From prasannasimha at gmail.com Sun Feb 1 07:46:17 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sat Jan 31 21:23:16 2009 Subject: [HSF] Incomplete OR case In-Reply-To: References: Message-ID: <89c4ed2d0901311816s5771fb9fj56f7f490472f8a8d@mail.gmail.com> She isnt getting extubated and her MR is "whitening" her lungs so she will need that fixed to come off the ventilator. Prasanna On Sun, Feb 1, 2009 at 1:06 AM, Edward Bender wrote: > Speaking of not doing all that should be done in the OR, sometimes you just > don?t get all the information that allows you to do everything indicated. > > Two weeks ago I was asked to see a case of a 40 year old female who had a > SJM aortic valve (21 mm) placed four years ago at another institution. One > year ago she had an embolic CVA from which she completely recovered. She > is > not very good about taking her coumadin. When I saw her, she had no > detectable BP, no clicking, and a heart rate of 140, so we rushed her off > to the OR, crashed on femoral bypass, and did a redo AVR for a completely > thrombosed prosthesis. On admission she had an echo performed which showed > a 5% EF, massively dilated LV, and mild MR. After she awoke, got > extubated, > and then re-intubated a few days later when her lungs whited out, I > repeated > the echo which now shows significant MR with no obvious flail, and an EF of > 60%. I fear she will need a mitral procedure in the near future. Would > anyone care to comment on timing? She weighs 40 kg, big smoker, > malnourished at the time of her acute illness. She is still intubated with > waxing and waning FiO2 requirements. She has yeast in her urine, MRSA on > her Swan-Ganz tip, but negative blood cultures since lines changed. She > grew MRSA form her sputum on admission (admitting diagnosis was pneumonia). > > Ed Bender, MD > _______________________________________________ > 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 Sun Feb 1 07:53:12 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sat Jan 31 21:30:06 2009 Subject: [HSF] to AVR or not to AVR In-Reply-To: References: Message-ID: <89c4ed2d0901311823q6d71a8cco33e428b165258cf4@mail.gmail.com> Was the left main disease "ostial' in nature ? could it be cardioplegia cannula induced ? If it was aortic prosthesis induced problems would have started on table. Prasanna On Sun, Feb 1, 2009 at 2:38 AM, wrote: > Ani, > You're right. I'll just leave the vein graft as is, do the LIMA to the > LAD, and the mitral. Going after the mitral with an aortic bioprosthesis > in > place is not something I'm eagerly anticipating. > > Hal > > > In a message dated 1/31/2009 4:02:00 P.M. Eastern Standard Time, > anianyanwu@hotmail.com writes: > > > >This 79 yo lady presented with severe > aortic stenosis and isolated > circumflex disease last July. One of my > partners did a vein graft the > circumflex > and an AVR. Cath revealed the LM was > obstructed (presumably by the > aortic > prosthesis) and the vein graft had a high > grade stenosis. > My plan is > to > regraft the CX, LIMA to the LAD > > > Well another vein graft down within a year - a problem we as a specialty > continue to deny exists in *our* individual practices with our wonderful > vein > harvests, physician assistants, surgeons and excellent surgical > techniques. And > this one is special because will have two reinterventions - one PCI and > one > CABG - within a year of its inception. I suppose it will probably be > replaced > again with another (endoscopic) vein graft but to what end? To go down > again > in 6 months? > > I do know it is just one patient and useless anecdote, but sorry I just > could not resist! > > On a more serious note though given her presentation and her prior history > with vein graft, would just a mitral valve repair and LIMA to the LAD not > suffice? What is the status of the stent in the vein graft? I just wonder > if the > benefit of doing the OM graft again is not so marginal that may not be > worth > the incremental risk, even if small. > > Ani > > > > From: Hgrmd@aol.com> Date: Sat, 31 Jan 2009 12:39:11 -0500> Subject: > Re: > [HSF] to AVR or not to AVR> To: OpenHeart-L@lists.hsforum.com> CC: > > > Michael,> As you can probably tell from the cases I have presented on HSF > the past > > few years, I really hate leaving behind significant correctable cardiac > > pathology. Though the case is more complex, I believe the patients do > better in > > the short and long term. > I've got a lovely case for Monday. This 79 yo > lady presented with severe > aortic stenosis and isolated circumflex > disease > last July. One of my > partners did a vein graft the circumflex and an AVR > (19mm Magna) with a Nicks > annular enlargement. She had an uneventful > postop > course. However, several months > later, she represented with pulmonary > edema. > Cath revealed the LM was > obstructed (presumably by the aortic > prosthesis) > and the vein graft had a high > grade stenosis. The RCA was OK. The aortic > prosthesis had no leak and only a > 15 mm gradient. In addition, there was > now > severe MR. A PCI of the vein > graft was carried out. She is now > functional > class 3. The EF is in the 40's. > My plan is to regraft the CX, LIMA to > the > LAD, and repair the mitral via the > superior septal approach. I haven't > seen > the previous intraop TEE, but wonder > how much MR there was at the time.> > > > Hal> > > In a message dated 1/31/2009 12:17:54 P.M. Eastern Standard Time, > > > msfirst@gmail.com writes:> > Dr Frater -> > Sorry but my sarcasm did not > come > through appropriately. We have a > healthy business of fixing various > things > that were not fixed the > first time (as I am sure others are fixing my > misadventures) - kinda > like VADs and transplants (or high risk > CABG/MVRepairs) > in patients > with thrombosed proximal LAD stents. I think it is > interesting > how > many times the intra-operative plan changes on the ioTEE (there was > a > > good recent Annals paper on this) and along the lines of this thread, > I > wonder how many times the ioTEE finds things that should get fixed, > but > dont > - we just seem to hear (read?) about the things that are > "discovered" > and > fixed. Thoughts?> > -michael> > > On Jan 31, 2009, at 1:44 AM, > Rwmfglycar@aol.com wrote:> > > Michael> > Why are you sure? Far more > likely it was already > calcified and on > > its way to an area of <1cm2. There are papers on this > subject in > > which attempts have been made to predict which mild aortic > pathology? > > is on a rapid course to severe pathology and which not. > Degenerative > > calcific aortic stenosis does not develop overnight. But > once it > > > gets to a certain level the laws of physics determine that very > > small > extra > calcium deposits will change? noncritical to critical.> > By the way it is > not only in community hospitals that significant > > pathology is ignored > while a surgeon takes the easy course without > > regard for the future. > There > was a very distinguished? chairman in > > NY who said he did not do redo's > because he was a busy man.?A few of > > his ignored aortic valves drifted > up to > the Bronx with vein grafts > > on the ascending aorta for their aortic > valves > to be done,> > Bob> >> >> > I have a 79 year/old with 4 patent grafts and > an > AVA of 0.8 and an > > EF~35%> >> next week. His CABG was about 3-4 > years/ago > at a community > >> hospital..... I> >> wonder what his aortic valve > looked > like then? I am sure it was > >> normal.> >>> >>> >> >> >> >> > > -----Original Message-----> > From: Prasanna Simha M < > prasannasimha@gmail.com>> > To: > OpenHeart-L@lists.hsforum.com> > Sent: Sat, 31 Jan 2009 3:13 am> > > Subject: Re: > [HSF] to AVR or not to AVR> >> >> >> > So should we "prophylactically > replace " or more appropriately> > "prophetically" replace ?> > Prasanna> > >> > On > Sat, Jan 31, 2009 at 3:19 AM, Michael Firstenberg > > >wrote:> >> >> In the words of Tea-speak, it is amazing how we forget the > > >> > literature of> >> the> >> greats (thank you Dr Frater) to suit our whims > at > the moment. So > >> rather> >> than doing what may be the right operation > the > first time (like CABG > >> +AVR)> >> we> >> settle for the easy way out > and do > a couple of grafts off-pump (how > >> about> >> bringing that RIMA thru > the > transverse sinus to the Circ? or cross> >> midline?)> >> and claim > victory...... let the next surgeon deal with the redo AVR > >> and> >> > patent grafts > in a couple of years.> >>> >> I have a 79 year/old with 4 patent grafts > and an > AVA of 0.8 and an > >> EF~35%> >> next week. His CABG was about 3-4 > years/ago at a community > >> hospital..... I> >> wonder what his aortic > valve > looked like then? I am sure it was > >> normal.> >>> >>> >> -michael> >>> > >>> >>> > >> On Fri, Jan 30, 2009 at 4:17 PM, Donald Ross > > >> > wrote:> >>> >>>> >>>> I bet you if one did a study to find how such a > patient > was > >>>> managed by a> >>>> cohort of ON-pump as compared to Off-pump > surgeons one would find > >>>> more> >>>> replacements of the aortic valve > in > the on-pump surgeons as > >>>> compared to> >> the> >>>> off-pump > surgeons. > This is not to say though that replacement of > >>>> the> >> valve> >>>> > is the > right decision to make but just to illustrate how our biases> >> affect> > >>>> the decisions we make. Another example would be the attitude to > > >>>> > moderate> >>>> ischemic MR - off-pump surgeons are more likely to ignore > this > > >>>> while> >> many> >>>> on-pump surgeons would add in a ring.> >>>>> > >>> > Ani,> >>> I had a feeling you would strike if I dropped my guard.> >>> BTW > I > think the treatment of moderate MR is much more important in > >>> he> > >>> > context of ischaemic heart disease than mild non calcified AS and > >>> I > do> > >>> repair MR rather than just a "down and dirty opcab" ( Hal's quote)> > >>>> > >>>>> >>>> Don> >>> _______________________________________________> >>> > OpenHeart-L mailing list> >>>> >>> Send postings to:> >>> O> > > penHeart-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 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 Wall > Street to Main Street and everywhere in between, stay > up-to-date with > the > latest news. (http://aol.com?ncid=emlcntaolcom00000023)> > _______________________________________________> 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> > ----------------------------------------- > _________________________________________________________________ > Twice the fun?Share photos while you chat with Windows Live Messenger. > Learn > more. > > http://www.microsoft.com/uk/windows/windowslive/products/messenger.aspx_______ > ________________________________________ > 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 Wall Street to Main Street and everywhere in between, > stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 > ) > _______________________________________________ > 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 Sun Feb 1 09:11:38 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sat Jan 31 22:42:07 2009 Subject: [HSF] to AVR or not to AVR In-Reply-To: References: Message-ID: <89c4ed2d0901311941j21e8850bvf39e90490d75897a@mail.gmail.com> Thanks for the info. Usually augmentation of the aorta should cause the root to billow and allow coronary flow but then things happen !! On Sun, Feb 1, 2009 at 8:43 AM, wrote: > Prasanna, > No, the LM is completely occluded by the prosthesis. My partner's > original op note describes a very small annulus requiring enlargement just > to get in > a 19 mm valve. Fortunately, he did a vein graft to a large OM that wasn't > that tight. Thus, retrograde filling supplied the rest of the left > system. > You can actually see this on subsequent cath. If he hadn't done the vein > graft, he would never have been able to get off pump. > > Hal > > > In a message dated 1/31/2009 9:31:43 P.M. Eastern Standard Time, > prasannasimha@gmail.com writes: > > Was the left main disease "ostial' in nature ? could it be cardioplegia > cannula induced ? If it was aortic prosthesis induced problems would have > started on table. > Prasanna > > On Sun, Feb 1, 2009 at 2:38 AM, wrote: > > > Ani, > > You're right. I'll just leave the vein graft as is, do the LIMA to > the > > LAD, and the mitral. Going after the mitral with an aortic > bioprosthesis > > in > > place is not something I'm eagerly anticipating. > > > > Hal > > > > > > In a message dated 1/31/2009 4:02:00 P.M. Eastern Standard Time, > > anianyanwu@hotmail.com writes: > > > > > > >This 79 yo lady presented with severe > aortic stenosis and isolated > > circumflex disease last July. One of my > partners did a vein graft > the > > circumflex > > and an AVR. Cath revealed the LM was > obstructed (presumably by the > > aortic > > prosthesis) and the vein graft had a high > grade stenosis. > My plan > is > > to > > regraft the CX, LIMA to the LAD > > > > > > Well another vein graft down within a year - a problem we as a > specialty > > continue to deny exists in *our* individual practices with our > wonderful > > vein > > harvests, physician assistants, surgeons and excellent surgical > > techniques. And > > this one is special because will have two reinterventions - one PCI and > > one > > CABG - within a year of its inception. I suppose it will probably be > > replaced > > again with another (endoscopic) vein graft but to what end? To go down > > again > > in 6 months? > > > > I do know it is just one patient and useless anecdote, but sorry I just > > could not resist! > > > > On a more serious note though given her presentation and her prior > history > > with vein graft, would just a mitral valve repair and LIMA to the LAD > not > > suffice? What is the status of the stent in the vein graft? I just > wonder > > if the > > benefit of doing the OM graft again is not so marginal that may not be > > worth > > the incremental risk, even if small. > > > > Ani > > > > > > > From: Hgrmd@aol.com> Date: Sat, 31 Jan 2009 12:39:11 -0500> > Subject: > > Re: > > [HSF] to AVR or not to AVR> To: OpenHeart-L@lists.hsforum.com> CC: > > > > Michael,> As you can probably tell from the cases I have presented on > HSF > > the past > > > few years, I really hate leaving behind significant correctable cardiac > > > > pathology. Though the case is more complex, I believe the patients do > > better in > > > the short and long term. > I've got a lovely case for Monday. This 79 > yo > > lady presented with severe > aortic stenosis and isolated circumflex > > disease > > last July. One of my > partners did a vein graft the circumflex and an > AVR > > (19mm Magna) with a Nicks > annular enlargement. She had an uneventful > > postop > > course. However, several months > later, she represented with > pulmonary > > edema. > > Cath revealed the LM was > obstructed (presumably by the aortic > > prosthesis) > > and the vein graft had a high > grade stenosis. The RCA was OK. The > aortic > > prosthesis had no leak and only a > 15 mm gradient. In addition, there > was > > now > > severe MR. A PCI of the vein > graft was carried out. She is now > > functional > > class 3. The EF is in the 40's. > My plan is to regraft the CX, LIMA to > > the > > LAD, and repair the mitral via the > superior septal approach. I > haven't > > seen > > the previous intraop TEE, but wonder > how much MR there was at the > time.> > > > > > Hal> > > In a message dated 1/31/2009 12:17:54 P.M. Eastern Standard > Time, > > > > > msfirst@gmail.com writes:> > Dr Frater -> > Sorry but my sarcasm did > not > > come > > through appropriately. We have a > healthy business of fixing various > > things > > that were not fixed the > first time (as I am sure others are fixing my > > misadventures) - kinda > like VADs and transplants (or high risk > > CABG/MVRepairs) > > in patients > with thrombosed proximal LAD stents. I think it is > > interesting > > how > many times the intra-operative plan changes on the ioTEE (there > was > > a > > > good recent Annals paper on this) and along the lines of this thread, > > I > > wonder how many times the ioTEE finds things that should get fixed, > > but > > dont > > - we just seem to hear (read?) about the things that are > "discovered" > > and > > fixed. Thoughts?> > -michael> > > On Jan 31, 2009, at 1:44 AM, > > Rwmfglycar@aol.com wrote:> > > Michael> > Why are you sure? Far more > > likely it was already > > calcified and on > > its way to an area of <1cm2. There are papers on > this > > subject in > > which attempts have been made to predict which mild > aortic > > pathology? > > is on a rapid course to severe pathology and which not. > > Degenerative > > calcific aortic stenosis does not develop overnight. > But > > once it > > > > gets to a certain level the laws of physics determine that very > > > small > > extra > > calcium deposits will change? noncritical to critical.> > By the way it > is > > not only in community hospitals that significant > > pathology is > ignored > > while a surgeon takes the easy course without > > regard for the > future. > > There > > was a very distinguished? chairman in > > NY who said he did not do > redo's > > because he was a busy man.?A few of > > his ignored aortic valves > drifted > > up to > > the Bronx with vein grafts > > on the ascending aorta for their aortic > > valves > > to be done,> > Bob> >> >> > I have a 79 year/old with 4 patent grafts > and > > an > > AVA of 0.8 and an > > EF~35%> >> next week. His CABG was about 3-4 > > years/ago > > at a community > >> hospital..... I> >> wonder what his aortic valve > > looked > > like then? I am sure it was > >> normal.> >>> >>> >> >> >> >> > > > -----Original Message-----> > From: Prasanna Simha M < > > prasannasimha@gmail.com>> > To: > > OpenHeart-L@lists.hsforum.com> > Sent: Sat, 31 Jan 2009 3:13 am> > > > Subject: Re: > > [HSF] to AVR or not to AVR> >> >> >> > So should we "prophylactically > > replace " or more appropriately> > "prophetically" replace ?> > > Prasanna> > > >> > On > > Sat, Jan 31, 2009 at 3:19 AM, Michael Firstenberg > > > > >wrote:> >> >> In the words of Tea-speak, it is amazing how we forget > the > > > >> > > literature of> >> the> >> greats (thank you Dr Frater) to suit our > whims > > at > > the moment. So > >> rather> >> than doing what may be the right > operation > > the > > first time (like CABG > >> +AVR)> >> we> >> settle for the easy way > out > > and do > > a couple of grafts off-pump (how > >> about> >> bringing that RIMA > thru > > the > > transverse sinus to the Circ? or cross> >> midline?)> >> and claim > > victory...... let the next surgeon deal with the redo AVR > >> and> >> > > patent grafts > > in a couple of years.> >>> >> I have a 79 year/old with 4 patent grafts > > and an > > AVA of 0.8 and an > >> EF~35%> >> next week. His CABG was about 3-4 > > years/ago at a community > >> hospital..... I> >> wonder what his > aortic > > valve > > looked like then? I am sure it was > >> normal.> >>> >>> >> -michael> > >>> > > >>> >>> > > >> On Fri, Jan 30, 2009 at 4:17 PM, Donald Ross > > > > >> > > wrote:> >>> >>>> >>>> I bet you if one did a study to find how such a > > patient > > was > >>>> managed by a> >>>> cohort of ON-pump as compared to > Off-pump > > surgeons one would find > >>>> more> >>>> replacements of the aortic > valve > > in > > the on-pump surgeons as > >>>> compared to> >> the> >>>> off-pump > > surgeons. > > This is not to say though that replacement of > >>>> the> >> valve> > >>>> > > is the > > right decision to make but just to illustrate how our biases> >> > affect> > > >>>> the decisions we make. Another example would be the attitude to > > > >>>> > > moderate> >>>> ischemic MR - off-pump surgeons are more likely to > ignore > > this > > > >>>> while> >> many> >>>> on-pump surgeons would add in a ring.> > >>>>> > > >>> > > Ani,> >>> I had a feeling you would strike if I dropped my guard.> >>> > BTW > > I > > think the treatment of moderate MR is much more important in > >>> > he> > > >>> > > context of ischaemic heart disease than mild non calcified AS and > >>> > I > > do> > > >>> repair MR rather than just a "down and dirty opcab" ( Hal's quote)> > > >>>> > > >>>>> >>>> Don> >>> _______________________________________________> > >>> > > OpenHeart-L mailing list> >>>> >>> Send postings to:> >>> O> > > > penHeart-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 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 > Wall > > Street to Main Street and everywhere in between, stay > up-to-date with > > the > > latest news. (http://aol.com?ncid=emlcntaolcom00000023)> > > _______________________________________________> 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> > > ----------------------------------------- > > _________________________________________________________________ > > Twice the fun?Share photos while you chat with Windows Live Messenger. > > Learn > > more. > > > > > > http://www.microsoft.com/uk/windows/windowslive/products/messenger.aspx_______ > > ________________________________________ > > 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 Wall Street to Main Street and everywhere in between, > > stay > > up-to-date with the latest news. ( > http://aol.com?ncid=emlcntaolcom00000023 > > ) > > _______________________________________________ > > 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 > ----------------------------------------- > > **************From Wall Street to Main Street and everywhere in between, > stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 > ) > _______________________________________________ > 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 anianyanwu at hotmail.com Sun Feb 1 04:03:09 2009 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Sat Jan 31 23:03:41 2009 Subject: [HSF] to AVR or not to AVR In-Reply-To: <6.2.1.2.2.20090131205158.01d98760@pop.east.cox.net> References: <6.2.1.2.2.20090131205158.01d98760@pop.east.cox.net> Message-ID: > Excuse me, Ani, for my own edification, what conduit would you have> recommended for the circ in a 78yo woman having an AVR? Mitch >From Hal's later description of the OR report I would likely have done an isolated AVR here. In general I would not bypass a non-critical coronary lesion in an elderly patient that does not have angina pectoris. I remember Hal in particular cautioning on trouble one can get to bypassing either a non-critical or tiny circumflex, trouble which is not called for in an already high-risk operation to relieve valvar stenosis. Chances that this lesion has been, or will ever be, a problem in this 78 year old have to be minimal - provided other coronaries are free from significant disease. However, to answer your question in general terms, for an elderly patient with severe symptomatic AS and a circumflex stenosis, my strategy in order of preference, and also practice, would be 1) Isolated AVR 2) Isolated AVR with hybrid PCI on same admission 3) CABG (only if high grade lesion in big vessel and in a virgin chest) If I did do CABG, my choice of conduit would be same as for any single vessel on the left side which is the internal mammary artery. I would use a vein graft only if there are overriding reasons not to use the IMA or if I feel a need to have a conduit as a route to myocardial protection in the region served by the OM. Ani ---------------------------------------- > Date: Sat, 31 Jan 2009 20:54:57 -0600 > To: OpenHeart-L@lists.hsforum.com > From: drmitch@cox.net > Subject: RE: [HSF] to AVR or not to AVR > CC: > > Excuse me, Ani, for my own edification, what conduit would you have > recommended for the circ in a 78yo woman having an AVR?At 12:59 PM > 1/31/2009, you wrote: > > >>Mitch >>>This 79 yo lady presented with severe> aortic stenosis and isolated >> circumflex disease last July. One of my> partners did a vein graft the >> circumflex and an AVR. Cath revealed the LM was> obstructed (presumably >> by the aortic prosthesis) and the vein graft had a high> grade >> stenosis.> My plan is to regraft the CX, LIMA to the LAD >> >> >>Well another vein graft down within a year - a problem we as a specialty >>continue to deny exists in *our* individual practices with our wonderful >>vein harvests, physician assistants, surgeons and excellent surgical >>techniques. And this one is special because will have two reinterventions >>- one PCI and one CABG - within a year of its inception. I suppose it will >>probably be replaced again with another (endoscopic) vein graft but to >>what end? To go down again in 6 months? >> >>I do know it is just one patient and useless anecdote, but sorry I just >>could not resist! >> >>On a more serious note though given her presentation and her prior history >>with vein graft, would just a mitral valve repair and LIMA to the LAD not >>suffice? What is the status of the stent in the vein graft? I just wonder >>if the benefit of doing the OM graft again is not so marginal that may not >>be worth the incremental risk, even if small. >> >>Ani >> >> >>> From: Hgrmd@aol.com> Date: Sat, 31 Jan 2009 12:39:11 -0500> Subject: >> Re: [HSF] to AVR or not to AVR> To: OpenHeart-L@lists.hsforum.com> >> CC:>> Michael,> As you can probably tell from the cases I have >> presented on HSF the past> few years, I really hate leaving behind >> significant correctable cardiac> pathology. Though the case is more >> complex, I believe the patients do better in> the short and long term.> >> I've got a lovely case for Monday. This 79 yo lady presented with >> severe> aortic stenosis and isolated circumflex disease last July. One >> of my> partners did a vein graft the circumflex and an AVR (19mm Magna) >> with a Nicks> annular enlargement. She had an uneventful postop course. >> However, several months> later, she represented with pulmonary edema. >> Cath revealed the LM was> obstructed (presumably by the aortic >> prosthesis) and the vein graft had a high> grade stenosis. The RCA was >> OK. The aortic prosthesis had no leak and only a> 15 mm gradient. In >> addition, there was now severe MR. A PCI of the vein> graft was carried >> out. She is now functional class 3. The EF is in the 40's.> My plan is >> to regraft the CX, LIMA to the LAD, and repair the mitral via the> >> superior septal approach. I haven't seen the previous intraop TEE, but >> wonder> how much MR there was at the time.>> Hal>>> In a message >> dated 1/31/2009 12:17:54 P.M. Eastern Standard Time,> msfirst@gmail.com >> writes:>> Dr Frater ->> Sorry but my sarcasm did not come through >> appropriately. We have a> healthy business of fixing various things that >> were not fixed the> first time (as I am sure others are fixing my >> misadventures) - kinda> like VADs and transplants (or high risk >> CABG/MVRepairs) in patients> with thrombosed proximal LAD stents. I >> think it is interesting how> many times the intra-operative plan changes >> on the ioTEE (there was a> good recent Annals paper on this) and along >> the lines of this thread,> I wonder how many times the ioTEE finds >> things that should get fixed,> but dont - we just seem to hear (read?) >> about the things that are> "discovered" and fixed. Thoughts?>> >> -michael>>> On Jan 31, 2009, at 1:44 AM, Rwmfglycar@aol.com wrote:>>> >> Michael>> Why are you sure? Far more likely it was already calcified and >> on>> its way to an area of > in>> which attempts have been made to predict which mild aortic >> pathology?>> is on a rapid course to severe pathology and which not. >> Degenerative>> calcific aortic stenosis does not develop overnight. But >> once it>> gets to a certain level the laws of physics determine that >> very>> small extra calcium deposits will change? noncritical to >> critical.>> By the way it is not only in community hospitals that >> significant>> pathology is ignored while a surgeon takes the easy >> course without>> regard for the future. There was a very distinguished? >> chairman in>> NY who said he did not do redo's because he was a busy >> man.?A few of>> his ignored aortic valves drifted up to the Bronx with >> vein grafts>> on the ascending aorta for their aortic valves to be >> done,>> Bob>>>>>> I have a 79 year/old with 4 patent grafts and an >> AVA of 0.8 and an>> EF~35%>>> next week. His CABG was about 3-4 >> years/ago at a community>>> hospital..... I>>> wonder what his aortic >> valve looked like then? I am sure it was>>> >> normal.>>>>>>>>>>>>>>>> -----Original Message----->> From: >> Prasanna Simha M>> To: >> OpenHeart-L@lists.hsforum.com>> Sent: Sat, 31 Jan 2009 3:13 am>> >> Subject: Re: [HSF] to AVR or not to AVR>>>>>>>> So should we >> "prophylactically replace " or more appropriately>> "prophetically" >> replace ?>> Prasanna>>>> On Sat, Jan 31, 2009 at 3:19 AM, Michael >> Firstenberg>>wrote:>>>>> In the words of >> Tea-speak, it is amazing how we forget the>>> literature of>>> the>>> >> greats (thank you Dr Frater) to suit our whims at the moment. So>>> >> rather>>> than doing what may be the right operation the first time >> (like CABG>>> +AVR)>>> we>>> settle for the easy way out and do a >> couple of grafts off-pump (how>>> about>>> bringing that RIMA thru the >> transverse sinus to the Circ? or cross>>> midline?)>>> and claim >> victory...... let the next surgeon deal with the redo AVR>>> and>>> >> patent grafts in a couple of years.>>>>>> I have a 79 year/old with 4 >> patent grafts and an AVA of 0.8 and an>>> EF~35%>>> next week. His >> CABG was about 3-4 years/ago at a community>>> hospital..... I>>> >> wonder what his aortic valve looked like then? I am sure it was>>> >> normal.>>>>>>>>> -michael>>>>>>>>>>>> On Fri, Jan 30, 2009 at 4:17 >> PM, Donald Ross>>> wrote:>>>>>>>>>>>> I bet >> you if one did a study to find how such a patient was>>>>> managed by >> a>>>>> cohort of ON-pump as compared to Off-pump surgeons one would >> find>>>>> more>>>>> replacements of the aortic valve in the on-pump >> surgeons as>>>>> compared to>>> the>>>>> off-pump surgeons. This is >> not to say though that replacement of>>>>> the>>> valve>>>>> is the >> right decision to make but just to illustrate how our biases>>> >> affect>>>>> the decisions we make. Another example would be the attitude >> to>>>>> moderate>>>>> ischemic MR - off-pump surgeons are more likely >> to ignore this>>>>> while>>> many>>>>> on-pump surgeons would add in >> a ring.>>>>>>>>> Ani,>>>> I had a feeling you would strike if I >> dropped my guard.>>>> BTW I think the treatment of moderate MR is much >> more important in>>>> he>>>> context of ischaemic heart disease than >> mild non calcified AS and>>>> I do>>>> repair MR rather than just a >> "down and dirty opcab" ( Hal's quote)>>>>>>>>>>>>>> Don>>>> >> _______________________________________________>>>> OpenHeart-L mailing >> list>>>>>>>> Send postings to:>>>> O>> >> penHeart-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 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 Wall >> Street to Main Street and everywhere in between, stay> up-to-date with >> the latest news. (http://aol.com?ncid=emlcntaolcom00000023)> >> _______________________________________________> 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> >> ----------------------------------------- >>_________________________________________________________________ >>Twice the fun?Share photos while you chat with Windows Live Messenger. >>Learn more. >>http://www.microsoft.com/uk/windows/windowslive/products/messenger.aspx_______________________________________________ >>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 > ----------------------------------------- _________________________________________________________________ Windows Live Messenger just got better .Video display pics, contact updates & more. http://www.download.live.com/messenger From govindgovind at hotmail.com Sun Feb 1 09:34:05 2009 From: govindgovind at hotmail.com (govinda kubal) Date: Sat Jan 31 23:04:24 2009 Subject: [HSF] On pump vs Off In-Reply-To: <8CB523028F90BFB-17B4-1395@FWM-M18.sysops.aol.com> References: <8CB523028F90BFB-17B4-1395@FWM-M18.sysops.aol.com> Message-ID: For any surgeon actively engaged in CABG on pump, learning the ropes for off pump method is a definite advantage.Both methods are eminently successful in getting good results and we need to apply either judiciouly as per the clinical problem.There is no need to be a diehard supporter of only one method. If some of the surgeons are trying to use off pump method from marketing angle it is not the method which is at fault. govindakubal> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] On pump vs Off> Date: Sat, 31 Jan 2009 21:58:57 -0500> From: tdmartin2000@aol.com> CC: > > Bill> ?Laurie Davies is the principle investigator and has the manuscript. She was appointed to the Florida Board of Medicine during the study and was subsequently appointed as Chair of the Board - a big time consuming job. She has just completed her tenure on the board and will be completing the paper soon. It shows just what you would suspect but I cannot write it here as it has not been published and the journals don't like it when you give out the data.> Let's just say that it has not converted me.