From prasannasimha at gmail.com Tue Jan 1 00:03:18 2008 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Mon Dec 31 13:33:49 2007 Subject: [HSF] Happy New Year from India (UTC +5.30 Hrs) Message-ID: <89c4ed2d0712311033l7028b67do4b2443c68a56d5a2@mail.gmail.com> Happy New Year 2008 Prasanna -- Prasanna Simha M From hgrmd at aol.com Tue Jan 1 01:43:21 2008 From: hgrmd at aol.com (hgrmd@aol.com) Date: Mon Dec 31 20:43:49 2007 Subject: [HSF] Happy New Year from India (UTC +5.30 Hrs), South Africa, In-Reply-To: References: <89c4ed2d0712311033l7028b67do4b2443c68a56d5a2@mail.gmail.com><8CA1A130E070D18-E18-3659@webmail-mf12.sysops.aol.com><64299DC1-ABE8-49DC-91C9-97A53E031B55@charter.net> Message-ID: <304254538-1199151798-cardhu_decombobulator_blackberry.rim.net-302209746-@bxe003.bisx.prod.on.blackberry> SnVzdCBmaW5pc2hlZCBteSBsYXN0IGNhc2UgZm9yIHRoZSB5ZWFyLiAgSGFwcHkgTmV3IFllYXIu DQoNCkhhbA0KU2VudCBmcm9tIG15IFZlcml6b24gV2lyZWxlc3MgQmxhY2tCZXJyeQ0KDQotLS0t 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<002601c84ba8$6749ae10$650fa8c0@cce5ca73a59a42d> References: <118419.89708.qm@web81615.mail.mud.yahoo.com><915EFB22-36D6-43F2-BD28-04252A6E4E59@bigpond.com> <4F8309F68D37E844B4C23BDD075C8C6E0375CB2E@tocexch01.tocad.orclinic.com> <002601c84ba8$6749ae10$650fa8c0@cce5ca73a59a42d> Message-ID: Mark Levinson could have done both via a subxyphoid incision. Nowhere near an intercostal nerve or a robot. Don On 31/12/2007, at 11:26 PM, Zhandong Zhou wrote: > In this day of age, just talking about survival for open heart > surgery or coronary artery disease is not enough. PCI has never > matched CABG in terms of survival or MACE (major adverse cardiac > event). PCI is gaining ground every year. We have to do our part as > well. Here is the case I did today. > > 65 year old active patient has 1 year history of increasing SOB. > TEE show large ASD not candidate for closure device. Cath show 70% > LAD take off lesion. left to right shunt 2.5:1. PA pressure about > 60mmHg with resistance about 3 woods unit. (I can not remember > exact number, if someone interested, I can find it) Patient's > cardiologist ask me if I can do it with minimal invasive approach > as the patient wanted go back to normal life in short period time > without restrictions. > > Although it is general rule that I do not do CABG for mini-valve or > ASD, I decided to give a try. I used robot to take down LIMA, then > went to the right chest with 2.5 inch incision. Fem-fem cannulation > and clamp the aorta with modified heart-port technique. Fix the ASD > with a 3cm autologus pericardial patch. With aorta still clamped, I > made a second incision in left chest about 2 inch size and suture > the LIMA to LAD. It took me a little over 5 hours to do the > surgery, patient is doing well, already wake and will be extubated > tonight. Alternative, I could have done the whole thing with a > sternotomy in less than 3 hours. > > In summery, patient end up with two mini-thoracotomy incision, one > is 2.5 inches in the right chest, one is 2 inches in the left > chest. He also has a small incision for femoral cannulation. The > advantage, no sternotomy, no rib cutting, he can go back to normal > acrivities in 2 weeks with no restrictions. Disadvantage, longer > surgery time and a little more work for the surgeon. > > Any comments? > > Z Zhou > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From hgrmd at aol.com Tue Jan 1 01:49:20 2008 From: hgrmd at aol.com (hgrmd@aol.com) Date: Mon Dec 31 20:49:46 2007 Subject: [HSF] ASD with LAD Disease In-Reply-To: <002601c84ba8$6749ae10$650fa8c0@cce5ca73a59a42d> References: <118419.89708.qm@web81615.mail.mud.yahoo.com><915EFB22-36D6-43F2-BD28-04252A6E4E59@bigpond.com><4F8309F68D37E844B4C23BDD075C8C6E0375CB2E@tocexch01.tocad.orclinic.com><002601c84ba8$6749ae10$650fa8c0@cce5ca73a59a42d> Message-ID: 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<4F8309F68D37E844B4C23BDD075C8C6E0375CB2E@tocexch01.tocad.orclinic.com> <002601c84ba8$6749ae10$650fa8c0@cce5ca73a59a42d> Message-ID: Dr Zhou Certainly these are the sort of innovative areas we should focus more on rather than beating the dead horse of 'CABG is better than PCI'. A reminder to us too that although a sternotomy is probably 'better' than the approach you used but it doesn't mean it is the most desirable. I think we should offer more and more operations like this to *patients who want them*. I also notice you chose to leave the heart clamped to do the LAD hence de-emphasizing, as myself and others have suggested previously on HSF, the relevance of avoiding cardiac ischemia and cardiopulmonary bypass. I think focusing on what the patient is interested in (like size of incisions and impact on activites of daily living and return to work) is far important for our future that what we are interested in (such as avoiding CPB and cardiac ischemia). You seem so positive though he can return to normal activities in two weeks. On what do you base this? The patient is not even extubated! I must say also I am intrigued about the length of the incision - 2 inches is 5 cm. Having said that would an 8cm lower hemisternotomy not offer you the same operation through one incision without breaching either pleural cavity? I am also surprised they did not do a hybrid for the PCI but all well and good that cardiologists are beginning to re-entertain the surgical solution. How exactly did you clamp the aorta? Also how did you deal with deairing the heart? Thanks Ani > From: zzhoumd@pol.net> To: OpenHeart-L@lists.hsforum.com> Date: Mon, 31 Dec 2007 20:26:43 +0800> CC: > Subject: [HSF] ASD with LAD Disease> > In this day of age, just talking about survival for open heart surgery or coronary artery disease is not enough. PCI has never matched CABG in terms of survival or MACE (major adverse cardiac event). PCI is gaining ground every year. We have to do our part as well. Here is the case I did today.> > 65 year old active patient has 1 year history of increasing SOB. TEE show large ASD not candidate for closure device. Cath show 70% LAD take off lesion. left to right shunt 2.5:1. PA pressure about 60mmHg with resistance about 3 woods unit. (I can not remember exact number, if someone interested, I can find it) Patient's cardiologist ask me if I can do it with minimal invasive approach as the patient wanted go back to normal life in short period time without restrictions. > > Although it is general rule that I do not do CABG for mini-valve or ASD, I decided to give a try. I used robot to take down LIMA, then went to the right chest with 2.5 inch incision. Fem-fem cannulation and clamp the aorta with modified heart-port technique. Fix the ASD with a 3cm autologus pericardial patch. With aorta still clamped, I made a second incision in left chest about 2 inch size and suture the LIMA to LAD. It took me a little over 5 hours to do the surgery, patient is doing well, already wake and will be extubated tonight. Alternative, I could have done the whole thing with a sternotomy in less than 3 hours.> > In summery, patient end up with two mini-thoracotomy incision, one is 2.5 inches in the right chest, one is 2 inches in the left chest. He also has a small incision for femoral cannulation. The advantage, no sternotomy, no rib cutting, he can go back to normal acrivities in 2 weeks with no restrictions. Disadvantage, longer surgery time and a little more work for the surgeon.> > Any comments?> > Z Zhou> _________________________________________________________________ Free games, great prizes - get gaming at Gamesbox. http://www.searchgamesbox.com From zzhoumd at pol.net Tue Jan 1 00:36:26 2008 From: zzhoumd at pol.net (Zhandong Zhou) Date: Tue Jan 1 00:36:03 2008 Subject: [HSF] ASD with LAD Disease References: <118419.89708.qm@web81615.mail.mud.yahoo.com><915EFB22-36D6-43F2-BD28-04252A6E4E59@bigpond.com><4F8309F68D37E844B4C23BDD075C8C6E0375CB2E@tocexch01.tocad.orclinic.com><002601c84ba8$6749ae10$650fa8c0@cce5ca73a59a42d> Message-ID: <008101c84bcb$49bb11e0$650fa8c0@cce5ca73a59a42d> Michael, Thanks for all the comments. Mini invasive surgery dose not change the basics of open heart surgery. It is done with the same principle, but different approach with different instruments. I do not see the contra-indications for surgery have ever changed for sicker patients. But I did see patients with less of disease become more acceptable for surgery. For example, single vessel disease such as we discussed earlier. Like Ani suggested, some cardiologists will manage single vessel disease medically. But I do have growing number of cases that cardiologists will send to me for single graft to OM or RCA as patient is symptomatic. I have one patient has chronically occluded RCA for many years. After I grafted the distal RCA with a mini incision and Robotic RIMA takedown, he told me that he felt 20 years younger and full of energy. Now come back to your question about bad lungs or obese patients. If just graft the LAD, the surgery can be down without bypass or sternotomy. I have done many of them and they do well. Patients with severe COPD, usually tolerate single lung ventilation well as I learned from my thoracic surgery experience. Obese patients can be challange, but I have done patients up to 300 pounds. For Mitral or ASD, with videoscope assistance or robot, it can be done as well. I think Hal can tell you more. Most patients can tolerate some degree of hypoxia. However, if I see sats below 90, I just let the anesthesiologist ventilate both lungs then find out the problem. LIMA takedown can be performed with both lung ventilation by increasing CO2 pressue in the left chest to creat enough space. I never hesitate to convert someone to regular sternotomy. For ASD or mitral valve, just go on bypass with femoral cannulation then drop both lungs. Regarding heart-port, I just use the femoral cannulation part and their instruments. I never used their endo balloon. To avoid femoral cannulation complications, just ask anesthesia to check the descending aorta make sure no dissection. Most common complication is seroma, it can be avoided by less of dissection and using Seldinger technique. One of my partner's patients did have compartment sydrome from DVT. There is no doubt that the surgery can be done much quicker with standard sternotomy. It is a little more work to do mini incisions. Therefore, the argument is, when finish and done, it looked really nice, if the patient did well, it may be worth it. If not, I will never do this again. Happy new year to everyone! Z Zhou ----- Original Message ----- From: "Michael