[HSF] Aortic Valve Stenosis and Carotid Stenosis

Wed Jan 23 20:42:48 EST 2008

Sounds to me like we are pushing into land of the Black Swans. Just as it makes a huge difference in the both the intent to treat and cross over rate in a population study to draw probabilistic curves, it seems problematic to draw conclusions from aortic valve series/ populations series of AS with unknown status of carotid disease about its likely meaning for elderly patients with known AS and carotid disease. If it is from Dr. Novick's series perhaps we might be less skeptical as to the safety of a null hypothesis.

Further i suspect that much of our "outlier" results for procedures of high volume arise precisely because of unknown and unaccountable comorbid occurrences. History of PVD or other general category is not much of a specific determinant predictor. HIT stroke, etc added together cause much of our morbidity that we witness.

I am not stating an affirmative position. I am just skeptical of the expert analysis of the skeptics.

tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Tuesday, January 22, 2008 8:18:50 AM
Subject: RE: [HSF] Aortic Valve Stenosis and Carotid Stenosis

> possibility of MI is real, but the possibility of permanent cardiac > damage with moderate AS (in the short term) is low. .> Ed Bender, MD

Ed

Ed with an indexed AVA of 0.4, would your patient not qualify as severe AS? I am uncertain really as to the indication for carotid surgery here - is it to reduce risk of perioperative stroke or is it required on its own merit? I am not sure of the wisdom of putting someone with severe AS through two operations before the definitive (life-saving or life-prolonging) one as each procedure places her at risk and I am not sure that the risk and cumulative morbidity of the 3 operations will be less, and the benefit greater, than that of a single operation to replace his aortic valve. In an elderly patient we must not underestimate the impact of multiple surgeries done in quick succession - you accept this yourself when you say you will do the second carotid "when the patient is feeling well and recovered". Sometimes staged candidates never make it to the final definitive procedure (because of complications, death or debilitation). If the same patient required
 other non-cardiac surgery, such as a hernia repair, he would not be cleared for that till the AS is fixed - what makes a carotid procedure different that it should be done first? 

Personally, I do not see rationale for obtaining the carotid ultrasound in an elderly patient with asymptomatic AS and certainly I would not go operating on the carotids in a patient with severe AS unless indicated by symptoms. I also do not listen for carotid bruits anymore as it is a poor screening test, many patients without bruit have carotid disease,  and it is unclear what to do with the information it yields. I think in the setting of ischemic heart disease there is more literature to support carotid screening but there is a clear disticntion in the natural history of IHD vs aortic stenosis that makes the arguments different. I think part of the bias in management here comes from our tendency to do things (carotid in this instance) because we can. As a cardiovascular surgeon you would feel comfortable doing the carotids and can likely do so with little incremental risk (I have the reverse bias because I am not vascular trained so a reluctance to
 intervene in this case and general reluctance to involve another team of surgeons in managing cardiac surgical patients) but can we really say we have the data to support this approach in patients with valvular heart disease?  If you did her aortic valve first, would you still go ahead to fix the carotids?

Ani

> From: ebender001 at charter.net> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Aortic Valve Stenosis and Carotid Stenosis> Date: Mon, 21 Jan 2008 23:07:00 -0600> CC: > > The only difference that I see is that in CAD patients is that the > possibility of MI is real, but the possibility of permanent cardiac > damage with moderate AS (in the short term) is low. Having said that, > I still agree with your sentiments regarding order of procedures. I > can also effectively treat CHF ( a little more lasix, etc) better than > I can treat a stroke (a little more tube feeds).> Ed Bender, MD> > > On Jan 21, 2008, at 10:52 PM, Tea Acuff wrote:> > > We recently did a similar case status post CABG several years ago. I > > did each carotid a couple of days apart and the the patient (who was > > elderly siad uncel and we gave him a week or so prior to redo > > sterntomy for AVR. This is what i do for CAB and carotids also. I > > see no clear difference in the
 face of no documented difference.> >> > tea> >> >> > ----- Original Message ----> > From: "Douville, Chuck" <ecdouville at orclinic.com>> > To: OpenHeart-L at lists.hsforum.com> > Sent: Monday, January 21, 2008 10:17:31 PM> > Subject: RE: [HSF] Aortic Valve Stenosis and Carotid Stenosis> >> > Ed interesting question. I personally would stage the carotids, > > about 3 days apart and do the valve shortly thereafter. We have had > > good results with combining urgent carotids with CABG but have no > > experience with your situation. I would stage them because of the > > literature we are all familiar with, no other (better) reason. chuck> >> > ________________________________> >> > From: openheart-l-bounces at lists.hsforum.com on behalf of zzhoumd at pol.net> > Sent: Mon 1/21/2008 8:07 PM> > To: OpenHeart-L at lists.hsforum.com> > Subject: Re: [HSF] Aortic Valve Stenosis and Carotid Stenosis> >> >> >> >> > In a asymptomatic patient, the stroke rate is low whatever you
 do > > probably not much of difference either way.> >> > Sent via BlackBerry by AT&T> >> > -----Original Message-----> > From: Edward Bender <ebender001 at charter.net>> >> > Date: Mon, 21 Jan 2008 21:07:47> > To:OpenHeart-L <OpenHeart-L at hsforum.com>> > Subject: [HSF] Aortic Valve Stenosis and Carotid Stenosis> >> >> > I'd be interested in the members' opinions about the following> > patient. She is a 74 year old diabetic patient admitted to an outside> > hospital with chest pain and class 2 heart failure symptoms. She> > underwent echo and cardiac cath showing trivial coronary artery> > disease (50% LAD at most), 50 mmHg gradient across the aortic valve,> > normal LV function. The indexed valve area is 0.4. She underwent> > carotid dopplers due to a bruit. This showed over 80% stenosis in> > both internal carotid arteries. She is left dominant. I repeated the> > cardiac and carotid echos in our hospital and the outside studies are> > supported by our
 studies. The outside cath did not include an LV> > gram, and I see no attempt to have crossed the aortic valve.> >> > The patient is a relative of one of our local physicians, and she is> > now an outpatient on appropriate medical therapy. Although I think> > that she will need AVR, I do not think it is an urgent requirement.> > The outside hospital cardiologist said she needed 3 bypasses and an> > aortic valve next week, and that he would have a surgeon come down> > from a major midwestern university to do the operation at their> > hospital (itinerant surgery). Needless to say, after the patient was> > discharged on medical therapy, the local physician took his relative> > out of that hospital system.> >> > I was planning to do a left carotid endarterectomy, followed by a> > right carotid when the patient is feeling well and recovered. Any> > thoughts about doing the aortic valve at the time of the second> > carotid surgery? I do this alot with
 coronaries (I think we had> > several discussions about this topic), but have not had the same> > scenario with valvular heart disease in the absence of important> > carotid disease.> >> > Ed Bender, MD> > _______________________________________________> > 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> > -----------------------------------------> >> >> >> >> >> > -----Inline Attachment Follows-----> >> > _______________________________________________> > 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>
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