[HSF] Intimal Tears

Tue Feb 5 08:18:56 EST 2008

Logistic Euroscore of 98 % chance of dying. The comorbidities must have been
great to give that high a euroscore.
Prasannae

On Feb 5, 2008 8:01 AM, Edward Bender <ebender001 at charter.net> wrote:

> 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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-- 
Prasanna Simha M