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

[Edward Bender]

Here is a demonstration of how simplistic I am.  I am very happy when
patients' anticipated procedures are in quadrant 1, and very unhappy when
patients are in quadrant 4 of the attached illustration.  In quadrants 2 and
3, then there is discussion.

Ed Bender, MD




On 2/10/08 2:15 PM, "Ani Anyanwu" <anianyanwu at hotmail.com> wrote:

>> 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=aolcmp00300000
>> 0025> 48)> _______________________________________________> OpenHeart-L
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