sometimes say no, as I did to a 71  
> year old in post infarct cardiogenic shock last week with a logistic  
> euroSCORE of 98. Also all patients having VADs and high risk valve  
> operations are sick, very sick and symptomatic. We (doctors) do not  
> go looking for them - they look for us. Screen triggered disease and  
> VOMIT is different because you are operating on people who never  
> complained about whatever it is you say they need fixing. I am  
> operating on one such patient this week, incidental coronary disease  
> in a patient needing kidney transplant and I still feel uneasy about  
> whether I am doing the right thing. Dr Frater put it very well - we  
> should be prepared to hold conflicting views on what we do in our  
> heads at the same time. My views have little to do with my practice  
> as a surgeon or as a doctor. I just don't like brain washing whether  
> I am at the giving end or receiving end.
>
> Ani
>
>
>
>
>
>> Date: Mon, 4 Feb 2008 18:13:23 -0600> Subject: Re: [HSF] Intimal  
>> Tears> From: ebender001 at charter.net> To: OpenHeart-L at lists.hsforum.com 
>> > CC: > > I don't mean to "pile on" Ani with this question, but  
>> ever since our> discussions about carotid artery surgery Ani's  
>> responses about avoidance of> medical personnel and "VOMIT" have  
>> been bothering me. Ani, I gather from> your missives that you have  
>> the difficult job of performing a lot of> desperate operations on  
>> desperate patients. Naturally, a lot of the> outcomes are  
>> predictably fatal, with the successes being all that much> sweeter.  
>> Do you think that your aversion to aggressive diagnosis and>  
>> intervention has anything to do with the arena in which you  
>> perform? I bet> that if I had to go through what you go through, I  
>> would be averse to> "looking for trouble" also. I remember Tom  
>> Starzl commenting that he found> the renal transplant work  
>> enjoyable, and the research was challenging, but> when he started  
>> in on liver transplants, that was when the torture really> began  
>> for him.> > Ed Bender, MD> > > On 2/4/08 5:28 PM, "Tea Acuff" <tacuff at swbell.net 
>> > wrote:> > > Of course the problem with logic and prospective  
>> complications is that one can> > argue either way retrospectively.  
>> Some are stronger arguments (as in Ani's> > calculations), but none  
>> are clear.> > > > tea> > > > > > ----- Original Message ----> >  
>> From: Prasanna Simha M <prasannasimha at gmail.com>> > To: OpenHeart-L at lists.hsforum.com 
>> > > Sent: Monday, February 4, 2008 10:45:19 AM> > Subject: Re:  
>> [HSF] Intimal Tears> > > > Playing Ani's ethics game - is it  
>> ethical to postpone surgery to> > demonstrate liabilities (which  
>> may not ever occur or if occurs may not> > change outcomes and is  
>> in no way concerned with patient outcome ) versus> > going ahead  
>> with surgery (whose outcomes also may not change.> > Prasanna> > >  
>> > On Feb 4, 2008 5:19 PM, Ani Anyanwu <anianyanwu at hotmail.com>  
>> wrote:> > > >>> and close the rent with a purse string. The last  
>> option is remove the>> >> dilator , compress and cancel the case  
>> for 24 hours.> >> > >> Prasanna> >> > >> This last option has two  
>> advantages - 1) It will differentiate a carotid> >> puncture  
>> related stroke from a surgeon related stroke - you never know what>  
>> >> the anesthesiologist has done and if any drugs have been given.  
>> We recently> >> had a patient stroke after direct administration of  
>> norepinephrine and> >> propofol into the carotid artery (this was  
>> in an ICU patient with the line> >> placed by a surgeon). 2) Avoids  
>> a neck incision.> >> > >> We had a similar case to yours in a child  
>> when I was at Harefield, where> >> we could not get the ACT to rise  
>> despite boluses and boluses of heparin. In> >> the end doing it the  
>> old fashioned way worked (directly injecting into the> >> RA). At  
>> some point in the surgery the right pleura was opened to reveal> >>  
>> white fluid (propofol) - all the medication had been going straight  
>> into the> >> pleural cavity where the tip of the line resided.> >>  
>> > >> Ani> >> > >> > >> > >> > >> > >>> > > > > > > >  
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