Firstenberg" To: Sent: Tuesday, January 01, 2008 10:04 AM Subject: Re: [HSF] ASD with LAD Disease > Z- > > Nice job, but this case clearly illustrates one of the problems with > "modern medicine" and that being that everything can be fixed with a > pill or a small "mini" incision. > Would you (should you) have done the same operation had the Woods > units been 10? (these are the ones we see) or if the patient was > morbidly obese, 80 pack/year smoker? What about if his PAs were in > the 30's from right heart failure. I know these are all "what ifs" - > but we are talking about major life threatening/limiting problems > where I think the magnitude and scope of the problems (or potential > problems) that we deal with are underappreciated by all. The > Interventionalist in the communities rarely see their patients with > thrombosed LAD stents getting VAD or transplants (oh, wait it was > just the patient's disease or their non-compliance). I assume you > had to use single lung ventilation to get down the IMA - what would > you have done had the increased PVR or hypoxemia put your patient > into acute right heart failure? (and in the midst of trying > medications to help, anesthesia - none for there attention to such > details - give a giant air bolus which goes into the left heart and > up to the brain?). May be a little hard to go back to work then. We > all need to be realistic about the problems and promise we make, lest > we make deals with the Devil. What in a full sternotomy, LIMA-LAD, > standard bicaval cannulation, ASD closure - prevents him from going > back to "a normal life" in 2 weeks. In fact, since the last couple > of topics delt with how bad CPB is, I bet a "standard" approach would > have resulted in a much shorter pump run. Are 2 "mini" thoracotomies > less painful than 1 sternotomy (you probably would not have had to > open that widely). What are the statistics on complications of groin > cannulation? 5 hours, hmmm - didnt we present a case recently of an > compartment syndrome from femoral cannulation for an elective case. > I thought Heart-Ports have fallen out of favor due to > "problems"...... I could go on, but I admit I am a wuss and I am sure > Hal will beat me up for this. > > I worked with a thoracic surgeon who "got away" with a lot due to his > "innovative" (?creative) approaches - the problem, he also did not > get away with it at times and had some huge problems from such > misadventures. > > Nevertheless, great job - glad you helped the patient and made > everyone happy. Just offering the other side > > -michael > > > On Dec 31, 2007, at 7:26 AM, Zhandong Zhou wrote: > >> In this day of age, just talking about survival for open heart >> surgery or coronary artery disease is not enough. PCI has never >> matched CABG in terms of survival or MACE (major adverse cardiac >> event). PCI is gaining ground every year. We have to do our part as >> well. Here is the case I did today. >> >> 65 year old active patient has 1 year history of increasing SOB. >> TEE show large ASD not candidate for closure device. Cath show 70% >> LAD take off lesion. left to right shunt 2.5:1. PA pressure about >> 60mmHg with resistance about 3 woods unit. (I can not remember >> exact number, if someone interested, I can find it) Patient's >> cardiologist ask me if I can do it with minimal invasive approach >> as the patient wanted go back to normal life in short period time >> without restrictions. >> >> Although it is general rule that I do not do CABG for mini-valve or >> ASD, I decided to give a try. I used robot to take down LIMA, then >> went to the right chest with 2.5 inch incision. Fem-fem cannulation >> and clamp the aorta with modified heart-port technique. Fix the ASD >> with a 3cm autologus pericardial patch. With aorta still clamped, I >> made a second incision in left chest about 2 inch size and suture >> the LIMA to LAD. It took me a little over 5 hours to do the >> surgery, patient is doing well, already wake and will be extubated >> tonight. Alternative, I could have done the whole thing with a >> sternotomy in less than 3 hours. >> >> In summery, patient end up with two mini-thoracotomy incision, one >> is 2.5 inches in the right chest, one is 2 inches in the left >> chest. He also has a small incision for femoral cannulation. The >> advantage, no sternotomy, no rib cutting, he can go back to normal >> acrivities in 2 weeks with no restrictions. Disadvantage, longer >> surgery time and a little more work for the surgeon. >> >> Any comments? >> >> Z Zhou >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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@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 > ----------------------------------------- From toruasai at belle.shiga-med.ac.jp Tue Jan 1 15:29:40 2008 From: toruasai at belle.shiga-med.ac.jp (Tohru Asai) Date: Tue Jan 1 01:30:39 2008 Subject: [HSF] High CK release - low MB fraction after cardiac surgery References: <751228.2893.qm@web81614.mail.mud.yahoo.com> <000601c84afa$8df62f60$650fa8c0@cce5ca73a59a42d> Message-ID: <20080101152939.21B03896@belle.shiga-med.ac.jp> We all know you look and talk unique, Tea. Tohru > all Asians look and talk alike, Prasanna. > tea Tohru Asai Professor and Director,Cardiovascular Surgery Department of Surgery Shiga University of Medical Science Otsu Japan From rwmfglycar at aol.com Tue Jan 1 02:05:28 2008 From: rwmfglycar at aol.com (rwmfglycar@aol.com) Date: Tue Jan 1 02:09:44 2008 Subject: [HSF] ASD with LAD Disease In-Reply-To: References: <118419.89708.qm@web81615.mail.mud.yahoo.com><915EFB22-36D6-43F2-BD28-04252A6E4E59@bigpond.com> <4F8309F68D37E844B4C23BDD075C8C6E0375CB2E@tocexch01.tocad.orclinic.com> <002601c84ba8$6749ae10$650fa8c0@cce5ca73a59a42d> Message-ID: <8CA1A5BD2FA2800-A20-1829@MBLK-M24.sysops.aol.com> There is an assumption being made here that sternotomy carries an obligation to observe strict limitations on activity. Thia is enormously variable. If the surgeon cranks the sternum open only enough to see what is needed to do the operation properly and allows the patient to do postop?whatever he finds he can do comfortably, many patients have very little discomfort from median sternotomy. If they have been told? by the nurse or cardiologist that they cannot lift this or that small weight and must not drive for 6 wks, only the adventuresome amongst them will disobey those restrictions. There is absolutely no "evidence '" for these "rules". They are part of the?mythology that governs much of medical practice. Spending time with the patient after surgery allows the surgeon? to gain personal observational kinowledge of the natural history of sternotomy healing. Bob -----Original Message----- From: Michael Firstenberg To: OpenHeart-L@lists.hsforum.com Sent: Mon, 31 Dec 2007 9:04 pm Subject: Re: [HSF] ASD with LAD Disease Z-? ? Nice job, but this case clearly illustrates one of the problems with "modern medicine" and that being that everything can be fixed with a pill or a small "mini" incision.? Would you (should you) have done the same operation had the Woods units been 10? (these are the ones we see) or if the patient was morbidly obese, 80 pack/year smoker? What about if his PAs were in the 30's from right heart failure. I know these are all "what ifs" - but we are talking about major life threatening/limiting problems where I think the magnitude and scope of the problems (or potential problems) that we deal with are underappreciated by all. The Interventionalist in the communities rarely see their patients with thrombosed LAD stents getting VAD or transplants (oh, wait it was just the patient's disease or their non-compliance). I assume you had to use single lung ventilation to get down the IMA - what would you have done had the increased PVR or hypoxemia put your patient into acute right heart failure? (and in the midst of trying medications to help, anesthesia - none for there attention to such details - give a giant air bolus which goes into the left heart and up to the brain?). May be a little hard to go back to work then. We all need to be realistic about the problems and promise we make, lest we make deals with the Devil. What in a full sternotomy, LIMA-LAD, standard bicaval cannulation, ASD closure - prevents him from going back to "a normal life" in 2 weeks. In fact, since the last couple of topics delt with how bad CPB is, I bet a "standard" approach would have resulted in a much shorter pump run. Are 2 "mini" thoracotomies less painful than 1 sternotomy (you probably would not have had to open that widely). What are the statistics on complications of groin cannulation? 5 hours, hmmm - didnt we present a case recently of an compartment syndrome from femoral cannulation for an elective case. I thought Heart-Ports have fallen out of favor due to "problems"...... I could go on, but I admit I am a wuss and I am sure Hal will beat me up for this.? ? I worked with a thoracic surgeon who "got away" with a lot due to his "innovative" (?creative) approaches - the problem, he also did not get away with it at times and had some huge problems from such misadventures.? ? Nevertheless, great job - glad you helped the patient and made everyone happy. Just offering the other side? ? -michael? ? On Dec 31, 2007, at 7:26 AM, Zhandong Zhou wrote:? ? > In this day of age, just talking about survival for open heart > surgery or coronary artery disease is not enough. PCI has never > matched CABG in terms of survival or MACE (major adverse cardiac > event). PCI is gaining ground every year. We have to do our part as > well. Here is the case I did today.? >? > 65 year old active patient has 1 year history of increasing SOB. > TEE show large ASD not candidate for closure device. Cath show 70% > LAD take off lesion. left to right shunt 2.5:1. PA pressure about > 60mmHg with resistance about 3 woods unit. (I can not remember > exact number, if someone interested, I can find it) Patient's > cardiologist ask me if I can do it with minimal invasive approach > as the patient wanted go back to normal life in short period time > without restrictions.? >? > Although it is general rule that I do not do CABG for mini-valve or > ASD, I decided to give a try. I used robot to take down LIMA, then > went to the right chest with 2.5 inch incision. Fem-fem cannulation > and clamp the aorta with modified heart-port technique. Fix the ASD > with a 3cm autologus pericardial patch. With aorta still clamped, I > made a second incision in left chest about 2 inch size and suture > the LIMA to LAD. It took