> > Tom> > > -----Original Message-----> From: wftjrtyler@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Fri, 30 Jan 2009 6:57 pm> Subject: Re: [HSF] On pump vs Off> > > > Tom, several years(and threads) ago, you were randomizing Opcabs vs. Oncab > at UF. Is your study in progress or did i miss the paper? bill turner> > > In a message dated 1/29/2009 8:53:17 P.M. Central Standard Time, > tdmartin2000@aol.com writes:> > agree> > > -----Original Message-----> From: hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:58 pm> Subject: Re: [HSF] On pump vs Off> > > > Tom,> You and I are essentially on the same side. Of course Dors and valves don't > apply. However, my perception, based on personal experience as well as the > literature, is that elderly vasculopaths with hostile aortas benefit from > OPCAB. > For the average case, it probably doesn't matter. You and I would agree > that > there are a lot of surgeons out there trying to use OPCAB for a marketing > angle. > I consider OPCAB an excellent technique to have in one's armamentarium. In > fact, I was recently summoned to the OR to take over my junior surgeon's > CABG > when he unexpectedly encountered a bad aorta. I stepped in and did a 3 > vessel > OPCAB. The patient did fine.> > Hal> > Hal > Sent from my Verizon Wireless BlackBerry> > -----Original Message-----> From: tdmartin2000@aol.com> > Date: Wed, 28 Jan 2009 23:44:34 > To: > Subject: Re: [HSF] On pump vs Off> > > Hal> I'm not sure John refuted as much as attacked it. His whole premise was on > the > difference between an administrative and a clinical data base. The presenter > had?a good rebuttal to John's rebuttal. I can't wait to see the manuscript > and > review it myself. It's hard to refute the conclusions of death, stroke, > length > of stay and costs when there is data on 63,000 pts no matter what kind of > data > base. I also have to?ask what your definition of a high risk case is and > where > the data is to confirm your premise. It is hard to do an off pump redo CABG > AVR > or MVR, or a CABG Dor, or a CABG, ascending, etc.. These would fall into the > > high risk cases for me. As you know I brought this up for the sake of > dis> cussion > and controversy.> > Tom> > > > > -----Original Message-----> From: hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:25 pm> Subject: Re: [HSF] On pump vs Off> > > > Tom,> Yes, it was provocative, but I thought John Puskas pretty much refuted it in > the discussion. As you know, his own group at Emory as well as thorough > exam of > > the STS database comes to the opposite conclusions. Again, I don't think > the 2 > approaches ar> e that distinguishable for low risk cases. However, most high risk > > subsets do better.> > Hal> ------Original Message------> From: tdmartin2000@aol.com> Sender: openheart-l-bounces@lists.hsforum.com> To: OpenHeart-L@lists.hsforum.com> ReplyTo: OpenHeart-L@lists.hsforum.com> Sent: Jan 28, 2009 11:18 PM> Subject: [HSF] On pump vs Off> > I really hate to get this going again but I REALLY don't believe that off is > better than on in any group except pts with significant aortic calcification > or > atheroma. There was an interesting paper just presented here at the STS that > created a sig controversy.> > On-pump vs Off-Pump Coronary Artery Bypass Surgery in a Cohort of 63,000 > Patients-? from Baylor and Texas Heart- reviewing the 2004 Nationwide > Inpatient > Sample database- admittedly an administrative database but with some really > good > > statistics.> Conclusions- 1. Opcab does not produce lower mortality or stroke 2. Opcab > has > longer hospital stays and higher costs ($1500) 3. Performing Opcab in all > candidates for myocardial revascularization may not be justifiable.> > Comments> > Tom Martin> U of Florida> Gainesville> _______________________________________________> 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> -----------------------------------------> > > Sent from my Verizon Wireless Black> Berry> > > > _______________________________________________> 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 ma> iling 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> -----------------------------------------> > > **************A Good Credit Score is 700 or Above. See yours in just 2 easy > steps! > (http://pr.atwola.com/promoclk/100000075x1215855013x1201028747/aol?redir=http://www.freecreditreport.com/pm/default.aspx?sc=668072%26hmpgID=62%26bcd=De> cemailfooterNO62)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHe> art-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> ----------------------------------------- _________________________________________________________________ Wish to Marry Now? Join MSN Matrimony FREE! http://www.in.msn.com/matrimony From CSPassik at aol.com Sun Feb 1 00:29:22 2009 From: CSPassik at aol.com (CSPassik@aol.com) Date: Sun Feb 1 00:29:53 2009 Subject: [HSF] Re:TR Message-ID: Hal, Actually, you're comments are fascinating, particularly the fact that the RV seemed to be moving well. I would have expected the RV to be big and suffering in appearance. This perhaps speaks for another mechanism- do you think it may be possible for regional RV wall motion abnormalities to cause TR from asynergy- just like regional LV abnormalities can cause transient bad MR with an overall good ventricle? Even in the absence of much air on TEE, I very frequently see air bubbles come right down the acute marginals after unclamping- this certainly gives global and perhaps regional RV abnormalities. The native RCA always takes the hit before the RCA graft. A useful technique that I use in this situation( and reported in a letter commenting on a paper by Salerno in the Annals in 1996) is to nick 1 or 2 small acute marginals to let the air escape- the RV returns very quickly. Now I will start to look at what happens to the tricuspid with this maneuver. The tummy tuck or breast enlargement is optional and purely facetious. Cary **************Great Deals on Dell Laptops. Starting at $499. (http://pr.atwola.com/promoclk/100000075x1217883258x1201191827/aol?redir=http://www.dell.com/co ntent/products/features.aspx/laptops_great_deals?c=us%26cs=19%26l=en%26s=d hs%26~ck=anavml) From robertobattellini at hotmail.com Sun Feb 1 09:47:37 2009 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Sun Feb 1 03:48:28 2009 Subject: [HSF] Incomplete OR case In-Reply-To: References: Message-ID: Great job done, Ed Significant MR and if patient can?t get out of respirator = death Now, How-to-do-it is a chapter: cold fibrilating heart? clamping the aorta and coronary sinus perfusion, beating heart? Which would be your preference? Roberto > Subject: RE: [HSF] Incomplete OR case> Date: Sat, 31 Jan 2009 14:33:22 -0800> From: ecdouville@orclinic.com> To: OpenHeart-L@lists.hsforum.com> CC: > > Ed what a great save on your part to get her to this point. I would repair or replace her mitral valve this admit. chuckdouville> > ________________________________> > From: openheart-l-bounces@lists.hsforum.com on behalf of Edward Bender> Sent: Sat 1/31/2009 11:36 AM> To: HSF List> Subject: [HSF] Incomplete OR case> > > > Speaking of not doing all that should be done in the OR, sometimes you just> don?t get all the information that allows you to do everything indicated.> > Two weeks ago I was asked to see a case of a 40 year old female who had a> SJM aortic valve (21 mm) placed four years ago at another institution. One> year ago she had an embolic CVA from which she completely recovered. She is> not very good about taking her coumadin. When I saw her, she had no> detectable BP, no clicking, and a heart rate of 140, so we rushed her off> to the OR, crashed on femoral bypass, and did a redo AVR for a completely> thrombosed prosthesis. On admission she had an echo performed which showed> a 5% EF, massively dilated LV, and mild MR. After she awoke, got extubated,> and then re-intubated a few days later when her lungs whited out, I repeated> the echo which now shows significant MR with no obvious flail, and an EF of> 60%. I fear she will need a mitral procedure in the near future. Would> anyone care to comment on timing? She weighs 40 kg, big smoker,> malnourished at the time of her acute illness. She is still intubated with> waxing and waning FiO2 requirements. She has yeast in her urine, MRSA on> her Swan-Ganz tip, but negative blood cultures since lines changed. She> grew MRSA form her sputum on admission (admitting diagnosis was pneumonia).> > Ed Bender, MD> _______________________________________________> 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 Sun Feb 1 06:47:58 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Feb 1 06:48:27 2009 Subject: [HSF] On pump vs Off Message-ID: I whole heartedly agree with you. Even the most die hard on pump surgeon is bound to eventually encounter a case that he will screw up if he isn't able to do at least the occasional off pump. Because Florida is now reporting the mortality statistics of all surgeons (like New York), I plan to do more isolated CABG's. I suspect at least half will be OPCAB. Hal In a message dated 1/31/2009 11:06:20 P.M. Eastern Standard Time, govindgovind@hotmail.com writes: For any surgeon actively engaged in CABG on pump, learning the ropes for off pump method is a definite advantage.Both methods are eminently successful in getting good results and we need to apply either judiciouly as per the clinical problem.There is no need to be a diehard supporter of only one method. If some of the surgeons are trying to use off pump method from marketing angle it is not the method which is at fault. govindakubal> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] On pump vs Off> Date: Sat, 31 Jan 2009 21:58:57 -0500> From: tdmartin2000@aol.com> CC: > > Bill> ?Laurie Davies is the principle investigator and has the manuscript. She was appointed to the Florida Board of Medicine during the study and was subsequently appointed as Chair of the Board - a big time consuming job. She has just completed her tenure on the board and will be completing the paper soon. It shows just what you would suspect but I cannot write it here as it has not been published and the journals don't like it when you give out the data.> Let's just say that it has not converted me.> > Tom> > > -----Original Message-----> From: wftjrtyler@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Fri, 30 Jan 2009 6:57 pm> Subject: Re: [HSF] On pump vs Off> > > > Tom, several years(and threads) ago, you were randomizing Opcabs vs. Oncab > at UF. Is your study in progress or did i miss the paper? bill turner> > > In a message dated 1/29/2009 8:53:17 P.M. Central Standard Time, > tdmartin2000@aol.com writes:> > agree> > > -----Original Message-----> From: hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:58 pm> Subject: Re: [HSF] On pump vs Off> > > > Tom,> You and I are essentially on the same side. Of course Dors and valves don't > apply. However, my perception, based on personal experience as well as the > literature, is that elderly vasculopaths with hostile aortas benefit from > OPCAB. > For the average case, it probably doesn't matter. You and I would agree > that > there are a lot of surgeons out there trying to use OPCAB for a marketing > angle. > I consider OPCAB an excellent technique to have in one's armamentarium. In > fact, I was recently summoned to the OR to take over my junior surgeon's > CABG > when he unexpectedly encountered a bad aorta. I stepped in and did a 3 > vessel > OPCAB. The patient did fine.> > Hal> > Hal > Sent from my Verizon Wireless BlackBerry> > -----Original Message-----> From: tdmartin2000@aol.com> > Date: Wed, 28 Jan 2009 23:44:34 > To: > Subject: Re: [HSF] On pump vs Off> > > Hal> I'm not sure John refuted as much as attacked it. His whole premise was on > the > difference between an administrative and a clinical data base. The presenter > had?a good rebuttal to John's rebuttal. I can't wait to see the manuscript > and > review it myself. It's hard to refute the conclusions of death, stroke, > length > of stay and costs when there is data on 63,000 pts no matter what kind of > data > base. I also have to?ask what your definition of a high risk case is and > where > the data is to confirm your premise. It is hard to do an off pump redo CABG > AVR > or MVR, or a CABG Dor, or a CABG, ascending, etc.. These would fall into the > > high risk cases for me. As you know I brought this up for the sake of > dis> cussion > and controversy.> > Tom> > > > > -----Original Message-----> From: hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:25 pm> Subject: Re: [HSF] On pump vs Off> > > > Tom,> Yes, it was provocative, but I thought John Puskas pretty much refuted it in > the discussion. As you know, his own group at Emory as well as thorough > exam of > > the STS database comes to the opposite conclusions. Again, I don't think > the 2 > approaches ar> e that distinguishable for low risk cases. However, most high risk > > subsets do better.> > Hal> ------Original Message------> From: tdmartin2000@aol.com> Sender: openheart-l-bounces@lists.hsforum.com> To: OpenHeart-L@lists.hsforum.com> ReplyTo: OpenHeart-L@lists.hsforum.com> Sent: Jan 28, 2009 11:18 PM> Subject: [HSF] On pump vs Off> > I really hate to get this going again but I REALLY don't believe that off is > better than on in any group except pts with significant aortic calcification > or > atheroma. There was an interesting paper just presented here at the STS that > created a sig controversy.> > On-pump vs Off-Pump Coronary Artery Bypass Surgery in a Cohort of 63,000 > Patients-? from Baylor and Texas Heart- reviewing the 2004 Nationwide > Inpatient > Sample database- admittedly an administrative database but with some really > good > > statistics.> Conclusions- 1. Opcab does not produce lower mortality or stroke 2. Opcab > has > longer hospital stays and higher costs ($1500) 3. Performing Opcab in all > candidates for myocardial revascularization may not be justifiable.> > Comments> > Tom Martin> U of Florida> Gainesville> _______________________________________________> 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> -----------------------------------------> > > Sent from my Verizon Wireless Black> Berry> > > > _______________________________________________> 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 ma> iling 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> -----------------------------------------> > > **************A Good Credit Score is 700 or Above. See yours in just 2 easy > steps! > (http://pr.atwola.com/promoclk/100000075x1215855013x1201028747/aol?redir=http://www.freecreditreport. com/pm/default.aspx?sc=668072%26hmpgID=62%26bcd=De> cemailfooterNO62)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHe> art-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> ----------------------------------------- _________________________________________________________________ Wish to Marry Now? Join MSN Matrimony FREE! http://www.in.msn.com/matrimony_______________________________________________ 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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) From Hgrmd at aol.com Sun Feb 1 06:49:39 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Feb 1 06:50:43 2009 Subject: [HSF] Re:TR Message-ID: Cary, I knew you were kidding. Your tip to nick the acute marginals is excellent. What do you use, a 27 gauge needle? Hal In a message dated 2/1/2009 12:31:53 A.M. Eastern Standard Time, CSPassik@aol.com writes: Hal, Actually, you're comments are fascinating, particularly the fact that the RV seemed to be moving well. I would have expected the RV to be big and suffering in appearance. This perhaps speaks for another mechanism- do you think it may be possible for regional RV wall motion abnormalities to cause TR from asynergy- just like regional LV abnormalities can cause transient bad MR with an overall good ventricle? Even in the absence of much air on TEE, I very frequently see air bubbles come right down the acute marginals after unclamping- this certainly gives global and perhaps regional RV abnormalities. The native RCA always takes the hit before the RCA graft. A useful technique that I use in this situation( and reported in a letter commenting on a paper by Salerno in the Annals in 1996) is to nick 1 or 2 small acute marginals to let the air escape- the RV returns very quickly. Now I will start to look at what happens to the tricuspid with this maneuver. The tummy tuck or breast enlargement is optional and purely facetious. Cary **************Great Deals on Dell Laptops. Starting at $499. (http://pr.atwola.com/promoclk/100000075x1217883258x1201191827/aol?redir=http: //www.dell.com/co ntent/products/features.aspx/laptops_great_deals?c=us%26cs=19%26l=en%26s=d hs%26~ck=anavml) _______________________________________________ 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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) From cspassik at aol.com Sun Feb 1 09:12:29 2009 From: cspassik at aol.com (cspassik@aol.com) Date: Sun Feb 1 09:13:04 2009 Subject: [HSF] Re:TR In-Reply-To: References: Message-ID: <8CB528E40549CFA-884-18F2@webmail-db11.sysops.aol.com> Hal, No, an 11 blade-you just have to pick a small one or two to sacrifice for the good of the rest of the heart. It's a neat trick I learned 20 years ago from Dr Francisco Puga, who was an outstanding congenital surgeon. The RV can improve almost immediately. ? It's in the ATS, 1996, v62 p.630. Cary -----Original Message----- From: Hgrmd@aol.com To: OpenHeart-L@lists.hsforum.com Sent: Sun, 1 Feb 2009 6:49 am Subject: Re: [HSF] Re:TR Cary, I knew you were kidding. Your tip to nick the acute marginals is excellent. What do you use, a 27 gauge needle? Hal In a message dated 2/1/2009 12:31:53 A.M. Eastern Standard Time, CSPassik@aol.com writes: Hal, Actually, you're comments are fascinating, particularly the fact that the RV seemed to be moving well. I would have expected the RV to be big and suffering in appearance. This perhaps speaks for another mechanism- do you think it may be possible for regional RV wall motion abnormalities to cause TR from asynergy- just like regional LV abnormalities can cause transient bad MR with an overall good ventricle? Even in the absence of much air on TEE, I very frequently see air bubbles come right down the acute marginals after unclamping- this certainly gives global and perhaps regional RV abnormalities. The native RCA always takes the hit before the RCA graft. A useful technique that I use in this situation( and reported in a letter commenting on a paper by Salerno in the Annals in 1996) is to nick 1 or 2 small acute marginals to let the air escape- the RV returns very quickly. Now I will start to look at what happens to the tricuspid with this maneuver. The tummy tuck or breast enlargement is optional and purely facetious. Cary **************Great Deals on Dell Laptops. Starting at $499. (http://pr.atwola.com/promoclk/100000075x1217883258x1201191827/aol?redir=http: //www.dell.com/co ntent/products/features.aspx/laptops_great_deals?c=us%26cs=19%26l=en%26s=d hs%26~ck=anavml) _______________________________________________ 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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) _______________________________________________ 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 Sun Feb 1 14:17:17 2009 From: hgrmd at aol.com (hgrmd@aol.com) Date: Sun Feb 1 09:17:41 2009 Subject: [HSF] Re:TR In-Reply-To: <8CB528E40549CFA-884-18F2@webmail-db11.sysops.aol.com> References: <8CB528E40549CFA-884-18F2@webmail-db11.sysops.aol.com> Message-ID: <396759382-1233497832-cardhu_decombobulator_blackberry.rim.net-1144432095-@bxe016.bisx.prod.on.blackberry> VGhhbmtzIENhcnkuICBJdCdzIHRpcHMgbGlrZSB0aGlzIHRoYXQgbWFrZSBIU0Ygd29ydGh3aGls ZSAuDQoNCkhhbA0KU2VudCBmcm9tIG15IFZlcml6b24gV2lyZWxlc3MgQmxhY2tCZXJyeQ0KDQot 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dGluZm8vb3BlbmhlYXJ0LWwNCg0KQWxsIG1lc3NhZ2VzIHRyYW5zbWl0dGVkIGJ5IHRoZSBPcGVu SGVhcnQtTCBhcmUgc3ViamVjdCB0byB0aGUgcG9saWNpZXMgYW5kIA0KZGlzY2xhaW1lcnMgcG9z dGVkIGF0Og0KaHR0cDovL3d3dy5oc2ZvcnVtLmNvbS9saXN0ZGlzY2xhaW0NCi0tLS0tLS0tLS0t LS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tDQo= From ebender001 at me.com Sun Feb 1 06:49:03 2009 From: ebender001 at me.com (Edward Bender) Date: Sun Feb 1 09:49:39 2009 Subject: [HSF] Incomplete OR case In-Reply-To: References: Message-ID: <92586646247717015438440420932125430839-Webmail@me.com> Thanks, Roberto. Actually, she has no coronary disease, normal EF now, so the only potential difficult issue regarding the conduct of the operation is the presence of an aortic prosthesis. I usually do these cases trans-septally. Still, the surgical procedure itself will only be a small part of the patient's recovery. I am really worried about her overall debilitated state and expect a trach, PEG, and long-term acute care facility eventually. Ed Bender, MD On Sunday, February 01, 2009, at 12:47AM, "Roberto Battellini" wrote: > >Great job done, Ed > >Significant MR and if patient can?t get out of respirator = death >Now, How-to-do-it is a chapter: cold fibrilating heart? clamping the aorta and coronary sinus perfusion, beating heart? > >Which would be your preference? >Roberto > >> Subject: RE: [HSF] Incomplete OR case> Date: Sat, 31 Jan 2009 14:33:22 -0800> From: ecdouville@orclinic.com> To: OpenHeart-L@lists.hsforum.com> CC: > > Ed what a great save on your part to get her to this point. I would repair or replace her mitral valve this admit. chuckdouville> > ________________________________> > From: openheart-l-bounces@lists.hsforum.com on behalf of Edward Bender> Sent: Sat 1/31/2009 11:36 AM> To: HSF List> Subject: [HSF] Incomplete OR case> > > > Speaking of not doing all that should be done in the OR, sometimes you just> don?t get all the information that allows you to do everything indicated.> > Two weeks ago I was asked to see a case of a 40 year old female who had a> SJM aortic valve (21 mm) placed four years ago at another institution. One> year ago she had an embolic CVA from which she completely recovered. She is> not very good about taking her coumadin. When I saw her, she had no> detectable BP, no clicking, and a heart rate of 140, so we rushed her off> to the OR, crashed on femoral bypass, and did a redo AVR for a completely> thrombosed prosthesis. On admission she had an echo performed which showed> a 5% EF, massively dilated LV, and mild MR. After she awoke, got extubated,> and then re-intubated a few days later when her lungs whited out, I repeated> the echo which now shows significant MR with no obvious flail, and an EF of> 60%. I fear she will need a mitral procedure in the near future. Would> anyone care to comment on timing? She weighs 40 kg, big smoker,> malnourished at the time of her acute illness. She is still intubated with> waxing and waning FiO2 requirements. She has yeast in her urine, MRSA on> her Swan-Ganz tip, but negative blood cultures since lines changed. She> grew MRSA form her sputum on admission (admitting diagnosis was pneumonia).> > Ed Bender, MD> _______________________________________________> 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 Sun Feb 1 06:54:40 2009 From: tacuff at swbell.net (Tea Acuff) Date: Sun Feb 1 09:55:09 2009 Subject: [HSF] On pump vs Off Message-ID: <654814.79899.qm@web81606.mail.mud.yahoo.com> What format will they use for reporting? Tea Sent from my iPhone On Feb 1, 2009, at 5:47 AM, Hgrmd@aol.com wrote: I whole heartedly agree with you. Even the most die hard on pump surgeon is bound to eventually encounter a case that he will screw up if he isn't able to do at least the occasional off pump. Because Florida is now reporting the mortality statistics of all surgeons (like New York), I plan to do more isolated CABG's. I suspect at least half will be OPCAB. Hal In a message dated 1/31/2009 11:06:20 P.M. Eastern Standard Time, govindgovind@hotmail.com writes: For any surgeon actively engaged in CABG on pump, learning the ropes for off pump method is a definite advantage.Both methods are eminently successful in getting good results and we need to apply either judiciouly as per the clinical problem.There is no need to be a diehard supporter of only one method. If some of the surgeons are trying to use off pump method from marketing angle it is not the method which is at fault. govindakubal> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] On pump vs Off> Date: Sat, 31 Jan 2009 21:58:57 -0500> From: tdmartin2000@aol.com> CC: > > Bill> ?Laurie Davies is the principle investigator and has the manuscript. She was appointed to the Florida Board of Medicine during the study and was subsequently appointed as Chair of the Board - a big time consuming job. She has just completed her tenure on the board and will be completing the paper soon. It shows just what you would suspect but I cannot write it here as it has not been published and the journals don't like it when you give out the data.> Let's just say that it has not converted me.> > Tom> > > -----Original Message-----> From: wftjrtyler@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Fri, 30 Jan 2009 6:57 pm> Subject: Re: [HSF] On pump vs Off> > > > Tom, several years(and threads) ago, you were randomizing Opcabs vs. Oncab > at UF. Is your study in progress or did i miss the paper? bill turner> > > In a message dated 1/29/2009 8:53:17 P.M. Central Standard Time, > tdmartin2000@aol.com writes:> > agree> > > -----Original Message-----> From: hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:58 pm> Subject: Re: [HSF] On pump vs Off> > > > Tom,> You and I are essentially on the same side. Of course Dors and valves don't > apply. However, my perception, based on personal experience as well as the > literature, is that elderly vasculopaths with hostile aortas benefit from > OPCAB. > For the average case, it probably doesn't matter. You and I would agree > that > there are a lot of surgeons out there trying to use OPCAB for a marketing > angle. > I consider OPCAB an excellent technique to have in one's armamentarium. In > fact, I was recently summoned to the OR to take over my junior surgeon's > CABG > when he unexpectedly encountered a bad aorta. I stepped in and did a 3 > vessel > OPCAB. The patient did fine.> > Hal> > Hal > Sent from my Verizon Wireless BlackBerry> > -----Original Message-----> From: tdmartin2000@aol.com> > Date: Wed, 28 Jan 2009 23:44:34 > To: > Subject: Re: [HSF] On pump vs Off> > > Hal> I'm not sure John refuted as much as attacked it. His whole premise was on > the > difference between an administrative and a clinical data base. The presenter > had?a good rebuttal to John's rebuttal. I can't wait to see the manuscript > and > review it myself. It's hard to refute the conclusions of death, stroke, > length > of stay and costs when there is data on 63,000 pts no matter what kind of > data > base. I also have to?ask what your definition of a high risk case is and > where > the data is to confirm your premise. It is hard to do an off pump redo CABG > AVR > or MVR, or a CABG Dor, or a CABG, ascending, etc.. These would fall into the > > high risk cases for me. As you know I brought this up for the sake of > dis> cussion > and controversy.> > Tom> > > > > -----Original Message-----> From: hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:25 pm> Subject: Re: [HSF] On pump vs Off> > > > Tom,> Yes, it was provocative, but I thought John Puskas pretty much refuted it in > the discussion. As you know, his own group at Emory as well as thorough > exam of > > the STS database comes to the opposite conclusions. Again, I don't think > the 2 > approaches ar> e that distinguishable for low risk cases. However, most high risk > > subsets do better.> > Hal> ------Original Message------> From: tdmartin2000@aol.com> Sender: openheart-l-bounces@lists.hsforum.com> To: OpenHeart-L@lists.hsforum.com> ReplyTo: OpenHeart-L@lists.hsforum.com> Sent: Jan 28, 2009 11:18 PM> Subject: [HSF] On pump vs Off> > I really hate to get this going again but I REALLY don't believe that off is > better than on in any group except pts with significant aortic calcification > or > atheroma. There was an interesting paper just presented here at the STS that > created a sig controversy.> > On-pump vs Off-Pump Coronary Artery Bypass Surgery in a Cohort of 63,000 > Patients-? from Baylor and Texas Heart- reviewing the 2004 Nationwide > Inpatient Sample database- admittedly an administrative database but with some really > good > > statistics.> Conclusions- 1. Opcab does not produce lower mortality or stroke 2. Opcab > has > longer hospital stays and higher costs ($1500) 3. Performing Opcab in all > candidates for myocardial revascularization may not be justifiable.> > Comments> > Tom Martin> U of Florida> Gainesville> _______________________________________________> 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> -----------------------------------------> > > Sent from my Verizon Wireless Black> Berry> > > > _______________________________________________> 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 ma> iling 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> -----------------------------------------> > > **************A Good Credit Score is 700 or Above. See yours in just 2 easy > steps! > (http://pr.atwola.com/promoclk/100000075x1215855013x1201028747/aol?redir=http://www.freecreditreport. com/pm/default.aspx?sc=668072%26hmpgID=62%26bcd=De> cemailfooterNO62)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHe> art-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> ----------------------------------------- _________________________________________________________________ Wish to Marry Now? Join MSN Matrimony FREE! http://www.in.msn.com/matrimony_______________________________________________ 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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) _______________________________________________ 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 Sun Feb 1 15:00:10 2009 From: hgrmd at aol.com (hgrmd@aol.com) Date: Sun Feb 1 10:00:36 2009 Subject: [HSF] On pump vs Off In-Reply-To: <654814.79899.qm@web81606.mail.mud.yahoo.com> References: <654814.79899.qm@web81606.mail.mud.yahoo.com> Message-ID: <1095840663-1233500406-cardhu_decombobulator_blackberry.rim.net-390820265-@bxe016.bisx.prod.on.blackberry> VGVhLA0KICBJJ20gbm90IHN1cmUsIGJ1dCB3b3VsZG4ndCBiZSBzdXJwcmlzZWQgaWYgdGhlIHN0 YXRzIG1ha2UgaXQgdG8gdGhlIG5ld3NwYXBlci4gIENlcnRhaW5seSwgaXQgd2lsbCBiZSBvbmxp 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LS0tLS0tLS0tLS0tLS0tLS0tLS0NCg== From tacuff at swbell.net Sun Feb 1 07:03:31 2009 From: tacuff at swbell.net (Tea Acuff) Date: Sun Feb 1 10:04:01 2009 Subject: [HSF] On pump vs Off References: <654814.79899.qm@web81606.mail.mud.yahoo.com> <1095840663-1233500406-cardhu_decombobulator_blackberry.rim.net-390820265-@bxe016.bisx.prod.on.blackberry> Message-ID: <238202.11619.qm@web81601.mail.mud.yahoo.com> So. Is it just "heart mortality" or what. tea ________________________________ From: "hgrmd@aol.com" To: OpenHeart-L@lists.hsforum.com Sent: Sunday, February 1, 2009 9:00:10 AM Subject: Re: [HSF] On pump vs Off Tea, ? I'm not sure, but wouldn't be surprised if the stats make it to the newspaper.? Certainly, it will be online.? Anyway, I'm at a disadvantage since my case load if over 95 per cent valves. Hal Sent from my Verizon Wireless BlackBerry -----Original Message----- From: Tea Acuff Date: Sun, 1 Feb 2009 06:54:40 To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] On pump vs Off What format will they use for reporting? Tea Sent from my iPhone On Feb 1, 2009, at 5:47 AM, Hgrmd@aol.com wrote: I whole heartedly agree with you.? Even the most die hard on pump? surgeon is bound to eventually encounter a case that he will screw up if he? isn't able to do at least the occasional off pump.? Because Florida is now? reporting the mortality statistics of all surgeons (like New York), I plan to do? more isolated CABG's.? I suspect at least half will be OPCAB. Hal In a message dated 1/31/2009 11:06:20 P.M. Eastern Standard Time,? govindgovind@hotmail.com writes: For any surgeon actively engaged in CABG on pump, learning? the ropes for off pump method is a definite advantage.Both methods are? eminently successful in getting good results and we need to apply either? judiciouly as per the clinical problem.There is no need to be a diehard? supporter of only one method. If some of the surgeons are trying to use off? pump method from marketing angle it is not the method which is at? fault. govindakubal> To: OpenHeart-L@lists.hsforum.com> Subject:? Re: [HSF] On pump vs Off> Date: Sat, 31 Jan 2009 21:58:57 -0500> From:? tdmartin2000@aol.com> CC: > > Bill> ?Laurie Davies is the? principle investigator and has the manuscript. She was appointed to the? Florida Board of Medicine during the study and was subsequently appointed as? Chair of the Board - a big time consuming job. She has just completed her? tenure on the board and will be completing the paper soon. It shows just what? you would suspect but I cannot write it here as it has not been published and? the journals don't like it when you give out the data.> Let's just say that? it has not converted me.> > Tom> > > -----Original Message-----> From: wftjrtyler@aol.com> To:? OpenHeart-L@lists.hsforum.com> Sent: Fri, 30 Jan 2009 6:57 pm> Subject:? Re: [HSF] On pump vs Off> > > > Tom, several years(and threads)? ago, you were randomizing Opcabs vs. Oncab > at UF. Is your study in? progress or did i miss the paper? bill turner> > > In a message dated? 1/29/2009 8:53:17 P.M. Central Standard Time, > tdmartin2000@aol.com? writes:> > agree> > > -----Original Message-----> From:? hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009? 11:58 pm> Subject: Re: [HSF] On pump vs Off> > > > Tom,> You? and I are essentially on the same side. Of course Dors and valves don't >? apply. However, my perception, based on personal experience as well as the? > literature, is that elderly vasculopaths with hostile aortas benefit from? > OPCAB. > For the average case, it probably doesn't matter. You and I? would agree > that > there are a lot of surgeons out there trying to use? OPCAB for a marketing > angle. > I consider OPCAB an excellent technique? to have in one's armamentarium. In > fact, I was recently summoned to the? OR to take over my junior surgeon's > CABG > when he unexpectedly? encountered a bad aorta. I stepped in and did a 3 > vessel > OPCAB. The? patient did fine.