AW: [HSF] Aortic Valve Stenosis and Carotid Stenosis

Tea Acuff tacuff at swbell.net
Thu Jan 31 18:54:40 EST 2008 

Ben, 

I don't remember saying this exactly, but mercifully I don't remember most of what I say. I am almost always surprised by what people retain of my comments. Regardless the syntax is a little off. I submit that evidence whatever its limitations (possibly or possibly not excluding the completely erroneous) represents or is a surrogate for reality. It is the context in which we hold that evidence that is a state of mind. And for this reason that so much of what we believe to be supported by this evidence that has the texture of religion and the changing our opinion of the meaning of the evidence the resemblance of conversion.

tea


----- Original Message ----
From: Ben Bidstrup <benjamin.bidstrup at bigpond.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Monday, January 28, 2008 1:50:09 AM
Subject: Re: AW: [HSF] Aortic Valve Stenosis and Carotid Stenosis

So Roberto, who needs evidence. As Tea says, it is just another state of mind!

>Ani,
>I´ve just attended the LINC, Leipzig International Course, endovascular. The
>cariologists, angiologists and radiologists are stenting every carotid,
>regardless of symptomatology. If we do let them do everything, they´ll
>perform in 10 years all the vascular, aortic and valve surgery by stents,
>you´ll remain only with your TX and severe endocarditis!.
>Roberto
>
>-----Ursprüngliche Nachricht-----
>Von: openheart-l-bounces at lists.hsforum.com
>[mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von
>ebender001 at charter.net
>Gesendet: Sonntag, 27. Januar 2008 23:09
>An: OpenHeart-L at lists.hsforum.com
>Betreff: RE: [HSF] Aortic Valve Stenosis and Carotid Stenosis
>
>Should we refrain from operating on the asymptomatic solitary pulmonary
>nodule?  Ani, where is this diagnostic and therapeutic nihilism coming from?
>If you had an 80% carotid stenosis, would you want it fixed, or would you
>want to wait for a symptom (like hemiplegia)?
>See you at dinner.
>Ed Bender, MD
>
>
>---- Ani Anyanwu <anianyanwu at hotmail.com> wrote:
>>  Tea
>>
>>  I am generally against screening - apart from finding more work and
>patients and money for physicians, industry and their consorts, there are
>few scenarios in which these screening tests actually benefit the patients.
>I am against the epidemic of diagnostic testing in modern medical practice
>which often yields 'new' diseases and problems which may have been best left
>sleeping but now become things doctors can treat. Obtaining information to
>allow prognostication and informed consent is one thing but it does not
>necessarily follow that by dealing with the 'disease' we will do anything to
>change the prognosis. Maybe we should go on....
>>
>>  Ani
>>
>>
>>
>>  > Date: Wed, 23 Jan 2008 20:19:36 -0800> From: tacuff at swbell.net> Subject:
>Re: [HSF] Aortic Valve Stenosis and Carotid Stenosis> To:
>OpenHeart-L at lists.hsforum.com> CC: > > Why would you suggest it? Are you
>against screening patients with neither known CAD or AS? I could go on but
>this is enough.> > tea> > > ----- Original Message ----> From: "Douville,
>Chuck" <ecdouville at orclinic.com>> To: OpenHeart-L at lists.hsforum.com> Sent:
>Tuesday, January 22, 2008 11:23:00 AM> Subject: RE: [HSF] Aortic Valve
>Stenosis and Carotid Stenosis> > I would suggest that screening carotids in
>pure aortic valve disease is not indicated, However, Ed's pt had coronary
>artery disease; it is reasonable to screen elderly pts with coronary disease
>for concomittant carotid disease. Some, eg Drs. Waering and Kouchoukos at
>Wash U 12 years ago or so, have demonstrated significant improvement in
>neurologic outcomes with such an aggressive strategy.> >
>________________________________> > From:
>openheart-l-bounces at lists.hsforum.com on behalf of Ani Anyanwu> Sent: Tue
>1/22/2008 6:18 AM> To: openheart-l at lists.hsforum.com> 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> >
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--
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon
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