me a little over 5 hours to do the > surgery, patient is doing well, already wake and will be extubated > tonight. Alternative, I could have done the whole thing with a > sternotomy in less than 3 hours.? >? > In summery, patient end up with two mini-thoracotomy incision, one > is 2.5 inches in the right chest, one is 2 inches in the left > chest. He also has a small incision for femoral cannulation. The > advantage, no sternotomy, no rib cutting, he can go back to normal > acrivities in 2 weeks with no restrictions. Disadvantage, longer > surgery time and a little more work for the surgeon.? >? > Any comments?? >? > Z Zhou? >? > _______________________________________________? > OpenHeart-L mailing list? >? > Send postings to:? > OpenHeart-L@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@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 anddisclaimers posted at:? http://www.hsforum.com/listdisclaim? -----------------------------------------? ________________________________________________________________________ More new features than ever. Check out the new AOL Mail ! - http://webmail.aol.com From cmurtaza at hotmail.com Tue Jan 1 07:47:54 2008 From: cmurtaza at hotmail.com (murtaza chishti) Date: Tue Jan 1 02:48:22 2008 Subject: [HSF] ASD with LAD Disease In-Reply-To: <008101c84bcb$49bb11e0$650fa8c0@cce5ca73a59a42d> References: <118419.89708.qm@web81615.mail.mud.yahoo.com><915EFB22-36D6-43F2-BD28-04252A6E4E59@bigpond.com><4F8309F68D37E844B4C23BDD075C8C6E0375CB2E@tocexch01.tocad.orclinic.com><002601c84ba8$6749ae10$650fa8c0@cce5ca73a59a42d> <008101c84bcb$49bb11e0$650fa8c0@cce5ca73a59a42d> Message-ID: if the surgeon has the will, the patience, the skills and the infra-structure and can achieve the same surgical objective via a less traumatic and less disruptive approach, has the wisdom to select the appropriate candidate for a relatively unfamiliar operation and the foresight to anticipate trouble and the ability to forestall potential disasters, he/she should, without doubt , go ahead and do it; or else , how does the art and science of surgery advance? great work Dr Zhou murtaza > From: zzhoumd@pol.net > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] ASD with LAD Disease > Date: Tue, 1 Jan 2008 00:36:26 +0800 > CC: > > Michael, > > Thanks for all the comments. Mini invasive surgery dose not change the basics of open heart surgery. It is done with the same principle, but different approach with different instruments. I do not see the contra-indications for surgery have ever changed for sicker patients. But I did see patients with less of disease become more acceptable for surgery. For example, single vessel disease such as we discussed earlier. Like Ani suggested, some cardiologists will manage single vessel disease medically. But I do have growing number of cases that cardiologists will send to me for single graft to OM or RCA as patient is symptomatic. I have one patient has chronically occluded RCA for many years. After I grafted the distal RCA with a mini incision and Robotic RIMA takedown, he told me that he felt 20 years younger and full of energy. > > Now come back to your question about bad lungs or obese patients. If just graft the LAD, the surgery can be down without bypass or sternotomy. I have done many of them and they do well. Patients with severe COPD, usually tolerate single lung ventilation well as I learned from my thoracic surgery experience. Obese patients can be challange, but I have done patients up to 300 pounds. For Mitral or ASD, with videoscope assistance or robot, it can be done as well. I think Hal can tell you more. > > Most patients can tolerate some degree of hypoxia. However, if I see sats below 90, I just let the anesthesiologist ventilate both lungs then find out the problem. LIMA takedown can be performed with both lung ventilation by increasing CO2 pressue in the left chest to creat enough space. I never hesitate to convert someone to regular sternotomy. For ASD or mitral valve, just go on bypass with femoral cannulation then drop both lungs. > > Regarding heart-port, I just use the femoral cannulation part and their instruments. I never used their endo balloon. To avoid femoral cannulation complications, just ask anesthesia to check the descending aorta make sure no dissection. Most common complication is seroma, it can be avoided by less of dissection and using Seldinger technique. One of my partner's patients did have compartment sydrome from DVT. > > There is no doubt that the surgery can be done much quicker with standard sternotomy. It is a little more work to do mini incisions. Therefore, the argument is, when finish and done, it looked really nice, if the patient did well, it may be worth it. If not, I will never do this again. > > Happy new year to everyone! > > Z Zhou > > > ----- Original Message ----- > From: "Michael Firstenberg" > To: > Sent: Tuesday, January 01, 2008 10:04 AM > Subject: Re: [HSF] ASD with LAD Disease > > > > Z- > > > > Nice job, but this case clearly illustrates one of the problems with > > "modern medicine" and that being that everything can be fixed with a > > pill or a small "mini" incision. > > Would you (should you) have done the same operation had the Woods > > units been 10? (these are the ones we see) or if the patient was > > morbidly obese, 80 pack/year smoker? What about if his PAs were in > > the 30's from right heart failure. I know these are all "what ifs" - > > but we are talking about major life threatening/limiting problems > > where I think the magnitude and scope of the problems (or potential > > problems) that we deal with are underappreciated by all. The > > Interventionalist in the communities rarely see their patients with > > thrombosed LAD stents getting VAD or transplants (oh, wait it was > > just the patient's disease or their non-compliance). I assume you > > had to use single lung ventilation to get down the IMA - what would > > you have done had the increased PVR or hypoxemia put your patient > > into acute right heart failure? (and in the midst of trying > > medications to help, anesthesia - none for there attention to such > > details - give a giant air bolus which goes into the left heart and > > up to the brain?). May be a little hard to go back to work then. We > > all need to be realistic about the problems and promise we make, lest > > we make deals with the Devil. What in a full sternotomy, LIMA-LAD, > > standard bicaval cannulation, ASD closure - prevents him from going > > back to "a normal life" in 2 weeks. In fact, since the last couple > > of topics delt with how bad CPB is, I bet a "standard" approach would > > have resulted in a much shorter pump run. Are 2 "mini" thoracotomies > > less painful than 1 sternotomy (you probably would not have had to > > open that widely). What are the statistics on complications of groin > > cannulation? 5 hours, hmmm - didnt we present a case recently of an > > compartment syndrome from femoral cannulation for an elective case. > > I thought Heart-Ports have fallen out of favor due to > > "problems"...... I could go on, but I admit I am a wuss and I am sure > > Hal will beat me up for this. > > > > I worked with a thoracic surgeon who "got away" with a lot due to his > > "innovative" (?creative) approaches - the problem, he also did not > > get away with it at times and had some huge problems from such > > misadventures. > > > > Nevertheless, great job - glad you helped the patient and made > > everyone happy. Just offering the other side > > > > -michael > > > > > > On Dec 31, 2007, at 7:26 AM, Zhandong Zhou wrote: > > > >> In this day of age, just talking about survival for open heart > >> surgery or coronary artery disease is not enough. PCI has never > >> matched CABG in terms of survival or MACE (major adverse cardiac > >> event). PCI is gaining ground every year. We have to do our part as > >> well. Here is the case I did today. > >> > >> 65 year old active patient has 1 year history of increasing SOB. > >> TEE show large ASD not candidate for closure device. Cath show 70% > >> LAD take off lesion. left to right shunt 2.5:1. PA pressure about > >> 60mmHg with resistance about 3 woods unit. (I can not remember > >> exact number, if someone interested, I can find it) Patient's > >> cardiologist ask me if I can do it with minimal invasive approach > >> as the patient wanted go back to normal life in short period time > >> without restrictions. > >> > >> Although it is general rule that I do not do CABG for mini-valve or > >> ASD, I decided to give a try. I used robot to take down LIMA, then > >> went to the right chest with 2.5 inch incision. Fem-fem cannulation > >> and clamp the aorta with modified heart-port technique. Fix the ASD > >> with a 3cm autologus pericardial patch. With aorta still clamped, I > >> made a second incision in left chest about 2 inch size and suture > >> the LIMA to LAD. It took me a little over 5 hours to do the > >> surgery, patient is doing well, already wake and will be extubated > >> tonight. Alternative, I could have done the whole thing with a > >> sternotomy in less than 3 hours. > >> > >> In summery, patient end up with two mini-thoracotomy incision, one > >> is 2.5 inches in the right chest, one is 2 inches in the left > >> chest. He also has a small incision for femoral cannulation. The > >> advantage, no sternotomy, no rib cutting, he can go back to normal > >> acrivities in 2 weeks with no restrictions. Disadvantage, longer > >> surgery time and a little more work for the surgeon. > >> > >> Any comments? > >> > >> Z Zhou > >> > >> _______________________________________________ > >> OpenHeart-L mailing list > >> > >> Send postings to: > >> OpenHeart-L@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@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 > > ----------------------------------------- _________________________________________________________________ Tried the new MSN Messenger? It?s cool! Download now. http://messenger.msn.com/Download/Default.aspx?mkt=en-in From toruasai at belle.shiga-med.ac.jp Tue Jan 1 16:54:13 2008 From: toruasai at belle.shiga-med.ac.jp (Tohru Asai) Date: Tue Jan 1 02:54:32 2008 Subject: [HSF] Happy New Year (OT) References: <89c4ed2d0712302106v68ffc6d1lca3aede086c140ed@mail.gmail.com> <20071231095411.33J31.136950.root@fepweb10> <89c4ed2d0712310831s43384d87s9b70e8a8a4691c74@mail.gmail.com> Message-ID: <20080101165413.26419657@belle.shiga-med.ac.jp> Prasanna I drove 3 hours to my parents' hometown, Kanazawa yestreday. Here we have cold weather with