> > Hal> > Hal > Sent from my Verizon Wireless? BlackBerry> > -----Original Message-----> From:? tdmartin2000@aol.com> > Date: Wed, 28 Jan 2009 23:44:34 > To:? > Subject: Re: [HSF] On pump vs? Off> > > Hal> I'm not sure John refuted as much as attacked it.? His whole premise was on > the > difference between an administrative? and a clinical data base. The presenter > had?a good rebuttal to John's? rebuttal. I can't wait to see the manuscript > and > review it myself.? It's hard to refute the conclusions of death, stroke, > length > of stay? and costs when there is data on 63,000 pts no matter what kind of > data? > base. I also have to?ask what your definition of a high risk case is and? > where > the data is to confirm your premise. It is hard to do an off? pump redo CABG > AVR > or MVR, or a CABG Dor, or a CABG, ascending,? etc.. These would fall into the > > high risk cases for me. As you know? I brought this up for the sake of > dis> cussion > and? controversy.> > Tom> > > > > -----Original? Message-----> From: hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com>? Sent: Wed, 28 Jan 2009 11:25 pm> Subject: Re: [HSF] On pump vs Off> >? > > Tom,> Yes, it was provocative, but I thought John Puskas pretty? much refuted it in > the discussion. As you know, his own group at Emory as? well as thorough > exam of > > the STS database comes to the opposite? conclusions. Again, I don't think > the 2 > approaches ar> e that? distinguishable for low risk cases. However, most high risk > > subsets? do better.> > Hal> ------Original Message------> From:? tdmartin2000@aol.com> Sender: openheart-l-bounces@lists.hsforum.com> To:? OpenHeart-L@lists.hsforum.com> ReplyTo: OpenHeart-L@lists.hsforum.com>? Sent: Jan 28, 2009 11:18 PM> Subject: [HSF] On pump vs Off> > I? really hate to get this going again but I REALLY don't believe that off is? > better than on in any group except pts with significant aortic? calcification > or > atheroma. There was an interesting paper just? presented here at the STS that > created a sig controversy.> >? On-pump vs Off-Pump Coronary Artery Bypass Surgery in a Cohort of 63,000 >? Patients-? from Baylor and Texas Heart- reviewing the 2004 Nationwide >? Inpatient Sample database- admittedly an administrative database but with? some really > good > > statistics.> Conclusions- 1. Opcab does not? produce lower mortality or stroke 2. Opcab > has > longer hospital stays? and higher costs ($1500) 3. Performing Opcab in all > candidates for? myocardial revascularization may not be justifiable.> > Comments>? > Tom Martin> U of Florida> Gainesville>? _______________________________________________> 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> -----------------------------------------> > > Sent from my Verizon? Wireless Black> Berry> > > >? _______________________________________________> 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 ma> iling? list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To? 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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> -----------------------------------------> > > **************A Good? Credit Score is 700 or Above. See yours in just 2 easy > steps! >? (http://pr.atwola.com/promoclk/100000075x1215855013x1201028747/aol?redir=http://www.freecreditreport. com/pm/default.aspx?sc=668072%26hmpgID=62%26bcd=De>? cemailfooterNO62)> _______________________________________________>? OpenHeart-L mailing list> > Send postings to:> OpenHe>? art-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> ----------------------------------------- _________________________________________________________________ Wish? to Marry Now? Join MSN Matrimony? FREE! http://www.in.msn.com/matrimony_______________________________________________ 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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) _______________________________________________ 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 Sun Feb 1 07:05:52 2009 From: tacuff at swbell.net (Tea Acuff) Date: Sun Feb 1 10:06:20 2009 Subject: [HSF] Incomplete OR case References: <92586646247717015438440420932125430839-Webmail@me.com> Message-ID: <909216.46955.qm@web81607.mail.mud.yahoo.com> I guess the question that makes me pause on rushing in is when and why did this MR come up? tea ________________________________ From: Edward Bender To: OpenHeart-L@lists.hsforum.com Sent: Sunday, February 1, 2009 8:49:03 AM Subject: RE: [HSF] Incomplete OR case Thanks, Roberto. Actually, she has no coronary disease, normal EF now, so the only potential difficult issue regarding the conduct of the operation is the presence of an aortic prosthesis.? I usually do these cases trans-septally.? Still, the surgical procedure itself will only be a small part of the patient's recovery. I am really worried about her overall debilitated state and expect a trach, PEG, and long-term acute care facility eventually. Ed Bender, MD On Sunday, February 01, 2009, at 12:47AM, "Roberto Battellini" wrote: > >Great job done, Ed > >Significant MR and if patient can?t get out of respirator = death >Now, How-to-do-it is a chapter: cold fibrilating heart? clamping the aorta and coronary sinus perfusion, beating heart? > >Which would be your preference? >Roberto > >> Subject: RE: [HSF] Incomplete OR case> Date: Sat, 31 Jan 2009 14:33:22 -0800> From: ecdouville@orclinic.com> To: OpenHeart-L@lists.hsforum.com> CC: > > Ed what a great save on your part to get her to this point. I would repair or replace her mitral valve this admit. chuckdouville> > ________________________________> > From: openheart-l-bounces@lists.hsforum.com on behalf of Edward Bender> Sent: Sat 1/31/2009 11:36 AM> To: HSF List> Subject: [HSF] Incomplete OR case> > > > Speaking of not doing all that should be done in the OR, sometimes you just> don?t get all the information that allows you to do everything indicated.> > Two weeks ago I was asked to see a case of a 40 year old female who had a> SJM aortic valve (21 mm) placed four years ago at another institution. One> year ago she had an embolic CVA from which she completely recovered. She is> not very good about taking her coumadin. When I saw her, she had no> detectable BP, no clicking, and a heart rate of 140, so we rushed her off> to the OR, crashed on femoral bypass, and did a redo AVR for a completely> thrombosed prosthesis. On admission she had an echo performed which showed> a 5% EF, massively dilated LV, and mild MR. After she awoke, got extubated,> and then re-intubated a few days later when her lungs whited out, I repeated> the echo which now shows significant MR with no obvious flail, and an EF of> 60%. I fear she will need a mitral procedure in the near future. Would> anyone care to comment on timing? She weighs 40 kg, big smoker,> malnourished at the time of her acute illness. She is still intubated with> waxing and waning FiO2 requirements. She has yeast in her urine, MRSA on> her Swan-Ganz tip, but negative blood cultures since lines changed. She> grew MRSA form her sputum on admission (admitting diagnosis was pneumonia).> > Ed Bender, MD> _______________________________________________> 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 ----------------------------------------- From Hgrmd at aol.com Sun Feb 1 10:24:41 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Feb 1 10:25:13 2009 Subject: [HSF] On pump vs Off Message-ID: Tea, Again, I'm not sure. Supposedly, the results will be risk stratified. However, given the ignorance of the general public, I suspect the raw mortality will really be the bottom line. Hal In a message dated 2/1/2009 10:05:54 A.M. Eastern Standard Time, tacuff@swbell.net writes: So. Is it just "heart mortality" or what. tea ________________________________ From: "hgrmd@aol.com" To: OpenHeart-L@lists.hsforum.com Sent: Sunday, February 1, 2009 9:00:10 AM Subject: Re: [HSF] On pump vs Off Tea, I'm not sure, but wouldn't be surprised if the stats make it to the newspaper. Certainly, it will be online. Anyway, I'm at a disadvantage since my case load if over 95 per cent valves. Hal Sent from my Verizon Wireless BlackBerry -----Original Message----- From: Tea Acuff Date: Sun, 1 Feb 2009 06:54:40 To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] On pump vs Off What format will they use for reporting? Tea Sent from my iPhone On Feb 1, 2009, at 5:47 AM, Hgrmd@aol.com wrote: I whole heartedly agree with you. Even the most die hard on pump surgeon is bound to eventually encounter a case that he will screw up if he isn't able to do at least the occasional off pump. Because Florida is now reporting the mortality statistics of all surgeons (like New York), I plan to do more isolated CABG's. I suspect at least half will be OPCAB. Hal In a message dated 1/31/2009 11:06:20 P.M. Eastern Standard Time, govindgovind@hotmail.com writes: For any surgeon actively engaged in CABG on pump, learning the ropes for off pump method is a definite advantage.Both methods are eminently successful in getting good results and we need to apply either judiciouly as per the clinical problem.There is no need to be a diehard supporter of only one method. If some of the surgeons are trying to use off pump method from marketing angle it is not the method which is at fault. govindakubal> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] On pump vs Off> Date: Sat, 31 Jan 2009 21:58:57 -0500> From: tdmartin2000@aol.com> CC: > > Bill> ?Laurie Davies is the principle investigator and has the manuscript. She was appointed to the Florida Board of Medicine during the study and was subsequently appointed as Chair of the Board - a big time consuming job. She has just completed her tenure on the board and will be completing the paper soon. It shows just what you would suspect but I cannot write it here as it has not been published and the journals don't like it when you give out the data.> Let's just say that it has not converted me.> > Tom> > > -----Original Message-----> From: wftjrtyler@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Fri, 30 Jan 2009 6:57 pm> Subject: Re: [HSF] On pump vs Off> > > > Tom, several years(and threads) ago, you were randomizing Opcabs vs. Oncab > at UF. Is your study in progress or did i miss the paper? bill turner> > > In a message dated 1/29/2009 8:53:17 P.M. Central Standard Time, > tdmartin2000@aol.com writes:> > agree> > > -----Original Message-----> From: hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:58 pm> Subject: Re: [HSF] On pump vs Off> > > > Tom,> You and I are essentially on the same side. Of course Dors and valves don't > apply. However, my perception, based on personal experience as well as the > literature, is that elderly vasculopaths with hostile aortas benefit from > OPCAB. > For the average case, it probably doesn't matter. You and I would agree > that > there are a lot of surgeons out there trying to use OPCAB for a marketing > angle. > I consider OPCAB an excellent technique to have in one's armamentarium. In > fact, I was recently summoned to the OR to take over my junior surgeon's > CABG > when he unexpectedly encountered a bad aorta. I stepped in and did a 3 > vessel > OPCAB. The patient did fine.> > Hal> > Hal > Sent from my Verizon Wireless BlackBerry> > -----Original Message-----> From: tdmartin2000@aol.com> > Date: Wed, 28 Jan 2009 23:44:34 > To: > Subject: Re: [HSF] On pump vs Off> > > Hal> I'm not sure John refuted as much as attacked it. His whole premise was on > the > difference between an administrative and a clinical data base. The presenter > had?a good rebuttal to John's rebuttal. I can't wait to see the manuscript > and > review it myself. It's hard to refute the conclusions of death, stroke, > length > of stay and costs when there is data on 63,000 pts no matter what kind of > data > base. I also have to?ask what your definition of a high risk case is and > where > the data is to confirm your premise. It is hard to do an off pump redo CABG > AVR > or MVR, or a CABG Dor, or a CABG, ascending, etc.. These would fall into the > > high risk cases for me. As you know I brought this up for the sake of > dis> cussion > and controversy.> > Tom> > > > > -----Original Message-----> From: hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:25 pm> Subject: Re: [HSF] On pump vs Off> > > > Tom,> Yes, it was provocative, but I thought John Puskas pretty much refuted it in > the discussion. As you know, his own group at Emory as well as thorough > exam of > > the STS database comes to the opposite conclusions. Again, I don't think > the 2 > approaches ar> e that distinguishable for low risk cases. However, most high risk > > subsets do better.> > Hal> ------Original Message------> From: tdmartin2000@aol.com> Sender: openheart-l-bounces@lists.hsforum.com> To: OpenHeart-L@lists.hsforum.com> ReplyTo: OpenHeart-L@lists.hsforum.com> Sent: Jan 28, 2009 11:18 PM> Subject: [HSF] On pump vs Off> > I really hate to get this going again but I REALLY don't believe that off is > better than on in any group except pts with significant aortic calcification > or > atheroma. There was an interesting paper just presented here at the STS that > created a sig controversy.> > On-pump vs Off-Pump Coronary Artery Bypass Surgery in a Cohort of 63,000 > Patients-? from Baylor and Texas Heart- reviewing the 2004 Nationwide > Inpatient Sample database- admittedly an administrative database but with some really > good > > statistics.> Conclusions- 1. Opcab does not produce lower mortality or stroke 2. Opcab > has > longer hospital stays and higher costs ($1500) 3. Performing Opcab in all > candidates for myocardial revascularization may not be justifiable.> > Comments> > Tom Martin> U of Florida> Gainesville> _______________________________________________> 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> -----------------------------------------> > > Sent from my Verizon Wireless Black> Berry> > > > _______________________________________________> 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 ma> iling 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> -----------------------------------------> > > **************A Good Credit Score is 700 or Above. See yours in just 2 easy > steps! > (http://pr.atwola.com/promoclk/100000075x1215855013x1201028747/aol?redir=http: //www.freecreditreport. com/pm/default.aspx?sc=668072%26hmpgID=62%26bcd=De> cemailfooterNO62)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHe> art-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> ----------------------------------------- _________________________________________________________________ Wish to Marry Now? Join MSN Matrimony FREE! http://www.in.msn.com/matrimony_______________________________________________ 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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. 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(http://aol.com?ncid=emlcntaolcom00000023) From anianyanwu at hotmail.com Sun Feb 1 15:27:13 2009 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Sun Feb 1 10:28:02 2009 Subject: [HSF] CABG reporting. In-Reply-To: <1095840663-1233500406-cardhu_decombobulator_blackberry.rim.net-390820265-@bxe016.bisx.prod.on.blackberry> References: <654814.79899.qm@web81606.mail.mud.yahoo.com> <1095840663-1233500406-cardhu_decombobulator_blackberry.rim.net-390820265-@bxe016.bisx.prod.on.blackberry> Message-ID: Hal One would only be at a disadvantage if one sees the stats as a means to promote or validate one's status as a top coronary surgeon - to do this one would need a high volume of CABG with low mortality (I assume that has to be the 'outcome' they will look at). However, given that you are not predominantly a coronary surgeon it shouldnt matter much to you. Assuming you do only 10 to 20 isolated CABGs per year then you would likely be excluded from ranking analysis (otherwise if you did 15 with no death, just like I did last year, then you would be ranked as the top coronary surgeon with a zero mortality risk which would make no sense). If one did include your cases in a report the confidence interval would be so wide such as to make your results meaningless. Only surgeons doing say 50 plus or so CABGs per year need worry about data reporting as the ranking and results would be more stable. If a low volume CABG surgeon wants to look good in the reports then one has to get more volume and try and aim to do at least 100 procedures per year for the data to have meaning. (the caveat though is that while a low volume surgeon will not get credited with low mortality, they will still get penalized for high mortality; if one does 10 cases and 5 die then small numbers wont protect from that). What is the stated goal of the Florida reporting exercise? I find it odd that with CABG in decline new reporting systems still emerge to track isolated CABG. I think one will find that cardiac surgery is becoming more like general thoracic where the make up of ones practice is very heterogenous with very few two operations being alike. The days where isolated CABG, isolated AVR and isolated MVR constituted 95% of most practices are long gone. We now have a plethora of operations and hybrids with various manners of combined procedures on an even more heterogenous group of patients which makes it very difficult to define index operations and compare outcomes. Why does the reporting make you plan to do more isolated CABGs? Ani > To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] On pump vs Off> From: hgrmd@aol.com> Date: Sun, 1 Feb 2009 15:00:10 +0000> CC: > > Tea,> I'm not sure, but wouldn't be surprised if the stats make it to the newspaper. Certainly, it will be online. Anyway, I'm at a disadvantage since my case load if over 95 per cent valves.> > Hal> Sent from my Verizon Wireless BlackBerry> > -----Original Message-----> From: Tea Acuff > > Date: Sun, 1 Feb 2009 06:54:40 > To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] On pump vs Off> > > What format will they use for reporting?> Tea> > Sent from my iPhone> > On Feb 1, 2009, at 5:47 AM, Hgrmd@aol.com wrote:> > I whole heartedly agree with you. Even the most die hard on pump surgeon is > bound to eventually encounter a case that he will screw up if he isn't able > to do at least the occasional off pump. Because Florida is now reporting the > mortality statistics of all surgeons (like New York), I plan to do more > isolated CABG's. I suspect at least half will be OPCAB.> > Hal> > > In a message dated 1/31/2009 11:06:20 P.M. Eastern Standard Time, > govindgovind@hotmail.com writes:> > > > > For any surgeon actively engaged in CABG on pump, learning the ropes for off > pump method is a definite advantage.Both methods are eminently successful in > getting good results and we need to apply either judiciouly as per the > clinical problem.There is no need to be a diehard supporter of only one method. If > some of the surgeons are trying to use off pump method from marketing angle > it is not the method which is at fault.> > govindakubal> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] On pump > vs Off> Date: Sat, 31 Jan 2009 21:58:57 -0500> From: tdmartin2000@aol.com> > CC: > > Bill> ?Laurie Davies is the principle investigator and has the > manuscript. She was appointed to the Florida Board of Medicine during the study and > was subsequently appointed as Chair of the Board - a big time consuming job. > She has just completed her tenure on the board and will be completing the > paper soon. It shows just what you would suspect but I cannot write it here as it > has not been published and the journals don't like it when you give out the > data.> Let's just say that it has not converted me.> > Tom> > > -----Original > Message-----> From: wftjrtyler@aol.com> To: OpenHeart-L@lists.hsforum.com> > Sent: Fri, 30 Jan 2009 6:57 pm> Subject: Re: [HSF] On pump vs Off> > > > Tom, > several years(and threads) ago, you were randomizing Opcabs vs. Oncab > at > UF. Is your study in progress or did i miss the paper? bill turner> > > In a > message dated 1/29/2009 8:53:17 P.M. Central Standard Time, > > tdmartin2000@aol.com writes:> > agree> > > -----Original Message-----> From: hgrmd@aol.com> > To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:58 pm> Subject: > Re: [HSF] On pump vs Off> > > > Tom,> You and I are essentially on the same > side. Of course Dors and valves don't > apply. However, my perception, based > on personal experience as well as the > literature, is that elderly > vasculopaths with hostile aortas benefit from > OPCAB. > For the average case, it > probably doesn't matter. You and I would agree > that > there are a lot of > surgeons out there trying to use OPCAB for a marketing > angle. > I consider OPCAB > an excellent technique to have in one's armamentarium. In > fact, I was > recently summoned to the OR to take over my junior surgeon's > CABG > when he > unexpectedly encountered a bad aorta. I stepped in and did a 3 > vessel > OPCAB. > The patient did fine.> > Hal> > Hal > Sent from my Verizon Wireless > BlackBerry> > -----Original Message-----> From: tdmartin2000@aol.com> > Date: Wed, 28 > Jan 2009 23:44:34 > To: > Subject: Re: [HSF] > On pump vs Off> > > Hal> I'm not sure John refuted as much as attacked it. > His whole premise was on > the > difference between an administrative and a > clinical data base. The presenter > had?a good rebuttal to John's rebuttal. I > can't wait to see the manuscript > and > review it myself. It's hard to refute > the conclusions of death, stroke, > length > of stay and costs when there is > data on 63,000 pts no matter what kind of > data > base. I also have to?ask > what your definition of a high risk case is and > where > the data is to > confirm your premise. It is hard to do an off pump redo CABG > AVR > or MVR, or a > CABG Dor, or a CABG, ascending, etc.. These would fall into the > > high risk > cases for me. As you know I brought this up for the sake of > dis> cussion > > and controversy.> > Tom> > > > > -----Original Message-----> From: > hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:25 pm> > Subject: Re: [HSF] On pump vs Off> > > > Tom,> Yes, it was provocative, but I > thought John Puskas pretty much refuted it in > the discussion. As you know, > his own group at Emory as well as thorough > exam of > > the STS database > comes to the opposite conclusions. Again, I don't think > the 2 > approaches ar> > e that distinguishable for low risk cases. However, most high risk > > > subsets do better.> > Hal> ------Original Message------> From: > tdmartin2000@aol.com> Sender: openheart-l-bounces@lists.hsforum.com> To: > OpenHeart-L@lists.hsforum.com> ReplyTo: OpenHeart-L@lists.hsforum.com> Sent: Jan 28, 2009 11:18 PM> > Subject: [HSF] On pump vs Off> > I really hate to get this going again but I > REALLY don't believe that off is > better than on in any group except pts > with significant aortic calcification > or > atheroma. There was an interesting > paper just presented here at the STS that > created a sig controversy.> > > On-pump vs Off-Pump Coronary Artery Bypass Surgery in a Cohort of 63,000 > > Patients-? from Baylor and Texas Heart- reviewing the 2004 Nationwide > Inpatient > Sample database- admittedly an administrative database but with some > really > good > > statistics.> Conclusions- 1. Opcab does not produce lower > mortality or stroke 2. Opcab > has > longer hospital stays and higher costs ($1500) > 3. Performing Opcab in all > candidates for myocardial revascularization may > not be justifiable.> > Comments> > Tom Martin> U of Florida> Gainesville> > _______________________________________________> 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>> -----------------------------------------> > > Sent from my Verizon Wireless > Black> Berry> > > > _______________________________________________> 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 ma> iling 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>> -----------------------------------------> > > **************A Good Credit > Score is 700 or Above. See yours in just 2 easy > steps! > > (http://pr.atwola.com/promoclk/100000075x1215855013x1201028747/aol?redir=http://www.freecreditreport.> com/pm/default.aspx?sc=668072%26hmpgID=62%26bcd=De> cemailfooterNO62)> > _______________________________________________> OpenHeart-L mailing list> > Send > postings to:> OpenHe> art-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>> -----------------------------------------> _________________________________________________________________> Wish to Marry Now? Join MSN Matrimony FREE!> http://www.in.msn.com/matrimony_______________________________________________> 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 Wall Street to Main Street and everywhere in between, stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023)> _______________________________________________> 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> ----------------------------------------- _________________________________________________________________ Check out the new and improved services from Windows Live. Learn more! http://clk.atdmt.com/UKM/go/132630768/direct/01/ From ebender001 at me.com Sun Feb 1 07:30:01 2009 From: ebender001 at me.com (Edward Bender) Date: Sun Feb 1 10:30:26 2009 Subject: [HSF] Incomplete OR case In-Reply-To: <909216.46955.qm@web81607.mail.mud.yahoo.com> References: <92586646247717015438440420932125430839-Webmail@me.com> <909216.46955.qm@web81607.mail.mud.yahoo.com> Message-ID: <86287407688965555110662629206492397649-Webmail@me.com> I agree. I am getting a TEE this am to better define the valve morphology. We have no pre-catastrophe echos, so I can not know the "when" part of the question. Ed Bender, MD On Sunday, February 01, 2009, at 07:05AM, "Tea Acuff" wrote: >I guess the question that makes me pause on rushing in is when and why did this MR come up? > >tea > > > > >________________________________ >From: Edward Bender >To: OpenHeart-L@lists.hsforum.com >Sent: Sunday, February 1, 2009 8:49:03 AM >Subject: RE: [HSF] Incomplete OR case > >Thanks, Roberto. >Actually, she has no coronary disease, normal EF now, so the only potential difficult issue regarding the conduct of the operation is the presence of an aortic prosthesis.? I usually do these cases trans-septally.? Still, the surgical procedure itself will only be a small part of the patient's recovery. I am really worried about her overall debilitated state and expect a trach, PEG, and long-term acute care facility eventually. >Ed Bender, MD > > >On Sunday, February 01, 2009, at 12:47AM, "Roberto Battellini" wrote: >> >>Great job done, Ed >> >>Significant MR and if patient can?t get out of respirator = death >>Now, How-to-do-it is a chapter: cold fibrilating heart? clamping the aorta and coronary sinus perfusion, beating heart? >> >>Which would be your preference? >>Roberto >> >>> Subject: RE: [HSF] Incomplete OR case> Date: Sat, 31 Jan 2009 14:33:22 -0800> From: ecdouville@orclinic.com> To: OpenHeart-L@lists.hsforum.com> CC: > > Ed what a great save on your part to get her to this point. I would repair or replace her mitral valve this admit. chuckdouville> > ________________________________> > From: openheart-l-bounces@lists.hsforum.com on behalf of Edward Bender> Sent: Sat 1/31/2009 11:36 AM> To: HSF List> Subject: [HSF] Incomplete OR case> > > > Speaking of not doing all that should be done in the OR, sometimes you just> don?t get all the information that allows you to do everything indicated.> > Two weeks ago I was asked to see a case of a 40 year old female who had a> SJM aortic valve (21 mm) placed four years ago at another institution. One> year ago she had an embolic CVA from which she completely recovered. She is> not very good about taking her coumadin. When I saw her, she had no> detectable BP, no clicking, and a > heart rate of 140, so we rushed her off> to the OR, crashed on femoral bypass, and did a redo AVR for a completely> thrombosed prosthesis. On admission she had an echo performed which showed> a 5% EF, massively dilated LV, and mild MR. After she awoke, got extubated,> and then re-intubated a few days later when her lungs whited out, I repeated> the echo which now shows significant MR with no obvious flail, and an EF of> 60%. I fear she will need a mitral procedure in the near future. Would> anyone care to comment on timing? She weighs 40 kg, big smoker,> malnourished at the time of her acute illness. She is still intubated with> waxing and waning FiO2 requirements. She has yeast in her urine, MRSA on> her Swan-Ganz tip, but negative blood cultures since lines changed. She> grew MRSA form her sputum on admission (admitting diagnosis was pneumonia).> > Ed Bender, MD> _______________________________________________> 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 >----------------------------------------- > >_______________________________________________ >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 Sun Feb 1 10:40:04 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Feb 1 10:41:08 2009 Subject: [HSF] CABG reporting. Message-ID: Ani, To be honest, I've really no idea what's going to be reported. I recently attended a meeting with administration at one of my hospitals where they outlined this new system. It's my uhderstanding that it will include AVR, MVR, CABG, and their combinations. Things like Dors, thoracic aortic procedures, and some others will be excluded. I plan to do a few more stand alone CABG's because, probably like you, my last death from an isolated CABG was several years ago. It's all a matter of playing the game. While we're discussing this crap, what about the STS's bone head rule that counts a postop permanent pacemaker as a "bring back for surgery" if it's done in the OR, but not if it's done in the EP lab? Honestly, who's side are they on? Hal In a message dated 2/1/2009 10:29:06 A.M. Eastern Standard Time, anianyanwu@hotmail.com writes: Hal One would only be at a disadvantage if one sees the stats as a means to promote or validate one's status as a top coronary surgeon - to do this one would need a high volume of CABG with low mortality (I assume that has to be the 'outcome' they will look at). However, given that you are not predominantly a coronary surgeon it shouldnt matter much to you. Assuming you do only 10 to 20 isolated CABGs per year then you would likely be excluded from ranking analysis (otherwise if you did 15 with no death, just like I did last year, then you would be ranked as the top coronary surgeon with a zero mortality risk which would make no sense). If one did include your cases in a report the confidence interval would be so wide such as to make your results meaningless. Only surgeons doing say 50 plus or so CABGs per year need worry about data reporting as the ranking and results would be more stable. If a low volume CABG surgeon wants to look good in the reports then one has to get more volume and try and aim to do at least 100 procedures per year for the data to have meaning. (the caveat though is that while a low volume surgeon will not get credited with low mortality, they will still get penalized for high mortality; if one does 10 cases and 5 die then small numbers wont protect from that). What is the stated goal of the Florida reporting exercise? I find it odd that with CABG in decline new reporting systems still emerge to track isolated CABG. I think one will find that cardiac surgery is becoming more like general thoracic where the make up of ones practice is very heterogenous with very few two operations being alike. The days where isolated CABG, isolated AVR and isolated MVR constituted 95% of most practices are long gone. We now have a plethora of operations and hybrids with various manners of combined procedures on an even more heterogenous group of patients which makes it very difficult to define index operations and compare outcomes. Why does the reporting make you plan to do more isolated CABGs? Ani > To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] On pump vs Off> From: hgrmd@aol.com> Date: Sun, 1 Feb 2009 15:00:10 +0000> CC: > > Tea,> I'm not sure, but wouldn't be surprised if the stats make it to the newspaper. Certainly, it will be online. Anyway, I'm at a disadvantage since my case load if over 95 per cent valves.> > Hal> Sent from my Verizon Wireless BlackBerry> > -----Original Message-----> From: Tea Acuff > > Date: Sun, 1 Feb 2009 06:54:40 > To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] On pump vs Off> > > What format will they use for reporting?> Tea> > Sent from my iPhone> > On Feb 1, 2009, at 5:47 AM, Hgrmd@aol.com wrote:> > I whole heartedly agree with you. Even the most die hard on pump surgeon is > bound to eventually encounter a case that he will screw up if he isn't able > to do at least the occasional off pump. Because Florida is now reporting the > mortality statistics of all surgeons (like New York), I plan to do more > isolated CABG's. I suspect at least half will be OPCAB.> > Hal> > > In a message dated 1/31/2009 11:06:20 P.M. Eastern Standard Time, > govindgovind@hotmail.com writes:> > > > > For any surgeon actively engaged in CABG on pump, learning the ropes for off > pump method is a definite advantage.Both methods are eminently successful in > getting good results and we need to apply either judiciouly as per the > clinical problem.There is no need to be a diehard supporter of only one method. If > some of the surgeons are trying to use off pump method from marketing angle > it is not the method which is at fault.