[HSF] ASD with LAD Disease

[rwmfglycar at 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 <msfirst at gmail.com>
To: OpenHeart-L at 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?
>?
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