heavy snow falling, lightenings and thick clouds. I am spending New Year Holiday time quietly with family and great japanese foods. Probably Hal and you would never imagine it. HSF is great. Tohru Asai Professor and Director,Cardiovascular Surgery Department of Surgery Shiga University of Medical Science Otsu Japan From prasannasimha at gmail.com Tue Jan 1 13:40:38 2008 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Tue Jan 1 03:17:26 2008 Subject: [HSF] OT from Dallas In-Reply-To: <913987.4844.qm@web81613.mail.mud.yahoo.com> References: <913987.4844.qm@web81613.mail.mud.yahoo.com> Message-ID: <89c4ed2d0801010010t49c16d0cp342600cef8c54a5e@mail.gmail.com> So your wife did allow you to type after midnight !! Prasanna On Jan 1, 2008 11:15 AM, Tea Acuff wrote: > Happy New Year to all my virtual good friends. thank you, Mark, for > another good year. > > tea > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 From CardiacNse at aol.com Tue Jan 1 03:28:05 2008 From: CardiacNse at aol.com (CardiacNse@aol.com) Date: Tue Jan 1 03:32:22 2008 Subject: [HSF] Happy New Year (OT) Message-ID: We just had a wonderful, albeit flawed fireworks display off of the Seattle Space Needle. No rain, fairly clear skies and lots of celebration. Happy New Year to all of you who devote your lives, talents, and skills to compassion and healing. As Cardiac Surgery has been my niche since the first day I watched a patient go on bypass 26 years ago, you all would be among my favorite people. I've been honored to have worked the best of the best. Thank you for all you do and all you give and Bless you throughout the coming year. Becky Davis Washington State **************************************See AOL's top rated recipes (http://food.aol.com/top-rated-recipes?NCID=aoltop00030000000004) From zzhoumd at pol.net Tue Jan 1 11:42:07 2008 From: zzhoumd at pol.net (zzhoumd@pol.net) Date: Tue Jan 1 06:43:52 2008 Subject: [HSF] ASD with LAD Disease In-Reply-To: <8CA1A5BD2FA2800-A20-1829@MBLK-M24.sysops.aol.com> References: <118419.89708.qm@web81615.mail.mud.yahoo.com><915EFB22-36D6-43F2-BD28-04252A6E4E59@bigpond.com> <4F8309F68D37E844B4C23BDD075C8C6E0375CB2E@tocexch01.tocad.orclinic.com> <002601c84ba8$6749ae10$650fa8c0@cce5ca73a59a42d><8CA1A5BD2FA2800-A20-1829@MBLK-M24.sysops.aol.com> Message-ID: <1365857465-1199187741-cardhu_decombobulator_blackberry.rim.net-208606341-@bxe013.bisx.prod.on.blackberry> DQpCb2IsIHdoYXQgZG8geW91IHRlbGwgdGhlIHBhdGllbnRzIHRvIGRvIGFmdGVyIHN0ZXJub3Rv bXk/IEhvdyBtYW55IHdlZWtzIG9mIG5vIGRyaXZpbmcsIGxpbWl0YXRpb25zIG9mIGxpZnRpbmcs 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cnQtTEBsaXN0cy5oc2ZvcnVtLmNvbT8NCj4/DQo+IFRvIFVOU1VCU0NSSUJFLCB0byBDSEFOR0Ug ZW1haWwgYWRkcmVzcywgb3IgdG8gdmlldyBhcmNoaXZlczo/DQo+IGh0dHA6Ly9tbXAuY2pwLmNv bS9tYWlsbWFuL2xpc3RpbmZvL29wZW5oZWFydC1sPw0KPj8NCj4gQWxsIG1lc3NhZ2VzIHRyYW5z bWl0dGVkIGJ5IHRoZSBPcGVuSGVhcnQtTCBhcmUgc3ViamVjdCB0byB0aGUgPiBwb2xpY2llcyBh bmQ/DQo+IGRpc2NsYWltZXJzIHBvc3RlZCBhdDo/DQo+IGh0dHA6Ly93d3cuaHNmb3J1bS5jb20v bGlzdGRpc2NsYWltPw0KPiAtLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0t LT8NCj8NCl9fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fPw0K T3BlbkhlYXJ0LUwgbWFpbGluZyBsaXN0Pw0KPw0KU2VuZCBwb3N0aW5ncyB0bzo/DQpPcGVuSGVh cnQtTEBsaXN0cy5oc2ZvcnVtLmNvbT8NCj8NClRvIFVOU1VCU0NSSUJFLCB0byBDSEFOR0UgZW1h aWwgYWRkcmVzcywgb3IgdG8gdmlldyBhcmNoaXZlczo/DQpodHRwOi8vbW1wLmNqcC5jb20vbWFp bG1hbi9saXN0aW5mby9vcGVuaGVhcnQtbD8NCj8NCkFsbCBtZXNzYWdlcyB0cmFuc21pdHRlZCBi eSB0aGUgT3BlbkhlYXJ0LUwgYXJlIHN1YmplY3QgdG8gdGhlIHBvbGljaWVzIGFuZGRpc2NsYWlt ZXJzIHBvc3RlZCBhdDo/DQpodHRwOi8vd3d3LmhzZm9ydW0uY29tL2xpc3RkaXNjbGFpbT8NCi0t LS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tPw0KDQoNCl9fX19fX19fX19f X19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19f X19fXw0KTW9yZSBuZXcgZmVhdHVyZXMgdGhhbiBldmVyLiAgQ2hlY2sgb3V0IHRoZSBuZXcgQU9M IE1haWwgISAtIGh0dHA6Ly93ZWJtYWlsLmFvbC5jb20NCl9fX19fX19fX19fX19fX19fX19fX19f X19fX19fX19fX19fX19fX19fX19fX19fDQpPcGVuSGVhcnQtTCBtYWlsaW5nIGxpc3QNCg0KU2Vu ZCBwb3N0aW5ncyB0bzoNCiBPcGVuSGVhcnQtTEBsaXN0cy5oc2ZvcnVtLmNvbQ0KDQpUbyBVTlNV QlNDUklCRSwgdG8gQ0hBTkdFIGVtYWlsIGFkZHJlc3MsIG9yIHRvIHZpZXcgYXJjaGl2ZXM6DQpo dHRwOi8vbW1wLmNqcC5jb20vbWFpbG1hbi9saXN0aW5mby9vcGVuaGVhcnQtbA0KDQpBbGwgbWVz c2FnZXMgdHJhbnNtaXR0ZWQgYnkgdGhlIE9wZW5IZWFydC1MIGFyZSBzdWJqZWN0IHRvIHRoZSBw b2xpY2llcyBhbmQgDQpkaXNjbGFpbWVycyBwb3N0ZWQgYXQ6DQpodHRwOi8vd3d3LmhzZm9ydW0u Y29tL2xpc3RkaXNjbGFpbQ0KLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0t LS0NCg== From zzhoumd at pol.net Tue Jan 1 12:20:44 2008 From: zzhoumd at pol.net (zzhoumd@pol.net) Date: Tue Jan 1 07:21:26 2008 Subject: [HSF] ASD with LAD Disease In-Reply-To: References: <118419.89708.qm@web81615.mail.mud.yahoo.com><915EFB22-36D6-43F2-BD28-04252A6E4E59@bigpond.com><4F8309F68D37E844B4C23BDD075C8C6E0375CB2E@tocexch01.tocad.orclinic.com><002601c84ba8$6749ae10$650fa8c0@cce5ca73a59a42d> <008101c84bcb$49bb11e0$650fa8c0@cce5ca73a59a42d> Message-ID: <440587097-1199190058-cardhu_decombobulator_blackberry.rim.net-522688548-@bxe013.bisx.prod.on.blackberry> Murtaza, thanks for your comments. I think the same principle can be used in mini valve cases if the patient has 1-2 vessel CAD. Z Zhou Sent via BlackBerry by AT&T -----Original Message----- From: murtaza chishti Date: Tue, 1 Jan 2008 07:47:54 To: Subject: RE: [HSF] ASD with LAD Disease if the surgeon has the will, the patience, the skills and the infra-structure and can achieve the same surgical objective via a less traumatic and less disruptive approach, has the wisdom to select the appropriate candidate for a relatively unfamiliar operation and the foresight to anticipate trouble and the ability to forestall potential disasters, he/she should, without doubt , go ahead and do it; or else , how does the art and science of surgery advance? great work Dr Zhou murtaza > From: zzhoumd@pol.net > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] ASD with LAD Disease > Date: Tue, 1 Jan 2008 00:36:26 +0800 > CC: > > Michael, > > Thanks for all the comments. Mini invasive surgery dose not change the basics of open heart surgery. It is done with the same principle, but different approach with different instruments. I do not see the contra-indications for surgery have ever changed for sicker patients. But I did see patients with less of disease become more acceptable for surgery. For example, single vessel disease such as we discussed earlier. Like Ani suggested, some cardiologists will manage single vessel disease medically. But I do have growing number of cases that cardiologists will send to me for single graft to OM or RCA as patient is symptomatic. I have one patient has chronically occluded RCA for many years. After I grafted the distal RCA with a mini incision and Robotic RIMA takedown, he told me that he felt 20 years younger and full of energy. > > Now come back to your question about bad lungs or obese patients. If just graft the LAD, the surgery can be down without bypass or sternotomy. I have done many of them and they do well. Patients with severe COPD, usually tolerate single lung ventilation well as I learned from my thoracic surgery experience. Obese patients can be challange, but I have done patients up to 300 pounds. For Mitral or ASD, with videoscope assistance or robot, it can be done as well. I think Hal can tell you more. > > Most patients can tolerate some degree of hypoxia. However, if I see sats below 90, I just let the anesthesiologist ventilate both lungs then find out the problem. LIMA takedown can be performed with both lung ventilation by increasing CO2 pressue in the left chest to creat enough space. I never hesitate to convert someone to regular sternotomy. For ASD or mitral valve, just go on bypass with femoral cannulation then drop both lungs. > > Regarding heart-port, I just use the femoral cannulation part and their instruments. I never used their endo balloon. To avoid femoral cannulation complications, just ask anesthesia to check the descending aorta make sure no dissection. Most common complication is seroma, it can be avoided by less of dissection and using Seldinger technique. One of my partner's patients did have compartment sydrome from DVT. > > There is no doubt that the surgery can be done much quicker with standard sternotomy. It is a little more work to do mini incisions. Therefore, the argument is, when finish and done, it looked really nice, if the patient did well, it may be worth it. If not, I will never do this again. > > Happy new year to everyone! > > Z Zhou > > > ----- Original Message ----- > From: "Michael Firstenberg" > To: > Sent: Tuesday, January 01, 2008 10:04 AM > Subject: Re: [HSF] ASD with LAD Disease > > > > Z- > > > > Nice job, but this case clearly illustrates one of the problems with > > "modern medicine" and that being that everything can be fixed with a > > pill or a small "mini" incision. > > Would you (should you) have done the same operation had the Woods > > units been 10? (these are the ones we see) or if the patient was > > morbidly obese, 80 pack/year smoker? What about if his PAs were in > > the 30's from right heart failure. I know these are all "what ifs" - > > but we are talking about major life threatening/limiting problems > > where I think the magnitude and scope of the problems (or potential > > problems) that we deal with are underappreciated by all. The > > Interventionalist in the communities rarely see their patients with > > thrombosed LAD stents getting VAD or transplants (oh, wait it was > > just the patient's disease or their non-compliance). I assume you > > had to use single lung ventilation to get down the IMA - what would > > you have done had the increased PVR or hypoxemia put your patient > > into acute right heart failure? (and in the midst of trying > > medications to help, anesthesia - none for there attention to such > > details - give a giant air bolus which goes into the left heart and > > up to the brain?). May be a little hard to go back to work then. We > > all need to be realistic about the problems and promise we make, lest > > we make deals with the Devil. What in a full sternotomy, LIMA-LAD, > > standard bicaval cannulation, ASD closure - prevents him from going > > back to "a normal life" in 2 weeks. In fact, since the last couple > > of topics delt with how bad CPB is, I bet a "standard" approach would > > have resulted in a much shorter pump run. Are 2 "mini" thoracotomies > > less painful than 1 sternotomy (you probably would not have had to > > open that widely). What are the statistics on complications of groin > > cannulation? 