> > govindakubal> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] On pump > vs Off> Date: Sat, 31 Jan 2009 21:58:57 -0500> From: tdmartin2000@aol.com> > CC: > > Bill> ?Laurie Davies is the principle investigator and has the > manuscript. She was appointed to the Florida Board of Medicine during the study and > was subsequently appointed as Chair of the Board - a big time consuming job. > She has just completed her tenure on the board and will be completing the > paper soon. It shows just what you would suspect but I cannot write it here as it > has not been published and the journals don't like it when you give out the > data.> Let's just say that it has not converted me.> > Tom> > > -----Original > Message-----> From: wftjrtyler@aol.com> To: OpenHeart-L@lists.hsforum.com> > Sent: Fri, 30 Jan 2009 6:57 pm> Subject: Re: [HSF] On pump vs Off> > > > Tom, > several years(and threads) ago, you were randomizing Opcabs vs. Oncab > at > UF. Is your study in progress or did i miss the paper? bill turner> > > In a > message dated 1/29/2009 8:53:17 P.M. Central Standard Time, > > tdmartin2000@aol.com writes:> > agree> > > -----Original Message-----> From: hgrmd@aol.com> > To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:58 pm> Subject: > Re: [HSF] On pump vs Off> > > > Tom,> You and I are essentially on the same > side. Of course Dors and valves don't > apply. However, my perception, based > on personal experience as well as the > literature, is that elderly > vasculopaths with hostile aortas benefit from > OPCAB. > For the average case, it > probably doesn't matter. You and I would agree > that > there are a lot of > surgeons out there trying to use OPCAB for a marketing > angle. > I consider OPCAB > an excellent technique to have in one's armamentarium. In > fact, I was > recently summoned to the OR to take over my junior surgeon's > CABG > when he > unexpectedly encountered a bad aorta. I stepped in and did a 3 > vessel > OPCAB. > The patient did fine.> > Hal> > Hal > Sent from my Verizon Wireless > BlackBerry> > -----Original Message-----> From: tdmartin2000@aol.com> > Date: Wed, 28 > Jan 2009 23:44:34 > To: > Subject: Re: [HSF] > On pump vs Off> > > Hal> I'm not sure John refuted as much as attacked it. > His whole premise was on > the > difference between an administrative and a > clinical data base. The presenter > had?a good rebuttal to John's rebuttal. I > can't wait to see the manuscript > and > review it myself. It's hard to refute > the conclusions of death, stroke, > length > of stay and costs when there is > data on 63,000 pts no matter what kind of > data > base. I also have to?ask > what your definition of a high risk case is and > where > the data is to > confirm your premise. It is hard to do an off pump redo CABG > AVR > or MVR, or a > CABG Dor, or a CABG, ascending, etc.. These would fall into the > > high risk > cases for me. As you know I brought this up for the sake of > dis> cussion > > and controversy.> > Tom> > > > > -----Original Message-----> From: > hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:25 pm> > Subject: Re: [HSF] On pump vs Off> > > > Tom,> Yes, it was provocative, but I > thought John Puskas pretty much refuted it in > the discussion. As you know, > his own group at Emory as well as thorough > exam of > > the STS database > comes to the opposite conclusions. Again, I don't think > the 2 > approaches ar> > e that distinguishable for low risk cases. However, most high risk > > > subsets do better.> > Hal> ------Original Message------> From: > tdmartin2000@aol.com> Sender: openheart-l-bounces@lists.hsforum.com> To: > OpenHeart-L@lists.hsforum.com> ReplyTo: OpenHeart-L@lists.hsforum.com> Sent: Jan 28, 2009 11:18 PM> > Subject: [HSF] On pump vs Off> > I really hate to get this going again but I > REALLY don't believe that off is > better than on in any group except pts > with significant aortic calcification > or > atheroma. There was an interesting > paper just presented here at the STS that > created a sig controversy.> > > On-pump vs Off-Pump Coronary Artery Bypass Surgery in a Cohort of 63,000 > > Patients-? from Baylor and Texas Heart- reviewing the 2004 Nationwide > Inpatient > Sample database- admittedly an administrative database but with some > really > good > > statistics.> Conclusions- 1. Opcab does not produce lower > mortality or stroke 2. Opcab > has > longer hospital stays and higher costs ($1500) > 3. Performing Opcab in all > candidates for myocardial revascularization may > not be justifiable.> > Comments> > Tom Martin> U of Florida> Gainesville> > _______________________________________________> 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>> -----------------------------------------> > > Sent from my Verizon Wireless > Black> Berry> > > > _______________________________________________> 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 ma> iling 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>> -----------------------------------------> > > **************A Good Credit > Score is 700 or Above. 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(http://aol.com?ncid=emlcntaolcom00000023) From anianyanwu at hotmail.com Sun Feb 1 15:42:16 2009 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Sun Feb 1 10:43:04 2009 Subject: [HSF] Incomplete OR case In-Reply-To: <86287407688965555110662629206492397649-Webmail@me.com> References: <92586646247717015438440420932125430839-Webmail@me.com> <909216.46955.qm@web81607.mail.mud.yahoo.com> <86287407688965555110662629206492397649-Webmail@me.com> Message-ID: how about the post bypass TEE? how much MR then and what were your feelings at that point? Ani > Date: Sun, 1 Feb 2009 07:30:01 -0800> From: ebender001@me.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] Incomplete OR case> CC: > > I agree. I am getting a TEE this am to better define the valve morphology. We have no pre-catastrophe echos, so I can not know the "when" part of the question.> > Ed Bender, MD> > > On Sunday, February 01, 2009, at 07:05AM, "Tea Acuff" wrote:> >I guess the question that makes me pause on rushing in is when and why did this MR come up?> >> >tea> >> >> >> >> >________________________________> >From: Edward Bender > >To: OpenHeart-L@lists.hsforum.com> >Sent: Sunday, February 1, 2009 8:49:03 AM> >Subject: RE: [HSF] Incomplete OR case> >> >Thanks, Roberto.> >Actually, she has no coronary disease, normal EF now, so the only potential difficult issue regarding the conduct of the operation is the presence of an aortic prosthesis. I usually do these cases trans-septally. Still, the surgical procedure itself will only be a small part of the patient's recovery. I am really worried about her overall debilitated state and expect a trach, PEG, and long-term acute care facility eventually.> >Ed Bender, MD> >> >> >On Sunday, February 01, 2009, at 12:47AM, "Roberto Battellini" wrote:> >>> >>Great job done, Ed> >> > >>Significant MR and if patient can?t get out of respirator = death> >>Now, How-to-do-it is a chapter: cold fibrilating heart? clamping the aorta and coronary sinus perfusion, beating heart?> >> > >>Which would be your preference?> >>Roberto> >> > >>> Subject: RE: [HSF] Incomplete OR case> Date: Sat, 31 Jan 2009 14:33:22 -0800> From: ecdouville@orclinic.com> To: OpenHeart-L@lists.hsforum.com> CC: > > Ed what a great save on your part to get her to this point. I would repair or replace her mitral valve this admit. chuckdouville> > ________________________________> > From: openheart-l-bounces@lists.hsforum.com on behalf of Edward Bender> Sent: Sat 1/31/2009 11:36 AM> To: HSF List> Subject: [HSF] Incomplete OR case> > > > Speaking of not doing all that should be done in the OR, sometimes you just> don?t get all the information that allows you to do everything indicated.> > Two weeks ago I was asked to see a case of a 40 year old female who had a> SJM aortic valve (21 mm) placed four years ago at another institution. One> year ago she had an embolic CVA from which she completely recovered. She is> not very good about taking her coumadin. When I saw her, she had no> detectable BP, no clicking, and a> > heart rate of 140, so we rushed her off> to the OR, crashed on femoral bypass, and did a redo AVR for a completely> thrombosed prosthesis. On admission she had an echo performed which showed> a 5% EF, massively dilated LV, and mild MR. After she awoke, got extubated,> and then re-intubated a few days later when her lungs whited out, I repeated> the echo which now shows significant MR with no obvious flail, and an EF of> 60%. I fear she will need a mitral procedure in the near future. Would> anyone care to comment on timing? She weighs 40 kg, big smoker,> malnourished at the time of her acute illness. She is still intubated with> waxing and waning FiO2 requirements. She has yeast in her urine, MRSA on> her Swan-Ganz tip, but negative blood cultures since lines changed. She> grew MRSA form her sputum on admission (admitting diagnosis was pneumonia).> > Ed Bender, MD> _______________________________________________> 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> >-----------------------------------------> >> >_______________________________________________> >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> ----------------------------------------- _________________________________________________________________ Check out the new and improved services from Windows Live. Learn more! http://clk.atdmt.com/UKM/go/132630768/direct/01/ From tacuff at swbell.net Sun Feb 1 08:24:14 2009 From: tacuff at swbell.net (Tea Acuff) Date: Sun Feb 1 11:24:43 2009 Subject: [HSF] Incomplete OR case References: <92586646247717015438440420932125430839-Webmail@me.com> <909216.46955.qm@web81607.mail.mud.yahoo.com> <86287407688965555110662629206492397649-Webmail@me.com> Message-ID: <762315.25395.qm@web81607.mail.mud.yahoo.com> but not intraop after the salvage AVR? tea ________________________________ From: Edward Bender To: OpenHeart-L@lists.hsforum.com Sent: Sunday, February 1, 2009 9:30:01 AM Subject: Re: [HSF] Incomplete OR case I agree.? I am getting a TEE this am to better define the valve morphology.? We have no pre-catastrophe echos, so I can not know the "when" part of the question. Ed Bender, MD On Sunday, February 01, 2009, at 07:05AM, "Tea Acuff" wrote: >I guess the question that makes me pause on rushing in is when and why did this MR come up? > >tea > > > > >________________________________ >From: Edward Bender >To: OpenHeart-L@lists.hsforum.com >Sent: Sunday, February 1, 2009 8:49:03 AM >Subject: RE: [HSF] Incomplete OR case > >Thanks, Roberto. >Actually, she has no coronary disease, normal EF now, so the only potential difficult issue regarding the conduct of the operation is the presence of an aortic prosthesis.? I usually do these cases trans-septally.? Still, the surgical procedure itself will only be a small part of the patient's recovery. I am really worried about her overall debilitated state and expect a trach, PEG, and long-term acute care facility eventually. >Ed Bender, MD > > >On Sunday, February 01, 2009, at 12:47AM, "Roberto Battellini" wrote: >> >>Great job done, Ed >> >>Significant MR and if patient can?t get out of respirator = death >>Now, How-to-do-it is a chapter: cold fibrilating heart? clamping the aorta and coronary sinus perfusion, beating heart? >> >>Which would be your preference? >>Roberto >> >>> Subject: RE: [HSF] Incomplete OR case> Date: Sat, 31 Jan 2009 14:33:22 -0800> From: ecdouville@orclinic.com> To: OpenHeart-L@lists.hsforum.com> CC: > > Ed what a great save on your part to get her to this point. I would repair or replace her mitral valve this admit. chuckdouville> > ________________________________> > From: openheart-l-bounces@lists.hsforum.com on behalf of Edward Bender> Sent: Sat 1/31/2009 11:36 AM> To: HSF List> Subject: [HSF] Incomplete OR case> > > > Speaking of not doing all that should be done in the OR, sometimes you just> don?t get all the information that allows you to do everything indicated.> > Two weeks ago I was asked to see a case of a 40 year old female who had a> SJM aortic valve (21 mm) placed four years ago at another institution. One> year ago she had an embolic CVA from which she completely recovered. She is> not very good about taking her coumadin. When I saw her, she had no> detectable BP, no clicking, and a > heart rate of 140, so we rushed her off> to the OR, crashed on femoral bypass, and did a redo AVR for a completely> thrombosed prosthesis. On admission she had an echo performed which showed> a 5% EF, massively dilated LV, and mild MR. After she awoke, got extubated,> and then re-intubated a few days later when her lungs whited out, I repeated> the echo which now shows significant MR with no obvious flail, and an EF of> 60%. I fear she will need a mitral procedure in the near future. Would> anyone care to comment on timing? She weighs 40 kg, big smoker,> malnourished at the time of her acute illness. She is still intubated with> waxing and waning FiO2 requirements. She has yeast in her urine, MRSA on> her Swan-Ganz tip, but negative blood cultures since lines changed. She> grew MRSA form her sputum on admission (admitting diagnosis was pneumonia).> > Ed Bender, MD> _______________________________________________> 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 >----------------------------------------- > >_______________________________________________ >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 msfirst at gmail.com Sun Feb 1 11:34:09 2009 From: msfirst at gmail.com (Michael Firstenberg) Date: Sun Feb 1 11:35:45 2009 Subject: [HSF] On pump vs Off In-Reply-To: References: Message-ID: <7F45B1BB-C6B1-4513-88CA-74A940CEE685@gmail.com> Do you think it will really matter? (the knee jerk response will be of course) but if you provide a good service - the referring physicians and patients will know. How many people chose their heart surgeon based on the local newspaper. We wrestle with some of the same issues - there is a community hospital not too far that boasts the "best outcomes". I will not comments further since everyone knows what that means....... my response then is, go there! I think the playing field gets leveled after a while but I get frustrated seeing how these "numbers" are used for marketing and other secondary gains. -michael On Feb 1, 2009, at 10:24 AM, hgrmd@aol.com wrote: > Tea, > Again, I'm not sure. Supposedly, the results will be risk > stratified. > However, given the ignorance of the general public, I suspect the > raw mortality > will really be the bottom line. > > Hal > > > In a message dated 2/1/2009 10:05:54 A.M. Eastern Standard Time, > tacuff@swbell.net writes: > > So. Is it just "heart mortality" or what. > tea > > > > > ________________________________ > From: "hgrmd@aol.com" > To: OpenHeart-L@lists.hsforum.com > Sent: Sunday, February 1, 2009 9:00:10 AM > Subject: Re: [HSF] On pump vs Off > > Tea, > I'm not sure, but wouldn't be surprised if the stats make it to the > newspaper. Certainly, it will be online. Anyway, I'm at a > disadvantage since my > case load if over 95 per cent valves. > > Hal > Sent from my Verizon Wireless BlackBerry > > -----Original Message----- > From: Tea Acuff > > Date: Sun, 1 Feb 2009 06:54:40 > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] On pump vs Off > > > What format will they use for reporting? > Tea > > Sent from my iPhone > > On Feb 1, 2009, at 5:47 AM, Hgrmd@aol.com wrote: > > I whole heartedly agree with you. Even the most die hard on pump > surgeon > is > bound to eventually encounter a case that he will screw up if he > isn't able > to do at least the occasional off pump. Because Florida is now > reporting > the > mortality statistics of all surgeons (like New York), I plan to do > more > isolated CABG's. I suspect at least half will be OPCAB. > > Hal > > > In a message dated 1/31/2009 11:06:20 P.M. Eastern Standard Time, > govindgovind@hotmail.com writes: > > > > > For any surgeon actively engaged in CABG on pump, learning the > ropes for > off > pump method is a definite advantage.Both methods are eminently > successful > in > getting good results and we need to apply either judiciouly as per > the > clinical problem.There is no need to be a diehard supporter of > only one > method. If > some of the surgeons are trying to use off pump method from > marketing angle > it is not the method which is at fault. > > govindakubal> To: OpenHeart-L@lists.hsforum.com> Subject: Re: > [HSF] On pump > vs Off> Date: Sat, 31 Jan 2009 21:58:57 -0500> From: tdmartin2000@aol.com > > > CC: > > Bill> ?Laurie Davies is the principle investigator and has > the > manuscript. She was appointed to the Florida Board of Medicine > during the > study and > was subsequently appointed as Chair of the Board - a big time > consuming > job. > She has just completed her tenure on the board and will be > completing the > paper soon. It shows just what you would suspect but I cannot > write it here > as it > has not been published and the journals don't like it when you > give out the > data.> Let's just say that it has not converted me.> > Tom> > > > -----Original > Message-----> From: wftjrtyler@aol.com> To: OpenHeart-L@lists.hsforum.com > > > Sent: Fri, 30 Jan 2009 6:57 pm> Subject: Re: [HSF] On pump vs Off> > > > > > Tom, > several years(and threads) ago, you were randomizing Opcabs vs. > Oncab > at > UF. Is your study in progress or did i miss the paper? bill > turner> > > In > a > message dated 1/29/2009 8:53:17 P.M. Central Standard Time, > > tdmartin2000@aol.com writes:> > agree> > > -----Original > Message-----> > From: hgrmd@aol.com> > To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:58 pm> > Subject: > Re: [HSF] On pump vs Off> > > > Tom,> You and I are essentially on > the same > side. Of course Dors and valves don't > apply. However, my > perception, > based > on personal experience as well as the > literature, is that elderly > vasculopaths with hostile aortas benefit from > OPCAB. > For the > average > case, it > probably doesn't matter. You and I would agree > that > there are > a lot of > surgeons out there trying to use OPCAB for a marketing > angle. > I > consider OPCAB > an excellent technique to have in one's armamentarium. In > fact, > I was > recently summoned to the OR to take over my junior surgeon's > > CABG > when > he > unexpectedly encountered a bad aorta. I stepped in and did a 3 > > vessel > > OPCAB. > The patient did fine.> > Hal> > Hal > Sent from my Verizon Wireless > BlackBerry> > -----Original Message-----> From: > tdmartin2000@aol.com> > > Date: Wed, 28 > Jan 2009 23:44:34 > To: > Subject: > Re: [HSF] > On pump vs Off> > > Hal> I'm not sure John refuted as much as > attacked it. > > His whole premise was on > the > difference between an > administrative and a > clinical data base. The presenter > had?a good rebuttal to John's > rebuttal. > I > can't wait to see the manuscript > and > review it myself. It's > hard to > refute > the conclusions of death, stroke, > length > of stay and costs > when there > is > data on 63,000 pts no matter what kind of > data > base. I also > have to?ask > what your definition of a high risk case is and > where > the data > is to > confirm your premise. It is hard to do an off pump redo CABG > AVR > > or > MVR, or a > CABG Dor, or a CABG, ascending, etc.. These would fall into the > > > high > risk > cases for me. As you know I brought this up for the sake of > dis> > cussion >> > and controversy.> > Tom> > > > > -----Original Message-----> From: > hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 > Jan 2009 > 11:25 pm> > Subject: Re: [HSF] On pump vs Off> > > > Tom,> Yes, it was > provocative, but > I > thought John Puskas pretty much refuted it in > the discussion. As > you > know, > his own group at Emory as well as thorough > exam of > > the STS > database > comes to the opposite conclusions. Again, I don't think > the 2 > > approaches ar> > e that distinguishable for low risk cases. However, most high risk > > > > subsets do better.> > Hal> ------Original Message------> From: > tdmartin2000@aol.com> Sender: openheart-l- > bounces@lists.hsforum.com> To: > OpenHeart-L@lists.hsforum.com> ReplyTo: OpenHeart- > L@lists.hsforum.com> > Sent: Jan 28, 2009 11:18 PM> > Subject: [HSF] On pump vs Off> > I really hate to get this going > again but > I > REALLY don't believe that off is > better than on in any group > except pts > with significant aortic calcification > or > atheroma. There was an > interesting > paper just presented here at the STS that > created a sig > controversy.> > > On-pump vs Off-Pump Coronary Artery Bypass Surgery in a Cohort of > 63,000 > > Patients-? from Baylor and Texas Heart- reviewing the 2004 > Nationwide > > Inpatient > Sample database- admittedly an administrative database but with some > really > good > > statistics.> Conclusions- 1. Opcab does not > produce lower > > mortality or stroke 2. Opcab > has > longer hospital stays and > higher costs > ($1500) > 3. Performing Opcab in all > candidates for myocardial > revascularization > may > not be justifiable.> > Comments> > Tom Martin> U of Florida> > Gainesville> > _______________________________________________> 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 > > > -----------------------------------------> > > Sent from my Verizon > Wireless > Black> Berry> > > > _______________________________________________> > 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 ma> > iling > 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 > > > -----------------------------------------> > > **************A > Good Credit > Score is 700 or Above. See yours in just 2 easy > steps! > > (http://pr.atwola.com/promoclk/100000075x1215855013x1201028747/aol?redir=http > : > //www.freecreditreport. > com/pm/default.aspx?sc=668072%26hmpgID=62%26bcd=De> > cemailfooterNO62)> > _______________________________________________> OpenHeart-L > mailing list> >> Send > postings to:> OpenHe> art-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> > ----------------------------------------- > _________________________________________________________________ > Wish to Marry Now? Join MSN Matrimony FREE! > http://www.in.msn.com/matrimony_______________________________________________ > > 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 Wall Street to Main Street and everywhere in > between, > stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 > ) > _______________________________________________ > 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 > ----------------------------------------- > > **************From Wall Street to Main Street and everywhere in > between, stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 > ) > _______________________________________________ > 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 Sun Feb 1 11:37:02 2009 From: msfirst at gmail.com (Michael Firstenberg) Date: Sun Feb 1 11:37:52 2009 Subject: [HSF] CABG reporting. In-Reply-To: References: Message-ID: <910E0CC0-4E8C-4B5E-A42E-8C6D911B8670@gmail.com> maybe it is a subtle jab that surgeons should not be putting in pacemakers? wow - all of the snow outside my window just melted from the blaze of fire directed at me. -michael On Feb 1, 2009, at 10:40 AM, hgrmd@aol.com wrote: > Ani, > To be honest, I've really no idea what's going to be reported. I > recently > attended a meeting with administration at one of my hospitals where > they > outlined this new system. It's my uhderstanding that it will > include AVR, MVR, > CABG, and their combinations. Things like Dors, thoracic aortic > procedures, > and some others will be excluded. I plan to do a few more stand > alone CABG's > because, probably like you, my last death from an isolated CABG was > several > years ago. It's all a matter of playing the game. > While we're discussing this crap, what about the STS's bone head > rule that > counts a postop permanent pacemaker as a "bring back for surgery" > if it's > done in the OR, but not if it's done in the EP lab? Honestly, > who's side are > they on? > > Hal > > > In a message dated 2/1/2009 10:29:06 A.M. Eastern Standard Time, > anianyanwu@hotmail.com writes: > > > Hal > > One would only be at a disadvantage if one sees the stats as a > means to > promote or validate one's status as a top coronary surgeon - to do > this one would > need a high volume of CABG with low mortality (I assume that has to > be the > 'outcome' they will look at). However, given that you are not > predominantly a > coronary surgeon it shouldnt matter much to you. > > Assuming you do only 10 to 20 isolated CABGs per year then you > would likely > be excluded from ranking analysis (otherwise if you did 15 with no > death, > just like I did last year, then you would be ranked as the top > coronary surgeon > with a zero mortality risk which would make no sense). If one did > include > your cases in a report the confidence interval would be so wide > such as to make > your results meaningless. > > Only surgeons doing say 50 plus or so CABGs per year need worry > about data > reporting as the ranking and results would be more stable. If a low > volume > CABG surgeon wants to look good in the reports then one has to get > more volume > and try and aim to do at least 100 procedures per year for the data > to have > meaning. (the caveat though is that while a low volume surgeon will > not get > credited with low mortality, they will still get penalized for high > mortality; > if one does 10 cases and 5 die then small numbers wont protect from > that). > > What is the stated goal of the Florida reporting exercise? I find > it odd > that with CABG in decline new reporting systems still emerge to > track isolated > CABG. I think one will find that cardiac surgery is becoming more > like general > thoracic where the make up of ones practice is very heterogenous > with very > few two operations being alike. The days where isolated CABG, > isolated AVR and > isolated MVR constituted 95% of most practices are long gone. We > now have a > plethora of operations and hybrids with various manners of combined > procedures on an even more heterogenous group of patients which > makes it very > difficult to define index operations and compare outcomes. > > Why does the reporting make you plan to do more isolated CABGs? > > Ani > > > > > > >> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] On pump vs >> Off> > From: hgrmd@aol.com> Date: Sun, 1 Feb 2009 15:00:10 +0000> CC: > > > Tea,> I'm not > sure, but wouldn't be surprised if the stats make it to the > newspaper. > Certainly, it will be online. Anyway, I'm at a disadvantage since > my case load if > over 95 per cent valves.> > Hal> Sent from my Verizon Wireless > BlackBerry> > > -----Original Message-----> From: Tea Acuff > > > Date: Sun, > 1 Feb 2009 06:54:40 > To: > OpenHeart-L@lists.hsforum.com> > Subject: Re: [HSF] On pump vs Off> > > What format will they use > for reporting?> Tea> > Sent from my iPhone> > On Feb 1, 2009, at > 5:47 AM, > Hgrmd@aol.com wrote:> > I whole heartedly agree with you. Even the > most die > hard on pump surgeon is > bound to eventually encounter a case that > he will > screw up if he isn't able > to do at least the occasional off pump. > Because > Florida is now reporting the > mortality statistics of all surgeons > (like New > York), I plan to do more > isolated CABG's. I suspect at least half > will be > OPCAB.> > Hal> > > In a message dated 1/31/2009 11:06:20 P.M. > Eastern Standard > Time, > govindgovind@hotmail.com writes:> > > > > For any surgeon > actively > engaged in CABG on pump, learning the ropes for off > pump method > is a definite > advantage.Both methods are eminently successful in > getting good > results and > we need to apply either judiciouly as per the > clinical > problem.There is no > need to be a diehard supporter of only one method. If > some of the > surgeons > are trying to use off pump method from marketing angle > it is not > the method > which is at fault.> > govindakubal> To: OpenHeart- > L@lists.hsforum.com> > Subject: Re: [HSF] On pump > vs Off> Date: Sat, 31 Jan 2009 > 21:58:57 -0500> From: > tdmartin2000@aol.com> > CC: > > Bill> ?Laurie Davies is the principle > investigator and has the > manuscript. She was appointed to the > Florida Board of > Medicine during the study and > was subsequently appointed as Chair > of the Board > - a big time consuming job. > She has just completed her tenure on > the board > and will be completing the > paper soon. It shows just what you would > suspect but I cannot write it here as it > has not been published > and the journals > don't like it when you give out the > data.> Let's just say that it > has not > converted me.> > Tom> > > -----Original > Message-----> From: > wftjrtyler@aol.com> To: OpenHeart-L@lists.hsforum.com> > Sent: Fri, > 30 Jan 2009 6:57 pm> > Subject: Re: [HSF] On pump vs Off> > > > Tom, > several years(and > threads) ago, > you were randomizing Opcabs vs. Oncab > at > UF. Is your study in > progress > or did i miss the paper? bill turner> > > In a > message dated > 1/29/2009 > 8:53:17 P.M. Central Standard Time, > > tdmartin2000@aol.com > writes:> > agree> > > > -----Original Message-----> From: hgrmd@aol.com> > To: > OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:58 pm> > Subject: > Re: [HSF] On pump vs > Off> > > > Tom,> You and I are essentially on the same > side. Of > course Dors > and valves don't > apply. However, my perception, based > on personal > experience as well as the > literature, is that elderly > > vasculopaths with hostile > aortas benefit from > OPCAB. > For the average case, it > probably > doesn't > matter. You and I would agree > that > there are a lot of > > surgeons out there > trying to use OPCAB for a marketing > angle. > I consider OPCAB > an > excellent technique to have in one's armamentarium. In > fact, I was > > recently > summoned to the OR to take over my junior surgeon's > CABG > when > he > > unexpectedly encountered a bad aorta. I stepped in and did a 3 > > vessel > OPCAB. > The > patient did fine.> > Hal> > Hal > Sent from my Verizon Wireless > > BlackBerry> >> -----Original Message-----> From: tdmartin2000@aol.com> > Date: >> Wed, 28 > > Jan 2009 23:44:34 > To: > Subject: > Re: [HSF] >> On pump vs Off> > > Hal> I'm not sure John refuted as much as >> attacked it. >> His whole premise was on > the > difference between an >> administrative and a >> clinical data base. The presenter > had?a good rebuttal to John's > rebuttal. I > can't wait to see the manuscript > and > review it > myself. It's hard to > refute > the conclusions of death, stroke, > length > of stay and > costs when > there is > data on 63,000 pts no matter what kind of > data > base. > I also > have to?ask > what your definition of a high risk case is and > > where > the > data is to > confirm your premise. It is hard to do an off pump > redo CABG > > AVR > or MVR, or a > CABG Dor, or a CABG, ascending, etc.. These > would fall > into the > > high risk > cases for me. As you know I brought this > up for the > sake of > dis> cussion > > and controversy.> > Tom> > > > > ----- > Original > Message-----> From: > hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com > > Sent: Wed, > 28 Jan 2009 11:25 pm> > Subject: Re: [HSF] On pump vs Off> > > > > Tom,> Yes, > it was provocative, but I > thought John Puskas pretty much refuted > it in > > the discussion. As you know, > his own group at Emory as well as > thorough > > exam of > > the STS database > comes to the opposite conclusions. > Again, I > don't think > the 2 > approaches ar> > e that distinguishable for > low risk > cases. However, most high risk > > > subsets do better.> > Hal> > ------Original > Message------> From: > tdmartin2000@aol.com> Sender: > openheart-l-bounces@lists.hsforum.com> To: > OpenHeart-L@lists.hsforum.com > > ReplyTo: > OpenHeart-L@lists.hsforum.com> Sent: Jan 28, 2009 11:18 PM> > > Subject: [HSF] On pump vs Off> > > I really hate to get this going again but I > REALLY don't believe > that off > is > better than on in any group except pts > with significant aortic > calcification > or > atheroma. There was an interesting > paper > just presented here > at the STS that > created a sig controversy.> > > On-pump vs Off-Pump > Coronary Artery Bypass Surgery in a Cohort of 63,000 > > Patients-? > from Baylor and > Texas Heart- reviewing the 2004 Nationwide > Inpatient > Sample > database- > admittedly an administrative database but with some > really > good > > > > statistics.> Conclusions- 1. Opcab does not produce lower > > mortality or stroke 2. > Opcab > has > longer hospital stays and higher costs ($1500) > 3. > Performing > Opcab in all > candidates for myocardial revascularization may > > not be > justifiable.> > Comments> > Tom Martin> U of Florida> Gainesville> > > _______________________________________________> 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 > >> > -----------------------------------------> > > Sent from my Verizon > Wireless > > Black> Berry> > > > > _______________________________________________> 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 ma> > iling 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>> > -----------------------------------------> > > **************A Good > Credit > Score is 700 or Above. See yours in > just 2 easy > steps! > > > (http://pr.atwola.com/promoclk/100000075x1215855013x1201028747/aol?redir=http://www.freecreditreport > .