[HSF] Aortic Valve Stenosis and Carotid Stenosis

Thu Jan 31 17:55:33 EST 2008

Logical statements tend to be consistent and thereby most often incorrect in prediction of the behavior an individual in a partially known system. If you criticize those that unthinking apply bias (evidential or calculated), how can you justify not applying bias by contrary protocol?

Coronary diesase is the most common cause of death in those with carotid disease...as it is likely for the rest of us. Another factor is what does an elderly patient fear the most who is symptomatic with cardiac disease. Frequently it is not death. Should we not offer them options to diminish incapacity if we have that ability? Should we assume the best specific calculation for the patient or the best random deal for the population? This is logically the same process as removing intent in analysis of experimental data is it not? Your calculation from data of the whole population (known or calculated) is not relevant to those with known (by screening or accident) comorbidities. It changes populations which changes the relevance of the test(s). Further almost all "incidents" or particulars that we label as categories are not binary in their behavior. Only the simplest systems are binary, which tend to be a characteristic of the observer and his measurement
 and not the observed and its possible behavior(s).

The natural history of dilated ischemic cardiomyopathy is clear also. Do we wait until the severely symptomatic need an LVAD or transplant and then pick the 1% that are lucky enough to see you and others who don't "solicit" patients? Am I wrong to argue incessantly (and largely fruitlessly) for screening all post infarction patients with abnormal function looking for the 10-20% patients that I may prevent (even if not completely proven) this fate?

tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Monday, January 28, 2008 7:34:25 AM
Subject: RE: [HSF] Aortic Valve Stenosis and Carotid Stenosis

> Dear Ani ,> > Why are you sure that there are far more patients "without" severe carotid disease who had beautiful AVRs and went home hemiplegic and aphasic?> Bob

I know that based on simple probability.

Let us assume by a liberal estimate that 20% of patients with severe AS have severe carotid stenosis (in reality it is much less but chose any figure).

If you operate on 1000 AVRs, 800 have no Carotid disease and 200 have Carotid disease.

In the 800 with no carotid disease you will expect 16 strokes (2% based on our local data which we published in JTCVS last year)

In the 200 with carotid disease you will expect 8 strokes (4% an odds ratio of 2 also based on our local data).

So you end up with the majority of patients with perioperative stroke having no carotid disease. If you assume a lower incidence of severe disease (probably less than 5% judging from the rarity of combined AS/CEA then even fewer people with stroke perioperatively will have carotid disease.

Carotid disease is not a major cause of stroke after cardiac surgery.

Ani

> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Aortic Valve Stenosis and Carotid Stenosis> Date: Mon, 28 Jan 2008 01:08:22 -0500> From: rwmfglycar at aol.com> CC: > > > Dear Ani ,> > Why are you sure that there are far more patients "without" severe carotid disease who had beautiful AVRs and went home hemiplegic and aphasic?> Bob> > > -----Original Message-----> From: Ani Anyanwu <anianyanwu at hotmail.com>> To: openheart-l at lists.hsforum.com> Sent: Sun, 27 Jan 2008 1:29 pm > Subject: RE: AW: [HSF] Aortic Valve Stenosis and Carotid Stenosis> > > > > I am sure someone has had such a patient but that is not to say that 1) the > symptomatic carotid caused the stroke or 2) surgery on the asymptomatic carotid > ould have prevented the stroke.> > am sure there are far many more patients *without* severe carotid disease who > ad beautiful AVRs and went home hemiplegic and aphasic.> > ni> > > Date: Wed, 23 Jan 2008 19:54:48 -0800> From: tacuff at swbell.net>
 Subject: Re: > W: [HSF] Aortic Valve Stenosis and Carotid Stenosis> To: OpenHeart-L at lists.hsforum.com> > C: > > One question Roberto. Have you ever had an AVR with an asymptomatic > arotid (whether it was noticed preop or not) have a beautiful operation (AVR) > nly to go home with hemiplegia or aphasia from a perioperative stroke?> > tea> > > ----- Original Message ----> From: Dr. Roberto Battellini > battr at medizin.uni-leipzig.de>> To: OpenHeart-L at lists.hsforum.com> Sent: > ednesday, January 23, 2008 6:52:08 PM> Subject: AW: [HSF] Aortic Valve Stenosis > nd Carotid Stenosis> > I remember one case of symptomatic carotid stenosis and > evere aortic> stenosis. In 1999, the cardiologists asked to do first the > arotid and later> the valve. Well, after a perfect carotid endarterectomy, and > xtubation of> the patient I went home, he was awake, all OK. Just to come the > ext day and> be informed he died at night suddenly in acute heart failure > ecause of
 the> valve. After that case I never more did a carotid first. And > efore that> case, in the late 80´s I had 3-4 cases in which I had to perform > rgently> coronary surgery after a well done carotid endarterectomy. Now we do > ll> together if the carotid is 90% or more stenosed or if symptomatic.> > So, > AVE of an aortic valve decompensation after carotid endarterectomy.> Roberto> > > ----Ursprüngliche Nachricht-----> Von: openheart-l-bounces at lists.hsforum.com> > mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von> > dmartin2000 at aol.com> Gesendet: Mittwoch, 23. Januar 2008 03:19> An: > penHeart-L at lists.hsforum.com> Betreff: Re: [HSF] Aortic Valve Stenosis and > arotid Stenosis> > > I really think it is dealer's choice in these situations. > > > > Tom Martin> > U of Florida> > Gainesville> > > -----Original > essage-----> From: Edward Bender <ebender001 at charter.net>> To: OpenHeart-L > OpenHeart-L at hsforum.com>> Sent: Mon, 21 Jan 2008 10:07 pm>
 Subject: [HSF] > ortic Valve Stenosis and Carotid Stenosis> > > > I'd be interested in the > embers' opinions about the following patient. She> is a 74 year old diabetic > atient admitted to an outside hospital with chest> pain and class 2 heart > ailure symptoms. She underwent echo and cardiac cath> showing trivial coronary > rtery disease (50% LAD at most), 50 mmHg gradient> across the aortic valve, > ormal LV function. The indexed valve area is 0.4.> She underwent carotid > opplers due to a bruit. This showed over 80% stenosis> in both internal carotid > rteries. She is left dominant. I repeated the> cardiac and carotid echos in our > ospital and the outside studies are> supported by our studies. The outside cath > id not include an LV gram, and I> see no attempt to have crossed the aortic > alve.?> ?> The patient is a relative of one of our local physicians, and she is > ow an> outpatient on appropriate medical therapy. Although I think that she >
 ill> need AVR, I do not think it is an urgent requirement. The outside > ospital> cardiologist said she needed 3 bypasses and an aortic valve next week, > nd> that he would have a surgeon come down from a major midwestern university > o> do the operation at their hospital (itinerant surgery). Needless to say,> > fter the patient was discharged on medical therapy, the local physician> took > is relative out of that hospital system.?> ?> I was planning to do a left > arotid endarterectomy, followed by a right> carotid when the patient is feeling > ell and recovered. Any thoughts about> doing the aortic valve at the time of > he second carotid surgery? I do this> alot with coronaries (I think we had > everal discussions about this topic),> but have not had the same scenario with > alvular heart disease in the> absence of important carotid disease.?> ?> Ed > ender, MD?> _______________________________________________?> OpenHeart-L > ailing list?> ?> Send
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