5 hours, hmmm - didnt we present a case recently of an > > compartment syndrome from femoral cannulation for an elective case. > > I thought Heart-Ports have fallen out of favor due to > > "problems"...... I could go on, but I admit I am a wuss and I am sure > > Hal will beat me up for this. > > > > I worked with a thoracic surgeon who "got away" with a lot due to his > > "innovative" (?creative) approaches - the problem, he also did not > > get away with it at times and had some huge problems from such > > misadventures. > > > > Nevertheless, great job - glad you helped the patient and made > > everyone happy. Just offering the other side > > > > -michael > > > > > > On Dec 31, 2007, at 7:26 AM, Zhandong Zhou wrote: > > > >> In this day of age, just talking about survival for open heart > >> surgery or coronary artery disease is not enough. PCI has never > >> matched CABG in terms of survival or MACE (major adverse cardiac > >> event). PCI is gaining ground every year. We have to do our part as > >> well. Here is the case I did today. > >> > >> 65 year old active patient has 1 year history of increasing SOB. > >> TEE show large ASD not candidate for closure device. Cath show 70% > >> LAD take off lesion. left to right shunt 2.5:1. PA pressure about > >> 60mmHg with resistance about 3 woods unit. (I can not remember > >> exact number, if someone interested, I can find it) Patient's > >> cardiologist ask me if I can do it with minimal invasive approach > >> as the patient wanted go back to normal life in short period time > >> without restrictions. > >> > >> Although it is general rule that I do not do CABG for mini-valve or > >> ASD, I decided to give a try. I used robot to take down LIMA, then > >> went to the right chest with 2.5 inch incision. Fem-fem cannulation > >> and clamp the aorta with modified heart-port technique. Fix the ASD > >> with a 3cm autologus pericardial patch. With aorta still clamped, I > >> made a second incision in left chest about 2 inch size and suture > >> the LIMA to LAD. It took me a little over 5 hours to do the > >> surgery, patient is doing well, already wake and will be extubated > >> tonight. Alternative, I could have done the whole thing with a > >> sternotomy in less than 3 hours. > >> > >> In summery, patient end up with two mini-thoracotomy incision, one > >> is 2.5 inches in the right chest, one is 2 inches in the left > >> chest. He also has a small incision for femoral cannulation. The > >> advantage, no sternotomy, no rib cutting, he can go back to normal > >> acrivities in 2 weeks with no restrictions. Disadvantage, longer > >> surgery time and a little more work for the surgeon. > >> > >> Any comments? > >> > >> Z Zhou > >> > >>_______________________________________________ > >> OpenHeart-L mailing list > >> > >> Send postings to: > >> OpenHeart-L@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@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 > > ----------------------------------------- _________________________________________________________________ Tried the new MSN Messenger? It?s cool! Download now. http://messenger.msn.com/Download/Default.aspx?mkt=en-in_______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From msfirst at gmail.com Tue Jan 1 08:40:27 2008 From: msfirst at gmail.com (Michael Firstenberg) Date: Tue Jan 1 08:40:53 2008 Subject: [HSF] ASD with LAD Disease In-Reply-To: <440587097-1199190058-cardhu_decombobulator_blackberry.rim.net-522688548-@bxe013.bisx.prod.on.blackberry> References: <118419.89708.qm@web81615.mail.mud.yahoo.com> <915EFB22-36D6-43F2-BD28-04252A6E4E59@bigpond.com> <4F8309F68D37E844B4C23BDD075C8C6E0375CB2E@tocexch01.tocad.orclinic.com> <002601c84ba8$6749ae10$650fa8c0@cce5ca73a59a42d> <008101c84bcb$49bb11e0$650fa8c0@cce5ca73a59a42d> <440587097-1199190058-cardhu_decombobulator_blackberry.rim.net-522688548-@bxe013.bisx.prod.on.blackberry> Message-ID: Z - I am not picking on you - I am am glad that you see my points. Just has we are operating on "less sick" patients such as yours (though it is suprising that with that big of an ASD that he did not have more problems) we are also operating on very sick patients and what concerns me is all of this enthusiasm for high technology and cosmetic cardiac surgery in patients with very little room for error. I assume your patient is extubated and doing ok? -m On 1/1/08, zzhoumd@pol.net wrote: > > > Murtaza, thanks for your comments. I think the same principle can be used > in mini valve cases if the patient has 1-2 vessel CAD. > > Z Zhou > > > Sent via BlackBerry by AT&T > > -----Original Message----- > From: murtaza chishti > > Date: Tue, 1 Jan 2008 07:47:54 > To: > Subject: RE: [HSF] ASD with LAD Disease > > > > > > if the surgeon has the will, the patience, the skills and > the infra-structure and can achieve the same surgical objective via a > less traumatic and less disruptive approach, has the wisdom to select the > appropriate candidate for a relatively unfamiliar operation and the > foresight to anticipate trouble and the ability to forestall potential > disasters, he/she should, without doubt , go ahead and do it; or else , how > does the art and science of surgery advance? > > great work Dr Zhou > > murtaza > > > > From: zzhoumd@pol.net > > To: OpenHeart-L@lists.hsforum.com > > Subject: Re: [HSF] ASD with LAD Disease > > Date: Tue, 1 Jan 2008 00:36:26 +0800 > > > CC: > > > > Michael, > > > > Thanks for all the comments. Mini invasive surgery dose not change the > basics of open heart surgery. It is done with the same principle, but > different approach with different instruments. I do not see the > contra-indications for surgery have ever changed for sicker patients. But I > did see patients with less of disease become more acceptable for surgery. > For example, single vessel disease such as we discussed earlier. Like Ani > suggested, some cardiologists will manage single vessel disease medically. > But I do have growing number of cases that cardiologists will send to me for > single graft to OM or RCA as patient is symptomatic. I have one patient has > chronically occluded RCA for many years. After I grafted the distal RCA with > a mini incision and Robotic RIMA takedown, he told me that he felt 20 years > younger and full of energy. > > > > Now come back to your question about bad lungs or obese patients. If > just graft the LAD, the surgery can be down without bypass or sternotomy. I > have done many of them and they do well. Patients with severe COPD, usually > tolerate single lung ventilation well as I learned from my thoracic surgery > experience. Obese patients can be challange, but I have done patients up to > 300 pounds. For Mitral or ASD, with videoscope assistance or robot, it can > be done as well. I think Hal can tell you more. > > > > Most patients can tolerate some degree of hypoxia. However, if I see > sats below 90, I just let the anesthesiologist ventilate both lungs then > find out the problem. LIMA takedown can be performed with both lung > ventilation by increasing CO2 pressue in the left chest to creat enough > space. I never hesitate to convert someone to regular sternotomy. For ASD or > mitral valve, just go on bypass with femoral cannulation then drop both > lungs. > > > > Regarding heart-port, I just use the femoral cannulation part and their > instruments. I never used their endo balloon. To avoid femoral cannulation > complications, just ask anesthesia to check the descending aorta make sure > no dissection. Most common complication is seroma, it can be avoided by less > of dissection and using Seldinger technique. One of my partner's patients > did have compartment sydrome from DVT. > > > > There is no doubt that the surgery can be done much quicker with > standard sternotomy. It is a little more work to do mini incisions. > Therefore, the argument is, when finish and done, it looked really nice, if > the patient did well, it may be worth it. If not, I will never do this > again. > > > > Happy new year to everyone! > > > > Z Zhou > > > > > > ----- Original Message ----- > > From: "Michael Firstenberg" > > To: > > Sent: Tuesday, January 01, 2008 10:04 AM > > Subject: Re: [HSF] ASD with LAD Disease > > > > > > > Z- > > > > > > Nice job, but this case clearly illustrates one of the problems with > > > "modern medicine" and that being that everything can be fixed with a > > > pill or a small "mini" incision. > > > Would you (should you) have done the same operation had the Woods > > > units been 10? (these are the ones we see) or if the patient was > > > morbidly obese, 80 pack/year smoker? What about if his PAs were in > > > the 30's from right heart failure. I know these are all "what ifs" - > > > but we are talking about major life threatening/limiting problems > > > where I think the magnitude and scope of the problems (or potential > > > problems) that we deal with are underappreciated by all. The > > > Interventionalist in the communities rarely see their patients with > > > thrombosed LAD stents getting VAD or transplants (oh, wait it was > > > just the patient's disease or their non-compliance). I assume you > > > had to use single lung ventilation to get down the IMA - what would > > > you have done had the increased PVR or hypoxemia put your patient > > > into acute right heart failure? (and in the midst of trying > > > medications to help, anesthesia - none for there attention to such > > > details - give a giant air bolus which goes into the left heart and > > > up to the brain?). May be a little hard to go back to work then. We > > > all need to be realistic about the problems and promise we make, lest > > > we make deals with the Devil. What in a full sternotomy, LIMA-LAD, > > > standard bicaval cannulation, ASD closure - prevents him from going > > > back to "a normal life" in 2 weeks. In fact, since the last couple > > > of topics delt with how bad CPB is, I bet a "standard" approach would > > > have resulted in a much shorter pump run. Are 2 "mini" thoracotomies > > > less painful than 1 sternotomy (you probably would not have had to > > > open that widely). What are the statistics on complications of groin > > > cannulation? 