> > com/pm/default.aspx?sc=668072%26hmpgID=62%26bcd=De> > cemailfooterNO62)> > > _______________________________________________> OpenHeart-L > mailing list> > Send > postings to:> OpenHe> > art-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>> > -----------------------------------------> > _________________________________________________________________> > Wish to > Marry Now? Join MSN Matrimony FREE!> > http://www.in.msn.com/matrimony_______________________________________________ > > 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 > Wall Street to Main Street > and everywhere in between, stay > up-to-date with the latest news. > (http://aol.com?ncid=emlcntaolcom00000023)> > _______________________________________________> 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 > > > ----------------------------------------- > _________________________________________________________________ > Check out the new and improved services from Windows Live. Learn > more! > http://clk.atdmt.com/UKM/go/132630768/direct/01/______________________________ > _________________ > 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 Wall Street to Main Street and everywhere in > between, stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 > ) > _______________________________________________ > 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 me.com Sun Feb 1 08:40:31 2009 From: ebender001 at me.com (Edward Bender) Date: Sun Feb 1 11:41:02 2009 Subject: [HSF] Incomplete OR case In-Reply-To: References: <92586646247717015438440420932125430839-Webmail@me.com> <909216.46955.qm@web81607.mail.mud.yahoo.com> <86287407688965555110662629206492397649-Webmail@me.com> Message-ID: <81845749590517258910231263145336765183-Webmail@me.com> We did not have time to place a TEE on arrival to the OR, and I did not want to risk contaminating the field once we were on bypass. Ed Bender, MD On Sunday, February 01, 2009, at 07:42AM, "Ani Anyanwu" wrote: > >how about the post bypass TEE? how much MR then and what were your feelings at that point? > >Ani > > >> Date: Sun, 1 Feb 2009 07:30:01 -0800> From: ebender001@me.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] Incomplete OR case> CC: > > I agree. I am getting a TEE this am to better define the valve morphology. We have no pre-catastrophe echos, so I can not know the "when" part of the question.> > Ed Bender, MD> > > On Sunday, February 01, 2009, at 07:05AM, "Tea Acuff" wrote:> >I guess the question that makes me pause on rushing in is when and why did this MR come up?> >> >tea> >> >> >> >> >________________________________> >From: Edward Bender > >To: OpenHeart-L@lists.hsforum.com> >Sent: Sunday, February 1, 2009 8:49:03 AM> >Subject: RE: [HSF] Incomplete OR case> >> >Thanks, Roberto.> >Actually, she has no coronary disease, normal EF now, so the only potential difficult issue regarding the conduct of the operation is the presence of an aortic prosthesis. I usually do these cases trans-septally. Still, the surgical procedure itself will only be a small part of the patient's recovery. I am really worried about her overall debilitated state and expect a trach, PEG, and long-term acute care facility eventually.> >Ed Bender, MD> >> >> >On Sunday, February 01, 2009, at 12:47AM, "Roberto Battellini" wrote:> >>> >>Great job done, Ed> >> > >>Significant MR and if patient can?t get out of respirator = death> >>Now, How-to-do-it is a chapter: cold fibrilating heart? clamping the aorta and coronary sinus perfusion, beating heart?> >> > >>Which would be your preference?> >>Roberto> >> > >>> Subject: RE: [HSF] Incomplete OR case> Date: Sat, 31 Jan 2009 14:33:22 -0800> From: ecdouville@orclinic.com> To: OpenHeart-L@lists.hsforum.com> CC: > > Ed what a great save on your part to get her to this point. I would repair or replace her mitral valve this admit. chuckdouville> > ________________________________> > From: openheart-l-bounces@lists.hsforum.com on behalf of Edward Bender> Sent: Sat 1/31/2009 11:36 AM> To: HSF List> Subject: [HSF] Incomplete OR case> > > > Speaking of not doing all that should be done in the OR, sometimes you just> don?t get all the information that allows you to do everything indicated.> > Two weeks ago I was asked to see a case of a 40 year old female who had a> SJM aortic valve (21 mm) placed four years ago at another institution. One> year ago she had an embolic CVA from which she completely recovered. She is> not very good about taking her coumadin. When I saw her, she had no> detectable BP, no clicking, and a> > heart rate of 140, so we rushed her off> to the OR, crashed on femoral bypass, and did a redo AVR for a completely> thrombosed prosthesis. On admission she had an echo performed which showed> a 5% EF, massively dilated LV, and mild MR. After she awoke, got extubated,> and then re-intubated a few days later when her lungs whited out, I repeated> the echo which now shows significant MR with no obvious flail, and an EF of> 60%. I fear she will need a mitral procedure in the near future. Would> anyone care to comment on timing? She weighs 40 kg, big smoker,> malnourished at the time of her acute illness. She is still intubated with> waxing and waning FiO2 requirements. She has yeast in her urine, MRSA on> her Swan-Ganz tip, but negative blood cultures since lines changed. She> grew MRSA form her sputum on admission (admitting diagnosis was pneumonia).> > Ed Bender, MD> _______________________________________________> 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> >-----------------------------------------> >> >_______________________________________________> >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> ----------------------------------------- >_________________________________________________________________ >Check out the new and improved services from Windows Live. Learn more! >http://clk.atdmt.com/UKM/go/132630768/direct/01/_______________________________________________ >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 me.com Sun Feb 1 08:42:06 2009 From: ebender001 at me.com (Edward Bender) Date: Sun Feb 1 11:42:37 2009 Subject: [HSF] Incomplete OR case In-Reply-To: <762315.25395.qm@web81607.mail.mud.yahoo.com> References: <92586646247717015438440420932125430839-Webmail@me.com> <909216.46955.qm@web81607.mail.mud.yahoo.com> <86287407688965555110662629206492397649-Webmail@me.com> <762315.25395.qm@web81607.mail.mud.yahoo.com> Message-ID: <44826499005037765279642825400778686296-Webmail@me.com> I am a slacker, aren't I? Ed Bender, MD On Sunday, February 01, 2009, at 08:24AM, "Tea Acuff" wrote: >but not intraop after the salvage AVR? >tea > > > > >________________________________ >From: Edward Bender >To: OpenHeart-L@lists.hsforum.com >Sent: Sunday, February 1, 2009 9:30:01 AM >Subject: Re: [HSF] Incomplete OR case > >I agree.? I am getting a TEE this am to better define the valve morphology.? We have no pre-catastrophe echos, so I can not know the "when" part of the question. > >Ed Bender, MD > > >On Sunday, February 01, 2009, at 07:05AM, "Tea Acuff" wrote: >>I guess the question that makes me pause on rushing in is when and why did this MR come up? >> >>tea >> >> >> >> >>________________________________ >>From: Edward Bender >>To: OpenHeart-L@lists.hsforum.com >>Sent: Sunday, February 1, 2009 8:49:03 AM >>Subject: RE: [HSF] Incomplete OR case >> >>Thanks, Roberto. >>Actually, she has no coronary disease, normal EF now, so the only potential difficult issue regarding the conduct of the operation is the presence of an aortic prosthesis.? I usually do these cases trans-septally.? Still, the surgical procedure itself will only be a small part of the patient's recovery. I am really worried about her overall debilitated state and expect a trach, PEG, and long-term acute care facility eventually. >>Ed Bender, MD >> >> >>On Sunday, February 01, 2009, at 12:47AM, "Roberto Battellini" wrote: >>> >>>Great job done, Ed >>> >>>Significant MR and if patient can?t get out of respirator = death >>>Now, How-to-do-it is a chapter: cold fibrilating heart? clamping the aorta and coronary sinus perfusion, beating heart? >>> >>>Which would be your preference? >>>Roberto >>> >>>> Subject: RE: [HSF] Incomplete OR case> Date: Sat, 31 Jan 2009 14:33:22 -0800> From: ecdouville@orclinic.com> To: OpenHeart-L@lists.hsforum.com> CC: > > Ed what a great save on your part to get her to this point. I would repair or replace her mitral valve this admit. chuckdouville> > ________________________________> > From: openheart-l-bounces@lists.hsforum.com on behalf of Edward Bender> Sent: Sat 1/31/2009 11:36 AM> To: HSF List> Subject: [HSF] Incomplete OR case> > > > Speaking of not doing all that should be done in the OR, sometimes you just> don?t get all the information that allows you to do everything indicated.> > Two weeks ago I was asked to see a case of a 40 year old female who had a> SJM aortic valve (21 mm) placed four years ago at another institution. One> year ago she had an embolic CVA from which she completely recovered. She is> not very good about taking her coumadin. When I saw her, she had no> detectable BP, no clicking, and a >> heart rate of 140, so we rushed her off> to the OR, crashed on femoral bypass, and did a redo AVR for a completely> thrombosed prosthesis. On admission she had an echo performed which showed> a 5% EF, massively dilated LV, and mild MR. After she awoke, got extubated,> and then re-intubated a few days later when her lungs whited out, I repeated> the echo which now shows significant MR with no obvious flail, and an EF of> 60%. I fear she will need a mitral procedure in the near future. Would> anyone care to comment on timing? She weighs 40 kg, big smoker,> malnourished at the time of her acute illness. She is still intubated with> waxing and waning FiO2 requirements. She has yeast in her urine, MRSA on> her Swan-Ganz tip, but negative blood cultures since lines changed. She> grew MRSA form her sputum on admission (admitting diagnosis was pneumonia).> > Ed Bender, MD> _______________________________________________> 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 >>----------------------------------------- >> >>_______________________________________________ >>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 >----------------------------------------- > > From Hgrmd at aol.com Sun Feb 1 11:43:02 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Feb 1 11:44:09 2009 Subject: [HSF] On pump vs Off Message-ID: Michael, Your words are comforting. Hopefully, the community will be able to tell where the truth lies. Since, it's all new to me, I will unfortunately have to turn down some marginal cases that I might have done in the past. Hal In a message dated 2/1/2009 11:36:59 A.M. Eastern Standard Time, msfirst@gmail.com writes: Do you think it will really matter? (the knee jerk response will be of course) but if you provide a good service - the referring physicians and patients will know. How many people chose their heart surgeon based on the local newspaper. We wrestle with some of the same issues - there is a community hospital not too far that boasts the "best outcomes". I will not comments further since everyone knows what that means....... my response then is, go there! I think the playing field gets leveled after a while but I get frustrated seeing how these "numbers" are used for marketing and other secondary gains. -michael On Feb 1, 2009, at 10:24 AM, hgrmd@aol.com wrote: > Tea, > Again, I'm not sure. Supposedly, the results will be risk > stratified. > However, given the ignorance of the general public, I suspect the > raw mortality > will really be the bottom line. > > Hal > > > In a message dated 2/1/2009 10:05:54 A.M. Eastern Standard Time, > tacuff@swbell.net writes: > > So. Is it just "heart mortality" or what. > tea > > > > > ________________________________ > From: "hgrmd@aol.com" > To: OpenHeart-L@lists.hsforum.com > Sent: Sunday, February 1, 2009 9:00:10 AM > Subject: Re: [HSF] On pump vs Off > > Tea, > I'm not sure, but wouldn't be surprised if the stats make it to the > newspaper. Certainly, it will be online. Anyway, I'm at a > disadvantage since my > case load if over 95 per cent valves. > > Hal > Sent from my Verizon Wireless BlackBerry > > -----Original Message----- > From: Tea Acuff > > Date: Sun, 1 Feb 2009 06:54:40 > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] On pump vs Off > > > What format will they use for reporting? > Tea > > Sent from my iPhone > > On Feb 1, 2009, at 5:47 AM, Hgrmd@aol.com wrote: > > I whole heartedly agree with you. Even the most die hard on pump > surgeon > is > bound to eventually encounter a case that he will screw up if he > isn't able > to do at least the occasional off pump. Because Florida is now > reporting > the > mortality statistics of all surgeons (like New York), I plan to do > more > isolated CABG's. I suspect at least half will be OPCAB. > > Hal > > > In a message dated 1/31/2009 11:06:20 P.M. Eastern Standard Time, > govindgovind@hotmail.com writes: > > > > > For any surgeon actively engaged in CABG on pump, learning the > ropes for > off > pump method is a definite advantage.Both methods are eminently > successful > in > getting good results and we need to apply either judiciouly as per > the > clinical problem.There is no need to be a diehard supporter of > only one > method. If > some of the surgeons are trying to use off pump method from > marketing angle > it is not the method which is at fault. > > govindakubal> To: OpenHeart-L@lists.hsforum.com> Subject: Re: > [HSF] On pump > vs Off> Date: Sat, 31 Jan 2009 21:58:57 -0500> From: tdmartin2000@aol.com > > > CC: > > Bill> ?Laurie Davies is the principle investigator and has > the > manuscript. She was appointed to the Florida Board of Medicine > during the > study and > was subsequently appointed as Chair of the Board - a big time > consuming > job. > She has just completed her tenure on the board and will be > completing the > paper soon. It shows just what you would suspect but I cannot > write it here > as it > has not been published and the journals don't like it when you > give out the > data.> Let's just say that it has not converted me.> > Tom> > > > -----Original > Message-----> From: wftjrtyler@aol.com> To: OpenHeart-L@lists.hsforum.com > > > Sent: Fri, 30 Jan 2009 6:57 pm> Subject: Re: [HSF] On pump vs Off> > > > > > Tom, > several years(and threads) ago, you were randomizing Opcabs vs. > Oncab > at > UF. Is your study in progress or did i miss the paper? bill > turner> > > In > a > message dated 1/29/2009 8:53:17 P.M. Central Standard Time, > > tdmartin2000@aol.com writes:> > agree> > > -----Original > Message-----> > From: hgrmd@aol.com> > To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:58 pm> > Subject: > Re: [HSF] On pump vs Off> > > > Tom,> You and I are essentially on > the same > side. Of course Dors and valves don't > apply. However, my > perception, > based > on personal experience as well as the > literature, is that elderly > vasculopaths with hostile aortas benefit from > OPCAB. > For the > average > case, it > probably doesn't matter. You and I would agree > that > there are > a lot of > surgeons out there trying to use OPCAB for a marketing > angle. > I > consider OPCAB > an excellent technique to have in one's armamentarium. In > fact, > I was > recently summoned to the OR to take over my junior surgeon's > > CABG > when > he > unexpectedly encountered a bad aorta. I stepped in and did a 3 > > vessel > > OPCAB. > The patient did fine.> > Hal> > Hal > Sent from my Verizon Wireless > BlackBerry> > -----Original Message-----> From: > tdmartin2000@aol.com> > > Date: Wed, 28 > Jan 2009 23:44:34 > To: > Subject: > Re: [HSF] > On pump vs Off> > > Hal> I'm not sure John refuted as much as > attacked it. > > His whole premise was on > the > difference between an > administrative and a > clinical data base. The presenter > had?a good rebuttal to John's > rebuttal. > I > can't wait to see the manuscript > and > review it myself. It's > hard to > refute > the conclusions of death, stroke, > length > of stay and costs > when there > is > data on 63,000 pts no matter what kind of > data > base. I also > have to?ask > what your definition of a high risk case is and > where > the data > is to > confirm your premise. It is hard to do an off pump redo CABG > AVR > > or > MVR, or a > CABG Dor, or a CABG, ascending, etc.. These would fall into the > > > high > risk > cases for me. As you know I brought this up for the sake of > dis> > cussion >> > and controversy.> > Tom> > > > > -----Original Message-----> From: > hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 > Jan 2009 > 11:25 pm> > Subject: Re: [HSF] On pump vs Off> > > > Tom,> Yes, it was > provocative, but > I > thought John Puskas pretty much refuted it in > the discussion. As > you > know, > his own group at Emory as well as thorough > exam of > > the STS > database > comes to the opposite conclusions. Again, I don't think > the 2 > > approaches ar> > e that distinguishable for low risk cases. However, most high risk > > > > subsets do better.> > Hal> ------Original Message------> From: > tdmartin2000@aol.com> Sender: openheart-l- > bounces@lists.hsforum.com> To: > OpenHeart-L@lists.hsforum.com> ReplyTo: OpenHeart- > L@lists.hsforum.com> > Sent: Jan 28, 2009 11:18 PM> > Subject: [HSF] On pump vs Off> > I really hate to get this going > again but > I > REALLY don't believe that off is > better than on in any group > except pts > with significant aortic calcification > or > atheroma. There was an > interesting > paper just presented here at the STS that > created a sig > controversy.> > > On-pump vs Off-Pump Coronary Artery Bypass Surgery in a Cohort of > 63,000 > > Patients-? from Baylor and Texas Heart- reviewing the 2004 > Nationwide > > Inpatient > Sample database- admittedly an administrative database but with some > really > good > > statistics.> Conclusions- 1. Opcab does not > produce lower > > mortality or stroke 2. Opcab > has > longer hospital stays and > higher costs > ($1500) > 3. Performing Opcab in all > candidates for myocardial > revascularization > may > not be justifiable.> > Comments> > Tom Martin> U of Florida> > Gainesville> > _______________________________________________> 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 > > > -----------------------------------------> > > Sent from my Verizon > Wireless > Black> Berry> > > > _______________________________________________> > 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 ma> > iling > 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 > > > -----------------------------------------> > > **************A > Good Credit > Score is 700 or Above. See yours in just 2 easy > steps! > > (http://pr.atwola.com/promoclk/100000075x1215855013x1201028747/aol?redir=http > : > //www.freecreditreport. > com/pm/default.aspx?sc=668072%26hmpgID=62%26bcd=De> > cemailfooterNO62)> > _______________________________________________> OpenHeart-L > mailing list> >> Send > postings to:> OpenHe> art-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> > ----------------------------------------- > _________________________________________________________________ > Wish to Marry Now? 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(http://aol.com?ncid=emlcntaolcom00000023) From Hgrmd at aol.com Sun Feb 1 11:48:48 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Feb 1 11:49:49 2009 Subject: [HSF] CABG reporting. Message-ID: Michael, My guess is you don't have much experience implanting pacemakers. I trained in a different era and practice in a different community. Here, the surgeons still implant the majority of the devices, including biventricular ICD's. Personally, I only implant pacers. However, I've done literally thousands over the past 23 years without a single fatality, and only one perforation requiring a window (92 yo lady developed an effusion on PPOD#2). In contrast, there's an EP in our community who has had more perforations in the few years he's been here than all of the cardiac surgeons in my group in their entire careers. In addition, guess who this hapless EP screams for when his ass is in a sling? BTW, Michael, aren't you the one who said you stand by for the EP's in your hospital when they are extracting leads? That's crazy. Quite frankly, only surgeons should be doing that since massive tamponade can develop within seconds with that procedure (linear tear in free wall of RA). Hal In a message dated 2/1/2009 11:39:16 A.M. Eastern Standard Time, msfirst@gmail.com writes: maybe it is a subtle jab that surgeons should not be putting in pacemakers? wow - all of the snow outside my window just melted from the blaze of fire directed at me. -michael On Feb 1, 2009, at 10:40 AM, hgrmd@aol.com wrote: > Ani, > To be honest, I've really no idea what's going to be reported. I > recently > attended a meeting with administration at one of my hospitals where > they > outlined this new system. It's my uhderstanding that it will > include AVR, MVR, > CABG, and their combinations. Things like Dors, thoracic aortic > procedures, > and some others will be excluded. I plan to do a few more stand > alone CABG's > because, probably like you, my last death from an isolated CABG was > several > years ago. It's all a matter of playing the game. > While we're discussing this crap, what about the STS's bone head > rule that > counts a postop permanent pacemaker as a "bring back for surgery" > if it's > done in the OR, but not if it's done in the EP lab? Honestly, > who's side are > they on? > > Hal > > > In a message dated 2/1/2009 10:29:06 A.M. Eastern Standard Time, > anianyanwu@hotmail.com writes: > > > Hal > > One would only be at a disadvantage if one sees the stats as a > means to > promote or validate one's status as a top coronary surgeon - to do > this one would > need a high volume of CABG with low mortality (I assume that has to > be the > 'outcome' they will look at). However, given that you are not > predominantly a > coronary surgeon it shouldnt matter much to you. > > Assuming you do only 10 to 20 isolated CABGs per year then you > would likely > be excluded from ranking analysis (otherwise if you did 15 with no > death, > just like I did last year, then you would be ranked as the top > coronary surgeon > with a zero mortality risk which would make no sense). If one did > include > your cases in a report the confidence interval would be so wide > such as to make > your results meaningless. > > Only surgeons doing say 50 plus or so CABGs per year need worry > about data > reporting as the ranking and results would be more stable. If a low > volume > CABG surgeon wants to look good in the reports then one has to get > more volume > and try and aim to do at least 100 procedures per year for the data > to have > meaning. (the caveat though is that while a low volume surgeon will > not get > credited with low mortality, they will still get penalized for high > mortality; > if one does 10 cases and 5 die then small numbers wont protect from > that). > > What is the stated goal of the Florida reporting exercise? I find > it odd > that with CABG in decline new reporting systems still emerge to > track isolated > CABG. I think one will find that cardiac surgery is becoming more > like general > thoracic where the make up of ones practice is very heterogenous > with very > few two operations being alike. The days where isolated CABG, > isolated AVR and > isolated MVR constituted 95% of most practices are long gone. We > now have a > plethora of operations and hybrids with various manners of combined > procedures on an even more heterogenous group of patients which > makes it very > difficult to define index operations and compare outcomes. > > Why does the reporting make you plan to do more isolated CABGs? > > Ani > > > > > > >> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] On pump vs >> Off> > From: hgrmd@aol.com> Date: Sun, 1 Feb 2009 15:00:10 +0000> CC: > > > Tea,> I'm not > sure, but wouldn't be surprised if the stats make it to the > newspaper. > Certainly, it will be online. Anyway, I'm at a disadvantage since > my case load if > over 95 per cent valves.> > Hal> Sent from my Verizon Wireless > BlackBerry> > > -----Original Message-----> From: Tea Acuff > > > Date: Sun, > 1 Feb 2009 06:54:40 > To: > OpenHeart-L@lists.hsforum.com> > Subject: Re: [HSF] On pump vs Off> > > What format will they use > for reporting?> Tea> > Sent from my iPhone> > On Feb 1, 2009, at > 5:47 AM, > Hgrmd@aol.com wrote:> > I whole heartedly agree with you. Even the > most die > hard on pump surgeon is > bound to eventually encounter a case that > he will > screw up if he isn't able > to do at least the occasional off pump. > Because > Florida is now reporting the > mortality statistics of all surgeons > (like New > York), I plan to do more > isolated CABG's. I suspect at least half > will be > OPCAB.> > Hal> > > In a message dated 1/31/2009 11:06:20 P.M. > Eastern Standard > Time, > govindgovind@hotmail.com writes:> > > > > For any surgeon > actively > engaged in CABG on pump, learning the ropes for off > pump method > is a definite > advantage.Both methods are eminently successful in > getting good > results and > we need to apply either judiciouly as per the > clinical > problem.There is no > need to be a diehard supporter of only one method. If > some of the > surgeons > are trying to use off pump method from marketing angle > it is not > the method > which is at fault.> > govindakubal> To: OpenHeart- > L@lists.hsforum.com> > Subject: Re: [HSF] On pump > vs Off> Date: Sat, 31 Jan 2009 > 21:58:57 -0500> From: > tdmartin2000@aol.com> > CC: > > Bill> ?Laurie Davies is the principle > investigator and has the > manuscript. She was appointed to the > Florida Board of > Medicine during the study and > was subsequently appointed as Chair > of the Board > - a big time consuming job. > She has just completed her tenure on > the board > and will be completing the > paper soon. It shows just what you would > suspect but I cannot write it here as it > has not been published > and the journals > don't like it when you give out the > data.> Let's just say that it > has not > converted me.> > Tom> > > -----Original > Message-----> From: > wftjrtyler@aol.com> To: OpenHeart-L@lists.hsforum.com> > Sent: Fri, > 30 Jan 2009 6:57 pm> > Subject: Re: [HSF] On pump vs Off> > > > Tom, > several years(and > threads) ago, > you were randomizing Opcabs vs. Oncab > at > UF. Is your study in > progress > or did i miss the paper? bill turner> > > In a > message dated > 1/29/2009 > 8:53:17 P.M. Central Standard Time, > > tdmartin2000@aol.com > writes:> > agree> > > > -----Original Message-----> From: hgrmd@aol.com> > To: > OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:58 pm> > Subject: > Re: [HSF] On pump vs > Off> > > > Tom,> You and I are essentially on the same > side. Of > course Dors > and valves don't > apply. However, my perception, based > on personal > experience as well as the > literature, is that elderly > > vasculopaths with hostile > aortas benefit from > OPCAB. > For the average case, it > probably > doesn't > matter. You and I would agree > that > there are a lot of > > surgeons out there > trying to use OPCAB for a marketing > angle. > I consider OPCAB > an > excellent technique to have in one's armamentarium. In > fact, I was > > recently > summoned to the OR to take over my junior surgeon's > CABG > when > he > > unexpectedly encountered a bad aorta. I stepped in and did a 3 > > vessel > OPCAB. > The > patient did fine.> > Hal> > Hal > Sent from my Verizon Wireless > > BlackBerry> >> -----Original Message-----> From: tdmartin2000@aol.com> > Date: >> Wed, 28 > > Jan 2009 23:44:34 > To: > Subject: > Re: [HSF] >> On pump vs Off> > > Hal> I'm not sure John refuted as much as >> attacked it. >> His whole premise was on > the > difference between an >> administrative and a >> clinical data base. The presenter > had?a good rebuttal to John's > rebuttal. I > can't wait to see the manuscript > and > review it > myself. It's hard to > refute > the conclusions of death, stroke, > length > of stay and > costs when > there is > data on 63,000 pts no matter what kind of > data > base. > I also > have to?ask > what your definition of a high risk case is and > > where > the > data is to > confirm your premise. It is hard to do an off pump > redo CABG > > AVR > or MVR, or a > CABG Dor, or a CABG, ascending, etc.. These > would fall > into the > > high risk > cases for me. As you know I brought this > up for the > sake of > dis> cussion > > and controversy.> > Tom> > > > > ----- > Original > Message-----> From: > hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com > > Sent: Wed, > 28 Jan 2009 11:25 pm> > Subject: Re: [HSF] On pump vs Off> > > > > Tom,> Yes, > it was provocative, but I > thought John Puskas pretty much refuted > it in > > the discussion. As you know, > his own group at Emory as well as > thorough > > exam of > > the STS database > comes to the opposite conclusions. > Again, I > don't think > the 2 > approaches ar> > e that distinguishable for > low risk > cases. However, most high risk > > > subsets do better.> > Hal> > ------Original > Message------> From: > tdmartin2000@aol.com> Sender: > openheart-l-bounces@lists.hsforum.com> To: > OpenHeart-L@lists.hsforum.com > > ReplyTo: > OpenHeart-L@lists.hsforum.com> Sent: Jan 28, 2009 11:18 PM> > > Subject: [HSF] On pump vs Off> > > I really hate to get this going again but I > REALLY don't believe > that off > is > better than on in any group except pts > with significant aortic > calcification > or > atheroma. There was an interesting > paper > just presented here > at the STS that > created a sig controversy.> > > On-pump vs Off-Pump > Coronary Artery Bypass Surgery in a Cohort of 63,000 > > Patients-? > from Baylor and > Texas Heart- reviewing the 2004 Nationwide > Inpatient > Sample > database- > admittedly an administrative database but with some > really > good > > > > statistics.> Conclusions- 1. Opcab does not produce lower > > mortality or stroke 2. > Opcab > has > longer hospital stays and higher costs ($1500) > 3. > Performing > Opcab in all > candidates for myocardial revascularization may > > not be > justifiable.> > Comments> > Tom Martin> U of Florida> Gainesville> > > _______________________________________________> 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 > >> > -----------------------------------------> > > Sent from my Verizon > Wireless > > Black> Berry> > > > > _______________________________________________> 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 ma> > iling 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>> > -----------------------------------------> > > **************A Good > Credit > Score is 700 or Above. See yours in > just 2 easy > steps! > > > (http://pr.atwola.com/promoclk/100000075x1215855013x1201028747/aol?redir=http://www.freecreditreport > .> > com/pm/default.aspx?sc=668072%26hmpgID=62%26bcd=De> > cemailfooterNO62)> > > _______________________________________________> OpenHeart-L > mailing list> > Send > postings to:> OpenHe> > art-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>> > -----------------------------------------> > _________________________________________________________________> > Wish to > Marry Now? Join MSN Matrimony FREE!> > http://www.in.msn.com/matrimony_______________________________________________ > > 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 > Wall Street to Main Street > and everywhere in between, stay > up-to-date with the latest news. > (http://aol.com?ncid=emlcntaolcom00000023)> > _______________________________________________> 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 > > > ----------------------------------------- > _________________________________________________________________ > Check out the new and improved services from Windows Live. Learn > more! > http://clk.atdmt.com/UKM/go/132630768/direct/01/______________________________ > _________________ > 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 Wall Street to Main Street and everywhere in > between, stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 > ) > _______________________________________________ > 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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) From damle at cableone.net Sun Feb 1 10:45:55 2009 From: damle at cableone.net (Ajit Damle) Date: Sun Feb 1 11:52:42 2009 Subject: [HSF] Re-do AVR In-Reply-To: References: <654814.79899.qm@web81606.mail.mud.yahoo.com> <1095840663-1233500406-cardhu_decombobulator_blackberry.rim.net-390820265-@bxe016.bisx.prod.on.blackberry> Message-ID: <001701c9848c$8d9c7a20$a8d56e60$@net> It sometimes seems that all my AVRs are re-dos after previous CABGs. Here is the latest one: 76 M, severe COPD, FEV1 50% of predicted, LIMA-LAD, SVG to OM 1996, Creatinine 1.6, Asc aorta 4.0. I saw him in 2006, Angio patent LIMA to a 100% large LAD, SVG occluded, 99% Cx and RCA. AS, valve area 1.0 sq cms. EF 65%. 