AW: [HSF] Tea´s thoughts-OT

Fri May 2 17:01:23 EDT 2008

Tea,
One letter more and you´ll write a Shakespeare theatre piece...
Roberto

-----Ursprüngliche Nachricht-----
Von: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von
wftjrtyler at aol.com
Gesendet: Donnerstag, 1. Mai 2008 02:10
An: OpenHeart-L at 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 at 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 based planetary
therapy?  Do 
the "best" of us practice orbital, solar planetary or galaxy medicine? Do
we 
need all of these? Do we as CV surgeons step forward in the clinic for the  
diagnosis and follow later the post op therapies? Do we get CT scans for our

demented and scope our anemic patients, or just worry about our our
protocols  
for CV patients. Shall we call a spade a spade or hide nakedly behind the
sign 
 named doctor and picket fences we call best
practice in our literature? Who  are we?

tea

----- Original Message ----
From: kenny  herskowitz <animal2830 at aol.com>
To:  OpenHeart-L at lists.hsforum.com
Sent: Tuesday, April 29, 2008 7:35:24  PM
Subject: Re: [HSF] RCA osteal lesion-osteal  reconstruction

ditto
On Apr 28, 2008, at 10:23 PM,  tdmartin2000 at aol.com wrote:

> Z
> I hate to disagree but it  isn't always what the surgeon is  
> "comfortable with". The data  to date would not support a robotic  
> anything over conventional  surgery. I think in most cases, surgeons  
> are using the thought  that cardiologists are sending pts to surgery  
> because of the  robot or mini approach because they think it is  
> better in some  way. What they need is good education on each  
> approach. I bet  if?we were totally honest with our cardiologists  
> about  minimally invasive procedures and told them that the data to  
>  date doesn't support any percieved benefit in terms of pain, length   
> of stay, mortality or morbidity? and in fact in many cases the   
> results are not as good, they would think twice about it. And if  we  
> educate them properly on the really excellent results  that  
> conventional surgery gets as compared to medical tx or  stents they  
> would be very receptive. In the end what we really  need to do is do  
> what is really the best for the  patient.
> ?
> Tom
>
>
> -----Original  Message-----
> From: zzhoumd at pol.net
> To:  OpenHeart-L at lists.hsforum.com
> Sent: Mon, 28 Apr 2008 12:02 am
>  Subject: Re: [HSF] RCA osteal lesion-osteal  reconstruction
>
>
>
>
> Tom,
>
>  The most important thing is surgeon's choice, what ever he feels   
> comfortable,
> whether robot or sternotomy.
>
> One  of the interesting thing that happens with mini invasive  
>  approach, is to see
> that cardiologists are sending some patients for  surgery that you do  
> not see in
> the past, I.e. Patients  they used to treat with medication and stents.
>
> Z  Zhou
>
>
>
> Sent via BlackBerry by  AT&T
>
> -----Original Message-----
> From:  tdmartin2000 at aol.com
>
> Date: Sun, 27 Apr 2008 18:33:59
>  To:OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] RCA osteal  lesion-osteal reconstruction
>
>
> I would have to agree  with those opinions so far that a PCI with a  
> large  stent
> is probably the first option. If that is not feasible or safe  then a  
> standard
> single vessel bypass to the right or  PDA. Your choice of grafts but  
> in a 60 year
> old I might  consider a RIMA. I hear all this about robots and  
> everything  else
> but come on guys- in an era where we are chiding the  cardiologists  
> about results
> of PCI and how the results  of coronary bypass is better- why would  
> you choose a
>  potentially inferior operation in a 60 year old patient that you can   
> do a
> standard operation via a sternotomy with a pump with  cardioplegia  
> and give her
> excellent 10 plus yr results  with a mortality of less than 1% and  
> probably in
> the  0.5% range and a hospital stay of 3 to 4 days?!
> Interested in the  feedback.
>
> Tom Martin
> U of Florida
>  Gainesville
>
>
> -----Original Message-----
> From:  Prasanna Simha M <prasannasimha at gmail.com>
> To:  OpenHeart-L at lists.hsforum.com
> Sent: Sat, 26 Apr 2008 11:32 am
>  Subject: Re: [HSF] RCA osteal lesion-osteal  reconstruction
>
>
>
> A single RCA lesion should  receive a PCI if possible. If not then it  
> can
> receive  any graft. No arterial graft has been shown to be better  
> than  a
> saphenous vein on the right side (In fact radials have been found  to  
> be
> worse if the lesion is less than 80 %). There is  no survival benefit  
> of a
> precrux arterial RCA graft and  the RIMA is better preserved for the  
> left
> system where  there is a possible shred of an evidence that a second  
> IMA  may
> be better.
> Prasanna
> On Sat, Apr 26, 2008 at 8:47  AM, yadav del <yadavluck at yahoo.com>  
>  wrote:
>
>>
>> We have a  60 yr old female  patient admitted with acute inferior MI  
>> with
>> RV  extension . At admission she was in shock and complete heart   
>> block,severe
>> MR and severe TR.She improved with  temporary pacemaking.
>> Repeat echo after 3 weeks shwoed mild mr  mild tr, EF 60% and coronoro
>> angiogram showed RCA [large and  dominant] with 98% osteal lesion .
>> Dobutamine echo showed viable  RCA territory.
>>
>> What is the optimal surgical   treatment? RCA graft or osteal
>>  reconstruction?
>>
>>
>>  ---------------------------------
>> Be a better friend, newshound,  and know-it-all with Yahoo! Mobile.  
>> Try it
>>  now.
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>
>
>  -- 
> Prasanna Simha M
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