[HSF] Rt thoracotomy MVR

Thu Mar 13 18:51:39 EDT 2008

Ani,

I appreciate your candor. I, too, am not interested in whether your theory is accurate, or whether you behave as you believe. We often see your disconnect (you tell us!) between behavior and belief. What I am primarily pointing out is your way of thinking about the problem which is quite respected. It is your way of thinking that I would like to high light.

Particularly I would like to focus on what you yourself recognize that you do: your "summation of reality and data", your 1) point. The fact that you use your data so well makes the problem of (your declaration of) reality so difficult.

Your use the data arranged on a quantitive (best, 100% effectve, etc) or Cartesian distribution that seems mathematical and absolute and is largely synonomous with scientific inquiry. In this particular example the previous context is that mitral repair is a better operation based on, say (Cartesian only allows a choice or two at a time) mortality, than other solutions. As we have talked before, population studies can not show whether this is always true , but that it is generally true and more generally and less specifically true for larger populations. I again don't even want to argue with you how true this theory or reality might be, except to note that the baseline is mortality verses repair, a Cartesian and specific (scientific?) definition of reality. 

As I have argued before we are really placing data points of  complex interaction(s) "onto" a Cartesian reality matrix only because we ignore so many other issues and subgroups, etc. in this and each"scientific" manipulation or summation of the data. 

What you have done with your "sternotomy is preferred" summation is to redistribute approaches on the new baseline of percent repairability. You fail to mention that the original defintion of (Cartesian) reality was mortality. So you in effect jump from one reality to different reality plugging data into the presumed, but not actual identical worlds. This is a logical error and clearly not a valid mathematical or Cartesian process. Your defense likely is that these "realities" are clearly closely related, which unfortumatedly is my argument as to why we can not take these "projections" from a real experience as the universal and Cartesian reality that you wish to claim from the beginning. The fact that you dazzle us with numbers and data is akin to finding the dice in the magician hands. This familair process is seemingly  self evident to those  that look (especially the unsophicated like our jurors), but its truth is often susceptible to the conscious
 (and unconscious sequelae) effect intended than the observed reality hoped for. This in a nut shell (or magicians hand) is the problem of EBM that we prefer to ignore.

Bob's diatribe against the Bible thumpers is misdirected unless this a metaphor which may be the case. In today's world Bible thumpers are easily dismissed and perhaps too easily so, since they see the loss of value in the science of numbers however bad their understanding of biological phenomena. It is the professional article thumping believers in EBM, ourselves included, that we need to fear. Science is the magic, or religion depending on one's predisposition, of our day. What to do with the meaning of what we see is the recurrent and persistent human question.

Lastly for perhaps a different discussion, surgery of the mitral valve, particularly repair, is an interesting choice to have the issue of approach be the prism through which we peer. Unlike like lobectomy or femoral artery cannulation, the mitral valve is "remote" through virtually all approaches and the gestalt of tactile feedback is almost absent. So visual analysis and feedback are primary. Does it really matter and in what ways, that the surgeon is 4 more inches, 4 more feet, or 4 more timezones remote than through the sternotomy? So is this issue more from the observer of the data or the data itself? More not which, since it is clearly relational and not objective in the absolute sense.

tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Thursday, March 13, 2008 4:37:14 PM
Subject: RE: [HSF] Rt thoracotomy MVR

Tea 

I think you are right in your analysis (of my view point), but just to clarify to others on my earlier contribution regarding right thoracotomy for mitral surgery.

1) My comments do not necessarily represent my personal views or practice but are my summation of reality and data  i may well do things different or believe different from what i say. 

2) Anything *is* possible through a right thoracotomy - even a heart transplant - provided it is big enough. That is not the manner in which thoracotomy for mitral surgery is marketed in the present day. It is sold as a mini-invasive procedure. I have seen several patients who had previous mini-mitral or aortic surgery via the right thorax where the thoracotomy scar is longer than the sternotomy scar. 