3D CT 06 showed LIMA plastered to back of sternum and coursing medially. His presentation was unstable angina. I recommended surgery and patient refused. Now increasing SOB, NYHA class III. EF now 25%, AV area 0.6sq cms, MR++, wants surgery. PFTs unchanged. I am planning CT, coronary angio, PET scan and perhaps a Dobutamine ECHO. Because of his coronary disease, he does not qualify for the percuteneous trial. I have been doing my re-dos now after Hal's description: CPB and moderate hypothermia before sternotomy. So although his LIMA has a high chance of injury, I will be able to deal with it. But overall the problems are daunting. Oh, and did I mention he is a Jehovah's Witness? At STS there was a presentation of AVR through a right thoracotomy. If I can stent the Cx and RCA, that might be the best option. What do you think? Ajit Damle From Hgrmd at aol.com Sun Feb 1 12:03:31 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Feb 1 12:04:04 2009 Subject: [HSF] Re-do AVR Message-ID: Ajit, First, it was nice as always to see you at the STS. I don't have any experience in doing AVR's via a right thoracotomy. However, I've watched a couple of cases. Are you sure this approach works for redos? One of the points made by the surgeon whose case I watched was that percardial sutures on the PA side of the aorta were necessary to deliver the aorta into the field. I'm not sure that would happen in a redo. If I was the hapless surgeon doing your case, I would first make sure the hematocrit was above 40. Preferably, I would take the patient aside (no family) and get his written opinion that he would accept blood if it was absolutely life or death. Finally, my operative approach would be a 6 cm upper sternal split with splitting of the right 4th ICS, taking care not to injure the RIMA. I would also get a preop CTA of the chest, abd, and pelvis to look for safe places to peripherally cannulate. The patient you describe could easily have too much aorto-iliac dz for femoral cannulation. If so, then I would hope to cannulate the right axillary artery. Let us know what happens. Hal In a message dated 2/1/2009 11:53:51 A.M. Eastern Standard Time, damle@cableone.net writes: It sometimes seems that all my AVRs are re-dos after previous CABGs. Here is the latest one: 76 M, severe COPD, FEV1 50% of predicted, LIMA-LAD, SVG to OM 1996, Creatinine 1.6, Asc aorta 4.0. I saw him in 2006, Angio patent LIMA to a 100% large LAD, SVG occluded, 99% Cx and RCA. AS, valve area 1.0 sq cms. EF 65%. 3D CT 06 showed LIMA plastered to back of sternum and coursing medially. His presentation was unstable angina. I recommended surgery and patient refused. Now increasing SOB, NYHA class III. EF now 25%, AV area 0.6sq cms, MR++, wants surgery. PFTs unchanged. I am planning CT, coronary angio, PET scan and perhaps a Dobutamine ECHO. Because of his coronary disease, he does not qualify for the percuteneous trial. I have been doing my re-dos now after Hal's description: CPB and moderate hypothermia before sternotomy. So although his LIMA has a high chance of injury, I will be able to deal with it. But overall the problems are daunting. Oh, and did I mention he is a Jehovah's Witness? At STS there was a presentation of AVR through a right thoracotomy. If I can stent the Cx and RCA, that might be the best option. What do you think? Ajit Damle _______________________________________________ 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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) From ebender001 at me.com Sun Feb 1 09:04:24 2009 From: ebender001 at me.com (Edward Bender) Date: Sun Feb 1 12:04:54 2009 Subject: [HSF] Re-do AVR In-Reply-To: <001701c9848c$8d9c7a20$a8d56e60$@net> References: <654814.79899.qm@web81606.mail.mud.yahoo.com> <1095840663-1233500406-cardhu_decombobulator_blackberry.rim.net-390820265-@bxe016.bisx.prod.on.blackberry> <001701c9848c$8d9c7a20$a8d56e60$@net> Message-ID: <117658950073428298359105162540022120235-Webmail@me.com> I would seriously consider LV to desc aortic conduit in a patient like this. See Jim Gammie's posts and excellent report. Ed Bender, MD On Sunday, February 01, 2009, at 08:45AM, "Ajit Damle" wrote: >It sometimes seems that all my AVRs are re-dos after previous CABGs. Here is >the latest one: > > > >76 M, severe COPD, FEV1 50% of predicted, LIMA-LAD, SVG to OM 1996, >Creatinine 1.6, Asc aorta 4.0. I saw him in 2006, Angio patent LIMA to a >100% large LAD, SVG occluded, 99% Cx and RCA. AS, valve area 1.0 sq cms. EF >65%. 3D CT 06 showed LIMA plastered to back of sternum and coursing >medially. His presentation was unstable angina. I recommended surgery and >patient refused. > > > >Now increasing SOB, NYHA class III. EF now 25%, AV area 0.6sq cms, MR++, >wants surgery. PFTs unchanged. I am planning CT, coronary angio, PET scan >and perhaps a Dobutamine ECHO. Because of his coronary disease, he does not >qualify for the percuteneous trial. > > > >I have been doing my re-dos now after Hal's description: CPB and moderate >hypothermia before sternotomy. So although his LIMA has a high chance of >injury, I will be able to deal with it. But overall the problems are >daunting. > > > >Oh, and did I mention he is a Jehovah's Witness? > > > >At STS there was a presentation of AVR through a right thoracotomy. If I can >stent the Cx and RCA, that might be the best option. > > > >What do you think? > > > >Ajit Damle > > > >_______________________________________________ >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 Sun Feb 1 12:06:28 2009 From: msfirst at gmail.com (Michael Firstenberg) Date: Sun Feb 1 12:06:53 2009 Subject: [HSF] CABG reporting. In-Reply-To: References: Message-ID: <8A8BB069-B02B-4A5E-9252-A8E6DDBBCF0B@gmail.com> Hal - True and your comments do not surprise me. But, my comments (not directed at you in particular) is dealing more with the fine tuning, follow-up, etc that goes into the devices. Who does the device checks? Monitors the thresholds? Optimizes the pacing/ATP/defib programming? Who supervises the clinics and the in- patient device activations/deactivations for elective procedures? Who gets called with the problems? Who admits the patients when the ICDs fire? Again, like everything else - it depends on the system in place. -michael On Feb 1, 2009, at 11:48 AM, Hgrmd@aol.com wrote: > Michael, > My guess is you don't have much experience implanting pacemakers. I > trained in a different era and practice in a different community. > Here, the > surgeons still implant the majority of the devices, including > biventricular ICD's. > Personally, I only implant pacers. However, I've done literally > thousands > over the past 23 years without a single fatality, and only one > perforation > requiring a window (92 yo lady developed an effusion on PPOD#2). > In contrast, > there's an EP in our community who has had more perforations in the > few years > he's been here than all of the cardiac surgeons in my group in > their entire > careers. In addition, guess who this hapless EP screams for when > his ass is > in a sling? BTW, Michael, aren't you the one who said you stand by > for the > EP's in your hospital when they are extracting leads? That's > crazy. Quite > frankly, only surgeons should be doing that since massive tamponade > can develop > within seconds with that procedure (linear tear in free wall of RA). > > Hal > > > In a message dated 2/1/2009 11:39:16 A.M. Eastern Standard Time, > msfirst@gmail.com writes: > > maybe it is a subtle jab that surgeons should not be putting in > pacemakers? > > wow - all of the snow outside my window just melted from the blaze of > fire directed at me. > > > -michael > > > > > > On Feb 1, 2009, at 10:40 AM, hgrmd@aol.com wrote: > >> Ani, >> To be honest, I've really no idea what's going to be reported. I >> recently >> attended a meeting with administration at one of my hospitals where >> they >> outlined this new system. It's my uhderstanding that it will >> include AVR, MVR, >> CABG, and their combinations. Things like Dors, thoracic aortic >> procedures, >> and some others will be excluded. I plan to do a few more stand >> alone CABG's >> because, probably like you, my last death from an isolated CABG was >> several >> years ago. It's all a matter of playing the game. >> While we're discussing this crap, what about the STS's bone head >> rule that >> counts a postop permanent pacemaker as a "bring back for surgery" >> if it's >> done in the OR, but not if it's done in the EP lab? Honestly, >> who's side are >> they on? >> >> Hal >> >> >> In a message dated 2/1/2009 10:29:06 A.M. Eastern Standard Time, >> anianyanwu@hotmail.com writes: >> >> >> Hal >> >> One would only be at a disadvantage if one sees the stats as a >> means to >> promote or validate one's status as a top coronary surgeon - to do >> this one would >> need a high volume of CABG with low mortality (I assume that has to >> be the >> 'outcome' they will look at). However, given that you are not >> predominantly a >> coronary surgeon it shouldnt matter much to you. >> >> Assuming you do only 10 to 20 isolated CABGs per year then you >> would likely >> be excluded from ranking analysis (otherwise if you did 15 with no >> death, >> just like I did last year, then you would be ranked as the top >> coronary surgeon >> with a zero mortality risk which would make no sense). If one did >> include >> your cases in a report the confidence interval would be so wide >> such as to make >> your results meaningless. >> >> Only surgeons doing say 50 plus or so CABGs per year need worry >> about data >> reporting as the ranking and results would be more stable. If a low >> volume >> CABG surgeon wants to look good in the reports then one has to get >> more volume >> and try and aim to do at least 100 procedures per year for the data >> to have >> meaning. (the caveat though is that while a low volume surgeon will >> not get >> credited with low mortality, they will still get penalized for high >> mortality; >> if one does 10 cases and 5 die then small numbers wont protect from >> that). >> >> What is the stated goal of the Florida reporting exercise? I find >> it odd >> that with CABG in decline new reporting systems still emerge to >> track isolated >> CABG. I think one will find that cardiac surgery is becoming more >> like general >> thoracic where the make up of ones practice is very heterogenous >> with very >> few two operations being alike. The days where isolated CABG, >> isolated AVR and >> isolated MVR constituted 95% of most practices are long gone. We >> now have a >> plethora of operations and hybrids with various manners of combined >> procedures on an even more heterogenous group of patients which >> makes it very >> difficult to define index operations and compare outcomes. >> >> Why does the reporting make you plan to do more isolated CABGs? >> >> Ani >> >> >> >> >> >> >>> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] On pump vs >>> Off> >> From: hgrmd@aol.com> Date: Sun, 1 Feb 2009 15:00:10 +0000> CC: > > >> Tea,> I'm not >> sure, but wouldn't be surprised if the stats make it to the >> newspaper. >> Certainly, it will be online. Anyway, I'm at a disadvantage since >> my case load if >> over 95 per cent valves.> > Hal> Sent from my Verizon Wireless >> BlackBerry> > >> -----Original Message-----> From: Tea Acuff > > >> Date: Sun, >> 1 Feb 2009 06:54:40 > To: >> OpenHeart-L@lists.hsforum.com> >> Subject: Re: [HSF] On pump vs Off> > > What format will they use >> for reporting?> Tea> > Sent from my iPhone> > On Feb 1, 2009, at >> 5:47 AM, >> Hgrmd@aol.com wrote:> > I whole heartedly agree with you. Even the >> most die >> hard on pump surgeon is > bound to eventually encounter a case that >> he will >> screw up if he isn't able > to do at least the occasional off pump. >> Because >> Florida is now reporting the > mortality statistics of all surgeons >> (like New >> York), I plan to do more > isolated CABG's. I suspect at least half >> will be >> OPCAB.> > Hal> > > In a message dated 1/31/2009 11:06:20 P.M. >> Eastern Standard >> Time, > govindgovind@hotmail.com writes:> > > > > For any surgeon >> actively >> engaged in CABG on pump, learning the ropes for off > pump method >> is a definite >> advantage.Both methods are eminently successful in > getting good >> results and >> we need to apply either judiciouly as per the > clinical >> problem.There is no >> need to be a diehard supporter of only one method. If > some of the >> surgeons >> are trying to use off pump method from marketing angle > it is not >> the method >> which is at fault.> > govindakubal> To: OpenHeart- >> L@lists.hsforum.com> >> Subject: Re: [HSF] On pump > vs Off> Date: Sat, 31 Jan 2009 >> 21:58:57 -0500> From: >> tdmartin2000@aol.com> > CC: > > Bill> ?Laurie Davies is the >> principle >> investigator and has the > manuscript. She was appointed to the >> Florida Board of >> Medicine during the study and > was subsequently appointed as Chair >> of the Board >> - a big time consuming job. > She has just completed her tenure on >> the board >> and will be completing the > paper soon. It shows just what you >> would >> suspect but I cannot write it here as it > has not been published >> and the journals >> don't like it when you give out the > data.> Let's just say that it >> has not >> converted me.> > Tom> > > -----Original > Message-----> From: >> wftjrtyler@aol.com> To: OpenHeart-L@lists.hsforum.com> > Sent: Fri, >> 30 Jan 2009 6:57 pm> >> Subject: Re: [HSF] On pump vs Off> > > > Tom, > several years(and >> threads) ago, >> you were randomizing Opcabs vs. Oncab > at > UF. Is your study in >> progress >> or did i miss the paper? bill turner> > > In a > message dated >> 1/29/2009 >> 8:53:17 P.M. Central Standard Time, > > tdmartin2000@aol.com >> writes:> > agree> > > >> -----Original Message-----> From: hgrmd@aol.com> > To: >> OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:58 pm> >> Subject: > Re: [HSF] On pump vs >> Off> > > > Tom,> You and I are essentially on the same > side. Of >> course Dors >> and valves don't > apply. However, my perception, based > on >> personal >> experience as well as the > literature, is that elderly > >> vasculopaths with hostile >> aortas benefit from > OPCAB. > For the average case, it > probably >> doesn't >> matter. You and I would agree > that > there are a lot of > >> surgeons out there >> trying to use OPCAB for a marketing > angle. > I consider OPCAB > an >> excellent technique to have in one's armamentarium. In > fact, I was >>> recently >> summoned to the OR to take over my junior surgeon's > CABG > when >> he > >> unexpectedly encountered a bad aorta. I stepped in and did a 3 > >> vessel > OPCAB. > The >> patient did fine.> > Hal> > Hal > Sent from my Verizon Wireless > >> BlackBerry> >>> -----Original Message-----> From: tdmartin2000@aol.com> > Date: >>> Wed, 28 > >> Jan 2009 23:44:34 > To: > Subject: >> Re: [HSF] >>> On pump vs Off> > > Hal> I'm not sure John refuted as much as >>> attacked it. >>> His whole premise was on > the > difference between an >>> administrative and a >>> clinical data base. The presenter > had?a good rebuttal to John's >> rebuttal. I > can't wait to see the manuscript > and > review it >> myself. It's hard to >> refute > the conclusions of death, stroke, > length > of stay and >> costs when >> there is > data on 63,000 pts no matter what kind of > data > base. >> I also >> have to?ask > what your definition of a high risk case is and > >> where > the >> data is to > confirm your premise. It is hard to do an off pump >> redo CABG > >> AVR > or MVR, or a > CABG Dor, or a CABG, ascending, etc.. These >> would fall >> into the > > high risk > cases for me. As you know I brought this >> up for the >> sake of > dis> cussion > > and controversy.> > Tom> > > > > ----- >> Original >> Message-----> From: > hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com >>> Sent: Wed, >> 28 Jan 2009 11:25 pm> > Subject: Re: [HSF] On pump vs Off> > > > >> Tom,> Yes, >> it was provocative, but I > thought John Puskas pretty much refuted >> it in > >> the discussion. As you know, > his own group at Emory as well as >> thorough > >> exam of > > the STS database > comes to the opposite conclusions. >> Again, I >> don't think > the 2 > approaches ar> > e that distinguishable for >> low risk >> cases. However, most high risk > > > subsets do better.> > Hal> >> ------Original >> Message------> From: > tdmartin2000@aol.com> Sender: >> openheart-l-bounces@lists.hsforum.com> To: > > OpenHeart-L@lists.hsforum.com >>> ReplyTo: >> OpenHeart-L@lists.hsforum.com> Sent: Jan 28, 2009 11:18 PM> > >> Subject: [HSF] On pump vs Off> > >> I really hate to get this going again but I > REALLY don't believe >> that off >> is > better than on in any group except pts > with significant >> aortic >> calcification > or > atheroma. There was an interesting > paper >> just presented here >> at the STS that > created a sig controversy.> > > On-pump vs Off- >> Pump >> Coronary Artery Bypass Surgery in a Cohort of 63,000 > > Patients-? >> from Baylor and >> Texas Heart- reviewing the 2004 Nationwide > Inpatient > Sample >> database- >> admittedly an administrative database but with some > really > good >>>> >> statistics.> Conclusions- 1. Opcab does not produce lower > >> mortality or stroke 2. >> Opcab > has > longer hospital stays and higher costs ($1500) > 3. >> Performing >> Opcab in all > candidates for myocardial revascularization may > >> not be >> justifiable.> > Comments> > Tom Martin> U of Florida> >> Gainesville> > >> _______________________________________________> 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 >>>> >> -----------------------------------------> > > Sent from my Verizon >> Wireless > >> Black> Berry> > > > >> _______________________________________________> 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 ma> >> iling 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>> >> -----------------------------------------> > > **************A Good >> Credit > Score is 700 or Above. 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Learn >> more! >> > http://clk.atdmt.com/UKM/go/132630768/direct/01/______________________________ >> _________________ >> 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 Wall Street to Main Street and everywhere in >> between, stay >> up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 >> ) >> _______________________________________________ >> 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 Wall Street to Main Street and everywhere in > between, stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 > ) > _______________________________________________ > 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 Sun Feb 1 17:15:49 2009 From: hgrmd at aol.com (hgrmd@aol.com) Date: Sun Feb 1 12:16:12 2009 Subject: [HSF] CABG reporting. In-Reply-To: <8A8BB069-B02B-4A5E-9252-A8E6DDBBCF0B@gmail.com> References: <8A8BB069-B02B-4A5E-9252-A8E6DDBBCF0B@gmail.com> Message-ID: <924886958-1233508544-cardhu_decombobulator_blackberry.rim.net-2144589884-@bxe016.bisx.prod.on.blackberry> VGhlIGNhcmRpb2xvZ2lzdHMgdGFrZSBjYXJlIG9mIGFsbCB0aGF0IGp1bmsuICBJJ20gbGlrZSB0 aGUgcGx1bWJlcjsgSSBkbyB0aGUgaW5zdGFsbGF0aW9uLiAgUXVpdGUgZnJhbmtseSwgYmV0d2Vl biBtZSBhbmQgdGhlIHBhY2VyIHJlcHMsIHRoZXJlJ3MgdmlydHVhbGx5IG5ldmVyIGEgY29tcGxh aW50IGZyb20gdGhlIGNhcmRpb2xvZ2lzdHMuICBUaGV5IGZyZXF1ZW50bHkgdGVsbCB0aGUgcmVw IHRoZSBleGFjdCBzZXR0aW5ncyB0aGV5IHdhbnQgcHJpb3IgdG8gdGhlIE9SLiAgSW4gYWRkaXRp b24sIEkga25vdyB3aGF0IGNvbXByaXNlIGdvb2QgbnVtYmVycyB3aGVuIGltcGxhbnRpbmcgYSBE REQgcGFjZXIuICBJdCBhaW4ndCB0aGF0IGhhcmQuICBUaGUgRVAncyB0cnkgdG8gbWFrZSBldmVy eW9uZSBiZWxpZXZlIHRoZXkgYXJlIHRoZSBiZXN0IGF0IGltcGxhbnRpbmcuICBVbmZvcnR1bmF0 ZWx5LCB0aGV5IGFyZSBub3QgdGhvcmFjaWMgc3VyZ2VvbnMuICBUaGV5IGNhbid0IGZpeCBtb3N0 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LS0tLS0tLS0tLS0tLQ0KDQpfX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19fX19f X19fX19fXw0KT3BlbkhlYXJ0LUwgbWFpbGluZyBsaXN0DQoNClNlbmQgcG9zdGluZ3MgdG86DQog T3BlbkhlYXJ0LUxAbGlzdHMuaHNmb3J1bS5jb20NCg0KVG8gVU5TVUJTQ1JJQkUsIHRvIENIQU5H RSBlbWFpbCBhZGRyZXNzLCBvciB0byB2aWV3IGFyY2hpdmVzOg0KaHR0cDovL21tcC5janAuY29t L21haWxtYW4vbGlzdGluZm8vb3BlbmhlYXJ0LWwNCg0KQWxsIG1lc3NhZ2VzIHRyYW5zbWl0dGVk IGJ5IHRoZSBPcGVuSGVhcnQtTCBhcmUgc3ViamVjdCB0byB0aGUgcG9saWNpZXMgYW5kIA0KZGlz Y2xhaW1lcnMgcG9zdGVkIGF0Og0KaHR0cDovL3d3dy5oc2ZvcnVtLmNvbS9saXN0ZGlzY2xhaW0N Ci0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tDQo= From anianyanwu at hotmail.com Sun Feb 1 17:24:23 2009 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Sun Feb 1 12:24:50 2009 Subject: [HSF] Re-do AVR In-Reply-To: <001701c9848c$8d9c7a20$a8d56e60$@net> References: <654814.79899.qm@web81606.mail.mud.yahoo.com> <1095840663-1233500406-cardhu_decombobulator_blackberry.rim.net-390820265-@bxe016.bisx.prod.on.blackberry> <001701c9848c$8d9c7a20$a8d56e60$@net> Message-ID: Ajit If a Jehovah's witness I personally (and I suspect many others) could not do the case as majority of our redos are still transfused, but I am sure you have good experience of redos in Jehovah's witnesses to have recommeneded surgery. However, I do feel this patient has used all his cards here in dictating to surgeons what they do and now the time has come for the surgeon to say 'my turn to say no'. One thing to say no to blood but then when he was in relatively good shape, and had a definite indication for surgery he said no, and now things are even worse he wants you to do it? Personally I would advise him to save money and go to europe and get a transcatheter valve, else find someone in the USA who can do it on compassionate grounds. Specifically in reference to your case: 1) As you know being on CPB for sternotomy will not protect you from catastophe if the LIMA is severed on entry. If that happens, I suspect outcome could be poor as you will start the operation on an uphill struggle with a very ischemic and already depressed ventricle that has just lost majority of its blood supply. 2) Going on CPB to open the chest may not be the best strategy for blood conservation as no matter what we do some blood cells will be lost from all that sternal and soft tissue ooze throughout the case. The longer the case and the more blood recirculated through the cell-saver and cardiotomy suction, the more coagulopathy one will see. 3) I have done two redo AVRs via right thoracotomy in patients with similar IMA anatomy and exposure was very difficult, though doable. Not sure how appropriate though in JW as little margin for error, and bypass run will be longer, though theoretically will bleed less. I like though when you say you will be able to deal with the LIMA if you injure it - is that really as near a certainity as you suggest? How many surgeons here have seen severed LIMAs in redos and roughly how many of these patients did survive? I suspect it is a much more fatal injury that we appreciate. I have been involved in or know about maybe ten such injuries - some occuring after institution of CPB - during my training and after and I can recall only one survivor. It is certainly not as benign as it sounds. Ani > From: damle@cableone.net> To: OpenHeart-L@lists.hsforum.com> Date: Sun, 1 Feb 2009 10:45:55 -0600> CC: > Subject: [HSF] Re-do AVR> > It sometimes seems that all my AVRs are re-dos after previous CABGs. Here is> the latest one:> > > > 76 M, severe COPD, FEV1 50% of predicted, LIMA-LAD, SVG to OM 1996,> Creatinine 1.6, Asc aorta 4.0. I saw him in 2006, Angio patent LIMA to a> 100% large LAD, SVG occluded, 99% Cx and RCA. AS, valve area 1.0 sq cms. EF> 65%. 3D CT 06 showed LIMA plastered to back of sternum and coursing> medially. His presentation was unstable angina. I recommended surgery and> patient refused.> > > > Now increasing SOB, NYHA class III. EF now 25%, AV area 0.6sq cms, MR++,> wants surgery. PFTs unchanged. I am planning CT, coronary angio, PET scan> and perhaps a Dobutamine ECHO. Because of his coronary disease, he does not> qualify for the percuteneous trial.> > > > I have been doing my re-dos now after Hal's description: CPB and moderate> hypothermia before sternotomy. So although his LIMA has a high chance of> injury, I will be able to deal with it. But overall the problems are> daunting. > > > > Oh, and did I mention he is a Jehovah's Witness?> > > > At STS there was a presentation of AVR through a right thoracotomy. If I can> stent the Cx and RCA, that might be the best option.> > > > What do you think?> > > > Ajit Damle> > > > _______________________________________________> 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> ----------------------------------------- _________________________________________________________________ Check out the new and improved services from Windows Live. Learn more! http://clk.atdmt.com/UKM/go/132630768/direct/01/ From prasannasimha at gmail.com Sun Feb 1 23:07:09 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sun Feb 1 12:45:38 2009 Subject: [HSF] Re-do AVR In-Reply-To: <001701c9848c$8d9c7a20$a8d56e60$@net> References: <654814.79899.qm@web81606.mail.mud.yahoo.com> <1095840663-1233500406-cardhu_decombobulator_blackberry.rim.net-390820265-@bxe016.bisx.prod.on.blackberry> <001701c9848c$8d9c7a20$a8d56e60$@net> Message-ID: <89c4ed2d0902010937k10b09519qd6f14562406f751c@mail.gmail.com> AVR can be done through right thoracotomy . In a redo if you dont have an endoclamp it you can use a Foleys introducd via a purse string. If you want to plege the heart give 40 Meq of K into the pump. Have a hemofilter in the set. Heart will plege via the aptent LIMA and additional cardioplegia.either ostial /retroplegia. Problem will be wrt return from patent ostia. hemofiler to remove K. One problem with right thoracotomy is the NCC RCC junction is not that well seen. Prasanna On Sun, Feb 1, 2009 at 10:15 PM, Ajit Damle wrote: > It sometimes seems that all my AVRs are re-dos after previous CABGs. Here > is > the latest one: > > > > 76 M, severe COPD, FEV1 50% of predicted, LIMA-LAD, SVG to OM 1996, > Creatinine 1.6, Asc aorta 4.0. I saw him in 2006, Angio patent LIMA to a > 100% large LAD, SVG occluded, 99% Cx and RCA. AS, valve area 1.0 sq cms. EF > 65%. 3D CT 06 showed LIMA plastered to back of sternum and coursing > medially. His presentation was unstable angina. I recommended surgery and > patient refused. > > > > Now increasing SOB, NYHA class III. EF now 25%, AV area 0.6sq cms, MR++, > wants surgery. PFTs unchanged. I am planning CT, coronary angio, PET scan > and perhaps a Dobutamine ECHO. Because of his coronary disease, he does not > qualify for the percuteneous trial. > > > > I have been doing my re-dos now after Hal's description: CPB and moderate > hypothermia before sternotomy. So although his LIMA has a high chance of > injury, I will be able to deal with it. But overall the problems are > daunting. > > > > Oh, and did I mention he is a Jehovah's Witness? > > > > At STS there was a presentation of AVR through a right thoracotomy. If I > can > stent the Cx and RCA, that might be the best option. > > > > What do you think? > > > > Ajit Damle > > > > _______________________________________________ > 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 msfirst at gmail.com Sun Feb 1 12:48:02 2009 From: msfirst at gmail.com (Michael Firstenberg) Date: Sun Feb 1 12:48:30 2009 Subject: [HSF] Re-do AVR In-Reply-To: <001701c9848c$8d9c7a20$a8d56e60$@net> References: <654814.79899.qm@web81606.mail.mud.yahoo.com> <1095840663-1233500406-cardhu_decombobulator_blackberry.rim.net-390820265-@bxe016.bisx.prod.on.blackberry> <001701c9848c$8d9c7a20$a8d56e60$@net> Message-ID: <45DBBC1D-C8E9-4F12-A2A2-4334C4FFADF8@gmail.com> In my hands - inoperable. In fact, I would not even risk his kidneys with all of the contrast working him up. If someone else - like a big aortic center (reference?) wants to deal with this - then go for it. With his kidneys going bad, he is probably anemic also? -michael On Feb 1, 2009, at 11:45 AM, Ajit Damle wrote: > It sometimes seems that all my AVRs are re-dos after previous CABGs. > Here is > the latest one: > > > > 76 M, severe COPD, FEV1 50% of predicted, LIMA-LAD, SVG to OM 1996, > Creatinine 1.6, Asc aorta 4.0. I saw him in 2006, Angio patent LIMA > to a > 100% large LAD, SVG occluded, 99% Cx and RCA. AS, valve area 1.0 sq > cms. EF > 65%. 3D CT 06 showed LIMA plastered to back of sternum and coursing > medially. His presentation was unstable angina. I recommended > surgery and > patient refused. > > > > Now increasing SOB, NYHA class III. EF now 25%, AV area 0.6sq cms, MR > ++, > wants surgery. PFTs unchanged. I am planning CT, coronary angio, PET > scan > and perhaps a Dobutamine ECHO. Because of his coronary disease, he > does not > qualify for the percuteneous trial. > > > > I have been doing my re-dos now after Hal's description: CPB and > moderate > hypothermia before sternotomy. So although his LIMA has a high > chance of > injury, I will be able to deal with it. But overall the problems are > daunting. > > > > Oh, and did I mention he is a Jehovah's Witness? > > > > At STS there was a presentation of AVR through a right thoracotomy. > If I can > stent the Cx and RCA, that might be the best option. > > > > What do you think? > > > > Ajit Damle > > > > _______________________________________________ > 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 enaseri at hotmail.com.tr Sun Feb 1 17:56:50 2009 From: enaseri at hotmail.com.tr (=?windows-1254?Q?erdin=E7_naseri?=) Date: Sun Feb 1 12:57:38 2009 Subject: [HSF] Re-do AVR In-Reply-To: <001701c9848c$8d9c7a20$a8d56e60$@net> References: <654814.79899.qm@web81606.mail.mud.yahoo.com> <1095840663-1233500406-cardhu_decombobulator_blackberry.rim.net-390820265-@bxe016.bisx.prod.on.blackberry> <001701c9848c$8d9c7a20$a8d56e60$@net> Message-ID: Ajit, 1.What is the cause of decline in EF from 60 to 25%? 2.You can proceed as per Hal's recommendation and deal with Lima meticulously and if an injury happens then a vein graft will be Ok in a 76 Y/O patient with severe COPD and RF. 3.You have to either control Lima by a supraclavicular approach or use continous coronary sinus( by a pump head) and lima prefusion in a fibrilating heart. Erdinc > From: damle@cableone.net> To: OpenHeart-L@lists.hsforum.com> Date: Sun, 1 Feb 2009 10:45:55 -0600> CC: > Subject: [HSF] Re-do AVR> > It sometimes seems that all my AVRs are re-dos after previous CABGs. Here is> the latest one:> > > > 76 M, severe COPD, FEV1 50% of predicted, LIMA-LAD, SVG to OM 1996,> Creatinine 1.6, Asc aorta 4.0. I saw him in 2006, Angio patent LIMA to a> 100% large LAD, SVG occluded, 99% Cx and RCA. AS, valve area 1.0 sq cms. EF> 65%. 3D CT 06 showed LIMA plastered to back of sternum and coursing> medially. His presentation was unstable angina. I recommended surgery and> patient refused.> > > > Now increasing SOB, NYHA class III. EF now 25%, AV area 0.6sq cms, MR++,> wants surgery. PFTs unchanged. I am planning CT, coronary angio, PET scan> and perhaps a Dobutamine ECHO. Because of his coronary disease, he does not> qualify for the percuteneous trial.> > > > I have been doing my re-dos now after Hal's description: CPB and moderate> hypothermia before sternotomy. So although his LIMA has a high chance of> injury, I will be able to deal with it. But overall the problems are> daunting. > > > > Oh, and did I mention he is a Jehovah's Witness?> > > > At STS there was a presentation of AVR through a right thoracotomy. If I can> stent the Cx and RCA, that might be the best option.> > > > What do you think?> > > > Ajit Damle> > > > _______________________________________________> 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 Sun Feb 1 23:07:35 2009 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sun Feb 1 12:59:50 2009 Subject: [HSF] Re-do AVR Message-ID: <89c4ed2d0902010937k33b70d66v599d2fc4a3a504c4@mail.gmail.com> By choice I still would prefer to do it by midline. Prasanna 2009/2/1 Prasanna Simha M > AVR can be done through right thoracotomy . > In a redo if you dont have an endoclamp it you can use a Foleys introducd > via a purse string. > If you want to plege the heart give 40 Meq of K into the pump. Have a > hemofilter in the set. Heart will plege via the aptent LIMA and additional > cardioplegia.either ostial /retroplegia. > Problem will be wrt return from patent ostia. hemofiler to remove K. > One problem with right thoracotomy is the NCC RCC junction is not that well > seen. > Prasanna > > On Sun, Feb 1, 2009 at 10:15 PM, Ajit Damle wrote: > >> It sometimes seems that all my AVRs are re-dos after previous CABGs. Here >> is >> the latest one: >> >> >> >> 76 M, severe COPD, FEV1 50% of predicted, LIMA-LAD, SVG to OM 1996, >> Creatinine 1.6, Asc aorta 4.0. I saw him in 2006, Angio patent LIMA to a >> 100% large LAD, SVG occluded, 99% Cx and RCA. AS, valve area 1.0 sq cms. >> EF >> 65%. 3D CT 06 showed LIMA plastered to back of sternum and coursing >> medially. His presentation was unstable angina. I recommended surgery and >> patient refused. >> >> >> >> Now increasing SOB, NYHA class III. EF now 25%, AV area 0.6sq cms, MR++, >> wants surgery. PFTs unchanged. I am planning CT, coronary angio, PET scan >> and perhaps a Dobutamine ECHO. Because of his coronary disease, he does >> not >> qualify for the percuteneous trial. >> >> >> >> I have been doing my re-dos now after Hal's description: CPB and moderate >> hypothermia before sternotomy. So although his LIMA has a high chance of >> injury, I will be able to deal with it. But overall the problems are >> daunting. >> >> >> >> Oh, and did I mention he is a Jehovah's Witness? >> >> >> >> At STS there was a presentation of AVR through a right thoracotomy. If I >> can >> stent the Cx and RCA, that might be the best option. >> >> >> >> What do you think? >> >> >> >> Ajit Damle >> >> >> >> _______________________________________________ >> 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 From enaseri at hotmail.com.tr Sun Feb 1 18:04:30 2009 From: enaseri at hotmail.com.tr (=?windows-1254?Q?erdin=E7_naseri?