[HSF] Intimal Tears

Tue Feb 5 03:49:18 EST 2008

Yes EuroSCORE 98% - 71 y female with severe atherosclerotic disease, smoker with COPD, previous MVR, creatinine 2.5, on IABP and inotropes for cardiogenic shock following massive anterior MI three days previously with EF 20% and now decompensating acutely with post-infarct VSD needing emergency life saving surgery - virtually unsurvivable if you trust euroSCORE. The euroSCORE per se was not the issue but the almost certainty that she would require a VAD to wean of bypass and prospect of return to good quality life were near zero - if her ventricular function were better and her MI not so massive then would offer conventional surgery for that 10% or so chance (noting that euroSCORE overestimates risk of death).

Ed the reason for hesitation in the asymptomatic dialysis patient is that he has severe peripheral vascular disease - like everything that can be blocked is blocked such that I wonder where they would anastomose the donor renal artery to - I asked renal team and they said his disease does not contraindicate transplant. I have seen this before with transplant programs where they refuse to turn down patients and look for excuse not to do them with the expectation they die having the heart etc corrected or worked up and never get to transplant. My feeling is they never have any intent of transplanting this patient, so we are operating for 'nothing' - your point about potentially preventing MI is well taken but not so if he has a stroke or other vascular complication during this asymptomatic CABG. I had one such patient last year Child B cirrhosis being screened for liver transplant but liver team asked we should fix his AS first. When I did his aortic valve and few weeks later his liver failure got worse they said he was too high risk and would not transplant - he died of course.

Ani

> Date: Tue, 5 Feb 2008 08:18:56 +0530> From: prasannasimha at gmail.com> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Intimal Tears> CC: > > 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> >> > >> > >> > >> > >> > >>> > > > > > > >> > >> _______________________________________________> 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> > >> > -----------------------------------------> > > _________________________________________________________________> > > Get Hotmail on your mobile, text MSN to 63463!> > >> > http://mobile.uk.msn.com/pc/mail.aspx_______________________________________________> > > 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> > -----------------------------------------> >> > > > -- > 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> -----------------------------------------
_________________________________________________________________
Telly addicts unite!
http://www.searchgamesbox.com/tvtown.shtml