[HSF] ASD with LAD Disease

Tue Jan 1 10:47:16 EST 2008

Z-

Me too - finishing up a long call week - interesting cases though.
But, when I look at all of the discussions recently, I think the key is to
match the patient with the operation - have a full set of skills available -
and not just relexively say every CABG is on/off pump, every mitral gets
repaired thru a mini, etc.

Happy New Year.

-m

On 1/1/08, zzhoumd at pol.net <zzhoumd at pol.net> wrote:
>
> 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" <msfirst at gmail.com>
>
> Date: Tue, 1 Jan 2008 08:40:27
> To:OpenHeart-L at 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 at pol.net <zzhoumd at 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 <cmurtaza at hotmail.com>
> >
> > Date: Tue, 1 Jan 2008 07:47:54
> > To:<openheart-l at lists.hsforum.com>
> > 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 at pol.net
> > > To: OpenHeart-L at 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" <msfirst at gmail.com>
> > > To: <OpenHeart-L at lists.hsforum.com>
> > > 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 at 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 at 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 at 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 at 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 at 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 at 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
> -----------------------------------------
>