=) Date: Sun Feb 1 13:05:20 2009 Subject: [HSF] Re-do AVR In-Reply-To: References: <654814.79899.qm@web81606.mail.mud.yahoo.com> <1095840663-1233500406-cardhu_decombobulator_blackberry.rim.net-390820265-@bxe016.bisx.prod.on.blackberry> <001701c9848c$8d9c7a20$a8d56e60$@net> Message-ID: Ajit, I expressed my ideas about the surgical conduct of the case and not blood transfusion aspects.As for Lima injury , I had 1 patient with severed Lima and we did vein graft with no problems.Of course 1 case is of no statistical value. erdinc From msfirst at gmail.com Sun Feb 1 12:02:08 2009 From: msfirst at gmail.com (Michael Firstenberg) Date: Sun Feb 1 13:11:59 2009 Subject: [HSF] On pump vs Off In-Reply-To: References: Message-ID: Why turn them down? What are the consequences? (of course no one wants a bad rap for being a bad coronary surgeon or anything else for that matter) We dont have surgeon specific reporting in Ohio - although it may be coming and we talk about it a lot. Most surgeons, regardless, will know who they would send their Mother to. The irony is that in probably a complete multi-variate analysis, the actual surgeon probably contributes little to the 30 day outcome? These reporting programs are more geared towards dealing with systematic issues - and if your program has a higher than average CABG M&M - then that should be the motivation to fix "systemic issues". While in some cases, it may be the surgeon - my guess (IMvHO) it is programatic issues that are in effect. I hate to say this - but maybe that means YOU shouldnt be doing CABGs - a philosophical question as I am sure you are a great coronary surgeon, but if you are only doing 10-20 a year (hardly a "reference surgeon" by Ani's comments), maybe your efforts are better spent on the 79 year/old redo MVR with a previous AVR? Let the others deal with the headaches of CABGs - my Boss says that isolated CABGs are a thankless procedure these days - everything is expected to be perfect (regardless of elective or if the patient is coming to you with CPR in progress, nameless, from the cath lab with lytics on board?) -michael On Feb 1, 2009, at 11:43 AM, Hgrmd@aol.com wrote: > Michael, > Your words are comforting. Hopefully, the community will be able > to tell > where the truth lies. Since, it's all new to me, I will > unfortunately have > to turn down some marginal cases that I might have done in the past. > > Hal > > > In a message dated 2/1/2009 11:36:59 A.M. Eastern Standard Time, > msfirst@gmail.com writes: > > Do you think it will really matter? > (the knee jerk response will be of course) > but if you provide a good service - the referring physicians and > patients will know. > How many people chose their heart surgeon based on the local > newspaper. > > We wrestle with some of the same issues - there is a community > hospital not too far that boasts the "best outcomes". > I will not comments further since everyone knows what that > means....... > > my response then is, go there! > > I think the playing field gets leveled after a while but I get > frustrated seeing how these "numbers" are used for marketing and > other > secondary gains. > > -michael > > > > > On Feb 1, 2009, at 10:24 AM, hgrmd@aol.com wrote: > >> Tea, >> Again, I'm not sure. Supposedly, the results will be risk >> stratified. >> However, given the ignorance of the general public, I suspect the >> raw mortality >> will really be the bottom line. >> >> Hal >> >> >> In a message dated 2/1/2009 10:05:54 A.M. Eastern Standard Time, >> tacuff@swbell.net writes: >> >> So. Is it just "heart mortality" or what. >> tea >> >> >> >> >> ________________________________ >> From: "hgrmd@aol.com" >> To: OpenHeart-L@lists.hsforum.com >> Sent: Sunday, February 1, 2009 9:00:10 AM >> Subject: Re: [HSF] On pump vs Off >> >> Tea, >> I'm not sure, but wouldn't be surprised if the stats make it to the >> newspaper. Certainly, it will be online. Anyway, I'm at a >> disadvantage since my >> case load if over 95 per cent valves. >> >> Hal >> Sent from my Verizon Wireless BlackBerry >> >> -----Original Message----- >> From: Tea Acuff >> >> Date: Sun, 1 Feb 2009 06:54:40 >> To: OpenHeart-L@lists.hsforum.com >> Subject: Re: [HSF] On pump vs Off >> >> >> What format will they use for reporting? >> Tea >> >> Sent from my iPhone >> >> On Feb 1, 2009, at 5:47 AM, Hgrmd@aol.com wrote: >> >> I whole heartedly agree with you. Even the most die hard on pump >> surgeon >> is >> bound to eventually encounter a case that he will screw up if he >> isn't able >> to do at least the occasional off pump. Because Florida is now >> reporting >> the >> mortality statistics of all surgeons (like New York), I plan to do >> more >> isolated CABG's. I suspect at least half will be OPCAB. >> >> Hal >> >> >> In a message dated 1/31/2009 11:06:20 P.M. Eastern Standard Time, >> govindgovind@hotmail.com writes: >> >> >> >> >> For any surgeon actively engaged in CABG on pump, learning the >> ropes for >> off >> pump method is a definite advantage.Both methods are eminently >> successful >> in >> getting good results and we need to apply either judiciouly as per >> the >> clinical problem.There is no need to be a diehard supporter of >> only one >> method. If >> some of the surgeons are trying to use off pump method from >> marketing angle >> it is not the method which is at fault. >> >> govindakubal> To: OpenHeart-L@lists.hsforum.com> Subject: Re: >> [HSF] On pump >> vs Off> Date: Sat, 31 Jan 2009 21:58:57 -0500> From: > tdmartin2000@aol.com >>> >> CC: > > Bill> ?Laurie Davies is the principle investigator and >> has >> the >> manuscript. She was appointed to the Florida Board of Medicine >> during the >> study and >> was subsequently appointed as Chair of the Board - a big time >> consuming >> job. >> She has just completed her tenure on the board and will be >> completing the >> paper soon. It shows just what you would suspect but I cannot >> write it here >> as it >> has not been published and the journals don't like it when you >> give out the >> data.> Let's just say that it has not converted me.> > Tom> > > >> -----Original >> Message-----> From: wftjrtyler@aol.com> To: > OpenHeart-L@lists.hsforum.com >>> >> Sent: Fri, 30 Jan 2009 6:57 pm> Subject: Re: [HSF] On pump vs Off> >>>>> >> Tom, >> several years(and threads) ago, you were randomizing Opcabs vs. >> Oncab > at >> UF. Is your study in progress or did i miss the paper? bill >> turner> > > In >> a >> message dated 1/29/2009 8:53:17 P.M. Central Standard Time, > >> tdmartin2000@aol.com writes:> > agree> > > -----Original >> Message-----> >> From: hgrmd@aol.com> >> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:58 >> pm> >> Subject: >> Re: [HSF] On pump vs Off> > > > Tom,> You and I are essentially >> on >> the same >> side. Of course Dors and valves don't > apply. However, my >> perception, >> based >> on personal experience as well as the > literature, is that >> elderly >> vasculopaths with hostile aortas benefit from > OPCAB. > For the >> average >> case, it >> probably doesn't matter. You and I would agree > that > there are >> a lot of >> surgeons out there trying to use OPCAB for a marketing > angle. >> > I >> consider OPCAB >> an excellent technique to have in one's armamentarium. In > fact, >> I was >> recently summoned to the OR to take over my junior surgeon's > >> CABG > when >> he >> unexpectedly encountered a bad aorta. I stepped in and did a 3 > >> vessel > >> OPCAB. >> The patient did fine.> > Hal> > Hal > Sent from my Verizon >> Wireless >> BlackBerry> > -----Original Message-----> From: >> tdmartin2000@aol.com> > >> Date: Wed, 28 >> Jan 2009 23:44:34 > To: > Subject: >> Re: [HSF] >> On pump vs Off> > > Hal> I'm not sure John refuted as much as >> attacked it. >> >> His whole premise was on > the > difference between an >> administrative and a >> clinical data base. The presenter > had?a good rebuttal to John's >> rebuttal. >> I >> can't wait to see the manuscript > and > review it myself. It's >> hard to >> refute >> the conclusions of death, stroke, > length > of stay and costs >> when there >> is >> data on 63,000 pts no matter what kind of > data > base. I also >> have to?ask >> what your definition of a high risk case is and > where > the data >> is to >> confirm your premise. It is hard to do an off pump redo CABG > AVR >>> or >> MVR, or a >> CABG Dor, or a CABG, ascending, etc.. These would fall into the > >>> high >> risk >> cases for me. As you know I brought this up for the sake of > dis> >> cussion >>> >> and controversy.> > Tom> > > > > -----Original Message-----> >> From: >> hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 >> Jan 2009 >> 11:25 pm> >> Subject: Re: [HSF] On pump vs Off> > > > Tom,> Yes, it was >> provocative, but >> I >> thought John Puskas pretty much refuted it in > the discussion. As >> you >> know, >> his own group at Emory as well as thorough > exam of > > the STS >> database >> comes to the opposite conclusions. Again, I don't think > the 2 > >> approaches ar> >> e that distinguishable for low risk cases. However, most high risk >>>> >> subsets do better.> > Hal> ------Original Message------> From: >> tdmartin2000@aol.com> Sender: openheart-l- >> bounces@lists.hsforum.com> To: >> OpenHeart-L@lists.hsforum.com> ReplyTo: OpenHeart- >> L@lists.hsforum.com> >> Sent: Jan 28, 2009 11:18 PM> >> Subject: [HSF] On pump vs Off> > I really hate to get this going >> again but >> I >> REALLY don't believe that off is > better than on in any group >> except pts >> with significant aortic calcification > or > atheroma. There was >> an >> interesting >> paper just presented here at the STS that > created a sig >> controversy.> > >> On-pump vs Off-Pump Coronary Artery Bypass Surgery in a Cohort of >> 63,000 > >> Patients-? from Baylor and Texas Heart- reviewing the 2004 >> Nationwide > >> Inpatient >> Sample database- admittedly an administrative database but with >> some >> really > good > > statistics.> Conclusions- 1. Opcab does not >> produce lower >> >> mortality or stroke 2. Opcab > has > longer hospital stays and >> higher costs >> ($1500) >> 3. Performing Opcab in all > candidates for myocardial >> revascularization >> may >> not be justifiable.> > Comments> > Tom Martin> U of Florida> >> Gainesville> >> _______________________________________________> 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 >>> >> -----------------------------------------> > > Sent from my Verizon >> Wireless >> Black> Berry> > > > >> _______________________________________________> >> 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 ma> >> iling >> 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 >>> >> -----------------------------------------> > > **************A >> Good Credit >> Score is 700 or Above. See yours in just 2 easy > steps! > >> > (http://pr.atwola.com/promoclk/100000075x1215855013x1201028747/aol?redir=http >> : >> //www.freecreditreport. >> com/pm/default.aspx?sc=668072%26hmpgID=62%26bcd=De> >> cemailfooterNO62)> >> _______________________________________________> OpenHeart-L >> mailing list> >>> Send >> postings to:> OpenHe> art-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> >> ----------------------------------------- >> _________________________________________________________________ >> Wish to Marry Now? Join MSN Matrimony FREE! >> > http://www.in.msn.com/matrimony_______________________________________________ >> >> 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 Wall Street to Main Street and everywhere in >> between, >> stay >> up-to-date with the latest news. > (http://aol.com?ncid=emlcntaolcom00000023 >> ) >> _______________________________________________ >> 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 >> ----------------------------------------- >> >> **************From Wall Street to Main Street and everywhere in >> between, stay >> up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 >> ) >> _______________________________________________ >> 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 Wall Street to Main Street and everywhere in > between, stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 > ) > _______________________________________________ > 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 Sun Feb 1 13:14:26 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Feb 1 13:15:45 2009 Subject: [HSF] Re-do AVR Message-ID: Ed, If there isn't more than mild AI, that's an excellent suggestion. Hal In a message dated 2/1/2009 12:06:26 P.M. Eastern Standard Time, ebender001@me.com writes: I would seriously consider LV to desc aortic conduit in a patient like this. See Jim Gammie's posts and excellent report. Ed Bender, MD On Sunday, February 01, 2009, at 08:45AM, "Ajit Damle" wrote: >It sometimes seems that all my AVRs are re-dos after previous CABGs. Here is >the latest one: > > > >76 M, severe COPD, FEV1 50% of predicted, LIMA-LAD, SVG to OM 1996, >Creatinine 1.6, Asc aorta 4.0. I saw him in 2006, Angio patent LIMA to a >100% large LAD, SVG occluded, 99% Cx and RCA. AS, valve area 1.0 sq cms. EF >65%. 3D CT 06 showed LIMA plastered to back of sternum and coursing >medially. His presentation was unstable angina. I recommended surgery and >patient refused. > > > >Now increasing SOB, NYHA class III. EF now 25%, AV area 0.6sq cms, MR++, >wants surgery. PFTs unchanged. I am planning CT, coronary angio, PET scan >and perhaps a Dobutamine ECHO. Because of his coronary disease, he does not >qualify for the percuteneous trial. > > > >I have been doing my re-dos now after Hal's description: CPB and moderate >hypothermia before sternotomy. So although his LIMA has a high chance of >injury, I will be able to deal with it. But overall the problems are >daunting. > > > >Oh, and did I mention he is a Jehovah's Witness? > > > >At STS there was a presentation of AVR through a right thoracotomy. If I can >stent the Cx and RCA, that might be the best option. > > > >What do you think? > > > >Ajit Damle > > > >_______________________________________________ >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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) From Hgrmd at aol.com Sun Feb 1 13:21:59 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Feb 1 13:23:06 2009 Subject: [HSF] Re-do AVR Message-ID: Michael, The more I think about it, the more I agree with you. If the patient is a "Kamikaze J.W.", I would pass. Hal In a message dated 2/1/2009 12:49:38 P.M. Eastern Standard Time, msfirst@gmail.com writes: In my hands - inoperable. In fact, I would not even risk his kidneys with all of the contrast working him up. If someone else - like a big aortic center (reference?) wants to deal with this - then go for it. With his kidneys going bad, he is probably anemic also? -michael On Feb 1, 2009, at 11:45 AM, Ajit Damle wrote: > It sometimes seems that all my AVRs are re-dos after previous CABGs. > Here is > the latest one: > > > > 76 M, severe COPD, FEV1 50% of predicted, LIMA-LAD, SVG to OM 1996, > Creatinine 1.6, Asc aorta 4.0. I saw him in 2006, Angio patent LIMA > to a > 100% large LAD, SVG occluded, 99% Cx and RCA. AS, valve area 1.0 sq > cms. EF > 65%. 3D CT 06 showed LIMA plastered to back of sternum and coursing > medially. His presentation was unstable angina. I recommended > surgery and > patient refused. > > > > Now increasing SOB, NYHA class III. EF now 25%, AV area 0.6sq cms, MR > ++, > wants surgery. PFTs unchanged. I am planning CT, coronary angio, PET > scan > and perhaps a Dobutamine ECHO. Because of his coronary disease, he > does not > qualify for the percuteneous trial. > > > > I have been doing my re-dos now after Hal's description: CPB and > moderate > hypothermia before sternotomy. So although his LIMA has a high > chance of > injury, I will be able to deal with it. But overall the problems are > daunting. > > > > Oh, and did I mention he is a Jehovah's Witness? > > > > At STS there was a presentation of AVR through a right thoracotomy. > If I can > stent the Cx and RCA, that might be the best option. > > > > What do you think? > > > > Ajit Damle > > > > _______________________________________________ > 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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) From Hgrmd at aol.com Sun Feb 1 13:26:37 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Feb 1 13:27:43 2009 Subject: [HSF] Re-do AVR Message-ID: Ajit and Ani, I've injured a handful of mammaries in my time. The last one was several years ago. I only recall one fatality which was the first one. I was in training, opening a redo, when I transected the mammary. Of course, I wasn't even close to being able to go on bypass. The outcome was predictably horrible. In these cases, I prefer CPB prior to splitting the chest. At the very least, I would have a suitable peripheral artery available to crash on if such is needed. Hal In a message dated 2/1/2009 1:06:30 P.M. Eastern Standard Time, enaseri@hotmail.com.tr writes: Ajit, I expressed my ideas about the surgical conduct of the case and not blood transfusion aspects.As for Lima injury , I had 1 patient with severed Lima and we did vein graft with no problems.Of course 1 case is of no statistical value. erdinc _______________________________________________ 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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) From Hgrmd at aol.com Sun Feb 1 13:29:00 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Feb 1 13:29:58 2009 Subject: [HSF] On pump vs Off Message-ID: Michael, Actually, I do lots of concomitant grafting with my valve cases, so being facile with CABG isn't a problem. If all I did was isolated valve cases, your point would be very well taken. Hal In a message dated 2/1/2009 1:13:32 P.M. Eastern Standard Time, msfirst@gmail.com writes: Why turn them down? What are the consequences? (of course no one wants a bad rap for being a bad coronary surgeon or anything else for that matter) We dont have surgeon specific reporting in Ohio - although it may be coming and we talk about it a lot. Most surgeons, regardless, will know who they would send their Mother to. The irony is that in probably a complete multi-variate analysis, the actual surgeon probably contributes little to the 30 day outcome? These reporting programs are more geared towards dealing with systematic issues - and if your program has a higher than average CABG M&M - then that should be the motivation to fix "systemic issues". While in some cases, it may be the surgeon - my guess (IMvHO) it is programatic issues that are in effect. I hate to say this - but maybe that means YOU shouldnt be doing CABGs - a philosophical question as I am sure you are a great coronary surgeon, but if you are only doing 10-20 a year (hardly a "reference surgeon" by Ani's comments), maybe your efforts are better spent on the 79 year/old redo MVR with a previous AVR? Let the others deal with the headaches of CABGs - my Boss says that isolated CABGs are a thankless procedure these days - everything is expected to be perfect (regardless of elective or if the patient is coming to you with CPR in progress, nameless, from the cath lab with lytics on board?) -michael On Feb 1, 2009, at 11:43 AM, Hgrmd@aol.com wrote: > Michael, > Your words are comforting. Hopefully, the community will be able > to tell > where the truth lies. Since, it's all new to me, I will > unfortunately have > to turn down some marginal cases that I might have done in the past. > > Hal > > > In a message dated 2/1/2009 11:36:59 A.M. Eastern Standard Time, > msfirst@gmail.com writes: > > Do you think it will really matter? > (the knee jerk response will be of course) > but if you provide a good service - the referring physicians and > patients will know. > How many people chose their heart surgeon based on the local > newspaper. > > We wrestle with some of the same issues - there is a community > hospital not too far that boasts the "best outcomes". > I will not comments further since everyone knows what that > means....... > > my response then is, go there! > > I think the playing field gets leveled after a while but I get > frustrated seeing how these "numbers" are used for marketing and > other > secondary gains. > > -michael > > > > > On Feb 1, 2009, at 10:24 AM, hgrmd@aol.com wrote: > >> Tea, >> Again, I'm not sure. Supposedly, the results will be risk >> stratified. >> However, given the ignorance of the general public, I suspect the >> raw mortality >> will really be the bottom line. >> >> Hal >> >> >> In a message dated 2/1/2009 10:05:54 A.M. Eastern Standard Time, >> tacuff@swbell.net writes: >> >> So. Is it just "heart mortality" or what. >> tea >> >> >> >> >> ________________________________ >> From: "hgrmd@aol.com" >> To: OpenHeart-L@lists.hsforum.com >> Sent: Sunday, February 1, 2009 9:00:10 AM >> Subject: Re: [HSF] On pump vs Off >> >> Tea, >> I'm not sure, but wouldn't be surprised if the stats make it to the >> newspaper. Certainly, it will be online. Anyway, I'm at a >> disadvantage since my >> case load if over 95 per cent valves. >> >> Hal >> Sent from my Verizon Wireless BlackBerry >> >> -----Original Message----- >> From: Tea Acuff >> >> Date: Sun, 1 Feb 2009 06:54:40 >> To: OpenHeart-L@lists.hsforum.com >> Subject: Re: [HSF] On pump vs Off >> >> >> What format will they use for reporting? >> Tea >> >> Sent from my iPhone >> >> On Feb 1, 2009, at 5:47 AM, Hgrmd@aol.com wrote: >> >> I whole heartedly agree with you. Even the most die hard on pump >> surgeon >> is >> bound to eventually encounter a case that he will screw up if he >> isn't able >> to do at least the occasional off pump. Because Florida is now >> reporting >> the >> mortality statistics of all surgeons (like New York), I plan to do >> more >> isolated CABG's. I suspect at least half will be OPCAB. >> >> Hal >> >> >> In a message dated 1/31/2009 11:06:20 P.M. Eastern Standard Time, >> govindgovind@hotmail.com writes: >> >> >> >> >> For any surgeon actively engaged in CABG on pump, learning the >> ropes for >> off >> pump method is a definite advantage.Both methods are eminently >> successful >> in >> getting good results and we need to apply either judiciouly as per >> the >> clinical problem.There is no need to be a diehard supporter of >> only one >> method. If >> some of the surgeons are trying to use off pump method from >> marketing angle >> it is not the method which is at fault. >> >> govindakubal> To: OpenHeart-L@lists.hsforum.com> Subject: Re: >> [HSF] On pump >> vs Off> Date: Sat, 31 Jan 2009 21:58:57 -0500> From: > tdmartin2000@aol.com >>> >> CC: > > Bill> ?Laurie Davies is the principle investigator and >> has >> the >> manuscript. She was appointed to the Florida Board of Medicine >> during the >> study and >> was subsequently appointed as Chair of the Board - a big time >> consuming >> job. >> She has just completed her tenure on the board and will be >> completing the >> paper soon. It shows just what you would suspect but I cannot >> write it here >> as it >> has not been published and the journals don't like it when you >> give out the >> data.> Let's just say that it has not converted me.> > Tom> > > >> -----Original >> Message-----> From: wftjrtyler@aol.com> To: > OpenHeart-L@lists.hsforum.com >>> >> Sent: Fri, 30 Jan 2009 6:57 pm> Subject: Re: [HSF] On pump vs Off> >>>>> >> Tom, >> several years(and threads) ago, you were randomizing Opcabs vs. >> Oncab > at >> UF. Is your study in progress or did i miss the paper? bill >> turner> > > In >> a >> message dated 1/29/2009 8:53:17 P.M. Central Standard Time, > >> tdmartin2000@aol.com writes:> > agree> > > -----Original >> Message-----> >> From: hgrmd@aol.com> >> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:58 >> pm> >> Subject: >> Re: [HSF] On pump vs Off> > > > Tom,> You and I are essentially >> on >> the same >> side. Of course Dors and valves don't > apply. However, my >> perception, >> based >> on personal experience as well as the > literature, is that >> elderly >> vasculopaths with hostile aortas benefit from > OPCAB. > For the >> average >> case, it >> probably doesn't matter. You and I would agree > that > there are >> a lot of >> surgeons out there trying to use OPCAB for a marketing > angle. >> > I >> consider OPCAB >> an excellent technique to have in one's armamentarium. In > fact, >> I was >> recently summoned to the OR to take over my junior surgeon's > >> CABG > when >> he >> unexpectedly encountered a bad aorta. I stepped in and did a 3 > >> vessel > >> OPCAB. >> The patient did fine.> > Hal> > Hal > Sent from my Verizon >> Wireless >> BlackBerry> > -----Original Message-----> From: >> tdmartin2000@aol.com> > >> Date: Wed, 28 >> Jan 2009 23:44:34 > To: > Subject: >> Re: [HSF] >> On pump vs Off> > > Hal> I'm not sure John refuted as much as >> attacked it. >> >> His whole premise was on > the > difference between an >> administrative and a >> clinical data base. The presenter > had?a good rebuttal to John's >> rebuttal. >> I >> can't wait to see the manuscript > and > review it myself. It's >> hard to >> refute >> the conclusions of death, stroke, > length > of stay and costs >> when there >> is >> data on 63,000 pts no matter what kind of > data > base. I also >> have to?ask >> what your definition of a high risk case is and > where > the data >> is to >> confirm your premise. It is hard to do an off pump redo CABG > AVR >>> or >> MVR, or a >> CABG Dor, or a CABG, ascending, etc.. These would fall into the > >>> high >> risk >> cases for me. As you know I brought this up for the sake of > dis> >> cussion >>> >> and controversy.> > Tom> > > > > -----Original Message-----> >> From: >> hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 >> Jan 2009 >> 11:25 pm> >> Subject: Re: [HSF] On pump vs Off> > > > Tom,> Yes, it was >> provocative, but >> I >> thought John Puskas pretty much refuted it in > the discussion. As >> you >> know, >> his own group at Emory as well as thorough > exam of > > the STS >> database >> comes to the opposite conclusions. Again, I don't think > the 2 > >> approaches ar> >> e that distinguishable for low risk cases. However, most high risk >>>> >> subsets do better.> > Hal> ------Original Message------> From: >> tdmartin2000@aol.com> Sender: openheart-l- >> bounces@lists.hsforum.com> To: >> OpenHeart-L@lists.hsforum.com> ReplyTo: OpenHeart- >> L@lists.hsforum.com> >> Sent: Jan 28, 2009 11:18 PM> >> Subject: [HSF] On pump vs Off> > I really hate to get this going >> again but >> I >> REALLY don't believe that off is > better than on in any group >> except pts >> with significant aortic calcification > or > atheroma. There was >> an >> interesting >> paper just presented here at the STS that > created a sig >> controversy.> > >> On-pump vs Off-Pump Coronary Artery Bypass Surgery in a Cohort of >> 63,000 > >> Patients-? from Baylor and Texas Heart- reviewing the 2004 >> Nationwide > >> Inpatient >> Sample database- admittedly an administrative database but with >> some >> really > good > > statistics.> Conclusions- 1. Opcab does not >> produce lower >> >> mortality or stroke 2. Opcab > has > longer hospital stays and >> higher costs >> ($1500) >> 3. Performing Opcab in all > candidates for myocardial >> revascularization >> may >> not be justifiable.> > Comments> > Tom Martin> U of Florida> >> Gainesville> >> _______________________________________________> 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 >>> >> -----------------------------------------> > > Sent from my Verizon >> Wireless >> Black> Berry> > > > >> _______________________________________________> >> 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 ma> >> iling >> 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 >>> >> -----------------------------------------> > > **************A >> Good Credit >> Score is 700 or Above. See yours in just 2 easy > steps! > >> > (http://pr.atwola.com/promoclk/100000075x1215855013x1201028747/aol?redir=http >> : >> //www.freecreditreport. >> com/pm/default.aspx?sc=668072%26hmpgID=62%26bcd=De> >> cemailfooterNO62)> >> _______________________________________________> OpenHeart-L >> mailing list> >>> Send >> postings to:> OpenHe> art-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> >> ----------------------------------------- >> _________________________________________________________________ >> Wish to Marry Now? Join MSN Matrimony FREE! >> > http://www.in.msn.com/matrimony_______________________________________________ >> >> 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 Wall Street to Main Street and everywhere in >> between, >> stay >> up-to-date with the latest news. > (http://aol.com?ncid=emlcntaolcom00000023 >> ) >> _______________________________________________ >> 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 >> ----------------------------------------- >> >> **************From Wall Street to Main Street and everywhere in >> between, stay >> up-to-date with the latest news. 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(http://aol.com?ncid=emlcntaolcom00000023 > ) > _______________________________________________ > 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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) From ebender001 at me.com Sun Feb 1 12:37:45 2009 From: ebender001 at me.com (Edward Bender) Date: Sun Feb 1 13:38:18 2009 Subject: [HSF] Re-do AVR In-Reply-To: Message-ID: Ajit's case report mentions MR 2+, but no AI mentioned. I think the rational choice is a conduit. Even though Jim Gammie writes that he now prefers to do these cases off pump, I think that doing the LV portion on pump, would go a long way towards not needing a blood transfusion - at least not violating any religious tenets type of blood transfusion. Ed Bender, MD On 2/1/09 12:26 PM, "Harold Roberts" wrote: > Ajit and Ani, > I've injured a handful of mammaries in my time. The last one was several > years ago. I only recall one fatality which was the first one. I was in > training, opening a redo, when I transected the mammary. Of course, I wasn't > even close to being able to go on bypass. The outcome was predictably > horrible. > In these cases, I prefer CPB prior to splitting the chest. At the very > least, I would have a suitable peripheral artery available to crash on if > such > is needed. > > Hal > > > In a message dated 2/1/2009 1:06:30 P.M. Eastern Standard Time, > enaseri@hotmail.com.tr writes: > > > Ajit, > I expressed my ideas about the surgical conduct of the case and not blood > transfusion aspects.As for Lima injury , I had 1 patient with severed Lima > and we did vein graft with no > problems.Of course 1 case is of no statistical value. > erdinc > _______________________________________________ > 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 Wall Street to Main Street and everywhere in between, stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) > _______________________________________________ > 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 Sun Feb 1 13:42:10 2009 From: msfirst at gmail.com (Michael Firstenberg) Date: Sun Feb 1 13:47:49 2009 Subject: [HSF] On pump vs Off In-Reply-To: References: Message-ID: <85ECED37-9DD6-482B-B524-37DA40EAF79E@gmail.com> then my guess is that your isolate CABG outcomes are probably better than most - but you get my point (unfortunately most reporting systems dont) I remember having a conversation with Blackstone when I was at The Clinic about post-operative mortality and the way we report or describe it. Think about it - why do people die after a CABG? Yes, there are obvious technical components - so of which are avoidable (and diminish with experience) but many are often either system factors or patient factors - or typically a combination of both. But, I think the issues and causes are much more complex then we typically consider, discuss, and/or report. Look at all of the investigations that occur after a plane/shuttle crash compared to how we report things. This is an area that, I think, needs a lot of work. -michael On Feb 1, 2009, at 1:29 PM, Hgrmd@aol.com wrote: > Michael, > Actually, I do lots of concomitant grafting with my valve cases, > so being > facile with CABG isn't a problem. If all I did was isolated valve > cases, > your point would be very well taken. > > Hal > > > In a message dated 2/1/2009 1:13:32 P.M. Eastern Standard Time, > msfirst@gmail.com writes: > > Why turn them down? > > What are the consequences? > (of course no one wants a bad rap for being a bad coronary surgeon or > anything else for that matter) > > We dont have surgeon specific reporting in Ohio - although it may be > coming and we talk about it a lot. Most surgeons, regardless, will > know who they would send their Mother to. > The irony is that in probably a complete multi-variate analysis, the > actual surgeon probably contributes little to the 30 day outcome? > These reporting programs are more geared towards dealing with > systematic issues - and if your program has a higher than average > CABG > M&M - then that should be the motivation to fix "systemic issues". > While in some cases, it may be the surgeon - my guess (IMvHO) it is > programatic issues that are in effect. > > I hate to say this - but maybe that means YOU shouldnt be doing CABGs > - a philosophical question as I am sure you are a great coronary > surgeon, but if you are only doing 10-20 a year (hardly a "reference > surgeon" by Ani's comments), maybe your efforts are better spent on > the 79 year/old redo MVR with a previous AVR? Let the others deal > with the headaches of CABGs - my Boss says that isolated CABGs are a > thankless procedure these days - everything is expected to be perfect > (regardless of elective or if the patient is coming to you with CPR > in > progress, nameless, from the cath lab with lytics on board?) > > -michael > > > > > On Feb 1, 2009, at 11:43 AM, Hgrmd@aol.com wrote: > >> Michael, >> Your words are comforting. Hopefully, the community will be able >> to tell >> where the truth lies. Since, it's all new to me, I will >> unfortunately have >> to turn down some marginal cases that I might have done in the >> past. >> >> Hal >> >> >> In a message dated 2/1/2009 11:36:59 A.M. Eastern Standard Time, >> msfirst@gmail.com writes: >> >> Do you think it will really matter? >> (the knee jerk response will be of course) >> but if you provide a good service - the referring physicians and >> patients will know. >> How many people chose their heart surgeon based on the local >> newspaper. >> >> We wrestle with some of the same issues - there is a community >> hospital not too far that boasts the "best outcomes". >> I will not comments further since everyone knows what that >> means....... >> >> my response then is, go there! >> >> I think the playing field gets leveled after a while but I get >> frustrated seeing how these "numbers" are used for marketing and >> other >> secondary gains. >> >> -michael >> >> >> >> >> On Feb 1, 2009, at 10:24 AM, hgrmd@aol.com wrote: >> >>> Tea, >>> Again, I'm not sure. Supposedly, the results will be risk >>> stratified. >>> However, given the ignorance of the general public, I suspect the >>> raw mortality >>> will really be the bottom line. >>> >>> Hal >>> >>> >>> In a message dated 2/1/2009 10:05:54 A.M. Eastern Standard Time, >>> tacuff@swbell.net writes: >>> >>> So. Is it just "heart mortality" or what. >>> tea >>> >>> >>> >>> >>> ________________________________ >>> From: "hgrmd@aol.com" >>> To: OpenHeart-L@lists.hsforum.com >>> Sent: Sunday, February 1, 2009 9:00:10 AM >>> Subject: Re: [HSF] On pump vs Off >>> >>> Tea, >>> I'm not sure, but wouldn't be surprised if the stats make it to >>> the >>> newspaper. Certainly, it will be online. Anyway, I'm at a >>> disadvantage since my >>> case load if over 95 per cent valves. >>> >>> Hal >>> Sent from my Verizon Wireless BlackBerry >>> >>> -----Original Message----- >>> From: Tea Acuff >>> >>> Date: Sun, 1 Feb 2009 06:54:40 >>> To: OpenHeart-L@lists.hsforum.com >>> Subject: Re: [HSF] On pump vs Off >>> >>> >>> What format will they use for reporting? >>> Tea >>> >>> Sent from my iPhone >>> >>> On Feb 1, 2009, at 5:47 AM, Hgrmd@aol.com wrote: >>> >>> I whole heartedly agree with you. Even the most die hard on pump >>> surgeon >>> is >>> bound to eventually encounter a case that he will screw up if he >>> isn't able >>> to do at least the occasional off pump. Because Florida is now >>> reporting >>> the >>> mortality statistics of all surgeons (like New York), I plan to do >>> more >>> isolated CABG's. I suspect at least half will be OPCAB. >>> >>> Hal >>> >>> >>> In a message dated 1/31/2009 11:06:20 P.M. Eastern Standard Time, >>> govindgovind@hotmail.com writes: >>> >>> >>> >>> >>> For any surgeon actively engaged in CABG on pump, learning the >>> ropes for >>> off >>> pump method is a definite advantage.Both methods are eminently >>> successful >>> in >>> getting good results and we need to apply either judiciouly as >>> per >>> the >>> clinical problem.There is no need to be a diehard supporter of >>> only one >>> method. If >>> some of the surgeons are trying to use off pump method from >>> marketing angle >>> it is not the method which is at fault. >>> >>> govindakubal> To: OpenHeart-L@lists.hsforum.com> Subject: Re: >>> [HSF] On pump >>> vs Off> Date: Sat, 31 Jan 2009 21:58:57 -0500> From: >> tdmartin2000@aol.com >>>> >>> CC: > > Bill> ?Laurie Davies is the principle investigator and >>> has >>> the >>> manuscript. She was appointed to the Florida Board of Medicine >>> during the >>> study and >>> was subsequently appointed as Chair of the Board - a big time >>> consuming >>> job. >>> She has just completed her tenure on the board and will be >>> completing the >>> paper soon. It shows just what you would suspect but I cannot >>> write it here >>> as it >>> has not been published and the journals don't like it when you >>> give out the >>> data.