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

Sun Feb 10 19:52:45 EST 2008

Ah, there's the real debate in this question. I DO a lot of arterial  
grafting (including skeletonized BIMAs in diabetics), and would  
certainly consider that strategy in all patients. We have no problem  
in doing difficult redos (although we see them much less frequently  
since the routine use of LIMA-LADs. We even had a cardiologist  
jokingly ask if we could start using SVGs again, since he wasn't  
seeing patients come back for repeat caths anywhere near as often as  
he used to see in the past). The question is whether there is a REAL  
advantage, survival-wise, in a redo CABG where you are not grafting  
the LAD. If the redo includes the anterior wall, no question. The  
bigger problem remains in getting the cardiologists to refer the  
first-time patients for optimal treatment, which would include multi- 
vessel arterial grafting rather than multi-vessel stenting (or left  
main stenting).

Steven Schwartz

On Feb 10, 2008, at 3:36 PM, Ani Anyanwu wrote:

> If the 5 to 10% is not you that is not an excuse to deny a patient  
> appropriate therapy (assuming that is the appropriate therapy) and  
> recommend an inferior one.
>
>  If you are not the 5 to 10% then you should help the patient seek  
> a 5 to 10% surgeon - there are no doubt many such around. Same  
> applies to any inferior therapy where the perceived difference may  
> be substantial. For example, it is not justifiable (assuming no  
> specific indication) to place vein grafts on a 45 year old diabetic  
> because a BIMA does not work in my hands - such a patient should be  
> sent to a colleague.
>
> Ani
>
>
>
>
>
>> From: smschwartz at mac.com> Subject: Re: [HSF] Another Victory for  
>> the LAD Stent.....> Date: Sun, 10 Feb 2008 15:07:24 -0800> To:  
>> OpenHeart-L at lists.hsforum.com> CC: > > 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)> > >>  
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