5 hours, hmmm - didnt we present a case recently of an > > > compartment syndrome from femoral cannulation for an elective case. > > > I thought Heart-Ports have fallen out of favor due to > > > "problems"...... I could go on, but I admit I am a wuss and I am sure > > > Hal will beat me up for this. > > > > > > I worked with a thoracic surgeon who "got away" with a lot due to his > > > "innovative" (?creative) approaches - the problem, he also did not > > > get away with it at times and had some huge problems from such > > > misadventures. > > > > > > Nevertheless, great job - glad you helped the patient and made > > > everyone happy. Just offering the other side > > > > > > -michael > > > > > > > > > On Dec 31, 2007, at 7:26 AM, Zhandong Zhou wrote: > > > > > >> In this day of age, just talking about survival for open heart > > >> surgery or coronary artery disease is not enough. PCI has never > > >> matched CABG in terms of survival or MACE (major adverse cardiac > > >> event). PCI is gaining ground every year. We have to do our part as > > >> well. Here is the case I did today. > > >> > > >> 65 year old active patient has 1 year history of increasing SOB. > > >> TEE show large ASD not candidate for closure device. Cath show 70% > > >> LAD take off lesion. left to right shunt 2.5:1. PA pressure about > > >> 60mmHg with resistance about 3 woods unit. (I can not remember > > >> exact number, if someone interested, I can find it) Patient's > > >> cardiologist ask me if I can do it with minimal invasive approach > > >> as the patient wanted go back to normal life in short period time > > >> without restrictions. > > >> > > >> Although it is general rule that I do not do CABG for mini-valve or > > >> ASD, I decided to give a try. I used robot to take down LIMA, then > > >> went to the right chest with 2.5 inch incision. Fem-fem cannulation > > >> and clamp the aorta with modified heart-port technique. Fix the ASD > > >> with a 3cm autologus pericardial patch. With aorta still clamped, I > > >> made a second incision in left chest about 2 inch size and suture > > >> the LIMA to LAD. It took me a little over 5 hours to do the > > >> surgery, patient is doing well, already wake and will be extubated > > >> tonight. Alternative, I could have done the whole thing with a > > >> sternotomy in less than 3 hours. > > >> > > >> In summery, patient end up with two mini-thoracotomy incision, one > > >> is 2.5 inches in the right chest, one is 2 inches in the left > > >> chest. He also has a small incision for femoral cannulation. The > > >> advantage, no sternotomy, no rib cutting, he can go back to normal > > >> acrivities in 2 weeks with no restrictions. Disadvantage, longer > > >> surgery time and a little more work for the surgeon. > > >> > > >> Any comments? > > >> > > >> Z Zhou > > >> > > >>_______________________________________________ > > >> OpenHeart-L mailing list > > >> > > >> Send postings to: > > >> OpenHeart-L@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@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 > > > ----------------------------------------- > > _________________________________________________________________ > Tried the new MSN Messenger? It's cool! Download now. > > http://messenger.msn.com/Download/Default.aspx?mkt=en-in_______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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 > ----------------------------------------- > From Hgrmd at aol.com Tue Jan 1 10:03:34 2008 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Tue Jan 1 10:03:48 2008 Subject: [HSF] Happy New Year (OT) Message-ID: Dear Tohru, I spent my New Year's eve watching and listening to my DVD's of Jimi Hendrix at Woodstock as well as recent concert footage of the Cult at my good friend's party. He has a dynamite new home theater which recreates the ambiance of an actual movie theater. Hendrix and the Cult are a little different than Mozart, but no less enjoyable for me. Looking forward to seeing you once again in a few weeks. Hal **************************************See AOL's top rated recipes (http://food.aol.com/top-rated-recipes?NCID=aoltop00030000000004) From zzhoumd at pol.net Tue Jan 1 15:11:54 2008 From: zzhoumd at pol.net (zzhoumd@pol.net) Date: Tue Jan 1 10:13:41 2008 Subject: [HSF] ASD with LAD Disease In-Reply-To: References: <118419.89708.qm@web81615.mail.mud.yahoo.com><915EFB22-36D6-43F2-BD28-04252A6E4E59@bigpond.com><4F8309F68D37E844B4C23BDD075C8C6E0375CB2E@tocexch01.tocad.orclinic.com><002601c84ba8$6749ae10$650fa8c0@cce5ca73a59a42d><008101c84bcb$49bb11e0$650fa8c0@cce5ca73a59a42d><440587097-1199190058-cardhu_decombobulator_blackberry.rim.net-522688548-@bxe013.bisx.prod.on.blackberry> Message-ID: <1960396234-1199200328-cardhu_decombobulator_blackberry.rim.net-555223442-@bxe013.bisx.prod.on.blackberry> TWljaGFlbCwNCg0KSGFwcHkgbmV3IHllYXIhDQoNCkkganVzdCBzYXcgaGltIGFuZCBoZSBpcyB1 cCBpbiB0aGUgY2hhaXIuIE9uZSBvZiB0aGUgYWR2YW50YWdlcyBvZiBtaW5pIHRob3JhY290b215 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VU5TVUJTQ1JJQkUsIHRvIENIQU5HRSBlbWFpbCBhZGRyZXNzLCBvciB0byB2aWV3IGFyY2hpdmVz Og0KaHR0cDovL21tcC5janAuY29tL21haWxtYW4vbGlzdGluZm8vb3BlbmhlYXJ0LWwNCg0KQWxs IG1lc3NhZ2VzIHRyYW5zbWl0dGVkIGJ5IHRoZSBPcGVuSGVhcnQtTCBhcmUgc3ViamVjdCB0byB0 aGUgcG9saWNpZXMgYW5kIA0KZGlzY2xhaW1lcnMgcG9zdGVkIGF0Og0KaHR0cDovL3d3dy5oc2Zv cnVtLmNvbS9saXN0ZGlzY2xhaW0NCi0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0t LS0tLS0tDQo= From GoldmanS at MLHS.ORG Tue Jan 1 08:55:00 2008 From: GoldmanS at MLHS.ORG (Goldman, Scott) Date: Tue Jan 1 10:56:43 2008 Subject: [HSF] ASD with LAD Disease Message-ID: <20fa01c84c8e$c47dfb43$9b10650a@ad.mlhs.org> Agreed, we do heart ports on many sick patients. MV repairs on pretranplants, endocardis, acute ruptured cords ect. I feel that the lower amount of trauma with minimally invasive surgery contributes to a suvival advantage. Scott Goldman MD Chairman Department of Surgery MLH -----Original Message----- From: "zzhoumd@pol.net" Subj: Re: [HSF] ASD with LAD Disease Date: Tue Jan 1, 2008 8:14 am Size: 5K To: "OpenHeart-L@lists.hsforum.com" Michael, Happy new year! I just saw him and he is up in the chair. One of the advantages of mini thoracotomy is less bleeding. Total chest tube drainage is less than 200ml. Hct is 37 (39 pre-op). You brought up an important point. Mini invasive surgery is more for less sick patients, although I did robotic MIDCAB in some sick patients. I have also done heart port mitral valve replacement in a third time redo patient when she had endocarditis and in septic shock. Again, it is not a silver bullet. There should be different solutions for sicker patients like yours. OPCAB was developed as a first step to compete with PCI, but it is not the solution. We have to do better. For me, This is the last day on call for a five day long weekend. Z Zhou Sent via BlackBerry by AT&T -----Original Message----- From: "Michael Firstenberg" Date: Tue, 1 Jan 2008 08:40:27 To:OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] ASD with LAD Disease Z - I am not picking on you - I am am glad that you see my points. Just has we are operating on "less sick" patients such as yours (though it is suprising that with that big of an ASD that he did not have more problems) we are also operating on very sick patients and what concerns me is all of this enthusiasm for high technology and cosmetic cardiac surgery in patients with very little room for error. I assume your patient is extubated and doing ok? -m On 1/1/08, zzhoumd@pol.net wrote: > > > Murtaza, thanks for your comments. I think the same principle can be used > in mini valve cases if the patient has 1-2 vessel CAD. > > Z Zhou > > > Sent via BlackBerry by AT&T > > -----Original Message----- > From: murtaza chishti > > Date: Tue, 1 Jan 2008 07:47:54 > To: > Subject: RE: [HSF] ASD with LAD Disease > > > > > > if the surgeon has the will, the patience, the skills and > the infra-structure and can achieve the same surgical objective via a > less traumatic and less disruptive approach, has the wisdom to select the > appropriate candidate for a relatively unfamiliar operation and the > foresight to anticipate trouble and the ability to forestall potential > disasters, he/she should, without doubt , go ahead and do it; or else , how > does the art and science of surgery advance? > > great work Dr Zhou > > murtaza > > > > From: zzhoumd@pol.net > > To: OpenHeart-L@lists.hsforum.com > > Subject: Re: [HSF] ASD with LAD Disease > > Date: Tue, 1 Jan 2008 00:36:26 +0800 > > > CC: > > > > Michael, > > > > Thanks for all the comments. Mini invasive surgery dose not change the > basics of open heart surgery. It is done with the same principle, but > different approach with different instruments. I do not see the > contra-indications for surgery have ever changed for sicker patients. But I > did see patients with less of disease become more acceptable for surgery. > For example, single vessel disease such as we discussed earlier. Like Ani > suggested, some cardiologists will manage single vessel disease medically. > But I do have growing number of cases that cardiologists will send to me for > single graft to OM or RCA as patient is symptomatic. I have one patient has > chronically occluded RCA for many years. After I grafted the distal RCA with > a mini incision and Robotic RIMA takedown, he told me that he felt 20 years > younger and full of energy. > > > > Now come back to your question about bad lungs or obese patients. If > just graft the LAD, the surgery can be down without bypass or sternotomy. I > have done many of them and they do well. Patients with severe COPD, usually > tolerate single lung ventilation well as I learned from my thoracic surgery > experience. Obese patients can be challange, but I have done patients up to > 300 pounds. For Mitral or ASD, with videoscope assistance or robot, it can > be done as well. I think Hal can tell you more. > > > > Most patients can tolerate some degree of hypoxia. However, if I see > sats below 90, I just let the anesthesiologist ventilate both lungs then > find out the problem. LIMA takedown can be performed with both lung > ventilation by increasing CO2 pressue in the left chest to creat enough > space. I never hesitate to convert someone to regular sternotomy. For ASD or > mitral valve, just go on bypass with femoral cannulation then drop both > lungs. > > > > Regarding heart-port, I just use the femoral cannulation part and their > instruments. I never used their endo balloon. To avoid femoral cannulation > complications, just ask anesthesia to check the descending aorta make sure > no dissection. Most common complication is seroma, it can be avoided by less > of dissection and using Seldinger technique. One of my partner's patients > did have compartment sydrome from DVT. > > > > There is no doubt that the surgery can be done much quicker with > standard sternotomy. It is a little more work to do mini incisions. > Therefore, the ar