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

[Steven Schwartz]

Ani,
That 5-10% doesn't mean a thing unless it's YOU!
I have a hard time comparing what is a surgical treatment for  
symptomatic disease (redo CABG with patent LIMA-LAD for angina)  
versus a valve/CABG for a disease process that will result in an  
increased patient mortality if treated medically (LM stenosis, AS,  
AI, etc.).
Steven Schwartz

On Feb 10, 2008, at 12:15 PM, Ani Anyanwu 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=aolcmp003000000025> 48)>  
>> _______________________________________________> OpenHeart-L  
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