[HSF] Sympathy anyone.......

[Michael Firstenberg]

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 at aol.com <Hgrmd at 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
>
>
>
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