[HSF] Another Victory for the LAD Stent.....

[Ani Anyanwu]

> Ani,> You shouldn't be so binary.  Most > patients or potential patients, myself included, would rather have PCI if > possible.> > Hal
 
Hal
 
Agree the same. This summarizes the essence of why I brought up this issue. Some weeks back I was suggesting to the forum that there are overriding decisions other than logic or evidence that guide our decision making. I made the provocative statement regarding redo CABG just to demonstrate how this is the case and the responses to my supposition have done just that.
 
We criticise cardiologists because they are undertaking a less risky procedure (PCI) which is inferior to the more risky gold standard (CABG), yet we are prepared to recommend the same when it is a reoperative setting. We know looking at those angiograms that the solution for some (or even most) of these patients aint gonna be a stent but we try our best to encourage PCI rather than recommending the definitive, but risky, treatment of reop CABG which if successful will have a better long term outcome. As Don and others have suggested there are ways of achieving this (reop CABG) relatively safely but need some creativity.
 
So going on to the next point I wanted to demonstrate is that at the end of the day it is all about 'us'. The reason why we recommend PCI over redo CABG is not because it is better for the patient or less risky. Risk is not the issue. In most hands at least 90% of reop CABG patients will survive surgery. A 10% mortality is never a reason not to operate - most of the aortic aneurysms and multi-valve cases we do have a mortality risk in this region. Indeed using creative approaches, some of which are discussed here, some surgeons (not me) are able to offer reop CABG with a mortality well below 5%. In all honesty this risk is not as much as we make out when put in the scheme of affairs. The issue is not risk. Take another scenario a 90% left main in a 75 year old with low EF and renal dysfunction - easily matches the mortality of a redo CABG in a 60 year old. Who will turn the elderly left main down and recommend PCI? Few. Why?
 
The issue is convenience. We dont do the reop CABG because we dont like the operation - too much sweat and hassle on our part. We are either scared of the patent IMA or of the diseased vein graft, or both, depending on who you listen to. The same reason why we seek reasons or excuses not to do valve operations on patients with patent IMAs - we cant use PCI as the excuse this time. I am sure Hal you have done numerous mitrals on patients with prior CABG who have been turned down by surgeons elsewhere for various 'reasons'. We don't want to sweat it out to give the patient a potentially better longer term outcome. Whereas for the primary case we can bang on 3 grafts in 3 hours and go home so argue it is better than PCI. I bet you that if a reop cabg was an easy 4 hour operation we would be recommending it over PCI even if the risks were same (as now). These same arguments underlie the arterial grafting issue which you and Don brought up today.
 
Of course the other issue is the patient, as you also demonstrate. None of us want another heart operation - again little to do with which is more efficacious.
 
 
 
Ani
 
 



> From: Hgrmd at aol.com> Date: Sat, 9 Feb 2008 19:06:09 -0500> Subject: Re: [HSF] Another Victory for the LAD Stent.....> To: OpenHeart-L at lists.hsforum.com> CC: > > Ani,> You shouldn't be so binary. The risk of redo CABG is not trivial. Most > patients or potential patients, myself included, would rather have PCI if > possible.> > Hal> > > > **************Biggest Grammy Award surprises of all time on AOL Music. > (http://music.aol.com/grammys/pictures/never-won-a-grammy?NCID=aolcmp003000000025> 48)> _______________________________________________> 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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