From zzhoumd at pol.net Thu May 1 00:05:38 2008 From: zzhoumd at pol.net (zzhoumd@pol.net) Date: Wed Apr 30 19:06:07 2008 Subject: [HSF] RCA osteal lesion-osteal reconstruction In-Reply-To: References: Message-ID: <1722265698-1209596745-cardhu_decombobulator_blackberry.rim.net-1901169099-@bxe159.bisx.prod.on.blackberry> Hal, Agreed, whether you can do a good job with valve repair has lot to do with your understanding of the valve. Chest approach should not compromise the technique. If it is, than conversion should be done. Z Zhou Sent via BlackBerry by AT&T -----Original Message----- From: Hgrmd@aol.com Date: Wed, 30 Apr 2008 07:45:15 To:OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] RCA osteal lesion-osteal reconstruction "Animal", Actually, I'm more than OK with your stance. An old cowboy on TV once said, "a man's got to understand his limitations." In our zeal to advance surgical frontiers, we must not force those of us not comfortable or ready for the challenge. For instance, there may be misguided surgeons wishing to create a robotic mitral practice, who, in reality, have no significant mitral repair experience done via sternotomy. Certainly, it would be a mistake for such surgeons to think they will become safe robotic surgeons when they aren't even comfortable doing complex open repairs. Hal **************Need a new ride? Check out the largest site for U.S. used car listings at AOL Autos. (http://autos.aol.com/used?NCID=aolcmp00300000002851) _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From hgrmd at aol.com Thu May 1 00:13:13 2008 From: hgrmd at aol.com (hgrmd@aol.com) Date: Wed Apr 30 19:14:15 2008 Subject: [HSF] Re: [ccm-l] Image of the week Hemisternotomy In-Reply-To: References: <537727.63518.qm@web81606.mail.mud.yahoo.com> Message-ID: <490438732-1209597163-cardhu_decombobulator_blackberry.rim.net-1007138223-@bxe028.bisx.prod.on.blackberry> R2FiaSwNCiAgQmVsaWV2ZSBpdCBvciBub3QsIFByYXNhbm5hIGlzIHJlYWwuICBJIGhhZCB0aGUg cGxlYXN1cmUgb2YgbWVldGluZyBoaW0gaW4gTGVpcHppZy4gIEdyZWF0IGd1eS4NCg0KSGFsDQpT ZW50IGZyb20gbXkgVmVyaXpvbiBXaXJlbGVzcyBCbGFja0JlcnJ5DQoNCi0tLS0tT3JpZ2luYWwg TWVzc2FnZS0tLS0tDQpGcm9tOiBnYWJpIGZvcmQgPGdhYmlmb3JkQGhvdG1haWwuY29tPg0KDQpE YXRlOiBXZWQsIDMwIEFwciAyMDA4IDIyOjMwOjAwIA0KVG86PG9wZW5oZWFydC1sQGxpc3RzLmhz Zm9ydW0uY29tPg0KU3ViamVjdDogUkU6IFtIU0ZdIFJlOiBbY2NtLWxdIEltYWdlIG9mIHRoZSB3 ZWVrIEhlbWlzdGVybm90b215DQoNCg0KDQoNCiBGcm9tOiB0YWN1ZmZAc3diZWxsLm5ldA0KPiBQ bGVhc2Ugbm90ZSB0aGF0IHRoZSBhb3J0YSBjYW5udWxhdGlvbiBpcyAiZG9lYWJsZSIuIFRoaXMg aXMgY29kZSBmb3IgbGltaXRlZCBhY2Nlc3MuIEluIG1hbnkgYWx0ZXJuYXRpdmUgaW5jaXNpb25z IHRoZSBwcm94aW1hbHMgKGlmIHVzZWQsIERvbikgY2FuIGJlIGEgYmlnZ2VyIHByb2JsZW0gdGhh biB0aGUgZGlzdGFscy4gQW4gaW5hZHZlcnRlbnQgcHJvYmxlbSB3aXRoIHRoZSBhb3J0YSBjYW4g ZXhhY3QgYSBoaWdoIHByaWNlLiBBYmlsaXR5IHRvIGV4dGVuZCB0aGUgaW5jaXNpb24gaXMgYSBy ZWFsIHBsdXMsIGJ1dCBtYXkgbm90IGJlIHdvcnRoIHRoZSB0cmlwICh0byBJbmRpYSkuIE9uIHRo ZSBvdGhlciBoYW5kIGhhdmluZyBQcmFzYW5uYSBiZSB5b3VyIHN1cmdlb24gbWF5IGJlIHdvcnRo IHNvbWUgYnVtcHMgaW4gdGhlIHJvYWQuIEhlIHdhcyBub3QgYWR2ZXJ0aXNpbmcgZm9yIENBQiwg aG93ZXZlciwgb3Igc28gaXQgc2VlbXMuLg0KDQpObywgaGUgd2Fzbid0IGFkdmVydGlzaW5nLiAg ICBIYXMgaXQgY29tZSB0byB0aGF0PyAgOykNCkknZCBsaWtlIHRvIG1lZXQgUHJhc2FubmEgc29t ZXRpbWUuICBJIGhhdmUgYSBzdXNwaWNpb24gdGhhdCBoZSBpcyBhIGZha2UuICBIZSBpcyBwcm9i YWJseSA0IHBlb3BsZSBydW5uaW5nIHVuZGVyIG9uZSBuYW1lLiAgU29tZSBmYW50YXN0aWMgZGFk LCBDViBzdXJnZW9uLCBjb21wdXRlciBuZXJkIGFuZCBjYXQgZmFuY2llci4uLi5hbGwgb2YgdGhl bSBmdW5jdGlvbmluZyBleHRyZW1lbHkgd2VsbCBmdWxsIHRpbWUuDQoNCkdhYmkNCl9fX19fX19f X19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fDQpPcGVuSGVhcnQtTCBtYWls aW5nIGxpc3QNCg0KU2VuZCBwb3N0aW5ncyB0bzoNCiBPcGVuSGVhcnQtTEBsaXN0cy5oc2ZvcnVt LmNvbQ0KDQpUbyBVTlNVQlNDUklCRSwgdG8gQ0hBTkdFIGVtYWlsIGFkZHJlc3MsIG9yIHRvIHZp ZXcgYXJjaGl2ZXM6DQpodHRwOi8vbW1wLmNqcC5jb20vbWFpbG1hbi9saXN0aW5mby9vcGVuaGVh cnQtbA0KDQpBbGwgbWVzc2FnZXMgdHJhbnNtaXR0ZWQgYnkgdGhlIE9wZW5IZWFydC1MIGFyZSBz dWJqZWN0IHRvIHRoZSBwb2xpY2llcyBhbmQgDQpkaXNjbGFpbWVycyBwb3N0ZWQgYXQ6DQpodHRw Oi8vd3d3LmhzZm9ydW0uY29tL2xpc3RkaXNjbGFpbQ0KLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0t LS0tLS0tLS0tLS0tLS0tLS0NCg== From zzhoumd at pol.net Thu May 1 03:08:53 2008 From: zzhoumd at pol.net (zzhoumd@pol.net) Date: Wed Apr 30 22:10:28 2008 Subject: [HSF] Sympathy anyone....... In-Reply-To: References: Message-ID: <1227345180-1209607740-cardhu_decombobulator_blackberry.rim.net-222548375-@bxe159.bisx.prod.on.blackberry> What valve did you give him? Sent via BlackBerry by AT&T -----Original Message----- From: "Michael Firstenberg" Date: Wed, 30 Apr 2008 21:26:16 To:OpenHeart-L@lists.hsforum.com Subject: [HSF] Sympathy anyone....... 51 year/old.....presented with 4 day history of chest pain. Tall, thin, long fingers.... ST changes on ECG. Concern for AMI Given: ASA High dose Plavix Lovenox taken to cath lab found to have Type A dissection from valvue to iliacs........ oh, he also got reopro............ it has been a long day. -michael _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From prasannasimha at gmail.com Thu May 1 09:01:19 2008 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Wed Apr 30 22:38:40 2008 Subject: [HSF] Image of the week Hemisternotomy In-Reply-To: <9A045CF4-402E-48B8-8769-6AEC2CF9C633@shaw.ca> References: <89c4ed2d0804300138h2cf31d32ic0cf68fd8e76af5a@mail.gmail.com> <004501c8aacc$f994fbc0$b3160a06@HZLPC0679> <89c4ed2d0804300809t635cec04vb54a18adc5ca0a41@mail.gmail.com> <89c4ed2d0804300911q2c270862xbddbdd7020407d19@mail.gmail.com> <9A045CF4-402E-48B8-8769-6AEC2CF9C633@shaw.ca> Message-ID: <89c4ed2d0804301931r543ab95fo54da1b0289c76739@mail.gmail.com> I have done it even in older patients. The thing is to open the sternum in stages and not rapidly. If the sternum appears rigid, I give a small partial sternal cut (an incomplete T or L that gives an axis for sternal torque. The key is to ratchet the sternum in stages. First open it to an extent, hold open the pericardium, open a bit more release the pericardium over SVC and IVC , open a bit more and so on and so forth. The thing that I have noticed in older people is some have a springy sternum and some have a rigid rock like sternum. The springy ones open easily. The rigid rock like ones need to be opened slower or need a partial T or a lead cut if you want to open it faster. Prasanna On Thu, May 1, 2008 at 1:06 AM, V. Aldrete, M.D. wrote: > Hi Prassanna, > > With the lower hemisternotomy. Do I understand that there is no > transverse division at the upper end of the sternotomy? > If this is so, what is the average age of patients that can tolerate this > without sternal fracture? > > Remember than in North America our patients' average age is much higher. > Over half of my patients that had open heart surgery were over the age of > 60, and I hear that the average age is only getting higher. > > Cheers, > > Victor > > > On Apr 30, 2008, at 9:11 AM, Prasanna Simha M wrote: > > Roberto, > > I have shown how the exposure is good with a hemisternotomy. We have to > > use > > a small bit of trickery as is obvious in the two views. With a lttle > > head > > low you can see how the view dramatically improves. You can also use a > > rultract retractor to hook up the manubrial segment to get a better > > exposure. I use a towel clip /Langenbeck which can be ratcheted up to > > another towel clip or a attached to the ether screen instead of a > > rultract. > > Once aortic cannulation is done the head low is unecessary. Another > > thing > > is that the cross clamp must preferably not be like an L but mor of an > > oblique angle instead of a right angle .This prevents the clamp impeding > > the > > operative field. If that is not available it can be placed in reverse > > but > > will overlie the RV. > > > > Prasanna > > On Wed, Apr 30, 2008 at 8:39 PM, Prasanna Simha M < > > prasannasimha@gmail.com> > > wrote: > > > > Yes the exposure is not a problem for surgery . In fact it can be made > > > smaller by actually using the drain site as the site for the IVC > > > cannulae > > > and you can do the whole procedure with conventional instruments.and > > > direct > > > vision. Photography is a little bit problematic as the sternal > > > spreader > > > appears unaesthetic (though vision is not hampered. I think the only > > > thing > > > that one has to be careful is the ascending aortic cannulation which > > > is > > > actually not much of a problem. My resident and lecturer do these > > > cannulations under my supervision so it is doable. Actually I do not > > > do an L > > > or a T but give a small cut to act as a fulcrum for opening. In > > > children and > > > young adults even that is not necessary. The key is to stagewise and > > > slowly > > > open the spreader. If opened slowly it is surprising how the sternum > > > can be > > > opened adequately without fracturing it.I even do AVR's with the same > > > incision. though the bone cut may be slightly higher (depends on the > > > verticality of the heart and root position as seen on the Chest X Ray. > > > When > > > done for cosmessis an upper sternotomy is not acceptable. Also keeping > > > the > > > manubrium intact seems to help quick recovery. I was initially > > > skeptical but > > > patients do seem to feel better. > > > Prasanna > > > > > > > > > On Wed, Apr 30, 2008 at 7:47 PM, Dr. Roberto Battellini < > > > battr@medizin.uni-leipzig.de> wrote: > > > > > > Prasanna, > > > > Did you have a good view and comfortable from that approach? > > > > Better than mitral MIC as you saw by Mohr? > > > > Was the incision in L or in T? > > > > Roberto > > > > > > > > > > > > -----Urspr?ngliche Nachricht----- > > > > Von: openheart-l-bounces@lists.hsforum.com > > > > [mailto:openheart-l-bounces@lists.hsforum.com] Im Auftrag von > > > > Prasanna > > > > Simha > > > > M > > > > Gesendet: Mittwoch, 30. April 2008 09:38 > > > > An: OpenHeart-L; > > > > Betreff: [HSF] Image of the week Hemisternotomy > > > > > > > > Havent got any exiting photos from some time so posting a postop > > > > photo. > > > > Mitral valve repair done in a 20 year old patient via a > > > > hemisternotomy > > > > at > > > > his 6 month follow up.Not as small as the robots but getting > > > > somewhere > > > > there > > > > :). Patient is very happy with the cosmesis despite a hypertrophied > > > > scar > > > > as > > > > the scar is not seen even when his second shirt button is left open. > > > > Prasanna > > > > > > > > -- > > > > Prasanna Simha M > > > > > > > > _______________________________________________ > > > > OpenHeart-L mailing list > > > > > > > > Send postings to: > > > > OpenHeart-L@lists.hsforum.com > > > > > > > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > > > > http://mmp.cjp.com/mailman/listinfo/openheart-l > > > > > > > > All messages transmitted by the OpenHeart-L are subject to the > > > > policies > > > > and > > > > disclaimers posted at: > > > > http://www.hsforum.com/listdisclaim > > > > ----------------------------------------- > > > > > > > > > > > > > > > > > -- > > > Prasanna Simha M > > > > > > > > > > > > > -- > > Prasanna Simha M > > > vieweml.jpg>_______________________________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@lists.hsforum.com > > > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > > http://mmp.cjp.com/mailman/listinfo/openheart-l > > > > All messages transmitted by the OpenHeart-L are subject to the policies > > and > > disclaimers posted at: > > http://www.hsforum.com/listdisclaim > > ----------------------------------------- > > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies > anddisclaimers posted at: > > http://www.hsforum.com/listdisclaim > ----------------------------------------- > -- Prasanna Simha M From prasannasimha at gmail.com Thu May 1 09:09:07 2008 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Wed Apr 30 22:39:10 2008 Subject: [HSF] Re: [ccm-l] Image of the week Hemisternotomy In-Reply-To: <537727.63518.qm@web81606.mail.mud.yahoo.com> References: <537727.63518.qm@web81606.mail.mud.yahoo.com> Message-ID: <89c4ed2d0804301939w21d313b0s808f9d132ea91682@mail.gmail.com> By doable I meant even my resident could do it and so is an index of performability. Let me assure you that I tell every resident that they shall not do it independently without me around to reiterate the necessity of being first a safe surgeon . I have not done CABG's through this route but people have done it.The fact that you can do an AVR also indicates that a CABG is possible though I would have concern doing an OPCAB with this (I think Don Ross does it he can give better tips on how to do them off pump) In fact Dr Levinson and Dr Subramaniam do it trans xyphoid albeit in selected cases. In all these cases I think it is more important to know when to back off. For eg I do not do this in patients with a high PAPVC and in tetralogy cases though one of my friends in Kochi does Tetrads also through this route. (absolute hemostasis of the upper part of the RVOT patch is mandatory if using this approach. On Thu, May 1, 2008 at 3:26 AM, Tea Acuff wrote: > Please note that the aorta cannulation is "doeable". This is code for > limited access. In many alternative incisions the proximals (if used, Don) > can be a bigger problem than the distals. An inadvertant problem with the > arota can exact a high price. Ability to extend the incision is a real plus, > but may not be worth the trip (to India). On the other hand having Prasanna > be your surgeon may be worth some bumps in the road. He was not advertising > for CAB, however, or so it seems.. > > tea > > > > ----- Original Message ---- > From: Prasanna Simha M > To: gabi ford > Cc: OpenHeart-L ; "" < > ccm-l@ccm-l.org> > Sent: Wednesday, April 30, 2008 12:29:03 PM > Subject: [HSF] Re: [ccm-l] Image of the week Hemisternotomy > > swallow statins,exercise and diet instead of coming to get cut up !! > > Prasanna > > On Wed, Apr 30, 2008 at 10:57 PM, gabi ford wrote: > > > > > From: prasannasimha@gmail.com > > >This is a view of the mitral valve during a hemisternotomy. I do not > > think that the view is compromised. You can clearly see the subvalvar (I > am > > doing a combined chordoplasty (chordal shortening +neochordal > construction ) > > of the AML chordae. > > > > Prasanna, > > > > Dare I say it? AMAZING!!!!! :) > > > > How do we get together when I need my bypass? > > Your OR or mine? > > > > Thanks for the pic and explanation. As always, impressive. > > > > Gabi, RN > > > > > -- > Prasanna Simha M > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies > and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies > and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > -- Prasanna Simha M From prasannasimha at gmail.com Thu May 1 09:14:59 2008 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Wed Apr 30 22:52:09 2008 Subject: [HSF] Sympathy anyone....... In-Reply-To: References: Message-ID: <89c4ed2d0804301944o607211a6p17f8c32953dbf1a@mail.gmail.com> How do you manage postop bleeding in cases that receive the full whammy antiplatelet cocktail. I have seen patients die due to unstoppable "ooze" after clopidogrel itself despite platelets etc etc. One such patient was the uncle of one of our anesthesiologists and it was terrible.No surgical bleeder but blood everywhere. Prasanna On Thu, May 1, 2008 at 6:56 AM, Michael Firstenberg wrote: > 51 year/old.....presented with 4 day history of chest pain. > Tall, thin, long fingers.... > ST changes on ECG. > Concern for AMI > Given: > ASA > High dose Plavix > Lovenox > > taken to cath lab > > found to have Type A dissection from valvue to iliacs........ > > > oh, he also got reopro............ > > > it has been a long day. > > > -michael > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies > and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > -- Prasanna Simha M From prasannasimha at gmail.com Thu May 1 09:48:07 2008 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Wed Apr 30 23:18:28 2008 Subject: [HSF] RCA osteal lesion-osteal reconstruction In-Reply-To: <8CA794B1265CD15-166C-272F@webmail-me02.sysops.aol.com> References: <8CA794B1265CD15-166C-272F@webmail-me02.sysops.aol.com> Message-ID: <89c4ed2d0804302018o650649f2hcf69581d4868cda3@mail.gmail.com> I think the minimally invasive approach is not something that someone just jumps into . Understanding the limitations is inherent to it and not just because it can be done. Why is Hal successful with it while many are not. He is able to do repairs consistently open . Learnt thorcoscopic or robotic skills and systematically applied them. It needs a logical progression and addition of finer points along the way. When I wanted to do hemisternotomies I first did limited skin approach progressed to T/J and then avoided the cut progressively learning my surgical and physical limitations along the way.I still remember Dr TE Udwadia making us sit with rice grains and a box for months before we assisted his first laparoscopic cholecystectomies (He was a pioneer of this). If I had a robot and if I could consistently do it like Hal has observed why not ? I would love to do it.There have to be pioneers in this field or else we will stagnate and not progress. When I visited Herzzentrum I was struck by the zeal for innovation.They have maintained a consistently good track record and also have maintained the zeal for innovation.The day we become placid and think we have reached our zenith is the day we are doomed as a profession. Various procedures become fashionable and wither away.Some stay and parts of some operations persist . What we adopt over time becomes a distillation of the surgical experience. It is like OPCAB some do it consistently and in some hands it is a positive danger. For some doing cardiac surgery itself may be a dangerous proposition ;) The robot will not be the panacea for all cardiac procedures but maybe it will have a definable role in the surgeons armamentarium. Universal use would be more related to costs,device development and user friendliness. Heartport cannulae where new things and total percutaneous bypass was touted as the next big thing. Now it has been recognized for its utility .Not everycase is being done with them but they are a boon when required. Prasanna Prasanna On Thu, May 1, 2008 at 8:04 AM, wrote: > Hal > I commend you and others such as Bill Turner in Tyler who have done this > the right way. You have been very methodical, careful and insightful.But you > are the exceptin and not the rule. ?What really gets my hair standing on end > is the thought and talk of doing minimally invasive procedures in order to > please or appease the cardiologist and keep from loosing cases and $$. I can > actually see where mitral work is possibly ideal for this type of approach. > I would ask you, however, that if you are going to tout it as a technique > that is as good or better that you publish it and compare it to a case > matched control of all your other mitrals that you have done in the past or > even better yet, do a prospective randomized trial. > As for coronary work, I personally think that in most intances it is doing > an injustice to the patient. It is really hard to beat the standard coronary > bypass that Tagart, Guyton and others have talked about in their lectures > around the world. It's going to be really hard to even come close to the > less than 1% mortality, 3 to 5 day hospital stay, 1% stroke rate, and a 90 > to 95% one yr patentcy of all grafts, and a cost to the hospital of less > than $15,000. It would be interesting to take a poll of cardiac surgeons > across the country and ask them which they would rather have if they needed > a coronary bypass- full sternotomy and standard coronary bypass or a > minimally invasive approach with robotic takedown of their mammary. > Tom > > > -----Original Message----- > From: Hgrmd@aol.com > To: OpenHeart-L@lists.hsforum.com > Sent: Tue, 29 Apr 2008 7:34 am > Subject: Re: [HSF] RCA osteal lesion-osteal reconstruction > > > > Tom, > I beg to differ. Have you honestly ever sent a patient home on POD#2 > after a complex mitral valve repair? I have. Though the learning curve > is > daunting, I'm quite satisfied that I can offer selected patients an > operation > comparable or even better than the open approach. For one thing, the > high > percentage of CO2 in the closed right chest means I virtually never see > bubbles > on > the left side of the heart during TEE. In contrast, that never occurs > with > sternotomy. None of the nearly 50 robototic valve patients I've done > have had > a postop neurologic deficit. With the optics on the robot, I can see the > subvalvular structures better than with a sternotomy. I'm now doing > repairs > robotically that are at least as complex as what I do open. I still > don't use > robotics for calcified annuli. The instruments are too flimsy to > reliably > excise those areas. > Anyway, Tom, for us to stay relevant, we have to innovate. Otherwise, > we > will eventually go the way of the blacksmith. In understand your > reluctance > to embrace minimally invasive approaches. What are the residents going > to > do? One thing I can tell you the stuff I'm doing can't be done by a kid > who > was taking out colons 2 years earlier. It's a tough problem, but we have > to > embrace it. I'm hearing the same things about AVI's. Well, if you don't > learn > > to do that, you will probably lose a fair amount of your aortic valve > work. > > Hal > > > > **************Need a new ride? Check out the largest site for U.S. used > car > listings at AOL Autos. > (http://autos.aol.com/used?NCID=aolcmp00300000002851) > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies > and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies > and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > -- Prasanna Simha M From prasannasimha at gmail.com Thu May 1 09:52:05 2008 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Wed Apr 30 23:29:49 2008 Subject: [HSF] Image of the week Hemisternotomy In-Reply-To: References: <89c4ed2d0804301931r543ab95fo54da1b0289c76739@mail.gmail.com> Message-ID: <89c4ed2d0804302022i1e9ba2fdld9142ddcd6c66c90@mail.gmail.com> You must.Ratcheting the sternum slowly allows it to stretch. If the sternum is brittle give a small lead cut. It will allow a fulcrum to turn instead of randomly fracturing. Prasanna On Thu, May 1, 2008 at 8:21 AM, Edward Bender wrote: > I seem to remember Tirone David saying that when he does a partial > sternotomy, he just makes a vertical cut (usually upper) and allows the > sternum to fracture "naturally." I have yet to try it. > > Ed Bender, MD > > > On 4/30/08 9:31 PM, "Prasanna Simha M" wrote: > > > I have done it even in older patients. The thing is to open the sternum > in > > stages and not rapidly. If the sternum appears rigid, I give a small > partial > > sternal cut (an incomplete T or L that gives an axis for sternal torque. > The > > key is to ratchet the sternum in stages. First open it to an extent, > hold > > open the pericardium, open a bit more release the pericardium over SVC > and > > IVC , open a bit more and so on and so forth. > > The thing that I have noticed in older people is some have a springy > sternum > > and some have a rigid rock like sternum. The springy ones open easily. > The > > rigid rock like ones need to be opened slower or need a partial T or a > lead > > cut if you want to open it faster. > > Prasanna > > > > On Thu, May 1, 2008 at 1:06 AM, V. Aldrete, M.D. > wrote: > > > >> Hi Prassanna, > >> > >> With the lower hemisternotomy. Do I understand that there is no > >> transverse division at the upper end of the sternotomy? > >> If this is so, what is the average age of patients that can tolerate > this > >> without sternal fracture? > >> > >> Remember than in North America our patients' average age is much > higher. > >> Over half of my patients that had open heart surgery were over the age > of > >> 60, and I hear that the average age is only getting higher. > >> > >> Cheers, > >> > >> Victor > >> > >> > >> On Apr 30, 2008, at 9:11 AM, Prasanna Simha M wrote: > >> > >> Roberto, > >>> I have shown how the exposure is good with a hemisternotomy. We have > to > >>> use > >>> a small bit of trickery as is obvious in the two views. With a lttle > >>> head > >>> low you can see how the view dramatically improves. You can also use a > >>> rultract retractor to hook up the manubrial segment to get a better > >>> exposure. I use a towel clip /Langenbeck which can be ratcheted up to > >>> another towel clip or a attached to the ether screen instead of a > >>> rultract. > >>> Once aortic cannulation is done the head low is unecessary. Another > >>> thing > >>> is that the cross clamp must preferably not be like an L but mor of an > >>> oblique angle instead of a right angle .This prevents the clamp > impeding > >>> the > >>> operative field. If that is not available it can be placed in reverse > >>> but > >>> will overlie the RV. > >>> > >>> Prasanna > >>> On Wed, Apr 30, 2008 at 8:39 PM, Prasanna Simha M < > >>> prasannasimha@gmail.com> > >>> wrote: > >>> > >>> Yes the exposure is not a problem for surgery . In fact it can be > made > >>>> smaller by actually using the drain site as the site for the IVC > >>>> cannulae > >>>> and you can do the whole procedure with conventional instruments.and > >>>> direct > >>>> vision. Photography is a little bit problematic as the sternal > >>>> spreader > >>>> appears unaesthetic (though vision is not hampered. I think the only > >>>> thing > >>>> that one has to be careful is the ascending aortic cannulation which > >>>> is > >>>> actually not much of a problem. My resident and lecturer do these > >>>> cannulations under my supervision so it is doable. Actually I do not > >>>> do an L > >>>> or a T but give a small cut to act as a fulcrum for opening. In > >>>> children and > >>>> young adults even that is not necessary. The key is to stagewise and > >>>> slowly > >>>> open the spreader. If opened slowly it is surprising how the sternum > >>>> can be > >>>> opened adequately without fracturing it.I even do AVR's with the > same > >>>> incision. though the bone cut may be slightly higher (depends on the > >>>> verticality of the heart and root position as seen on the Chest X > Ray. > >>>> When > >>>> done for cosmessis an upper sternotomy is not acceptable. Also > keeping > >>>> the > >>>> manubrium intact seems to help quick recovery. I was initially > >>>> skeptical but > >>>> patients do seem to feel better. > >>>> Prasanna > >>>> > >>>> > >>>> On Wed, Apr 30, 2008 at 7:47 PM, Dr. Roberto Battellini < > >>>> battr@medizin.uni-leipzig.de> wrote: > >>>> > >>>> Prasanna, > >>>>> Did you have a good view and comfortable from that approach? > >>>>> Better than mitral MIC as you saw by Mohr? > >>>>> Was the incision in L or in T? > >>>>> Roberto > >>>>> > >>>>> > >>>>> -----Urspr?ngliche Nachricht----- > >>>>> Von: openheart-l-bounces@lists.hsforum.com > >>>>> [mailto:openheart-l-bounces@lists.hsforum.com] Im Auftrag von > >>>>> Prasanna > >>>>> Simha > >>>>> M > >>>>> Gesendet: Mittwoch, 30. April 2008 09:38 > >>>>> An: OpenHeart-L; > >>>>> Betreff: [HSF] Image of the week Hemisternotomy > >>>>> > >>>>> Havent got any exiting photos from some time so posting a postop > >>>>> photo. > >>>>> Mitral valve repair done in a 20 year old patient via a > >>>>> hemisternotomy > >>>>> at > >>>>> his 6 month follow up.Not as small as the robots but getting > >>>>> somewhere > >>>>> there > >>>>> :). Patient is very happy with the cosmesis despite a hypertrophied > >>>>> scar > >>>>> as > >>>>> the scar is not seen even when his second shirt button is left open. > >>>>> Prasanna > >>>>> > >>>>> -- > >>>>> Prasanna Simha M > >>>>> > >>>>> _______________________________________________ > >>>>> OpenHeart-L mailing list > >>>>> > >>>>> Send postings to: > >>>>> OpenHeart-L@lists.hsforum.com > >>>>> > >>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: > >>>>> http://mmp.cjp.com/mailman/listinfo/openheart-l > >>>>> > >>>>> All messages transmitted by the OpenHeart-L are subject to the > >>>>> policies > >>>>> and > >>>>> disclaimers posted at: > >>>>> http://www.hsforum.com/listdisclaim > >>>>> ----------------------------------------- > >>>>> > >>>>> > >>>> > >>>> > >>>> -- > >>>> Prasanna Simha M > >>>> > >>> > >>> > >>> > >>> > >>> -- > >>> Prasanna Simha M > >>> >>> vieweml.jpg>_______________________________________________ > >>> OpenHeart-L mailing list > >>> > >>> Send postings to: > >>> OpenHeart-L@lists.hsforum.com > >>> > >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: > >>> http://mmp.cjp.com/mailman/listinfo/openheart-l > >>> > >>> All messages transmitted by the OpenHeart-L are subject to the > policies > >>> and > >>> disclaimers posted at: > >>> http://www.hsforum.com/listdisclaim > >>> ----------------------------------------- > >>> > >> > >> _______________________________________________ > >> OpenHeart-L mailing list > >> > >> Send postings to: > >> OpenHeart-L@lists.hsforum.com > >> > >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: > >> http://mmp.cjp.com/mailman/listinfo/openheart-l > >> > >> All messages transmitted by the OpenHeart-L are subject to the policies > >> anddisclaimers posted at: > >> > >> http://www.hsforum.com/listdisclaim > >> ----------------------------------------- > >> > > > > > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies > and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > -- Prasanna Simha M From zzhoumd at pol.net Thu May 1 04:35:39 2008 From: zzhoumd at pol.net (zzhoumd@pol.net) Date: Wed Apr 30 23:37:16 2008 Subject: [HSF] RCA osteal lesion-osteal reconstruction In-Reply-To: <8CA794B1265CD15-166C-272F@webmail-me02.sysops.aol.com> References: <8CA794B1265CD15-166C-272F@webmail-me02.sysops.aol.com> Message-ID: <2012816626-1209612946-cardhu_decombobulator_blackberry.rim.net-1707077658-@bxe159.bisx.prod.on.blackberry> Tom, With all respect and nothing personal, here is my view. I know many people may disagree with me. In this day of age, a randanized trial is almost impossible without strong industrial backup. If I have sufficient funding, I will love to be part of such trial. In fact, we have talked to a few compamies, it is very difficult for varies reasons.. I think NIH should fund trial like this which has more clinical significance than some programs they are funding now. It is obvious that only a few academic centers are leaders in the innovative technologies. Most cases are done in community hospitals which make such trial even more difficult. The current criteria to judge a surgery based on the mortality or morbidity ignores the patient's choice/acceptance/invasiveness, just like the debate has been repeated many times on CABG vs PCI. I have many patients who will not accept a standard open heart surgery but will accept a mini invasive one even I told them this may not be ideal for them. In a few years, we will see more data. Zhandong Zhou Sent via BlackBerry by AT&T -----Original Message----- From: tdmartin2000@aol.com Date: Wed, 30 Apr 2008 22:34:53 To:OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] RCA osteal lesion-osteal reconstruction Hal I commend you and others such as Bill Turner in Tyler who have done this the right way. You have been very methodical, careful and insightful.But you are the exceptin and not the rule. ?What really gets my hair standing on end is the thought and talk of doing minimally invasive procedures in order to please or appease the cardiologist and keep from loosing cases and $$. I can actually see where mitral work is possibly ideal for this type of approach. I would ask you, however, that if you are going to tout it as a technique that is as good or better that you publish it and compare it to a case matched control of all your other mitrals that you have done in the past or even better yet, do a prospective randomized trial. As for coronary work, I personally think that in most intances it is doing an injustice to the patient. It is really hard to beat the standard coronary bypass that Tagart, Guyton and others have talked about in their lectures around the world. It's going to be really hard to even come close to the less than 1% mortality, 3 to 5 day hospital stay, 1% stroke rate, and a 90 to 95% one yr patentcy of all grafts, and a cost to the hospital of less than $15,000. It would be interesting to take a poll of cardiac surgeons across the country and ask them which they would rather have if they needed a coronary bypass- full sternotomy and standard coronary bypass or a minimally invasive approach with robotic takedown of their mammary. Tom -----Original Message----- From: Hgrmd@aol.com To: OpenHeart-L@lists.hsforum.com Sent: Tue, 29 Apr 2008 7:34 am Subject: Re: [HSF] RCA osteal lesion-osteal reconstruction Tom, I beg to differ. Have you honestly ever sent a patient home on POD#2 after a complex mitral valve repair? I have. Though the learning curve is daunting, I'm quite satisfied that I can offer selected patients an operation comparable or even better than the open approach. For one thing, the high percentage of CO2 in the closed right chest means I virtually never see bubbles on the left side of the heart during TEE. In contrast, that never occurs with sternotomy. None of the nearly 50 robototic valve patients I've done have had a postop neurologic deficit. With the optics on the robot, I can see the subvalvular structures better than with a sternotomy. I'm now doing repairs robotically that are at least as complex as what I do open. I still don't use robotics for calcified annuli. The instruments are too flimsy to reliably excise those areas. Anyway, Tom, for us to stay relevant, we have to innovate. Otherwise, we will eventually go the way of the blacksmith. In understand your reluctance to embrace minimally invasive approaches. What are the residents going to do? One thing I can tell you the stuff I'm doing can't be done by a kid who was taking out colons 2 years earlier. It's a tough problem, but we have to embrace it. I'm hearing the same things about AVI's. Well, if you don't learn to do that, you will probably lose a fair amount of your aortic valve work. Hal **************Need a new ride? Check out the largest site for U.S. used car listings at AOL Autos. (http://autos.aol.com/used?NCID=aolcmp00300000002851) _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From anianyanwu at hotmail.com Thu May 1 04:47:40 2008 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Wed Apr 30 23:48:28 2008 Subject: [HSF] RCA osteal lesion-osteal reconstruction In-Reply-To: <1722265698-1209596745-cardhu_decombobulator_blackberry.rim.net-1901169099-@bxe159.bisx.prod.on.blackberry> References: <1722265698-1209596745-cardhu_decombobulator_blackberry.rim.net-1901169099-@bxe159.bisx.prod.on.blackberry> Message-ID: > Chest approach should not compromise the technique. If it is, than conversion should be done.> > Z Zhou Z Unfortunately this is easier said than done and in reality surgeons rarely will convert from a mini approach to a sternotomy. What usually results in such cases (where a compromise in technique is forced) is that we do not convert but either struggle, accept inferior result or accept inferior technique. This as i have said previously is well documented in the literature as a higher valve replacement rate in the majority of reports on min-invasive mitral valve surgery. Looking through most series, one will also note that conversions, although talked about, are rare in practice. There is an understandable reluctance to give a patient a second scar or a larger scar. Ani > To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] RCA osteal lesion-osteal reconstruction> From: zzhoumd@pol.net> Date: Wed, 30 Apr 2008 23:05:38 +0000> CC: > > > Hal, > > Agreed, whether you can do a good job with valve repair has lot to do with your understanding of the valve. > > Chest approach should not compromise the technique. If it is, than conversion should be done.> > Z Zhou> > Sent via BlackBerry by AT&T> > -----Original Message-----> From: Hgrmd@aol.com> > Date: Wed, 30 Apr 2008 07:45:15 > To:OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] RCA osteal lesion-osteal reconstruction> > > "Animal",> Actually, I'm more than OK with your stance. An old cowboy on TV once > said, "a man's got to understand his limitations." In our zeal to advance > surgical frontiers, we must not force those of us not comfortable or ready for the > challenge. For instance, there may be misguided surgeons wishing to create > a robotic mitral practice, who, in reality, have no significant mitral repair > experience done via sternotomy. Certainly, it would be a mistake for such > surgeons to think they will become safe robotic surgeons when they aren't even > comfortable doing complex open repairs.> > Hal> > > > **************Need a new ride? Check out the largest site for U.S. used car > listings at AOL Autos. > (http://autos.aol.com/used?NCID=aolcmp00300000002851)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> ----------------------------------------- _________________________________________________________________ Play the Andrex Hello Softie Game & win great prizes http://www.thehellosoftiegame.co.uk From prasannasimha at gmail.com Thu May 1 10:24:14 2008 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Thu May 1 00:21:07 2008 Subject: [HSF] Image of the week Hemisternotomy In-Reply-To: <15FE701D-5C0B-463A-8D7C-052AD12AB63E@charter.net> References: <89c4ed2d0804301931r543ab95fo54da1b0289c76739@mail.gmail.com> <89c4ed2d0804302022i1e9ba2fdld9142ddcd6c66c90@mail.gmail.com> <15FE701D-5C0B-463A-8D7C-052AD12AB63E@charter.net> Message-ID: <89c4ed2d0804302054l36c28e1at79a1205c53afe52e@mail.gmail.com> Yes.When I did T cuts I noted that patients complained of pain when a T was done . This is strikingly absent when you do not do a cut. Maybe related to the final interlocking of the ends and stbilty too. Prasanna On Thu, May 1, 2008 at 9:08 AM, Edward Bender wrote: > Do you think there is a difference in pain or healing compared to an "L" > or a "T" sternotomy? > > Ed Bender, MD > > > > On Apr 30, 2008, at 10:22 PM, Prasanna Simha M wrote: > > You must.Ratcheting the sternum slowly allows it to stretch. If the > > sternum > > is brittle give a small lead cut. It will allow a fulcrum to turn > > instead of > > randomly fracturing. > > Prasanna > > > > On Thu, May 1, 2008 at 8:21 AM, Edward Bender > > wrote: > > > > I seem to remember Tirone David saying that when he does a partial > > > sternotomy, he just makes a vertical cut (usually upper) and allows > > > the > > > sternum to fracture "naturally." I have yet to try it. > > > > > > Ed Bender, MD > > > > > > > > > On 4/30/08 9:31 PM, "Prasanna Simha M" > > > wrote: > > > > > > I have done it even in older patients. The thing is to open the > > > > sternum > > > > > > > in > > > > > > > stages and not rapidly. If the sternum appears rigid, I give a small > > > > > > > partial > > > > > > > sternal cut (an incomplete T or L that gives an axis for sternal > > > > torque. > > > > > > > The > > > > > > > key is to ratchet the sternum in stages. First open it to an extent, > > > > > > > hold > > > > > > > open the pericardium, open a bit more release the pericardium over > > > > SVC > > > > > > > and > > > > > > > IVC , open a bit more and so on and so forth. > > > > The thing that I have noticed in older people is some have a springy > > > > > > > sternum > > > > > > > and some have a rigid rock like sternum. The springy ones open > > > > easily. > > > > > > > The > > > > > > > rigid rock like ones need to be opened slower or need a partial T or > > > > a > > > > > > > lead > > > > > > > cut if you want to open it faster. > > > > Prasanna > > > > > > > > On Thu, May 1, 2008 at 1:06 AM, V. Aldrete, M.D. > > > > > > > > > > > wrote: > > > > > > > > > > > Hi Prassanna, > > > > > > > > > > With the lower hemisternotomy. Do I understand that there is no > > > > > transverse division at the upper end of the sternotomy? > > > > > If this is so, what is the average age of patients that can > > > > > tolerate > > > > > > > > > this > > > > > > > without sternal fracture? > > > > > > > > > > Remember than in North America our patients' average age is much > > > > > > > > > higher. > > > > > > > Over half of my patients that had open heart surgery were over the > > > > > age > > > > > > > > > of > > > > > > > 60, and I hear that the average age is only getting higher. > > > > > > > > > > Cheers, > > > > > > > > > > Victor > > > > > > > > > > > > > > > On Apr 30, 2008, at 9:11 AM, Prasanna Simha M wrote: > > > > > > > > > > Roberto, > > > > > > > > > > > I have shown how the exposure is good with a hemisternotomy. We > > > > > > have > > > > > > > > > > > to > > > > > > > use > > > > > > a small bit of trickery as is obvious in the two views. With a > > > > > > lttle > > > > > > head > > > > > > low you can see how the view dramatically improves. You can also > > > > > > use a > > > > > > rultract retractor to hook up the manubrial segment to get a > > > > > > better > > > > > > exposure. I use a towel clip /Langenbeck which can be ratcheted > > > > > > up to > > > > > > another towel clip or a attached to the ether screen instead of > > > > > > a > > > > > > rultract. > > > > > > Once aortic cannulation is done the head low is unecessary. > > > > > > Another > > > > > > thing > > > > > > is that the cross clamp must preferably not be like an L but mor > > > > > > of an > > > > > > oblique angle instead of a right angle .This prevents the clamp > > > > > > > > > > > impeding > > > > > > > the > > > > > > operative field. If that is not available it can be placed in > > > > > > reverse > > > > > > but > > > > > > will overlie the RV. > > > > > > > > > > > > Prasanna > > > > > > On Wed, Apr 30, 2008 at 8:39 PM, Prasanna Simha M < > > > > > > prasannasimha@gmail.com> > > > > > > wrote: > > > > > > > > > > > > Yes the exposure is not a problem for surgery . In fact it can > > > > > > be > > > > > > > > > > > made > > > > > > > smaller by actually using the drain site as the site for the IVC > > > > > > > cannulae > > > > > > > and you can do the whole procedure with conventional > > > > > > > instruments.and > > > > > > > direct > > > > > > > vision. Photography is a little bit problematic as the > > > > > > > sternal > > > > > > > spreader > > > > > > > appears unaesthetic (though vision is not hampered. I think > > > > > > > the only > > > > > > > thing > > > > > > > that one has to be careful is the ascending aortic cannulation > > > > > > > which > > > > > > > is > > > > > > > actually not much of a problem. My resident and lecturer do > > > > > > > these > > > > > > > cannulations under my supervision so it is doable. Actually I > > > > > > > do not > > > > > > > do an L > > > > > > > or a T but give a small cut to act as a fulcrum for opening. > > > > > > > In > > > > > > > children and > > > > > > > young adults even that is not necessary. The key is to > > > > > > > stagewise and > > > > > > > slowly > > > > > > > open the spreader. If opened slowly it is surprising how the > > > > > > > sternum > > > > > > > can be > > > > > > > opened adequately without fracturing it.I even do AVR's with > > > > > > > the > > > > > > > > > > > > > same > > > > > > > incision. though the bone cut may be slightly higher (depends on the > > > > > > > verticality of the heart and root position as seen on the > > > > > > > Chest X > > > > > > > > > > > > > Ray. > > > > > > > When > > > > > > > done for cosmessis an upper sternotomy is not acceptable. Also > > > > > > > > > > > > > keeping > > > > > > > the > > > > > > > manubrium intact seems to help quick recovery. I was initially > > > > > > > skeptical but > > > > > > > patients do seem to feel better. > > > > > > > Prasanna > > > > > > > > > > > > > > > > > > > > > On Wed, Apr 30, 2008 at 7:47 PM, Dr. Roberto Battellini < > > > > > > > battr@medizin.uni-leipzig.de> wrote: > > > > > > > > > > > > > > Prasanna, > > > > > > > > > > > > > > > Did you have a good view and comfortable from that approach? > > > > > > > > Better than mitral MIC as you saw by Mohr? > > > > > > > > Was the incision in L or in T? > > > > > > > > Roberto > > > > > > > > > > > > > > > > > > > > > > > > -----Urspr?ngliche Nachricht----- > > > > > > > > Von: openheart-l-bounces@lists.hsforum.com > > > > > > > > [mailto:openheart-l-bounces@lists.hsforum.com] Im Auftrag > > > > > > > > von > > > > > > > > Prasanna > > > > > > > > Simha > > > > > > > > M > > > > > > > > Gesendet: Mittwoch, 30. April 2008 09:38 > > > > > > > > An: OpenHeart-L; > > > > > > > > Betreff: [HSF] Image of the week Hemisternotomy > > > > > > > > > > > > > > > > Havent got any exiting photos from some time so posting a > > > > > > > > postop > > > > > > > > photo. > > > > > > > > Mitral valve repair done in a 20 year old patient via a > > > > > > > > hemisternotomy > > > > > > > > at > > > > > > > > his 6 month follow up.Not as small as the robots but getting > > > > > > > > somewhere > > > > > > > > there > > > > > > > > :). Patient is very happy with the cosmesis despite a > > > > > > > > hypertrophied > > > > > > > > scar > > > > > > > > as > > > > > > > > the scar is not seen even when his second shirt button is > > > > > > > > left open. > > > > > > > > Prasanna > > > > > > > > > > > > > > > > -- > > > > > > > > Prasanna Simha M > > > > > > > > > > > > > > > > _______________________________________________ > > > > > > > > OpenHeart-L mailing list > > > > > > > > > > > > > > > > Send postings to: > > > > > > > > OpenHeart-L@lists.hsforum.com > > > > > > > > > > > > > > > > To UNSUBSCRIBE, to CHANGE email address, or to view > > > > > > > > archives: > > > > > > > > http://mmp.cjp.com/mailman/listinfo/openheart-l > > > > > > > > > > > > > > > > All messages transmitted by the OpenHeart-L are subject to > > > > > > > > the > > > > > > > > policies > > > > > > > > and > > > > > > > > disclaimers posted at: > > > > > > > > http://www.hsforum.com/listdisclaim > > > > > > > > ----------------------------------------- > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > -- > > > > > > > Prasanna Simha M > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > -- > > > > > > Prasanna Simha M > > > > > > > > > > > vieweml.jpg>_______________________________________________ > > > > > > OpenHeart-L mailing list > > > > > > > > > > > > Send postings to: > > > > > > OpenHeart-L@lists.hsforum.com > > > > > > > > > > > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > > > > > > http://mmp.cjp.com/mailman/listinfo/openheart-l > > > > > > > > > > > > All messages transmitted by the OpenHeart-L are subject to the > > > > > > > > > > > policies > > > > > > > and > > > > > > disclaimers posted at: > > > > > > http://www.hsforum.com/listdisclaim > > > > > > ----------------------------------------- > > > > > > > > > > > > > > > > > _______________________________________________ > > > > > OpenHeart-L mailing list > > > > > > > > > > Send postings to: > > > > > OpenHeart-L@lists.hsforum.com > > > > > > > > > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > > > > > http://mmp.cjp.com/mailman/listinfo/openheart-l > > > > > > > > > > All messages transmitted by the OpenHeart-L are subject to the > > > > > policies > > > > > anddisclaimers posted at: > > > > > > > > > > http://www.hsforum.com/listdisclaim > > > > > ----------------------------------------- > > > > > > > > > > > > > > > > > > > > > > > > _______________________________________________ > > > OpenHeart-L mailing list > > > > > > Send postings to: > > > OpenHeart-L@lists.hsforum.com > > > > > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > > > http://mmp.cjp.com/mailman/listinfo/openheart-l > > > > > > All messages transmitted by the OpenHeart-L are subject to the > > > policies > > > and > > > disclaimers posted at: > > > http://www.hsforum.com/listdisclaim > > > ----------------------------------------- > > > > > > > > > > > > -- > > Prasanna Simha M > > _______________________________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@lists.hsforum.com > > > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > > http://mmp.cjp.com/mailman/listinfo/openheart-l > > > > All messages transmitted by the OpenHeart-L are subject to the policies > > and > > disclaimers posted at: > > http://www.hsforum.com/listdisclaim > > ----------------------------------------- > > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies > anddisclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > -- Prasanna Simha M From donross at bigpond.com Thu May 1 19:31:39 2008 From: donross at bigpond.com (Donald Ross) Date: Thu May 1 04:33:12 2008 Subject: [HSF] Re: [ccm-l] Image of the week Hemisternotomy In-Reply-To: <537727.63518.qm@web81606.mail.mud.yahoo.com> References: <537727.63518.qm@web81606.mail.mud.yahoo.com> Message-ID: <8E6518C2-9942-4379-AEC5-6E895059C51E@bigpond.com> I use a hemisternotomy for lima to LAD and it is very nice with no compromise. I dabbled with complete revascularisation using a T off the lima but found I needed a left second interspace inverted L and since that is difficult to fix securely I have gone back to full sternotomy using a short skin incision which extends up to the bottom of the manubrium. I think a mitral via a hemisternotomy would be difficult in a crusty old patient but I haven't tried. Don On 01/05/2008, at 7:56 AM, Tea Acuff wrote: > Please note that the aorta cannulation is "doeable". This is code > for limited access. In many alternative incisions the proximals > (if used, Don) can be a bigger problem than the distals. An > inadvertant problem with the arota can exact a high price. Ability > to extend the incision is a real plus, but may not be worth the > trip (to India). On the other hand having Prasanna be your surgeon > may be worth some bumps in the road. He was not advertising for > CAB, however, or so it seems.. > > tea > > > > ----- Original Message ---- > From: Prasanna Simha M > To: gabi ford > Cc: OpenHeart-L ; "" l@ccm-l.org> > Sent: Wednesday, April 30, 2008 12:29:03 PM > Subject: [HSF] Re: [ccm-l] Image of the week Hemisternotomy > > swallow statins,exercise and diet instead of coming to get cut up !! > > Prasanna > > On Wed, Apr 30, 2008 at 10:57 PM, gabi ford > wrote: > >> >> From: prasannasimha@gmail.com >>> This is a view of the mitral valve during a hemisternotomy. I do not >> think that the view is compromised. You can clearly see the >> subvalvar (I am >> doing a combined chordoplasty (chordal shortening +neochordal >> construction ) >> of the AML chordae. >> >> Prasanna, >> >> Dare I say it? AMAZING!!!!! :) >> >> How do we get together when I need my bypass? >> Your OR or mine? >> >> Thanks for the pic and explanation. As always, impressive. >> >> Gabi, RN > > > > > -- > Prasanna Simha M > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the > policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the > policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- From donross at bigpond.com Thu May 1 19:34:18 2008 From: donross at bigpond.com (Donald Ross) Date: Thu May 1 04:34:50 2008 Subject: [HSF] Sympathy anyone....... In-Reply-To: References: Message-ID: <0202793B-02D1-4199-A512-271999C8AA94@bigpond.com> Cards are a class act! On 01/05/2008, at 11:26 AM, Michael Firstenberg wrote: > 51 year/old.....presented with 4 day history of chest pain. > Tall, thin, long fingers.... > ST changes on ECG. > Concern for AMI > Given: > ASA > High dose Plavix > Lovenox > > taken to cath lab > > found to have Type A dissection from valvue to iliacs........ > > > oh, he also got reopro............ > > > it has been a long day. > > > -michael > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the > policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- From Hgrmd at aol.com Thu May 1 08:53:44 2008 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Thu May 1 07:54:13 2008 Subject: [HSF] RCA osteal lesion-osteal reconstruction Message-ID: Tom, Thanks for your reasoned reply. I am carefully following all of these patients. Since I finally have developed some research infrastructure for my practice, I certainly plan to submit my results for publication in the near future. For starters, I have a video and poster in the upcoming ISMICS. As for coronary revascularization, I also share your concerns. One thing that has been unequivocally shown is that the LIMA to the LAD is life saving and paramount. If you screw it up, you've just shortened the patient's life. That said, our group has a small series of robotic MIDCAB's that have all done quite well (they are done by one of my associates). In addition, I've been very impressed that the Leipzig MIDCAB series is safe and reproducible. However, I've no doubt that a lot of patients have been hurt by failed attempts at minimally invasive revascularization. The only surgeon I know that regularly does robotic multivessel revasc is the Indian gentleman who used to be in Odessa, Texas and is now at the Univ of Chicago. I saw him do a case last summer in Belgium. Looked pretty torturous to say the least. The key to minimally invasive surgery is planning and training. Long before I touched a patient with my robot arm, I worked on plenty of cadavers and pig hearts. When working on new repair techniques, I often work on a pig heart in a plastic torso on a Saturday morning when I'm off. You can't just walk in and think I'm going to try this unless you've thoroughly done your homework. Even then, I've had some hair raising moments and a lot of mental discomfort. Hal **************Need a new ride? Check out the largest site for U.S. used car listings at AOL Autos. (http://autos.aol.com/used?NCID=aolcmp00300000002851) From Hgrmd at aol.com Thu May 1 09:06:32 2008 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Thu May 1 08:07:07 2008 Subject: [HSF] RCA osteal lesion-osteal reconstruction Message-ID: Ani, I must be the exception, because I unapologetically don't hesitate to convert a robot case to a sternotomy if I think it is appropriate. In fact, I tell my patients that I have 3 priorities in decreasing order of importance: 1) keep you safe. 2) give you a repair rather a replacement. 