From DukeB60 at aol.com Tue Jan 1 11:07:51 2008 From: DukeB60 at aol.com (DukeB60@aol.com) Date: Tue Jan 1 11:12:29 2008 Subject: [HSF] ASD with LAD Disease Message-ID: Z, I agree completely with your approach and experience. We have been going down the same path. To do the same quality of valve repair or revascularization but through a mini approach is, in fact, progress and patients universally prefer it. I am intrigued by Mark's subxypoid approach for revascularization to avoid the mini thoracotomy after robotic IMA harvest. Hope to visit him soon. Yesterday I did a 55 yo woman with supra systemic PA pressures due to MS. She had irradiation for Hodgkin's Lymphoma many years ago and five years ago had a three vessel CAB, AVR with St. Jude mechanical valve and mitral repair with 26 mm Cosgrove ring at another institution. LV was preserved. She now has a porcelain aorta very obvious on routine CXR and CT. I did her with femoral cannulation and right chest approach with beating heart, cooling to 23 C. in anticipation of possible PHCA but never had to do so. I replaced the valve which was stenotic due to misplaced band. Tried to re-repair but too much scar and calcium. She is extubated and neurologically intact with PA pressures already half what they were pre-op. I was able to get in a 27mm valve. Being familiar with the right chest approach, since almost all isolated mitrals are done this way, was an enormous benefit. Mini right chest valves are routine now and the next goal is port CAB possibly with Cardica's C-Port. I have fired a bunch on open cases and they give a good anastomosis for SVG and IMA with objective measurement and now need to figure out how to load through port etc. I use the robot for a lot of other things but not valves for a variety of reasons. Keep up the innovation as it is important for the specialty's future. Ed Edward P. Raines, M.D., J.D. BryanLGH Cardiothoracic Surgery BryanLGH Medical Center East 1600 South 48th Str. Lincoln, Nebraska 68506 Office: 402-481-8430 Cell: 402-730-9242 Fax: 402-481-8429 In a message dated 1/1/2008 9:15:38 A.M. Central Standard Time, zzhoumd@pol.net writes: Michael, Happy new year! I just saw him and he is up in the chair. One of the advantages of mini thoracotomy is less bleeding. Total chest tube drainage is less than 200ml. Hct is 37 (39 pre-op). You brought up an important point. Mini invasive surgery is more for less sick patients, although I did robotic MIDCAB in some sick patients. I have also done heart port mitral valve replacement in a third time redo patient when she had endocarditis and in septic shock. Again, it is not a silver bullet. There should be different solutions for sicker patients like yours. OPCAB was developed as a first step to compete with PCI, but it is not the solution. We have to do better. For me, This is the last day on call for a five day long weekend. Z Zhou Sent via BlackBerry by AT&T -----Original Message----- From: "Michael Firstenberg" Date: Tue, 1 Jan 2008 08:40:27 To:OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] ASD with LAD Disease Z - I am not picking on you - I am am glad that you see my points. Just has we are operating on "less sick" patients such as yours (though it is suprising that with that big of an ASD that he did not have more problems) we are also operating on very sick patients and what concerns me is all of this enthusiasm for high technology and cosmetic cardiac surgery in patients with very little room for error. I assume your patient is extubated and doing ok? -m On 1/1/08, zzhoumd@pol.net wrote: > > > Murtaza, thanks for your comments. I think the same principle can be used > in mini valve cases if the patient has 1-2 vessel CAD. > > Z Zhou > > > Sent via BlackBerry by AT&T > > -----Original Message----- > From: murtaza chishti > > Date: Tue, 1 Jan 2008 07:47:54 > To: > Subject: RE: [HSF] ASD with LAD Disease > > > > > > if the surgeon has the will, the patience, the skills and > the infra-structure and can achieve the same surgical objective via a > less traumatic and less disruptive approach, has the wisdom to select the > appropriate candidate for a relatively unfamiliar operation and the > foresight to anticipate trouble and the ability to forestall potential > disasters, he/she should, without doubt , go ahead and do it; or else , how > does the art and science of surgery advance? > > great work Dr Zhou > > murtaza > > > > From: zzhoumd@pol.net > > To: OpenHeart-L@lists.hsforum.com > > Subject: Re: [HSF] ASD with LAD Disease > > Date: Tue, 1 Jan 2008 00:36:26 +0800 > > > CC: > > > > Michael, > > > > Thanks for all the comments. Mini invasive surgery dose not change the > basics of open heart surgery. It is done with the same principle, but > different approach with different instruments. I do not see the > contra-indications for surgery have ever changed for sicker patients. But I > did see patients with less of disease become more acceptable for surgery. > For example, single vessel disease such as we discussed earlier. Like Ani > suggested, some cardiologists will manage single vessel disease medically. > But I do have growing number of cases that cardiologists will send to me for > single graft to OM or RCA as patient is symptomatic. I have one patient has > chronically occluded RCA for many years. After I grafted the distal RCA with > a mini incision and Robotic RIMA takedown, he told me that he felt 20 years > younger and full of energy. > > > > Now come back to your question about bad lungs or obese patients. If > just graft the LAD, the surgery can be down without bypass or sternotomy. I > have done many of them and they do well. Patients with severe COPD, usually > tolerate single lung ventilation well as I learned from my thoracic surgery > experience. Obese patients can be challange, but I have done patients up to > 300 pounds. For Mitral or ASD, with videoscope assistance or robot, it can > be done as well. I think Hal can tell you more. > > > > Most patients can tolerate some degree of hypoxia. However, if I see > sats below 90, I just let the anesthesiologist ventilate both lungs then > find out the problem. LIMA takedown can be performed with both lung > ventilation by increasing CO2 pressue in the left chest to creat enough > space. I never hesitate to convert someone to regular sternotomy. For ASD or > mitral valve, just go on bypass with femoral cannulation then drop both > lungs. > > > > Regarding heart-port, I just use the femoral cannulation part and their > instruments. I never used their endo balloon. To avoid femoral cannulation > complications, just ask anesthesia to check the descending aorta make sure > no dissection. Most common complication is seroma, it can be avoided by less > of dissection and using Seldinger technique. One of my partner's patients > did have compartment sydrome from DVT. > > > > There is no doubt that the surgery can be done much quicker with > standard sternotomy. It is a little more work to do mini incisions. > Therefore, the argument is, when finish and done, it looked really nice, if > the patient did well, it may be worth it. If not, I will never do this > again. > > > > Happy new year to everyone! > > > > Z Zhou > > > > > > ----- Original Message ----- > > From: "Michael Firstenberg" > > To: > > Sent: Tuesday, January 01, 2008 10:04 AM > > Subject: Re: [HSF] ASD with LAD Disease > > > > > > > Z- > > > > > > Nice job, but this case clearly illustrates one of the problems with > > > "modern medicine" and that being that everything can be fixed with a > > > pill or a small "mini" incision. > > > Would you (should you) have done the same operation had the Woods > > > units been 10? (these are the ones we see) or if the patient was > > > morbidly obese, 80 pack/year smoker? What about if his PAs were in > > > the 30's from right heart failure. I know these are all "what ifs" - > > > but we are talking about major life threatening/limiting problems > > > where I think the magnitude and scope of the problems (or potential > > > problems) that we deal with are underappreciated by all. The > > > Interventionalist in the communities rarely see their patients with > > > thrombosed LAD stents getting VAD or transplants (oh, wait it was > > > just the patient's disease or their non-compliance). I assume you > > > had to use single lung ventilation to get down the IMA - what would > > > you have done had the increased PVR or hypoxemia put your patient > > > into acute right heart failure? (and in the midst of trying > > > medications to help, anesthesia - none for there attention to such > > > details - give a giant air bolus which goes into the left heart and > > > up to the brain?). May be a little hard to go back to work then. We > > > all need to be realistic about the problems and promise we make, lest > > > we make deals with the Devil. What in a full sternotomy, LIMA-LAD, > > > standard bicaval cannulation, ASD closure - prevents him from going > > > back to "a normal life" in 2 weeks. In fact, since the last couple > > > of topics delt with how bad CPB is, I bet a "standard" approach would > > > have resulted in a much shorter pump run. Are 2 "mini" thoracotomies > > > less painful than 1 sternotomy (you probably would not have had to > > > open that widely). What are the statistics on complications of groin > > > cannulation? 