[HSF] ASD with LAD Disease

[Ani Anyanwu]

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 at pol.net> To: OpenHeart-L at 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> 
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