[HSF] Pericardial effusion post-AVR

Tue Mar 25 21:11:41 EDT 2008

Here's my take on the effect of location and referrals. For once I'll make no editorial (let me know if I slip, Ani). It's just the facts, sir. 

I set up a program about 13 years ago which does about 200-300 hearts a year. We run around STS average with a trend toward beter than average.
Last year we set up a specialty heart hospital that is small and does 600-700 hearts a year with 60 beds and a 0.5% cab mortality. Most cases are elective since it is new and difficult to transfer urgent in cases since the hospital and OR are usually full. I am one death away from having the worse mortality in this hospital (no deaths so far). I recently re-opened a program in which I have done three cases with one survivor. (Admittedly all were emergent and one was an emergency pulmonary embolectomy which may have been my first or possibly second in 20 years.) All on these hospitals are within 30 miles from each other. 

Which is the "best" hospital?

tea

----- Original Message ----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Tuesday, March 25, 2008 2:43:14 PM
Subject: Re: [HSF] Pericardial effusion post-AVR

Bob,

I am not sure I understand your correctly - you mean we have to
individualize our operation for the specific patient and their
social/medical comorbidities?  Take their requests into consideration?  Talk
with them?  Are you telling me that CCF or Man's Greatest Hospital or The
Mayo data can not always be applied to MY patient population (which probably
has more in common with Prasanna's villagers than a
health-wealthy-motivated, I want a USN&WR top hospital insured and employed
citizen)?

Blasphemy!

-michael

On 3/25/08, Rwmfglycar at aol.com <Rwmfglycar at aol.com> wrote:
>
>
>
> To start with did he have a hit on the head? What is the record of his
> coumadin therapy? (This should be available in a VA patient). Did he go
> out of
> control because of an extraneous factor?
> The factors that enter into the performance of a valve are many.andthere  is
> no one valve that suits all patients, every society, all surgeons, all
> hospitals or all healthcare systems. The St Jude valve is a good
> example.  The
> monumental 25 year study of the SJM reported by Bob Emery, done by a
> group  of
> good surgeons in a patient population that is orderly, disciplined
> and  educated
> tells one story. (hemorrhagic complications were really low). We  could
> not
> repeat these results in the Bronx despite our best efforts. We had
> to  learn a
> long time ago  how to reoperate at low risk on bioprostheses. Not  even
> this
> last point is uniform. There was a randomised study in Glasgow  published
> about
> 15 years ago in which the conclusion was reached that
> mitral  bioprostheses
> should never be used. Dead right in their hands, as we pointed out  in a
> letter
> to the editor: their mitral reoperative mortality was 19%.There
> were  several
> reasons for this which I will not go into but the point is that  general
> conclusions are just not possible. Even the  the Perimount  paper quoted
> by Ani,
> on which my name appears, cannot be regarded as  automatically
> representative.
> of the general US population. They started as  the patients selected for
> the
> FDA trial of the Perimount in the early 80's.  Einstein and the Cleveland
> Clinic were the largest contributors so there was  some mix of patient
> types.
> However as in any trial there were exclusions; they  probably do not
> represent the
> polypathological patients that are the  aveage fare for HSF surgeons
> patients
> 25 years later.
> Until we have mechanical valves that do not need AC and biological valves
> that last forever there will still be a matchmakers art in .the selection
> of a
> valve for a patient.
> Bob
>
> 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
> >
> >
>
>
>
>
>
>
>
> **************Create a Home Theater Like the Pros. Watch the video on AOL
> Home.
> (
> http://home.aol.com/diy/home-improvement-eric-stromer?video=15?ncid=aolhom00030000000001
> )
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