5 hours, hmmm - didnt we present a case recently of an > > > compartment syndrome from femoral cannulation for an elective case. > > > I thought Heart-Ports have fallen out of favor due to > > > "problems"...... I could go on, but I admit I am a wuss and I am sure > > > Hal will beat me up for this. > > > > > > I worked with a thoracic surgeon who "got away" with a lot due to his > > > "innovative" (?creative) approaches - the problem, he also did not > > > get away with it at times and had some huge problems from such > > > misadventures. > > > > > > Nevertheless, great job - glad you helped the patient and made > > > everyone happy. Just offering the other side > > > > > > -michael > > > > > > > > > On Dec 31, 2007, at 7:26 AM, Zhandong Zhou wrote: > > > > > >> In this day of age, just talking about survival for open heart > > >> surgery or coronary artery disease is not enough. PCI has never > > >> matched CABG in terms of survival or MACE (major adverse cardiac > > >> event). PCI is gaining ground every year. We have to do our part as > > >> well. Here is the case I did today. > > >> > > >> 65 year old active patient has 1 year history of increasing SOB. > > >> TEE show large ASD not candidate for closure device. Cath show 70% > > >> LAD take off lesion. left to right shunt 2.5:1. PA pressure about > > >> 60mmHg with resistance about 3 woods unit. (I can not remember > > >> exact number, if someone interested, I can find it) Patient's > > >> cardiologist ask me if I can do it with minimal invasive approach > > >> as the patient wanted go back to normal life in short period time > > >> without restrictions. > > >> > > >> Although it is general rule that I do not do CABG for mini-valve or > > >> ASD, I decided to give a try. I used robot to take down LIMA, then > > >> went to the right chest with 2.5 inch incision. Fem-fem cannulation > > >> and clamp the aorta with modified heart-port technique. Fix the ASD > > >> with a 3cm autologus pericardial patch. With aorta still clamped, I > > >> made a second incision in left chest about 2 inch size and suture > > >> the LIMA to LAD. It took me a little over 5 hours to do the > > >> surgery, patient is doing well, already wake and will be extubated > > >> tonight. Alternative, I could have done the whole thing with a > > >> sternotomy in less than 3 hours. > > >> > > >> In summery, patient end up with two mini-thoracotomy incision, one > > >> is 2.5 inches in the right chest, one is 2 inches in the left > > >> chest. He also has a small incision for femoral cannulation. The > > >> advantage, no sternotomy, no rib cutting, he can go back to normal > > >> acrivities in 2 weeks with no restrictions. Disadvantage, longer > > >> surgery time and a little more work for the surgeon. > > >> > > >> Any comments? > > >> > > >> Z Zhou > > >> > > >>_______________________________________________ > > >> OpenHeart-L mailing list > > >> > > >> Send postings to: > > >> OpenHeart-L@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@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 > > > ----------------------------------------- > > _________________________________________________________________ > Tried the new MSN Messenger? It's cool! Download now. > > http://messenger.msn.com/Download/Default.aspx?mkt=en-in_______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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@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@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@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 ----------------------------------------- **************************************See AOL's top rated recipes (http://food.aol.com/top-rated-recipes?NCID=aoltop00030000000004) From grescigno at mac.com Tue Jan 1 17:14:56 2008 From: grescigno at mac.com (Macbook) Date: Tue Jan 1 11:17:24 2008 Subject: [HSF] OT from Dallas In-Reply-To: <913987.4844.qm@web81613.mail.mud.yahoo.com> References: <913987.4844.qm@web81613.mail.mud.yahoo.com> Message-ID: <1FE79288-7231-4F11-8D74-47B0E95A947F@mac.com> I asked for 2008 to be able to understand at least 50% of Tea's 3D! This is due of course to my poor english and no relation with the complexity of Tea's toughts ;-) Giuseppe Il giorno 01/gen/08, alle ore 06:45, Tea Acuff ha scritto: > Happy New Year to all my virtual good friends. thank you, Mark, for > another good year. > > tea > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From msfirst at gmail.com Tue Jan 1 11:22:08 2008 From: msfirst at gmail.com (Michael Firstenberg) Date: Tue Jan 1 11:49:00 2008 Subject: [HSF] OT from Dallas In-Reply-To: <1FE79288-7231-4F11-8D74-47B0E95A947F@mac.com> References: <913987.4844.qm@web81613.mail.mud.yahoo.com> <1FE79288-7231-4F11-8D74-47B0E95A947F@mac.com> Message-ID: English, or should I say American, is my native language and I still dont completely understand 1/2 of the Tea'sm - and the other half I do not have the attention span to read though - but I do enjoy them nonetheless. -michael On 1/1/08, Macbook wrote: > > I asked for 2008 to be able to understand at least 50% of Tea's 3D! > This is due of course to my poor english and no relation with the > complexity of Tea's toughts ;-) > > Giuseppe > > > Il giorno 01/gen/08, alle ore 06:45, Tea Acuff ha scritto: > > > Happy New Year to all my virtual good friends. thank you, Mark, for > > another good year. > > > > tea > > _______________________________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@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@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 > ----------------------------------------- > From wftjrtyler at aol.com Tue Jan 1 11:49:34 2008 From: wftjrtyler at aol.com (wftjrtyler@aol.com) Date: Tue Jan 1 11:53:56 2008 Subject: [HSF] Happy New Year (OT) respect from peers Message-ID: In a message dated 1/1/2008 9:05:36 A.M. Central Standard Time, Hgrmd@aol.com writes: Hendrix and the Cult are a little different than Mozart, but no less enjoyable for me. My favorite Hendrix story: In a recent interview,Paul McCartney recounted when He and John Lennon went to see Jimi at a London venue circa '67,'68. Sgt. Peppers album released earlier THAT day. Jimi opens with Sgt. Peppers (track 1) THAT night!!!!! John and Paul numb with awe. Second favorite Jimi story: At Monterrey '67, The Who draw honor of following Jimi( burning Strat,etc.) Pete Townshend so distraught, stated he would concentrate on songwriting only and never ,EVER follow Jimi again. **************************************See AOL's top rated recipes (http://food.aol.com/top-rated-recipes?NCID=aoltop00030000000004) From wftjrtyler at aol.com Tue Jan 1 11:54:47 2008 From: wftjrtyler at aol.com (wftjrtyler@aol.com) Date: Tue Jan 1 11:58:54 2008 Subject: [HSF] OT from Dallas Message-ID: In a message dated 1/1/2008 10:51:14 A.M. Central Standard Time, msfirst@gmail.com writes: English, or should I say American, is my native language and I still dont completely understand 1/2 of the Tea'sm - and the other half I do not have the attention span to read though - but I do enjoy them nonetheless. I'll boast ~30%,but I've been" drinking the Tea" longer than most of you....bill turner **************************************See AOL's top rated recipes (http://food.aol.com/top-rated-recipes?NCID=aoltop00030000000004) From zzhoumd at pol.net Tue Jan 1 17:41:42 2008 From: zzhoumd at pol.net (zzhoumd@pol.net) Date: Tue Jan 1 12:42:29 2008 Subject: [HSF] ASD with LAD Disease In-Reply-To: References: Message-ID: <178682784-1199209318-cardhu_decombobulator_blackberry.rim.net-1171467822-@bxe013.bisx.prod.on.blackberry> RWQsIA0KDQpHb29kIGpvYiBpbiB0aGlzIGNvbXBsaWNhdGUgY2FzZS4gSXQgaGVscHMgYSBsb3Qg aWYgeW91IGtub3cgaG93IHRvIGdvIHRvIHRoZSByaWdodCBjaGVzdCBmb3IgbWl0cmFsIHZhbHZl IHN1cmdlcmllcywgZXNwZWNpYWxseSBpbiBzdWNoIGRpZmZpY3VsdCBjYXNlLiBJdCBhbHNvIHdv cmtzIGZvciB0cmljdXNwaWQgcmVwYWlycywgbXl4b21hLCBBU0QgZXRjLi4NCg0KSnVzdCBjdXJp b3VzIGFib3V0IHRoZSBraW5kIG9mIHZhbHZlIHlvdSBwdXQgaW4uIElmIHRoZSBwYXRpZW50IGlz IDY1IHllYXIgb2xkIGFuZCBhbHJlYWR5IGhhcyBhIFN0LiBKdWRlIHZhbHZlLCB3aWxsIHlvdSBz dGlsbCBwdXQgaW4gYSBTdC4gSnVkZSBvciBhIHRpc3N1ZSB2YWx2ZT8NCg0KWg0KDQoNClNlbnQg dmlhIEJsYWNrQmVycnkgYnkgQVQmVA0KDQotLS0tLU9yaWdpbmFsIE1lc3NhZ2UtLS0tLQ0KRnJv bTogRHVrZUI2MEBhb2wuY29tDQoNCkRhdGU6IFR1ZSwgMSBKYW4gMjAwOCAxMTowNzo1MSANClRv Ok9wZW5IZWFydC1MQGxpc3RzLmhzZm9ydW0uY29tDQpTdWJqZWN0OiBSZTogW0hTRl0gQVNEIHdp dGggTEFEIERpc2Vhc2UNCg0KDQpaLA0KICAgIEkgYWdyZWUgY29tcGxldGVseSB3aXRoIHlvdXIg YXBwcm9hY2ggYW5kICBleHBlcmllbmNlLiAgV2UgaGF2ZSBiZWVuIA0KZ29pbmcgZG93biB0aGUg c2FtZSBwYXRoLiAgVG8gZG8gdGhlIHNhbWUgIHF1YWxpdHkgb2YgdmFsdmUgcmVwYWlyIG9yIA0K cmV2YXNjdWxhcml6YXRpb24gYnV0IHRocm91Z2ggYSBtaW5pIGFwcHJvYWNoIGlzLCBpbiAgZmFj dCwgcHJvZ3Jlc3MgYW5kIHBhdGllbnRzIA0KdW5pdmVyc2FsbHkgcHJlZmVyIGl0LiAgSSBhbSBp bnRyaWd1ZWQgYnkgIE1hcmsncyBzdWJ4eXBvaWQgYXBwcm9hY2ggZm9yIA0KcmV2YXNjdWxhcml6 YXRpb24gdG8gYXZvaWQgdGhlIG1pbmkgdGhvcmFjb3RvbXkgIGFmdGVyIHJvYm90aWMgSU1BIGhh cnZlc3QuICBIb3BlIHRvIHZpc2l0IA0KaGltIHNvb24uDQogICAgWWVzdGVyZGF5IEkgZGlkIGEg NTUgeW8gd29tYW4gd2l0aCBzdXByYSBzeXN0ZW1pYyAgUEEgcHJlc3N1cmVzIGR1ZSB0byANCk1T LiAgU2hlIGhhZCBpcnJhZGlhdGlvbiBmb3IgSG9kZ2tpbidzIEx5bXBob21hIG1hbnkgIHllYXJz IGFnbyBhbmQgZml2ZSB5ZWFycyANCmFnbyBoYWQgYSB0aHJlZSB2ZXNzZWwgQ0FCLCBBVlIgd2l0 aCBTdC4gSnVkZSAgbWVjaGFuaWNhbCB2YWx2ZSBhbmQgbWl0cmFsIA0KcmVwYWlyIHdpdGggMjYg bW0gQ29zZ3JvdmUgcmluZyBhdCBhbm90aGVyICBpbnN0aXR1dGlvbi4gIExWIHdhcyBwcmVzZXJ2 ZWQuICBTaGUgDQpub3cgaGFzIGEgcG9yY2VsYWluIGFvcnRhIHZlcnkgIG9idmlvdXMgb24gcm91 dGluZSBDWFIgYW5kIENULiAgSSBkaWQgaGVyIHdpdGggDQpmZW1vcmFsIGNhbm51bGF0aW9uIGFu ZCAgcmlnaHQgY2hlc3QgYXBwcm9hY2ggd2l0aCBiZWF0aW5nIGhlYXJ0LCBjb29saW5nIHRvIA0K MjMgQy4gaW4gYW50aWNpcGF0aW9uICBvZiBwb3NzaWJsZSBQSENBIGJ1dCBuZXZlciBoYWQgdG8g ZG8gc28uICBJIHJlcGxhY2VkIHRoZSANCnZhbHZlICB3aGljaCB3YXMgc3Rlbm90aWMgZHVlIHRv IG1pc3BsYWNlZCBiYW5kLiAgVHJpZWQgdG8gcmUtcmVwYWlyIGJ1dCAgdG9vIA0KbXVjaCBzY2Fy IGFuZCBjYWxjaXVtLiAgIFNoZSBpcyBleHR1YmF0ZWQgYW5kIG5ldXJvbG9naWNhbGx5ICBpbnRh Y3Qgd2l0aCBQQSANCnByZXNzdXJlcyBhbHJlYWR5IGhhbGYgd2hhdCB0aGV5IHdlcmUgcHJlLW9w LiAgSSB3YXMgYWJsZSB0byAgZ2V0IGluIGEgMjdtbSANCnZhbHZlLiAgDQogICAgQmVpbmcgZmFt aWxpYXIgd2l0aCB0aGUgcmlnaHQgY2hlc3QgYXBwcm9hY2gsIHNpbmNlICBhbG1vc3QgYWxsIGlz b2xhdGVkIA0KbWl0cmFscyBhcmUgZG9uZSB0aGlzIHdheSwgd2FzIGFuICBlbm9ybW91cyBiZW5l Zml0LiAgDQogICAgTWluaSByaWdodCBjaGVzdCB2YWx2ZXMgYXJlIHJvdXRpbmUgbm93IGFuZCB0 aGUgIG5leHQgZ29hbCBpcyBwb3J0IENBQiANCnBvc3NpYmx5IHdpdGggQ2FyZGljYSdzIEMtUG9y dC4gIEkgaGF2ZSBmaXJlZCBhIGJ1bmNoICBvbiBvcGVuIGNhc2VzIGFuZCB0aGV5IA0KZ2l2ZSBh IGdvb2QgYW5hc3RvbW9zaXMgZm9yIFNWRyBhbmQgSU1BIHdpdGggb2JqZWN0aXZlICBtZWFzdXJl bWVudCBhbmQgbm93IG5lZWQgDQp0byBmaWd1cmUgb3V0IGhvdyB0byBsb2FkIHRocm91Z2ggcG9y dCBldGMuICBJIHVzZSAgdGhlIHJvYm90IGZvciBhIGxvdCBvZiANCm90aGVyIHRoaW5ncyBidXQg bm90IHZhbHZlcyBmb3IgYSB2YXJpZXR5IG9mICByZWFzb25zLiAgIEtlZXAgdXAgdGhlIGlubm92 YXRpb24gDQphcyBpdCBpcyBpbXBvcnRhbnQgZm9yIHRoZSAgc3BlY2lhbHR5J3MgZnV0dXJlLg0K IA0KICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAg ICAgICAgICAgICAgICAgICAgICAgICAgDQogICAgICAgICAgICAgICAgICAgICAgICAgICAgICAg ICAgICAgICAgICBFZCAgDQogDQpFZHdhcmQgUC4gUmFpbmVzLCBNLkQuLCBKLkQuDQpCcnlhbkxH SCAgQ2FyZGlvdGhvcmFjaWMgU3VyZ2VyeQ0KQnJ5YW5MR0ggTWVkaWNhbCBDZW50ZXIgRWFzdCAN CjE2MDAgU291dGggNDh0aCAgU3RyLg0KTGluY29sbiwgTmVicmFza2EgNjg1MDYNCk9mZmljZTog NDAyLTQ4MS04NDMwDQpDZWxsOiAgNDAyLTczMC05MjQyDQpGYXg6IDQwMi00ODEtODQyOQ0KDQoN Cg0KSW4gYSBtZXNzYWdlIGRhdGVkIDEvMS8yMDA4IDk6MTU6MzggQS5NLiBDZW50cmFsIFN0YW5k YXJkIFRpbWUsICANCnp6aG91bWRAcG9sLm5ldCB3cml0ZXM6DQoNCk1pY2hhZWwsDQoNCkhhcHB5 IG5ldyB5ZWFyIQ0KDQpJIGp1c3Qgc2F3IGhpbSBhbmQgaGUgaXMgdXAgaW4gIHRoZSBjaGFpci4g T25lIG9mIHRoZSBhZHZhbnRhZ2VzIG9mIG1pbmkgDQp0aG9yYWNvdG9teSBpcyBsZXNzIGJsZWVk aW5nLiBUb3RhbCAgY2hlc3QgdHViZSBkcmFpbmFnZSBpcyBsZXNzIHRoYW4gMjAwbWwuIEhjdCAN CmlzIDM3ICgzOSBwcmUtb3ApLg0KDQpZb3UgIGJyb3VnaHQgdXAgYW4gaW1wb3J0YW50IHBvaW50 LiBNaW5pIGludmFz