3) give you a small incision. Though it's now been a while, I converted around 5 patients while attempting robotic repair. In 2 of them, I did nice robotic repairs, but I couldn't get the left atriotomy securely closed. Fortunately, converting from ports (the largest is 18 mm) to a sternotomy isn't unusually traumatic. At least one of the ports I use for a chest tube. Hal **************Need a new ride? Check out the largest site for U.S. used car listings at AOL Autos. (http://autos.aol.com/used?NCID=aolcmp00300000002851) From Jbflegejr at aol.com Thu May 1 10:09:13 2008 From: Jbflegejr at aol.com (Jbflegejr@aol.com) Date: Thu May 1 09:09:23 2008 Subject: [HSF] Sympathy anyone....... Message-ID: Having already survived for four days since the onset of the dissection, I would think that the risk of waiting a few more days up to a week would be smaller than proceeding to operation while he is coagulopathic. In Wheat's report of treating Type A dissections without operation, 40% survived to leave the hospital. In a recent report derived from the International Registry there were about 160 patients who were not operated for one reason or another, mostly severe comorbidities or refusal, and 40% left the hospital alive. Both of these groups included patients from the outset of the dissection. Since the risk of dying from the dissection decreases with time, the risk your patient faces after surviving the high risk days is probably less than if you proceeded with operation now. John Flege **************Need a new ride? Check out the largest site for U.S. used car listings at AOL Autos. (http://autos.aol.com/used?NCID=aolcmp00300000002851) From anianyanwu at hotmail.com Thu May 1 14:39:13 2008 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Thu May 1 09:40:02 2008 Subject: [HSF] RCA osteal lesion-osteal reconstruction In-Reply-To: References: Message-ID: Hal You certainly are an exception and I think very few of us can say the same. It also takes a certain stature and seniority to regard conversion as an essential manouver to complete the desired operation rather than a failure. For the younger, less established and inexperienced such conversions are viewed by both themselves, the OR team and the cardiologists as the surgeons 'failure'. If you convert a patient, the cardiologist etc will say oh well it had to be done - good thing you were there to save the day. It also takes honesty to be able to critically appraise a new technique - many surgeons would not have called the conversions to sternotomy to control a left atrium as conversions; after all the mitral was done robotically. Recently we had a colleagues patient post OPCAB that crashed in ICU few hours later and had to have emergent CPB and regrafting - I bet you such patients when they occur in OPCAB series do not get counted as conversion as the initial procedure was completed off-pump. I think (honestly) you should write an opinion paper on your transformation from an experienced and established open surgeon to a robotic one. The key elements you mention including your use of simulated pig hearts on a Saturday morning and your rigorous audit of your results is I suspect unique but the difference I think between yourself and most who dabble in robotic mitrals is you have a (repair) standard to preserve and wont compromise on that so your goal remains a durable mitral repair (rather than doing a robotic operation as is generally the case with most who dabble into robotic mitrals). As you know I was very sceptical about robotic mitral surgery in the past but hearing your experience, and also knowing you to be one who will not compromise on results, I am beginning to believe it and may well even come down to Florida if I had a P2 prolapse... Ani > From: Hgrmd@aol.com> Date: Thu, 1 May 2008 08:06:32 -0400> Subject: Re: [HSF] RCA osteal lesion-osteal reconstruction> To: OpenHeart-L@lists.hsforum.com> CC: > > Ani,> I must be the exception, because I unapologetically don't hesitate to > convert a robot case to a sternotomy if I think it is appropriate. In fact, I > tell my patients that I have 3 priorities in decreasing order of importance: 1) > keep you safe. 2) give you a repair rather a replacement. 3) give you a > small incision. Though it's now been a while, I converted around 5 patients > while attempting robotic repair. In 2 of them, I did nice robotic repairs, but > I couldn't get the left atriotomy securely closed. > Fortunately, converting from ports (the largest is 18 mm) to a sternotomy > isn't unusually traumatic. At least one of the ports I use for a chest tube. > > > Hal> > > > **************Need a new ride? Check out the largest site for U.S. used car > listings at AOL Autos. > (http://autos.aol.com/used?NCID=aolcmp00300000002851)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> ----------------------------------------- _________________________________________________________________ All new Live Search at Live.com http://clk.atdmt.com/UKM/go/msnnkmgl0010000006ukm/direct/01/ From Rwmfglycar at aol.com Thu May 1 11:15:00 2008 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Thu May 1 10:15:29 2008 Subject: [HSF] RCA osteal lesion-osteal reconstruction Message-ID: In a message dated 5/1/2008 9:41:47 A.M. Eastern Daylight Time, anianyanwu@hotmail.com writes: I am beginning to believe it and may well even come down to Florida if I had a P2 prolapse... Ani Hedging your bets Ani? Bob **************Need a new ride? Check out the largest site for U.S. used car listings at AOL Autos. (http://autos.aol.com/used?NCID=aolcmp00300000002851) From tacuff at swbell.net Thu May 1 11:01:24 2008 From: tacuff at swbell.net (Tea Acuff) Date: Thu May 1 13:02:54 2008 Subject: [HSF] Sympathy anyone....... Message-ID: <231428.87746.qm@web81604.mail.mud.yahoo.com> In contrast with Ani's classification (eg the robotic mitral discussion), or perhaps in agreement with his meaning, intent to treat even if not performed at all has very real implications. We learn much from the patterns generated elsewhere. tea ----- Original Message ---- From: Donald Ross To: OpenHeart-L@lists.hsforum.com Sent: Thursday, May 1, 2008 3:34:18 AM Subject: Re: [HSF] Sympathy anyone....... Cards are a class act! On 01/05/2008, at 11:26 AM, Michael Firstenberg wrote: > 51 year/old.....presented with 4 day history of chest pain. > Tall, thin, long fingers.... > ST changes on ECG. > Concern for AMI > Given: > ASA > High dose Plavix > Lovenox > > taken to cath lab > > found to have Type A dissection from valvue to iliacs........ > > > oh, he also got reopro............ > > > it has been a long day. > > > -michael > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the > policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From tacuff at swbell.net Thu May 1 11:06:28 2008 From: tacuff at swbell.net (Tea Acuff) Date: Thu May 1 13:07:59 2008 Subject: [HSF] Sympathy anyone....... Message-ID: <184496.13389.qm@web81603.mail.mud.yahoo.com> I think you picked up on an important point. Not only might it be better for the patient, it might be easier for the care givers and perhaps family. The audacity of hope, perhaps. tea ----- Original Message ---- From: "Jbflegejr@aol.com" To: OpenHeart-L@lists.hsforum.com Sent: Thursday, May 1, 2008 8:09:13 AM Subject: Re: [HSF] Sympathy anyone....... Having already survived for four days since the onset of the dissection, I would think that the risk of waiting a few more days up to a week would be smaller than proceeding to operation while he is coagulopathic. In Wheat's report of treating Type A dissections without operation, 40% survived to leave the hospital. In a recent report derived from the International Registry there were about 160 patients who were not operated for one reason or another, mostly severe comorbidities or refusal, and 40% left the hospital alive. Both of these groups included patients from the outset of the dissection. Since the risk of dying from the dissection decreases with time, the risk your patient faces after surviving the high risk days is probably less than if you proceeded with operation now. John Flege **************Need a new ride? Check out the largest site for U.S. used car listings at AOL Autos. (http://autos.aol.com/used?NCID=aolcmp00300000002851) _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From msfirst at gmail.com Thu May 1 16:52:05 2008 From: msfirst at gmail.com (Michael Firstenberg) Date: Thu May 1 16:18:29 2008 Subject: [HSF] Sympathy anyone....... In-Reply-To: References: Message-ID: Ed - Thanks for the reassurance - I still feel pretty new at this, but often find myself jumping in head first. I feel very lucky to have great help. Tea - but they had a very short door to needle time (and even shorter time to OR)....... Prasanna - ahhh, intra/post-op bleeding. In cases like this, where I know it is going to be a problem. I think the key is anticipation of the problem. As I was making incision, I called the blood bank and told them that whatever they have, order more. We have a good relationship with the blood bank - but we have to notify them in advance. I usually get the stuff in the room right before I talk the cross-clamp off. Ince I am off pump, I will pack the chest while the protamine and products kick in (hopefully) while I am putting in chest tube and waiting. I think you need to give the products right away, if you wait for coagulopathy to start, then it can be too late. If they are really wet, and I am convinced that it is not a proline deficiency, then we also use a lot of hemostatic agents - Bioglue, CoSeal, FloSeal, Fibrilar, Surgicell, NuKnit, Arista - anything. Since we are not allowed to leave packs in the chest then I will tend to fill potential spaces to some of this biodegrable stuff. If still wet then an extra chest tube or 2 in the mediastinum and bring them to the ICU. There was an old saying in Cleveland - "dark and warm". We are VERY liberal with blood, products, and these agents. We also use a lot of rFVII. I try to be smart about it - like if they have anti-platelet agents on board, then give them platelets (duh) - but I know a lot of people will order everything. We also have intra-operative TEGs which help.....and if all else fails, we let them them bleed and bleed and bleed until they stop (which they usually do - at some point), tamponade (fortunately less often), or we bite the bullet and take them back. It is all very expensive, but it sometimes beats the alternatives. Most of our patients are on something coming to the OR, so we are a little use to post-op bleeding. I some sure others have tricks that work for them - but in some of these kinds of patients, I want them to just get out of the OR alive and we can live to fight another day. I had a lot of experience in general surgery/trauma with packing the abdomen for 24hrs to get them tuned up. Warm and dark...... and anticipate the problem. John - I do not disagree and we have discussed non-operative management, however I am not sure there is any sound medical (or legal) grounds to delaying surgery in a relatively healthy person just cuz they have poisons on board. Judging from how his aorta looked in the OR and how it was falling apart in my hands as I was trying to fix it, I can not imaging waiting. Again it is a philosophy - with a lot of literature to back it up. .... he is doing OK today, slowly waking up, no drips, keeping his pressure down and gentle sedation so that hopefully we can make a soft landing....... -michael On 4/30/08, Edward Bender wrote: > > Michael: > In a lot of your messages you beg indulgence due to your novice status. I > think that you must drop that now since you are doing a lot of "big-boy" > cases successfully. > > Ed Bender, MD > > > On 4/30/08 8:26 PM, "Michael Firstenberg" wrote: > > > 51 year/old.....presented with 4 day history of chest pain. > > Tall, thin, long fingers.... > > ST changes on ECG. > > Concern for AMI > > Given: > > ASA > > High dose Plavix > > Lovenox > > > > taken to cath lab > > > > found to have Type A dissection from valvue to iliacs........ > > > > > > oh, he also got reopro............ > > > > > > it has been a long day. > > > > > > -michael > > _______________________________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@lists.hsforum.com > > > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > > http://mmp.cjp.com/mailman/listinfo/openheart-l > > > > All messages transmitted by the OpenHeart-L are subject to the policies > and > > disclaimers posted at: > > http://www.hsforum.com/listdisclaim > > ----------------------------------------- > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies > and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > From ebender001 at charter.net Thu May 1 21:42:50 2008 From: ebender001 at charter.net (Edward Bender) Date: Thu May 1 21:43:29 2008 Subject: [HSF] RCA osteal lesion-osteal reconstruction In-Reply-To: References: <1722265698-1209596745-cardhu_decombobulator_blackberry.rim.net-1901169099-@bxe159.bisx.prod.on.blackberry> Message-ID: <9FD3E737-7390-4CE3-9B56-C874EF47857E@charter.net> Ani: I don't know where this impression comes from. I often change course, even before the operation starts, if I don't like what I see or am unhappy with catheter placement, etc. I have rarely converted to a full sternotomy, but have extended a small incision to a larger one quite a few times. Doing the best repair or replacement trumps small incisions. Ed Bender, MD On Apr 30, 2008, at 10:47 PM, Ani Anyanwu wrote: >> Chest approach should not compromise the technique. If it is, than >> conversion should be done.> > Z Zhou > > > Z > > Unfortunately this is easier said than done and in reality surgeons > rarely will convert from a mini approach to a sternotomy. What > usually results in such cases (where a compromise in technique is > forced) is that we do not convert but either struggle, accept > inferior result or accept inferior technique. This as i have said > previously is well documented in the literature as a higher valve > replacement rate in the majority of reports on min-invasive mitral > valve surgery. Looking through most series, one will also note that > conversions, although talked about, are rare in practice. > > There is an understandable reluctance to give a patient a second > scar or a larger scar. > > Ani > > > > > >> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] RCA osteal >> lesion-osteal reconstruction> From: zzhoumd@pol.net> Date: Wed, 30 >> Apr 2008 23:05:38 +0000> CC: > > > Hal, > > Agreed, whether you can >> do a good job with valve repair has lot to do with your >> understanding of the valve. > > Chest approach should not >> compromise the technique. If it is, than conversion should be >> done.> > Z Zhou> > Sent via BlackBerry by AT&T> > -----Original >> Message-----> From: Hgrmd@aol.com> > Date: Wed, 30 Apr 2008 >> 07:45:15 > To:OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] RCA >> osteal lesion-osteal reconstruction> > > "Animal",> Actually, I'm >> more than OK with your stance. An old cowboy on TV once > said, "a >> man's got to understand his limitations." In our zeal to advance > >> surgical frontiers, we must not force those of us not comfortable >> or ready for the > challenge. For instance, there may be misguided >> surgeons wishing to create > a robotic mitral practice, who, in >> reality, have no significant mitral repair > experience done via >> sternotomy. Certainly, it would be a mistake for such > surgeons to >> think they will become safe robotic surgeons when they aren't even >> > comfortable doing complex open repairs.