[HSF] Pericardial effusion post-AVR

Tue Mar 25 19:58:25 EDT 2008

Informed consent= "the sell", "nothing to hide" "informed consensus", others ? 

Sorry thought of one more="only one thing to sell"

tea

----- Original Message ----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Tuesday, March 25, 2008 6:57:43 AM
Subject: Re: [HSF] Pericardial effusion post-AVR

Ani -

Yes, it is all in the sell - but you can not tell a 54 year/old getting a
tissue valve that the risk for re-op is similar to a mechanical valve.
Regardless you can drown these people with data and frankly some people
clearly do not want a re-op and would rather deal with coumadin.  Right or
wrong, that is what they want and you have to respect that informed
decisions.

I had a similar case of a very active 34 year/old who I strongly suggested a
tissue valve on, but he and his wife insisted on a mechanical valve (I put
in an On-X with the hopes of low dose anti-coag).  I went to talk with the
family post-op and obviously his mom never knew about these conversations
and she started freaking out that her son now needs coumadin and that is a
"killer drug" and she new several people who had major complications on
coumadin.  It was his decision - but that talk made me sick to my stomach.

-michael

On 3/24/08, Prasanna Simha M <prasannasimha at gmail.com> wrote:
>
> What you say is hundred percent true but there is one small hitch to
> the equation in may parts of the world - the cost of the valve.
> Prasanna
>
> On Tue, Mar 25, 2008 at 7:48 AM,  <jbflegejr at aol.com> wrote:
> > Most of us have seen that a mechanical valve does not insure that
> reoperation will never be needed and patients who are not made aware of that
> cannot be considered informed. Many of the patients who have a serious
> problem with their mechanical valve never come to our attention. Last week I
> had a call from a worried cardiologist at the VAHospital who said that they
> had a man in his mid 50s with a St. Jude mitral prosthesis admitted with a
> subdural hematoma and what could they do? I did not have any really useful
> advice for her. I have removed mechanical valves on a couple of occassions
> from patients who had cerebral emboli despite what seemed to be appropriate
> anticoagulant therapy and I suppose that I might do the same in patients who
> could no longer take Coumadin for whatever reason. During the last 20 years
> I have rarely implanted a mechanical valve no matter what the age (I do not
> deal with children). I always discuss the two types of valves and ask the
> patient what he w
> an
> >  ts. Sometimes they counter by asking me what I suggest. Almost always
> they elect the biologic valve. This only proves that the way the information
> is presented determines what the selection will be. Safe and effective
> anticoagulant therapy depends on careful management by physician and
> patient. It is expensive. In this geographic area, anticoagulants are not
> well managed as a general rule. If one is going to commit a patient to long
> term Coumadin, he should be confident that the patient can afford it and
> will comply and that his physician understands and is concerned and knows
> that he will not get very well paid for his efforts. John Flege
> >
> >
> >
> >  -----Original Message-----
> >  From: Michael Firstenberg <msfirst at gmail.com>
> >  To: OpenHeart-L at lists.hsforum.com
> >
> >
> > Sent: Mon, 24 Mar 2008 5:38 pm
> >  Subject: Re: [HSF] Pericardial effusion post-AVR
> >
> >
> >
> >
> >
> >
> >
> >
> >  as a follow-up - they tapped 1000cc of bloody fluid off.
> >  I asked if they sent it for anything...... response: "oh we will, what
> do
> >  you want"?
> >
> >  and regarding mechanical valves in 54 year/old....... there are many
> people
> >  out there who do not want a re-op, period - even if it means coumadin
> for
> >  the rest of their lives.
> >
> >
> >  -michael
> >
> >
> >  On 3/24/08, Ani Anyanwu <anianyanwu at hotmail.com> wrote:
> >  >
> >  > Interesting - just last week we were hearing how a pacing wire that
> >  > perforated an RV in a patient with prior sternotomy could not cause
> >  > tamponade and now we start hearing that tamponade is indeed possible
> >  > distantly after prior sternotomy.
> >  >
> >  > Reinforces why I am often very skeptical of things I read or hear -
> rarely
> >  > do they represent the whole truth - the task is to find the
> (hopefully
> >  > little) falsehood in every truth. Even michael's story seems to lack
> the
> >  > whole truth - puzzles me why (if this has really been building up
> over a
> >  > year) the fluid would not drain through a catheter.
> >  >
> >  > I also found it interesting that 54 year old patients (or their
> surgeons)
> >  > still chose mechanical valves and leads me to wonder how informed
> such
> >  > decisions truly are... that of course is another topic.
> >  >
> >  > Ani
> >  >
> >  >
> >  >
> >  >
> >  > > Date: Sun, 23 Mar 2008 09:44:12 +0530> From:
> prasannasimha at gmail.com>
> >  > To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Pericardial
> effusion
> >  > post-AVR> CC: > > Happens rarely especially if anticoagulated (as in
> this
> >  > case) and> there was possible persistent fluid that prevented
> adhesions
> >  > from> forming.> Prasanna> > On Sun, Mar 23, 2008 at 2:40 AM, Michael
> >  > Firstenberg <msfirst at gmail.com> wrote:> > 55 year/old s/p mechanical
> AVR 1
> >  > year/ago (yes 1- year) presented> > with worsening SOB. Echo showed
> large
> >  > percardial effusion with RV> > compression (which I saw and agree
> with).
> >  > Attempted perc tap in cath> > lab unsuccessful (with INR=3), repeat
> under
> >  > ultrasound guidance also> > unsuccessful (INR=1.8). I was called -
> just
> >  > got a CT scan which> > confirms the effusion and a moderal pleural
> effusion
> >  > (also now with> > slight drop in HCT).> >> > Granted probably now
> needs to
> >  > be cleaned out (probably left VATs) -> > but more to the
> point/question -
> >  > anyone see tamponade 1 year out?> >> > something sounds very odd....>
> >> >
> >  > -michael> >> >> > _______________________________________________> >
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> Simha M>
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> --
> Prasanna Simha M
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