3) Whatever we mat claim, there is a limit to what is surgically possible via minithoracotomy compared to a median sternotomy. This limit varies from surgeon to surgeon. While some surgeons maybe able to repair an AV canal defect via a minithoracotomy others will only be comfortable placing an annuloplasty ring or replacment prosthesis.

4) Robotic surgery is a very different entity from right thoracotomy surgery. That the robotic ports are in the right thorax is incidental and a matter of convenience. I certainly agree that with a robot most things will be achievable - indeed it is likely that with a robot one can achieve some things with better ease and accuracy than via sternotomy because of superior vision, better instrumentation, and more degrees of freedom. 
5) While it may be true that some surgeons can perform ANY mitral procedure via the left or right chest, this is the exception rather than the rule. Only a few here even seem to be familiar with the left thoracotomy route. We can talk the talk all we like but the reality is that few surgeons are capable of performing even routine mitral procedures seamlessly via a left or right thoracotomy. Again I would caution on a team that is not used to this approach applying it in a complicated scenario. If list members recall, the last case I argued against use of a right thoracotomy (the reop TVR) ended up disatrous. In an unusual or complicated case, the median sternotomy is, in most scenarios, the safest and most controlled route.

6) Stating all mitrals can be done via any single incision (including sternotomy) is akin to our previous discussions like all CABG can be done off-pump, all CABG without aortic touch and all valve operations with a beating heart. Possible in a few hands but impossible in most hands.

7) While it is possible, I doubt most surgeons here would truly elect for the thoracotomy approach if they were treating this patient. I might be the only one speaking out but I think we are making this procedure much more complicated than it need be.

Ani

> Date: Wed, 12 Mar 2008 21:50:38 -0700> From: tacuff at swbell.net> Subject: Re: [HSF] Rt thoracotomy MVR> To: OpenHeart-L at lists.hsforum.com> CC: > > Interesting theory, Ani. Your ideas follow a pattern. We can talk about that later, but for now you suggest the following.> > Results are determined by approach. So far, perhaps, no problem. This however leads to standardization of approach for sake of the operation. Perhaps, not a problem, but I can think of collaries that show the error of such thought.> > comments?> > tea> > > > ----- Original Message ----> From: Ani Anyanwu <anianyanwu at hotmail.com>> To: openheart-l at lists.hsforum.com> Sent: Wednesday, March 12, 2008 6:27:35 PM> Subject: RE: [HSF] Rt thoracotomy MVR> > Hal> > This is most certainly fact. I am out of the country right now and have only limited internet access so am not able to get you exact references. However if you do a pubmed search on either of those authors and also search on Colvin,
 Cosgrove and Cohn (mini mitral via via non=endoscopic approach) you will get the exact figures and find replacement rates between 7 and 15 %. Indeed in Vanermans's initial series his replacement rate was 30%. There is no doubt that the limited access and tactile control limits what can be done via any mini-incision. Indeed I heard Chitwood give a lecture just this week and he still does the odd replacement via thoracotomy. It depends on what one's priorities are - if it is to use a side or mini incision for all cases then there will be some avoidable replacements. If it is to repair all cases then (as you will testify) the surgeon will agree that in some cases a sternotomy may be the preferable option. > > Obviously these data are historical as they include initial experience, and having overcome the learning curve these gurus can likely repair almost everything via mini access but the same definitely does not apply to the occasional 'side surgeon'.> >
 Ani> > > > > From: Hgrmd at aol.com> Date: Wed, 12 Mar 2008 06:19:16 -0400> Subject: Re: [HSF] Rt thoracotomy MVR> To: OpenHeart-L at lists.hsforum.com> CC: > > Dear Ani,> That's a pretty provocative statement you made about Vanermen, Chitwood, > and Mohr. Not that I'm doubting you, but could you please provide references > demonstrating what you stated? I realize your boss advertises a nearly > "100%" repair rate on his website. He is also quite vocal in his opposition to > any approach other than full sternotomy. The problem is the public doesn't > want a full sternal split for the average mitral repair.> > Hal> > > > **************It's Tax Time! Get tips, forms, and advice on AOL Money & > Finance. (http://money.aol.com/tax?NCID=aolprf00030000000001)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:>>
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