> > Hal> > > > >> **************Need a new ride? Check out the largest site for U.S. >> used car > listings at AOL Autos. > (http://autos.aol.com/used?NCID=aolcmp00300000002851 >> )> _______________________________________________> OpenHeart-L >> mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > >> To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l >> > > All messages transmitted by the OpenHeart-L are subject to the >> policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim >> > ----------------------------------------- > _________________________________________________________________ > Play the Andrex Hello Softie Game & win great prizes > http:// > www > .thehellosoftiegame > .co.uk_______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the > policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- From Hgrmd at aol.com Thu May 1 22:50:55 2008 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Thu May 1 21:51:27 2008 Subject: [HSF] RCA osteal lesion-osteal reconstruction Message-ID: Ani, Thanks for your kind words. It really carries a lot of weight since I know you've no hesitation in doing the opposite when you think I'm wrong. I wouldn't mind writing the editorial, but would certainly want your input. BTW, are you going to be at the AATS? If so, we should get together, because I always enjoy speaking with you. I I plan to attend the Sunday symposium on mitral repair that your boss will be chairing. Hal **************Wondering what's for Dinner Tonight? Get new twists on family favorites at AOL Food. (http://food.aol.com/dinner-tonight?NCID=aolfod00030000000001) From anianyanwu at hotmail.com Fri May 2 03:44:13 2008 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Thu May 1 22:44:40 2008 Subject: [HSF] RCA osteal lesion-osteal reconstruction In-Reply-To: References: Message-ID: Yes Hal I will be at the AATS - I am actually giving a talk at the mitral syposium on interpreting the literature. We will definitely get together at some stage. Ed - when experienced surgeons such as yourself and Hal do these procedures I am sure there is little hesitancy to convert - you have nothing to prove to yourself or to anybody else. When less experienced surgeons are performing such procedures it is different and such changes in plan you describe are rare and the young surgeon does not want it said that he tried so so and got in a muddle so had to do sternotomy to bail himself out. The tyro and the master have very different pressures and goals. For yourself and Hal the priority is to have a competent mitral valve but I bet for many less experienced surgeons there would be a wrong priority such as speed of surgery or maintaining a minimal incision. Ani > From: Hgrmd@aol.com> Date: Thu, 1 May 2008 21:50:55 -0400> Subject: Re: [HSF] RCA osteal lesion-osteal reconstruction> To: OpenHeart-L@lists.hsforum.com> CC: > > Ani,> Thanks for your kind words. It really carries a lot of weight since I > know you've no hesitation in doing the opposite when you think I'm wrong. I > wouldn't mind writing the editorial, but would certainly want your input. BTW, > are you going to be at the AATS? If so, we should get together, because I > always enjoy speaking with you. I I plan to attend the Sunday symposium on > mitral repair that your boss will be chairing.> > Hal> > > > **************Wondering what's for Dinner Tonight? Get new twists on family > favorites at AOL Food. > (http://food.aol.com/dinner-tonight?NCID=aolfod00030000000001)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> ----------------------------------------- _________________________________________________________________ Be a Hero and Win with Iron Man http://clk.atdmt.com/UKM/go/msnnkmgl0010000009ukm/direct/01/ From mmlevinson at hsforum.com Thu May 1 23:33:06 2008 From: mmlevinson at hsforum.com (Mark Levinson) Date: Thu May 1 23:33:36 2008 Subject: [HSF] Sympathy anyone....... In-Reply-To: References: Message-ID: <751B3C99-0549-415F-A8AE-E08E51B87869@hsforum.com> On May 1, 2008, at 2:52 PM, Michael Firstenberg wrote: > , we let > them them bleed and bleed and bleed until they stop (which they > usually do - > at some point), tamponade (fortunately less often), or we bite the > bullet > and take them back. ARDS from transfusions in this patient?? Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From anianyanwu at hotmail.com Fri May 2 04:33:12 2008 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Thu May 1 23:33:47 2008 Subject: [HSF] Sympathy anyone....... In-Reply-To: <0202793B-02D1-4199-A512-271999C8AA94@bigpond.com> References: <0202793B-02D1-4199-A512-271999C8AA94@bigpond.com> Message-ID: I am not sure I see this as one of our usual cath lab horrors. Are tall, thin and long fingered patients not entitled to have myocardial infarcts? ST elevation, enzyme rise and chest pain, regardless of habitus of patient, = myocardial ischemia or infarct until proven otherwise. A four day history moreso will push most doctors to a diagnosis of acute coronary syndrome - even if there are truly marfanoid features - as in the emergency medical cookbook, dissection is an acute presentation and not a four day one. I suspect the\is patient would have been managed the same way in many other western medical centers worldwide. I also suspect there are numerous other tall thin patients who suffer myocardial infarcts and are thrombolysed or have primary PCI every year that we do not get to hear of or criticize. Ani > From: donross@bigpond.com> Subject: Re: [HSF] Sympathy anyone.......> Date: Thu, 1 May 2008 18:34:18 +1000> To: OpenHeart-L@lists.hsforum.com> CC: > > Cards are a class act!> On 01/05/2008, at 11:26 AM, Michael Firstenberg wrote:> > > 51 year/old.....presented with 4 day history of chest pain.> > Tall, thin, long fingers....> > ST changes on ECG.> > Concern for AMI> > Given:> > ASA> > High dose Plavix> > Lovenox> >> > taken to cath lab> >> > found to have Type A dissection from valvue to iliacs........> >> >> > oh, he also got reopro............> >> >> > it has been a long day.> >> >> > -michael> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the > > policies and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> ----------------------------------------- _________________________________________________________________ Win Indiana Jones prizes with Live Search http://clk.atdmt.com/UKM/go/msnnkmgl0010000002ukm/direct/01/ From mmlevinson at hsforum.com Thu May 1 23:47:49 2008 From: mmlevinson at hsforum.com (Mark Levinson) Date: Thu May 1 23:48:08 2008 Subject: [HSF] RCA osteal lesion-osteal reconstruction In-Reply-To: References: Message-ID: <3338475C-7F5A-4A18-B804-7194FDA1151D@hsforum.com> On Apr 29, 2008, at 12:01 AM, DukeB60@aol.com wrote: > Z, > Check out the video on the Heart Surgery Forum website by Mark > Levinson. > He has some excellent photos and is a great resource for the > technique. If > you have the robot it greatly simplifies taking down one or both > IMA's, as > you well know. > > Subxiphoid OPCAB is safe if you understand the anatomy, technique, and add a few instruments to your tray. The key is using a double Rultract with a connecting bar to lift the lower sternum. The RIMA can be harvested in a standard manner, and OPCAB technique to the distal RCA is not too difficult. However, if you have not reviewed the technique before and prepared ahead of time for approach, I would not suggest you try it on this patient. I can give you more information if you are interested. Myself, in my own practice, I would offer this patient a subxiphoid RIMA- (or RGEA) to PDA as a alternative to a DES and lifelong Plavix..... Mark Mark Levinson, MD. Founder, Editor-in-Chief The Heart Surgery Forum? Multimedia Cardiothoracic Journal URL: http://www.hsforum.com URL: http://newoptionsinheartsurgery.com Emali: mmlevinson@hsforum.com From smschwartz at mac.com Thu May 1 11:45:02 2008 From: smschwartz at mac.com (Steven Schwartz) Date: Fri May 2 00:01:43 2008 Subject: [HSF] Sympathy anyone....... In-Reply-To: References: <1227345180-1209607740-cardhu_decombobulator_blackberry.rim.net-222548375-@bxe159.bisx.prod.on.blackberry> Message-ID: <0FAC0B6E-D115-4978-BEE2-3549407F2784@mac.com> Do you use a perimount already in a valve conduit, or have to hand sew it together? I had another dissection on Tuesday, 65 yo hypertensive, able to replace just the ascending Ao with a tube graft and resuspend the valve. He has extension of the dissection down the the 6.5 cm abd Ao aneurysm found incidentally on the CTS for his dissection diagnosis. Compromised flow into the celiac and SMA by the dissection, went to interventional radiology and had these vessels stented POD #1. How are others dealing with: 1. valve selection in these patients. We've always used St. Jude valve conduits when replacing the root, not wanting to have to deal with a failed bioprosthesis. 2. malperfusion problems. Viscera, renals, limbs, etc. Steve Schwartz On Apr 30, 2008, at 7:20 PM, Michael Firstenberg wrote: > 25mm Perimount > > I figured that coumadin would be a disaster (his tissues were > crap... I am > going to work him up for a connective tissue disorder), but I never > want to > be in his chest again (dont we always say that?) and I figure > Edwards will > be the most likely company to have a Perc AVR that will fit in one > of their > valves in a few years when he needs a redo......then again, maybe by > then I > will have forgotten how painful it was the first time - although a > redo > maybe not be all that bad (wait a minute... I need my head > examined)....... > > -michael > > > On 4/30/08, zzhoumd@pol.net wrote: >> >> >> What valve did you give him? >> >> >> >> Sent via BlackBerry by AT&T >> >> -----Original Message----- >> From: "Michael Firstenberg" >> >> Date: Wed, 30 Apr 2008 21:26:16 >> To:OpenHeart-L@lists.hsforum.com >> Subject: [HSF] Sympathy anyone....... >> >> >> 51 year/old.....presented with 4 day history of chest pain. >> Tall, thin, long fingers.... >> ST changes on ECG. >> Concern for AMI >> Given: >> ASA >> High dose Plavix >> Lovenox >> >> taken to cath lab >> >> found to have Type A dissection from valvue to iliacs........ >> >> >> oh, he also got reopro............ >> >> >> it has been a long day. >> >> >> -michael >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/listinfo/openheart-l >> >> All messages transmitted by the OpenHeart-L are subject to the >> policies >> and >> disclaimers posted at: >> http://www.hsforum.com/listdisclaim >> ----------------------------------------- >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/listinfo/openheart-l >> >> All messages transmitted by the OpenHeart-L are subject to the >> policies >> and >> disclaimers posted at: >> http://www.hsforum.com/listdisclaim >> ----------------------------------------- >> > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the > policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- Steven M. Schwartz, MD smschwartz@mac.com From zzhoumd at pol.net Fri May 2 01:17:09 2008 From: zzhoumd at pol.net (Zhandong Zhou) Date: Fri May 2 00:18:26 2008 Subject: [HSF] Sympathy anyone....... References: <1227345180-1209607740-cardhu_decombobulator_blackberry.rim.net-222548375-@bxe159.bisx.prod.on.blackberry> <0FAC0B6E-D115-4978-BEE2-3549407F2784@mac.com> Message-ID: <000601c8ac0b$6403d690$660fa8c0@workstation> Steven, I think you have to sew the valve into the Dacron graft. Just wonder how many of you will do a David I in acute dissection. I just did one today as he has 5cm root aneurysm presented with dissection. However, always worried about risk in these sick patients. Zhandong Zhou ----- Original Message ----- From: "Steven Schwartz" To: Sent: Thursday, May 01, 2008 1:45 PM Subject: Re: [HSF] Sympathy anyone....... > Do you use a perimount already in a valve conduit, or have to hand sew > it together? > I had another dissection on Tuesday, 65 yo hypertensive, able to > replace just the ascending Ao with a tube graft and resuspend the > valve. He has extension of the dissection down the the 6.5 cm abd Ao > aneurysm found incidentally on the CTS for his dissection diagnosis. > Compromised flow into the celiac and SMA by the dissection, went to > interventional radiology and had these vessels stented POD #1. > How are others dealing with: > 1. valve selection in these patients. We've always used St. Jude valve > conduits when replacing the root, not wanting to have to deal with a > failed bioprosthesis. > 2. malperfusion problems. Viscera, renals, limbs, etc. > Steve Schwartz > > On Apr 30, 2008, at 7:20 PM, Michael Firstenberg wrote: > >> 25mm Perimount >> >> I figured that coumadin would be a disaster (his tissues were >> crap... I am >> going to work him up for a connective tissue disorder), but I never >> want to >> be in his chest again (dont we always say that?) and I figure >> Edwards will >> be the most likely company to have a Perc AVR that will fit in one >> of their >> valves in a few years when he needs a redo......then again, maybe by >> then I >> will have forgotten how painful it was the first time - although a >> redo >> maybe not be all that bad (wait a minute... I need my head >> examined)....... >> >> -michael >> >> >> On 4/30/08, zzhoumd@pol.net wrote: >>> >>> >>> What valve did you give him? >>> >>> >>> >>> Sent via BlackBerry by AT&T >>> >>> -----Original Message----- >>> From: "Michael Firstenberg" >>> >>> Date: Wed, 30 Apr 2008 21:26:16 >>> To:OpenHeart-L@lists.hsforum.com >>> Subject: [HSF] Sympathy anyone....... >>> >>> >>> 51 year/old.....presented with 4 day history of chest pain. >>> Tall, thin, long fingers.... >>> ST changes on ECG. >>> Concern for AMI >>> Given: >>> ASA >>> High dose Plavix >>> Lovenox >>> >>> taken to cath lab >>> >>> found to have Type A dissection from valvue to iliacs........ >>> >>> >>> oh, he also got reopro............ >>> >>> >>> it has been a long day. >>> >>> >>> -michael >>> _______________________________________________ >>> OpenHeart-L mailing list >>> >>> Send postings to: >>> OpenHeart-L@lists.hsforum.com >>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>> http://mmp.cjp.com/mailman/listinfo/openheart-l >>> >>> All messages transmitted by the OpenHeart-L are subject to the >>> policies >>> and >>> disclaimers posted at: >>> http://www.hsforum.com/listdisclaim >>> ----------------------------------------- >>> >>> _______________________________________________ >>> OpenHeart-L mailing list >>> >>> Send postings to: >>> OpenHeart-L@lists.hsforum.com >>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>> http://mmp.cjp.com/mailman/listinfo/openheart-l >>> >>> All messages transmitted by the OpenHeart-L are subject to the >>> policies >>> and >>> disclaimers posted at: >>> http://www.hsforum.com/listdisclaim >>> ----------------------------------------- >>> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/listinfo/openheart-l >> >> All messages transmitted by the OpenHeart-L are subject to the >> policies and >> disclaimers posted at: >> http://www.hsforum.com/listdisclaim >> ----------------------------------------- > > Steven M. Schwartz, MD > smschwartz@mac.com > > > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- From Rwmfglycar at aol.com Fri May 2 06:09:00 2008 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Fri May 2 05:13:19 2008 Subject: [HSF] Sympathy anyone....... Message-ID: In a message dated 5/1/2008 11:36:34 P.M. Eastern Daylight Time, anianyanwu@hotmail.com writes: four day history moreso will push most doctors to a diagnosis of acute coronary syndrome - even if there are truly marfanoid features - as in the emergency medical cookbook, dissection is an acute presentation and not a four day one. Whatever your cookbook says, dissections are by no means always a one day presentation. Dissections can stutter along; in fact they can mimic numerous other symptom patterns for numerous diseases. Marfan patients are particularly prone to less than critical dissections prior to the big one. The truth of the matter is that the cardiologists were thinking down their own little alley and not engaging in the old fashioned exercise of differential diagnosis. Bob **************Wondering what's for Dinner Tonight? Get new twists on family favorites at AOL Food. (http://food.aol.com/dinner-tonight?NCID=aolfod00030000000001) From Hgrmd at aol.com Fri May 2 08:08:03 2008 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Fri May 2 07:12:23 2008 Subject: [HSF] Sympathy anyone....... Message-ID: Steve, I've done a few biologic Bentalls. It's really pretty straight forward. Measure the aortic annulus in the usual manner. If it's a 23 mm, add 5 and use a 28 graft (I currently favor the Valsalva). The graft is attached to the valve with a running 4-0 Prolene (doesn't have to be hemostatic). Hal **************Wondering what's for Dinner Tonight? Get new twists on family favorites at AOL Food. (http://food.aol.com/dinner-tonight?NCID=aolfod00030000000001) From wftjrtyler at aol.com Fri May 2 09:24:02 2008 From: wftjrtyler at aol.com (wftjrtyler@aol.com) Date: Fri May 2 08:24:35 2008 Subject: [HSF] RCA osteal lesion-osteal reconstruction In-Reply-To: <3338475C-7F5A-4A18-B804-7194FDA1151D@hsforum.com> References: <3338475C-7F5A-4A18-B804-7194FDA1151D@hsforum.com> Message-ID: <8CA7A668A7B4B1C-53C-5613@FWM-M43.sysops.aol.com> Mark, in addition to your article HSF '05, what other links,sources do you recommend??? thanks, bill turner -----Original Message----- From: Mark Levinson To: OpenHeart-L@lists.hsforum.com Sent: Thu, 1 May 2008 10:47 pm Subject: Re: [HSF] RCA osteal lesion-osteal reconstruction On Apr 29, 2008, at 12:01 AM, DukeB60@aol.com wrote:? ? > Z,? > Check out the video on the Heart Surgery Forum website by Mark > Levinson.? > He has some excellent photos and is a great resource for the > technique. If? > you have the robot it greatly simplifies taking down one or both > IMA's, as? > you well know.? >? >? ? Subxiphoid OPCAB is safe if you understand the anatomy, technique, and add a few instruments? to your tray.? ? The key is using a double Rultract with a connecting bar to lift the lower sternum. The RIMA can? be harvested in a standard manner, and OPCAB technique to the distal RCA is not too difficult.? ? However, if you have not reviewed the technique before and prepared ahead of time for approach, I would? not suggest you try it on this patient. I can give you more information if you are interested.? ? Myself, in my own practice, I would offer this patient a subxiphoid RIMA- (or RGEA) to PDA as a alternative to a DES and lifelong Plavix.....? ? Mark? ? Mark Levinson, MD.? Founder, Editor-in-Chief? The Heart Surgery Forum?? Multimedia Cardiothoracic Journal? URL: http://www.hsforum.com? URL: http://newoptionsinheartsurgery.com? Emali: mmlevinson@hsforum.com? ? _______________________________________________? OpenHeart-L mailing list? ? Send postings to:? OpenHeart-L@lists.hsforum.com? ? To UNSUBSCRIBE, to CHANGE email address, or to view archives:? http://mmp.cjp.com/mailman/listinfo/openheart-l? ? All messages transmitted by the OpenHeart-L are subject to the policies anddisclaimers posted at:? http://www.hsforum.com/listdisclaim? -----------------------------------------? From anianyanwu at hotmail.com Fri May 2 13:29:13 2008 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Fri May 2 08:30:01 2008 Subject: [HSF] Sympathy anyone....... In-Reply-To: References: Message-ID: > Whatever your cookbook says, dissections are by no means always a one day > presentation. > Bob Of course I agree with you Dr Frater but in the primary care setting such presentations *for patients with chest pain* are the exception rather than the rule. Although we consider the denominator as all patients with type A, and therefore recognize subacute presentations are not infrequent, in the primary care setting their denominator is the thousands of patients who have chest pain on a daily basis and such subacute presentations will be rare, well below 1% of patients they see with chest pain. In ordering diagnostic testing some system, consciously or subconsciously has to guide choice of testing. Many will use the Bayes Theorem - although Marfans may be more likely to dissect, the fact remains that a tall patient with chest pain is still far more likely to have a myocardial infarct than a dissection, so on initial presentation the pre-test probability (for myocardial infarction) in the view of most primary care doctors will be high. Then they do the first screening test and find ST elevation and high troponin, the post-test probability for AMI now becomes very high. So the next step is to order a confirmatory test (cardiac catheterization) which will turn out positive in the vast majority of patients. Remember the cardiologists did not get this patient of the street and they essentially are providing a service (diagnostic test to confirm coronary stenosis plus therapeutic intervention), the clinical assessment and diagnosis having been done by the primary or ER doctor and in many hospitals the patients literally move to the cath lab (on the order of the ER doctor) without a cardiological assessment. The antiplatelet agents are often now given in the ER before the cardiologist gets hold of the patient. If the same patient had a normal ECG then the post test probability for AMI would be low and other diagnoses would have come into consideration. Similarly if the patient had a wide mediastinum on CXR or aortic regurgitation then the post-test probability for AMI will be low and dissection goes high up the list. Most ERs see thousands of patients with chest pain in a year, of which acute aortic dissection will constitute no more than a handful, so it is IMHO expecting too much to ask they recognize atypical presentations. I last month operated on a patient who had a dissection that went undiagnosed for 3 weeks - in that three week period he attended hospital thrice include a one week admission for 'pneumonia'. It is not as easy as we see it to recognize rare diseases in the primary care setting. This is partly why some are testing immediate cardiac CT, rather than direct coronary angiography, as the next step diagnostic test for chest pain or dyspnoea as it will immediately differentiate patients with the three most life threatening conditions - AMI, acute dissection and pulmonary embolizsation. All who have worked in an ER or primary care setting will recognize where I am coming from as we have all sent home the odd patient with a diagnosis of flu, cold, gastritis etc, that comes back a day later with a myocardial infarct, meningitis, appendicits etc or worse (death). Ani > From: Rwmfglycar@aol.com> Date: Fri, 2 May 2008 05:09:00 -0400> Subject: Re: [HSF] Sympathy anyone.......> To: OpenHeart-L@lists.hsforum.com> CC: > > > > In a message dated 5/1/2008 11:36:34 P.M. Eastern Daylight Time, > anianyanwu@hotmail.com writes:> > four day history moreso will push most doctors to a diagnosis of acute > coronary syndrome - even if there are truly marfanoid features - as in the > emergency medical cookbook, dissection is an acute presentation and not a four day > one. > > > > > Whatever your cookbook says, dissections are by no means always a one day > presentation. Dissections can stutter along; in fact they can mimic numerous > other symptom patterns for numerous diseases. Marfan patients are particularly > prone to less than critical dissections prior to the big one.> The truth of the matter is that the cardiologists were thinking down their > own little alley and not engaging in the old fashioned exercise of differential > diagnosis.> Bob> > > > **************Wondering what's for Dinner Tonight? Get new twists on family > favorites at AOL Food. > (http://food.aol.com/dinner-tonight?NCID=aolfod00030000000001)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> ----------------------------------------- _________________________________________________________________ Discover and Win with Live Search http://clk.atdmt.com/UKM/go/msnnkmgl0010000007ukm/direct/01/ From battr at medizin.uni-leipzig.de Fri May 2 15:28:15 2008 From: battr at medizin.uni-leipzig.de (Dr. Roberto Battellini) Date: Fri May 2 08:32:16 2008 Subject: AW: [HSF] Re: [ccm-l] Image of the week Hemisternotomy In-Reply-To: <89c4ed2d0804300950j5fa8743fm9762e7215e2b0147@mail.gmail.com> References: <89c4ed2d0804300138h2cf31d32ic0cf68fd8e76af5a@mail.gmail.com><89c4ed2d0804300943h579789f5i1e68a2db90c6319f@mail.gmail.com> <89c4ed2d0804300950j5fa8743fm9762e7215e2b0147@mail.gmail.com> Message-ID: <009101c8ac50$029e0250$b3160a06@HZLPC0679> Prasanna, Congrats, but I think it is not possible without T or L cut in our big old patients with calcified sternum. Roberto -----Urspr?ngliche Nachricht----- Von: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] Im Auftrag von Prasanna Simha M Gesendet: Mittwoch, 30. April 2008 17:51 An: gabi ford Cc: OpenHeart-L; Betreff: [HSF] Re: [ccm-l] Image of the week Hemisternotomy Gabi, This is a view of the mitral valve during a hemisternotomy. I do not think that the view is compromised. You can clearly see the subvalvar (I am doing a combined chordoplasty (chordal shortening +neochordal construction ) of the AML chordae. Prasanna On Wed, Apr 30, 2008 at 10:13 PM, Prasanna Simha M wrote: > I do not think I am compromising on any step of the operation. I am doing > routine operations through this approach without changing any aspect - > central cannulation routine instrumentations etc and a smaller incision is > just an addon.They also seem to have less blood loss.Why would I do it in an > oldie - preservation of the manubrial continuity seems to help in postop > recovery, breathing etc.If nothing a smaller scar is always welcome !! I > will not hesitate to convert to a full sternotomy if required. My new > lecturer was worried when I was doing a double valve replacement + TV repair > in a patient(He was seeing it being done for the first time). He was > convinced after I showed him that there was no compromise in exposure. If > you see carefully the upper part of the sternotomy actually exposes the > suprasternal notch , innominate vein etc and the actual cannulation site is > not that high in most cases. > > Prasanna > > > On Wed, Apr 30, 2008 at 10:01 PM, gabi ford wrote: > > > > > From: prasannasimha@gmail.com > > > Havent got any exiting photos from some time so posting a postop > > photo. Mitral valve repair done in a 20 year old patient via a > > hemisternotomy at his 6 month follow up.Not as small as the robots but > > getting somewhere there :). Patient is very happy with the cosmesis despite > > a hypertrophied scar as the scar is not seen even when his second shirt > > button is left open. > > > > Prasanna, > > > > Only small evidence of the battle! :) > > Can you do better work with a bigger opening? What I'm getting at > > is the question > > of compromise in technique, etc. with a smaller field? > > Do you care how small the opening/scar is when the patient is old and > > presumably cares little about the size of a scar? > > > > Gabi, RN > > > > > -- > Prasanna Simha M -- Prasanna Simha M From zzhoumd at pol.net Fri May 2 13:32:01 2008 From: zzhoumd at pol.net (zzhoumd@pol.net) Date: Fri May 2 08:33:38 2008 Subject: [HSF] Sympathy anyone....... In-Reply-To: References: Message-ID: <634989169-1209731529-cardhu_decombobulator_blackberry.rim.net-339537270-@bxe159.bisx.prod.on.blackberry> What about the young patients? I did a young patient yesterday who is using drug and non compile. I endup did David I on him. Zhandong Sent via BlackBerry by AT&T -----Original Message----- From: Hgrmd@aol.com Date: Fri, 2 May 2008 07:08:03 To:OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Sympathy anyone....... Steve, I've done a few biologic Bentalls. It's really pretty straight forward. Measure the aortic annulus in the usual manner. If it's a 23 mm, add 5 and use a 28 graft (I currently favor the Valsalva). The graft is attached to the valve with a running 4-0 Prolene (doesn't have to be hemostatic). Hal **************Wondering what's for Dinner Tonight? Get new twists on family favorites at AOL Food. (http://food.aol.com/dinner-tonight?NCID=aolfod00030000000001) _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From msfirst at gmail.com Fri May 2 09:40:24 2008 From: msfirst at gmail.com (Michael Firstenberg) Date: Fri May 2 08:40:54 2008 Subject: [HSF] Sympathy anyone....... In-Reply-To: References: Message-ID: I also have done a few Bio-Bentall - I try to get someone to sew the valve on to the conduit while I am doing something else. While I am concerned about the redo also (probably less of a concern years down the road), but I am more concerned about Coumadin. I think Coumadin is one of the most dangerous drugs out there! Coumadin in a Marfan's patient with a chronic type B dissection - talk about a time bomb. I think if you look at the curves for structural valve degeneration and survival for various types of Type A - they are probably similar. I think part of my maturing process that Ed is referring to is that if the patient is dying from a lethal problem - dont get creative with valve spairing crap.......if the valve and annulus is fine that is one thing..... in my hands (for now) ANY AI gets a valve. Taking the cross clamp off and finding you still have +2 AI is a VERY bad problem. Furthermore, I am not aware of any good data about David's/etc for dissections. The Florida sleeve looks nice, but I think the valve and annulus, again, must look perfect. With regards to the ACS.... 4 days of chest pain with ST changes will and probably should get a STEMI work-up. The problem is that no longer is there time or thought that goes into the concept of a "differential diagnosis". Thanks to "scoring systems" there is such a rush to get them to the Cath lab that anything that gets in the way hurts "the system". These new protocols have no room for individual variations - we have had post-op patients come in to the ED with chest pain, abnormal ECGs and get taken to the cath lab without us getting notified. Does it matter that they had a clean cath 2 weeks prior and right before their surgery and they got a valve or something else? (so what if their ECG changes are from a pericarditis/effusion that needs to be drained on high dose Plavix). This is what happens when Doctors get taken out of the loop and they get replaced by automated systems/protocols/guidelines/scorecards/etc. On the other side of the coin, I took him right away from the Cath lab to the OR..... that helps me with my time from Cath to OR statistics - something else that is tracked in "our system". Fortunately, I dont get month blood utilization reports (at least not yet) - although the % of patients who get transfused is another "index". I guess you have to pick your battles - and me? I just want to get them home alive and away from the perils of the heathcare system. -michael On 5/2/08, Hgrmd@aol.com wrote: > > Steve, > I've done a few biologic Bentalls. It's really pretty straight forward. > Measure the aortic annulus in the usual manner. If it's a 23 mm, add 5 > and > use a 28 graft (I currently favor the Valsalva). The graft is attached > to the > valve with a running 4-0 Prolene (doesn't have to be hemostatic). > > Hal > > > > **************Wondering what's for Dinner Tonight? Get new twists on > family > favorites at AOL Food. > (http://food.aol.com/dinner-tonight?NCID=aolfod00030000000001) > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies > and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > From anianyanwu at hotmail.com Fri May 2 14:05:42 2008 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Fri May 2 09:06:31 2008 Subject: [HSF] Sympathy anyone....... In-Reply-To: References: Message-ID: > With regards to the ACS.... The problem is that no longer is there> time or thought that goes into the concept of a "differential diagnosis".> Thanks to "scoring systems" there is such a rush to get them to the Cath lab> that anything that gets in the way hurts "the system". ....On the other side of the coin,> I took him right away from the Cath lab to the OR..... that helps me with my> time from Cath to OR statistics > > -michael Well then Michael you are as guilty of what you accuse the cardiologists of - rushing the patient, who has had the condition for 4 days and just been given a host of antithrombotic drugs, straight from cath-lab to OR within minutes of seeing him cannot have given the patient due consideration and work-up either. Like the ER doctor and cardiologists, you are also following a cookbook which in our instance is that acute dissection=immediate surgery and like the cardiologist you also want a record (cath to OR) transfer time which does not consider appropriateness to the individual patient. As has been mentioned, in your patient, many would consider a delay in surgery beneficial and certainly there was no immediate need to operate asap (as having survived till four days the conditional probability of dying on the fifth day will be low - i do not know the data off hand but unlikely to even be 10% and may well be less than the incremental risk of death in operating on such an anticoagulated patient). Mind you I am not criticizing you - I have done same myself - but just trying to point out that we (cardiologists, surgeons, ER doctors) are all peas from the same pod. By the way I am sure you were not serious in saying any patient with type A you do with AI will get a valve replacement or were you just referring to the Marfan's cases? I would be cautious with liberal usage of blood transfusions - they are not innocuous. One day it may come back to haunt you. Ask those doctors who were jailed for giving people tainted blood in the 1980s...of all the drugs we give to bleeding patients, blood is probably the most toxic. Ani > Date: Fri, 2 May 2008 08:40:24 -0400> From: msfirst@gmail.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] Sympathy anyone.......> CC: > > I also have done a few Bio-Bentall - I try to get someone to sew the valve> on to the conduit while I am doing something else. While I am concerned> about the redo also (probably less of a concern years down the road), but I> am more concerned about Coumadin. I think Coumadin is one of the most> dangerous drugs out there! Coumadin in a Marfan's patient with a chronic> type B dissection - talk about a time bomb. I think if you look at the> curves for structural valve degeneration and survival for various types of> Type A - they are probably similar.> > I think part of my maturing process that Ed is referring to is that if the> patient is dying from a lethal problem - dont get creative with valve> spairing crap.......if the valve and annulus is fine that is one thing.....> in my hands (for now) ANY AI gets a valve. Taking the cross clamp off and> finding you still have +2 AI is a VERY bad problem. Furthermore, I am not> aware of any good data about David's/etc for dissections. The Florida> sleeve looks nice, but I think the valve and annulus, again, must look> perfect.> > With regards to the ACS.... 4 days of chest pain with ST changes will and> probably should get a STEMI work-up. The problem is that no longer is there> time or thought that goes into the concept of a "differential diagnosis".> Thanks to "scoring systems" there is such a rush to get them to the Cath lab> that anything that gets in the way hurts "the system". These new protocols> have no room for individual variations - we have had post-op patients come> in to the ED with chest pain, abnormal ECGs and get taken to the cath lab> without us getting notified. Does it matter that they had a clean cath 2> weeks prior and right before their surgery and they got a valve or something> else? (so what if their ECG changes are from a pericarditis/effusion that> needs to be drained on high dose Plavix). This is what happens when Doctors> get taken out of the loop and they get replaced by automated> systems/protocols/guidelines/scorecards/etc. On the other side of the coin,> I took him right away from the Cath lab to the OR..... that helps me with my> time from Cath to OR statistics - something else that is tracked in "our> system". Fortunately, I dont get month blood utilization reports (at least> not yet) - although the % of patients who get transfused is another> "index". I guess you have to pick your battles - and me? I just want to> get them home alive and away from the perils of the heathcare system.> > -michael> > > > > On 5/2/08, Hgrmd@aol.com wrote:> >> > Steve,> > I've done a few biologic Bentalls. It's really pretty straight forward.> > Measure the aortic annulus in the usual manner. If it's a 23 mm, add 5> > and> > use a 28 graft (I currently favor the Valsalva). The graft is attached> > to the> > valve with a running 4-0 Prolene (doesn't have to be hemostatic).> >> > Hal> >> >> >> > **************Wondering what's for Dinner Tonight? Get new twists on> > family> > favorites at AOL Food.> > (http://food.aol.com/dinner-tonight?NCID=aolfod00030000000001)> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies> > and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> ----------------------------------------- _________________________________________________________________ Discover and Win with Live Search http://clk.atdmt.com/UKM/go/msnnkmgl0010000007ukm/direct/01/ From battr at medizin.uni-leipzig.de Fri May 2 16:57:14 2008 From: battr at medizin.uni-leipzig.de (Dr. Roberto Battellini) Date: Fri May 2 10:00:25 2008 Subject: AW: [HSF] Re: [ccm-l] Image of the week Hemisternotomy-OT In-Reply-To: <490438732-1209597163-cardhu_decombobulator_blackberry.rim.net-1007138223-@bxe028.bisx.prod.on.blackberry> References: <537727.63518.qm@web81606.mail.mud.yahoo.com> <490438732-1209597163-cardhu_decombobulator_blackberry.rim.net-1007138223-@bxe028.bisx.prod.on.blackberry> Message-ID: <009201c8ac5c$6cfd08b0$b3160a06@HZLPC0679> Gabi, I had the pleasure to have had Prasanna 2 weeks at home in Leipzig (during December 2007). 1. He cooks excellent Indian style, vegetarian. 2. He does not drink alcohol, (it was cheaper for me, and I had to be abstinent too these days!) 3. He took my PC and never gave up, also in my office, always writing to the HSF 4. At 6 O'clock, when I got up, he had already made coffee! 5. When Fred was operating a Mitral MIC, and there were many big visitors like Hal, he could filtrate under them and look better through the incision. A real character! Roberto -----Urspr?ngliche Nachricht----- Von: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] Im Auftrag von hgrmd@aol.com Gesendet: Donnerstag, 1. Mai 2008 00:13 An: OpenHeart-L@lists.hsforum.com Betreff: Re: [HSF] Re: [ccm-l] Image of the week Hemisternotomy Gabi, Believe it or not, Prasanna is real. I had the pleasure of meeting him in Leipzig. Great guy. Hal Sent from my Verizon Wireless BlackBerry -----Original Message----- From: gabi ford Date: Wed, 30 Apr 2008 22:30:00 To: Subject: RE: [HSF] Re: [ccm-l] Image of the week Hemisternotomy From: tacuff@swbell.net > Please note that the aorta cannulation is "doeable". This is code for limited access. In many alternative incisions the proximals (if used, Don) can be a bigger problem than the distals. An inadvertent problem with the aorta can exact a high price. Ability to extend the incision is a real plus, but may not be worth the trip (to India). On the other hand having Prasanna be your surgeon may be worth some bumps in the road. He was not advertising for CAB, however, or so it seems.. No, he wasn't advertising. Has it come to that? ;) I'd like to meet Prasanna sometime. I have a suspicion that he is a fake. He is probably 4 people running under one name. Some fantastic dad, CV surgeon, computer nerd and cat fancier....all of them functioning extremely well full time. Gabi _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From battr at medizin.uni-leipzig.de Fri May 2 17:01:23 2008 From: battr at medizin.uni-leipzig.de (Dr. Roberto Battellini) Date: Fri May 2 10:05:04 2008 Subject: =?iso-8859-1?Q?AW:_=5BHSF=5D_Tea=B4s_thoughts-OT?= In-Reply-To: References: Message-ID: <009301c8ac5d$01628930$b3160a06@HZLPC0679> Tea, One letter more and you?ll write a Shakespeare theatre piece... Roberto -----Urspr?ngliche Nachricht----- Von: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] Im Auftrag von wftjrtyler@aol.com Gesendet: Donnerstag, 1. Mai 2008 02:10 An: OpenHeart-L@lists.hsforum.com Betreff: Re: [HSF] RCA osteal lesion-osteal reconstruction ......from "runnin on empty".....Jackson Browne....~78......."it takes a clear mind........" had this thread in mind......bill turner In a message dated 4/29/2008 9:22:22 P.M. Central Daylight Time, tacuff@swbell.net writes: I might suggest that we all take a step back and think through as best as we can the implications of the things that we propose as proper perspectives. If I may drift across some of the recent threads, we have surgeons appealing to standard evidence based positions and others pushing for the technical improvement and innovativation that seemingly drives patients to the better alternative of surgery. In the middle of this we have semicatheter based approaches with a few surgeons trying to stay ahead of the frontal assult by interventional cardiologists to develop the new surgeon of the future. Ani recently stated out of whole cloth uncontested that AVI (I think is the acronym) is its own standard and rightly so. This opinion is paramount to my observation (or rant) that EBM is more about the observation of doctors behavior to treatment of their patients than it is the more commonly held dictum that EBM is the analysis of patients behavior to therapy for their disease. I think it is both but we can not lose the clarity that these are very different things and our interventions in any order and every order greatly impact the possible outcomes of patient-doctor-disease interactions over the life of said interactions. How does an either/ or trial, the mainstay of EBM, deal with this complex interative system? Don't the patients also impact this before and throughout their so called informed consent discussions especially in EBM? But even to the narrow point raised by Ani. Which way shall it be? Are AVI, PCI, medical therapy (?inoperable??), robotic AVR and "AVR" all different therapies evaluated on their own terms? If so, is the same true for PCI, ONCAB, OFFCAB, hybrib, TECAB, all arterial CAB etc? Do we start thinking formally and especially OFFICALLY about how all of these interact or do we categorize each into their own orbits or perhaps speciality based solar planetary system? Aren't we by default actually doing specialty bas