> Let's just say that it has not converted me.> > Tom> > > >>> -----Original >>> Message-----> From: wftjrtyler@aol.com> To: >> OpenHeart-L@lists.hsforum.com >>>> >>> Sent: Fri, 30 Jan 2009 6:57 pm> Subject: Re: [HSF] On pump vs >>> Off> >>>>>> >>> Tom, >>> several years(and threads) ago, you were randomizing Opcabs vs. >>> Oncab > at >>> UF. Is your study in progress or did i miss the paper? bill >>> turner> > > In >>> a >>> message dated 1/29/2009 8:53:17 P.M. Central Standard Time, > >>> tdmartin2000@aol.com writes:> > agree> > > -----Original >>> Message-----> >>> From: hgrmd@aol.com> >>> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:58 >>> pm> >>> Subject: >>> Re: [HSF] On pump vs Off> > > > Tom,> You and I are essentially >>> on >>> the same >>> side. Of course Dors and valves don't > apply. However, my >>> perception, >>> based >>> on personal experience as well as the > literature, is that >>> elderly >>> vasculopaths with hostile aortas benefit from > OPCAB. > For the >>> average >>> case, it >>> probably doesn't matter. You and I would agree > that > there >>> are >>> a lot of >>> surgeons out there trying to use OPCAB for a marketing > angle. >>>> I >>> consider OPCAB >>> an excellent technique to have in one's armamentarium. In > >>> fact, >>> I was >>> recently summoned to the OR to take over my junior surgeon's > >>> CABG > when >>> he >>> unexpectedly encountered a bad aorta. I stepped in and did a 3 > >>> vessel > >>> OPCAB. >>> The patient did fine.> > Hal> > Hal > Sent from my Verizon >>> Wireless >>> BlackBerry> > -----Original Message-----> From: >>> tdmartin2000@aol.com> > >>> Date: Wed, 28 >>> Jan 2009 23:44:34 > To: > >>> Subject: >>> Re: [HSF] >>> On pump vs Off> > > Hal> I'm not sure John refuted as much as >>> attacked it. >>> >>> His whole premise was on > the > difference between an >>> administrative and a >>> clinical data base. The presenter > had?a good rebuttal to John's >>> rebuttal. >>> I >>> can't wait to see the manuscript > and > review it myself. It's >>> hard to >>> refute >>> the conclusions of death, stroke, > length > of stay and costs >>> when there >>> is >>> data on 63,000 pts no matter what kind of > data > base. I also >>> have to?ask >>> what your definition of a high risk case is and > where > the >>> data >>> is to >>> confirm your premise. It is hard to do an off pump redo CABG >>> > AVR >>>> or >>> MVR, or a >>> CABG Dor, or a CABG, ascending, etc.. These would fall into >>> the > >>>> high >>> risk >>> cases for me. As you know I brought this up for the sake of > >>> dis> >>> cussion >>>> >>> and controversy.> > Tom> > > > > -----Original Message-----> >>> From: >>> hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 >>> Jan 2009 >>> 11:25 pm> >>> Subject: Re: [HSF] On pump vs Off> > > > Tom,> Yes, it was >>> provocative, but >>> I >>> thought John Puskas pretty much refuted it in > the >>> discussion. As >>> you >>> know, >>> his own group at Emory as well as thorough > exam of > > the >>> STS >>> database >>> comes to the opposite conclusions. Again, I don't think > the >>> 2 > >>> approaches ar> >>> e that distinguishable for low risk cases. However, most high >>> risk >>>>> >>> subsets do better.> > Hal> ------Original Message------> From: >>> tdmartin2000@aol.com> Sender: openheart-l- >>> bounces@lists.hsforum.com> To: >>> OpenHeart-L@lists.hsforum.com> ReplyTo: OpenHeart- >>> L@lists.hsforum.com> >>> Sent: Jan 28, 2009 11:18 PM> >>> Subject: [HSF] On pump vs Off> > I really hate to get this going >>> again but >>> I >>> REALLY don't believe that off is > better than on in any group >>> except pts >>> with significant aortic calcification > or > atheroma. There was >>> an >>> interesting >>> paper just presented here at the STS that > created a sig >>> controversy.> > >>> On-pump vs Off-Pump Coronary Artery Bypass Surgery in a Cohort of >>> 63,000 > >>> Patients-? from Baylor and Texas Heart- reviewing the 2004 >>> Nationwide > >>> Inpatient >>> Sample database- admittedly an administrative database but with >>> some >>> really > good > > statistics.> Conclusions- 1. Opcab does not >>> produce lower >>> >>> mortality or stroke 2. Opcab > has > longer hospital stays and >>> higher costs >>> ($1500) >>> 3. Performing Opcab in all > candidates for myocardial >>> revascularization >>> may >>> not be justifiable.> > Comments> > Tom Martin> U of Florida> >>> Gainesville> >>> _______________________________________________> 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 >>>> >>> -----------------------------------------> > > Sent from my >>> Verizon >>> Wireless >>> Black> Berry> > > > >>> _______________________________________________> >>> 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 ma> >>> iling >>> 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 >>>> >>> -----------------------------------------> > > **************A >>> Good Credit >>> Score is 700 or Above. See yours in just 2 easy > steps! > >>> >> > (http://pr.atwola.com/promoclk/100000075x1215855013x1201028747/aol?redir=http >>> : >>> //www.freecreditreport. >>> com/pm/default.aspx?sc=668072%26hmpgID=62%26bcd=De> >>> cemailfooterNO62)> >>> _______________________________________________> OpenHeart-L >>> mailing list> >>>> Send >>> postings to:> OpenHe> art-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> >>> ----------------------------------------- >>> _________________________________________________________________ >>> Wish to Marry Now? Join MSN Matrimony FREE! >>> >> > http://www.in.msn.com/matrimony_______________________________________________ >>> >>> 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 Wall Street to Main Street and everywhere in >>> between, >>> stay >>> up-to-date with the latest news. >> (http://aol.com?ncid=emlcntaolcom00000023 >>> ) >>> _______________________________________________ >>> 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 >>> ----------------------------------------- >>> >>> **************From Wall Street to Main Street and everywhere in >>> between, stay >>> up-to-date with the latest news. > (http://aol.com?ncid=emlcntaolcom00000023 >>> ) >>> _______________________________________________ >>> 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 Wall Street to Main Street and everywhere in >> between, stay >> up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 >> ) >> _______________________________________________ >> 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 Wall Street to Main Street and everywhere in > between, stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 > ) > _______________________________________________ > 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 Sun Feb 1 14:03:16 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Feb 1 14:03:49 2009 Subject: [HSF] Re-do AVR Message-ID: Last year, I did an off pump aortic valve bypass with Gammie proctoring. We were completely ready to go on pump, but it wasn't necessary. With a J.W., I think staying off pump would definitely be of benefit. Ajit should contact Medtronic for technical support if he decides to pursue this avenue. Hal In a message dated 2/1/2009 1:39:26 P.M. Eastern Standard Time, ebender001@me.com writes: Ajit's case report mentions MR 2+, but no AI mentioned. I think the rational choice is a conduit. Even though Jim Gammie writes that he now prefers to do these cases off pump, I think that doing the LV portion on pump, would go a long way towards not needing a blood transfusion - at least not violating any religious tenets type of blood transfusion. Ed Bender, MD On 2/1/09 12:26 PM, "Harold Roberts" wrote: > Ajit and Ani, > I've injured a handful of mammaries in my time. The last one was several > years ago. I only recall one fatality which was the first one. I was in > training, opening a redo, when I transected the mammary. Of course, I wasn't > even close to being able to go on bypass. The outcome was predictably > horrible. > In these cases, I prefer CPB prior to splitting the chest. At the very > least, I would have a suitable peripheral artery available to crash on if > such > is needed. > > Hal > > > In a message dated 2/1/2009 1:06:30 P.M. Eastern Standard Time, > enaseri@hotmail.com.tr writes: > > > Ajit, > I expressed my ideas about the surgical conduct of the case and not blood > transfusion aspects.As for Lima injury , I had 1 patient with severed Lima > and we did vein graft with no > problems.Of course 1 case is of no statistical value. > erdinc > _______________________________________________ > 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 Wall Street to Main Street and everywhere in between, stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) > _______________________________________________ > 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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) From msfirst at gmail.com Sun Feb 1 14:07:39 2009 From: msfirst at gmail.com (Michael Firstenberg) Date: Sun Feb 1 14:09:09 2009 Subject: [HSF] Re-do AVR In-Reply-To: References: Message-ID: <21F95C5E-31E7-49D8-ADAB-8C6C54CE5241@gmail.com> off pump AVR? please explain....... (or are do you mean LV-descAo conduit?) -michael On Feb 1, 2009, at 2:03 PM, hgrmd@aol.com wrote: > Last year, I did an off pump aortic valve bypass with Gammie > proctoring. We > were completely ready to go on pump, but it wasn't necessary. With > a J.W., > I think staying off pump would definitely be of benefit. Ajit > should contact > Medtronic for technical support if he decides to pursue this avenue. > > Hal > > > In a message dated 2/1/2009 1:39:26 P.M. Eastern Standard Time, > ebender001@me.com writes: > > Ajit's case report mentions MR 2+, but no AI mentioned. I think > the rational > choice is a conduit. > Even though Jim Gammie writes that he now prefers to do these > cases off > pump, I think that doing the LV portion on pump, would go a long > way towards > not needing a blood transfusion - at least not violating any > religious > tenets type of blood transfusion. > Ed Bender, MD > > > On 2/1/09 12:26 PM, "Harold Roberts" wrote: > >> Ajit and Ani, >> I've injured a handful of mammaries in my time. The last one was > several >> years ago. I only recall one fatality which was the first one. I >> was in >> training, opening a redo, when I transected the mammary. Of >> course, I > wasn't >> even close to being able to go on bypass. The outcome was >> predictably >> horrible. >> In these cases, I prefer CPB prior to splitting the chest. At >> the very >> least, I would have a suitable peripheral artery available to >> crash on if >> such >> is needed. >> >> Hal >> >> >> In a message dated 2/1/2009 1:06:30 P.M. Eastern Standard Time, >> enaseri@hotmail.com.tr writes: >> >> >> Ajit, >> I expressed my ideas about the surgical conduct of the case and >> not blood >> transfusion aspects.As for Lima injury , I had 1 patient with >> severed > Lima >> and we did vein graft with no >> problems.Of course 1 case is of no statistical value. >> erdinc >> _______________________________________________ >> 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 Wall Street to Main Street and everywhere in >> between, > stay >> up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 >> ) >> _______________________________________________ >> 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 Wall Street to Main Street and everywhere in > between, stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 > ) > _______________________________________________ > 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 Sun Feb 1 14:15:09 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Feb 1 14:16:14 2009 Subject: [HSF] Re-do AVR Message-ID: Apical-aortic bypass. Hal In a message dated 2/1/2009 2:10:47 P.M. Eastern Standard Time, msfirst@gmail.com writes: off pump AVR? please explain....... (or are do you mean LV-descAo conduit?) -michael On Feb 1, 2009, at 2:03 PM, hgrmd@aol.com wrote: > Last year, I did an off pump aortic valve bypass with Gammie > proctoring. We > were completely ready to go on pump, but it wasn't necessary. With > a J.W., > I think staying off pump would definitely be of benefit. Ajit > should contact > Medtronic for technical support if he decides to pursue this avenue. > > Hal > > > In a message dated 2/1/2009 1:39:26 P.M. Eastern Standard Time, > ebender001@me.com writes: > > Ajit's case report mentions MR 2+, but no AI mentioned. I think > the rational > choice is a conduit. > Even though Jim Gammie writes that he now prefers to do these > cases off > pump, I think that doing the LV portion on pump, would go a long > way towards > not needing a blood transfusion - at least not violating any > religious > tenets type of blood transfusion. > Ed Bender, MD > > > On 2/1/09 12:26 PM, "Harold Roberts" wrote: > >> Ajit and Ani, >> I've injured a handful of mammaries in my time. The last one was > several >> years ago. I only recall one fatality which was the first one. I >> was in >> training, opening a redo, when I transected the mammary. Of >> course, I > wasn't >> even close to being able to go on bypass. The outcome was >> predictably >> horrible. >> In these cases, I prefer CPB prior to splitting the chest. At >> the very >> least, I would have a suitable peripheral artery available to >> crash on if >> such >> is needed. >> >> Hal >> >> >> In a message dated 2/1/2009 1:06:30 P.M. Eastern Standard Time, >> enaseri@hotmail.com.tr writes: >> >> >> Ajit, >> I expressed my ideas about the surgical conduct of the case and >> not blood >> transfusion aspects.As for Lima injury , I had 1 patient with >> severed > Lima >> and we did vein graft with no >> problems.Of course 1 case is of no statistical value. >> erdinc >> _______________________________________________ >> 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 Wall Street to Main Street and everywhere in >> between, > stay >> up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 >> ) >> _______________________________________________ >> 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 Wall Street to Main Street and everywhere in > between, stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 > ) > _______________________________________________ > 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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) From anianyanwu at hotmail.com Sun Feb 1 19:19:31 2009 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Sun Feb 1 14:20:20 2009 Subject: [HSF] Re-do AVR In-Reply-To: References: Message-ID: Hal Even after that unfortunate transapical case you saw in paris you would advocate off-pump apical conduit in this particular patient? I think fair if the surgeon does these off-pump apical conduits often, but for the surgeon with only occasional experience in apical conduits, off-pump apical cannulation might not be the best for a Jehovah's witness. If that thing bleeds the patient faces a high risk of death. I have done a number of LVADs off-pump so I am okay with cannulating the apex without the heart-lung machine, but the LVAD situation is very different as the LV pressures once device starts are very low so bleeding rarely a problem, but with the apicoaortic conduit and the LV systolic of 150 in many of these patients, if that thing bleeds then one may have big problem in a JW which is why I suspect safety of bypass will be ideal to get absolute hemostasis and minimize blood loss. I would stick with your earlier view that if the patient does not want blood all conventional surgical options are out. I dont think a thoracotomy changes this much. Ani ---------------------------------------- > From: Hgrmd@aol.com > Date: Sun, 1 Feb 2009 14:03:16 -0500 > Subject: Re: [HSF] Re-do AVR > To: OpenHeart-L@lists.hsforum.com > CC: > > Last year, I did an off pump aortic valve bypass with Gammie proctoring. We > were completely ready to go on pump, but it wasn't necessary. With a J.W., > I think staying off pump would definitely be of benefit. Ajit should contact > Medtronic for technical support if he decides to pursue this avenue. > > Hal > > > In a message dated 2/1/2009 1:39:26 P.M. Eastern Standard Time, > ebender001@me.com writes: > > Ajit's case report mentions MR 2+, but no AI mentioned. I think the rational > choice is a conduit. > Even though Jim Gammie writes that he now prefers to do these cases off > pump, I think that doing the LV portion on pump, would go a long way towards > not needing a blood transfusion - at least not violating any religious > tenets type of blood transfusion. > Ed Bender, MD > > > On 2/1/09 12:26 PM, "Harold Roberts" wrote: > >> Ajit and Ani, >> I've injured a handful of mammaries in my time. The last one was > several >> years ago. I only recall one fatality which was the first one. I was in >> training, opening a redo, when I transected the mammary. Of course, I > wasn't >> even close to being able to go on bypass. The outcome was predictably >> horrible. >> In these cases, I prefer CPB prior to splitting the chest. At the very >> least, I would have a suitable peripheral artery available to crash on if >> such >> is needed. >> >> Hal >> >> >> In a message dated 2/1/2009 1:06:30 P.M. Eastern Standard Time, >> enaseri@hotmail.com.tr writes: >> >> >> Ajit, >> I expressed my ideas about the surgical conduct of the case and not blood >> transfusion aspects.As for Lima injury , I had 1 patient with severed > Lima >> and we did vein graft with no >> problems.Of course 1 case is of no statistical value. >> erdinc >> _______________________________________________ >> 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 Wall Street to Main Street and everywhere in between, > stay >> up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) >> _______________________________________________ >> 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 Wall Street to Main Street and everywhere in between, stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) > _______________________________________________ > 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 > ----------------------------------------- _________________________________________________________________ Love Hotmail?? Check out the new services from Windows Live! http://clk.atdmt.com/UKM/go/132630768/direct/01/ From Hgrmd at aol.com Sun Feb 1 14:38:15 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Feb 1 14:38:49 2009 Subject: [HSF] Re-do AVR Message-ID: Ajit, If you could get a proctor, I bet you could do it, particularly with your LVAD experience. The one case I did lost very little blood. I'm obviously no expert, but that's what I might offer if I'm in your unfortunate position. However, as stated earlier, no operation is also certainly reasonable. Frankly, I really have a problem with these J.W.'s., and don't have that much sympathy for what I consider wacky beliefs. I know I may be offending some readers, but I'm just being candid. I'm sure part of my prejudice lies in the fact that about 15 years ago I got sued by a J.W.'s family after I refused to operate on him. This unfortunate man had infected epicardial ICD leads (remember those?) which had migrated and wrapped around the hilum of his right lung. A previous surgeon had tried to remove the leads, but bleeding around the hilum had forced him to abort. My sole contact with this patient was the 20 minutes it took for me to read the chart, examine him, and ask him if he was willing to take blood. He emphatically said no, and I told him I thought he would soon die and good luck. A few weeks later, the leads eroded into the PA while he was in a gas station bathroom. There was so much blood, that the police initially treated it as a potential homicide. I got sued because I had "abandoned" the patient. Fortunately, my good documentation torpedoed their case, but I had to go through the hassle and indignity of a deposition. Anyway, you get the picture. Hal In a message dated 2/1/2009 2:22:01 P.M. Eastern Standard Time, anianyanwu@hotmail.com writes: Hal Even after that unfortunate transapical case you saw in paris you would advocate off-pump apical conduit in this particular patient? I think fair if the surgeon does these off-pump apical conduits often, but for the surgeon with only occasional experience in apical conduits, off-pump apical cannulation might not be the best for a Jehovah's witness. If that thing bleeds the patient faces a high risk of death. I have done a number of LVADs off-pump so I am okay with cannulating the apex without the heart-lung machine, but the LVAD situation is very different as the LV pressures once device starts are very low so bleeding rarely a problem, but with the apicoaortic conduit and the LV systolic of 150 in many of these patients, if that thing bleeds then one may have big problem in a JW which is why I suspect safety of bypass will be ideal to get absolute hemostasis and minimize blood loss. I would stick with your earlier view that if the patient does not want blood all conventional surgical options are out. I dont think a thoracotomy changes this much. Ani ---------------------------------------- > From: Hgrmd@aol.com > Date: Sun, 1 Feb 2009 14:03:16 -0500 > Subject: Re: [HSF] Re-do AVR > To: OpenHeart-L@lists.hsforum.com > CC: > > Last year, I did an off pump aortic valve bypass with Gammie proctoring. We > were completely ready to go on pump, but it wasn't necessary. With a J.W., > I think staying off pump would definitely be of benefit. Ajit should contact > Medtronic for technical support if he decides to pursue this avenue. > > Hal > > > In a message dated 2/1/2009 1:39:26 P.M. Eastern Standard Time, > ebender001@me.com writes: > > Ajit's case report mentions MR 2+, but no AI mentioned. I think the rational > choice is a conduit. > Even though Jim Gammie writes that he now prefers to do these cases off > pump, I think that doing the LV portion on pump, would go a long way towards > not needing a blood transfusion - at least not violating any religious > tenets type of blood transfusion. > Ed Bender, MD > > > On 2/1/09 12:26 PM, "Harold Roberts" wrote: > >> Ajit and Ani, >> I've injured a handful of mammaries in my time. The last one was > several >> years ago. I only recall one fatality which was the first one. I was in >> training, opening a redo, when I transected the mammary. Of course, I > wasn't >> even close to being able to go on bypass. The outcome was predictably >> horrible. >> In these cases, I prefer CPB prior to splitting the chest. At the very >> least, I would have a suitable peripheral artery available to crash on if >> such >> is needed. >> >> Hal >> >> >> In a message dated 2/1/2009 1:06:30 P.M. Eastern Standard Time, >> enaseri@hotmail.com.tr writes: >> >> >> Ajit, >> I expressed my ideas about the surgical conduct of the case and not blood >> transfusion aspects.As for Lima injury , I had 1 patient with severed > Lima >> and we did vein graft with no >> problems.Of course 1 case is of no statistical value. >> erdinc >> _______________________________________________ >> 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 Wall Street to Main Street and everywhere in between, > stay >> up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) >> _______________________________________________ >> 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 Wall Street to Main Street and everywhere in between, stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) > _______________________________________________ > 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 > ----------------------------------------- _________________________________________________________________ Love Hotmail? Check out the new services from Windows Live! http://clk.atdmt.com/UKM/go/132630768/direct/01/______________________________ _________________ 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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) From Hgrmd at aol.com Sun Feb 1 14:39:21 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Feb 1 14:40:15 2009 Subject: [HSF] Re-do AVR Message-ID: Dear Ani, Sorry for mistaking you for Ajit. However, my thoughts are the same. Hal In a message dated 2/1/2009 2:22:01 P.M. Eastern Standard Time, anianyanwu@hotmail.com writes: Hal Even after that unfortunate transapical case you saw in paris you would advocate off-pump apical conduit in this particular patient? I think fair if the surgeon does these off-pump apical conduits often, but for the surgeon with only occasional experience in apical conduits, off-pump apical cannulation might not be the best for a Jehovah's witness. If that thing bleeds the patient faces a high risk of death. I have done a number of LVADs off-pump so I am okay with cannulating the apex without the heart-lung machine, but the LVAD situation is very different as the LV pressures once device starts are very low so bleeding rarely a problem, but with the apicoaortic conduit and the LV systolic of 150 in many of these patients, if that thing bleeds then one may have big problem in a JW which is why I suspect safety of bypass will be ideal to get absolute hemostasis and minimize blood loss. I would stick with your earlier view that if the patient does not want blood all conventional surgical options are out. I dont think a thoracotomy changes this much. Ani ---------------------------------------- > From: Hgrmd@aol.com > Date: Sun, 1 Feb 2009 14:03:16 -0500 > Subject: Re: [HSF] Re-do AVR > To: OpenHeart-L@lists.hsforum.com > CC: > > Last year, I did an off pump aortic valve bypass with Gammie proctoring. We > were completely ready to go on pump, but it wasn't necessary. With a J.W., > I think staying off pump would definitely be of benefit. Ajit should contact > Medtronic for technical support if he decides to pursue this avenue. > > Hal > > > In a message dated 2/1/2009 1:39:26 P.M. Eastern Standard Time, > ebender001@me.com writes: > > Ajit's case report mentions MR 2+, but no AI mentioned. I think the rational > choice is a conduit. > Even though Jim Gammie writes that he now prefers to do these cases off > pump, I think that doing the LV portion on pump, would go a long way towards > not needing a blood transfusion - at least not violating any religious > tenets type of blood transfusion. > Ed Bender, MD > > > On 2/1/09 12:26 PM, "Harold Roberts" wrote: > >> Ajit and Ani, >> I've injured a handful of mammaries in my time. The last one was > several >> years ago. I only recall one fatality which was the first one. I was in >> training, opening a redo, when I transected the mammary. Of course, I > wasn't >> even close to being able to go on bypass. The outcome was predictably >> horrible. >> In these cases, I prefer CPB prior to splitting the chest. At the very >> least, I would have a suitable peripheral artery available to crash on if >> such >> is needed. >> >> Hal >> >> >> In a message dated 2/1/2009 1:06:30 P.M. Eastern Standard Time, >> enaseri@hotmail.com.tr writes: >> >> >> Ajit, >> I expressed my ideas about the surgical conduct of the case and not blood >> transfusion aspects.As for Lima injury , I had 1 patient with severed > Lima >> and we did vein graft with no >> problems.Of course 1 case is of no statistical value. >> erdinc >> _______________________________________________ >> 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 Wall Street to Main Street and everywhere in between, > stay >> up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) >> _______________________________________________ >> 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 Wall Street to Main Street and everywhere in between, stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) > _______________________________________________ > 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 > ----------------------------------------- _________________________________________________________________ Love Hotmail? Check out the new services from Windows Live! http://clk.atdmt.com/UKM/go/132630768/direct/01/______________________________ _________________ 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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) From donross at bigpond.com Mon Feb 2 06:48:26 2009 From: donross at bigpond.com (Donald Ross) Date: Sun Feb 1 14:50:03 2009 Subject: [HSF] CABG reporting. In-Reply-To: <924886958-1233508544-cardhu_decombobulator_blackberry.rim.net-2144589884-@bxe016.bisx.prod.on.blackberry> References: <8A8BB069-B02B-4A5E-9252-A8E6DDBBCF0B@gmail.com> <924886958-1233508544-cardhu_decombobulator_blackberry.rim.net-2144589884-@bxe016.bisx.prod.on.blackberry> Message-ID: Hal. Do you realise how much radiation you get hunched over the X-ray machine doing pacers? It is a lot more than for any other procedure and a hellava lot more than the cards get cathing from the groin with plates of lead glass between their eyes & hands and the damn machine. Don On 02/02/2009, at 4:15 AM, hgrmd@aol.com wrote: > The cardiologists take care of all that junk. I'm like the plumber; > I do the installation. Quite frankly, between me and the pacer > reps, there's virtually never a complaint from the cardiologists. > They frequently tell the rep the exact settings they want prior to > the OR. In addition, I know what comprise good numbers when > implanting a DDD pacer. It ain't that hard. The EP's try to make > everyone believe they are the best at implanting. Unfortunately, > they are not thoracic surgeons. They can't fix most of their > complications. > > Hal > Sent from my Verizon Wireless BlackBerry > > -----Original Message----- > From: Michael Firstenberg > > Date: Sun, 1 Feb 2009 12:06:28 > To: > Subject: Re: [HSF] CABG reporting. > > > Hal - > True and your comments do not surprise me. > > But, my comments (not directed at you in particular) is dealing more > with the fine tuning, follow-up, etc that goes into the devices. Who > does the device checks? Monitors the thresholds? Optimizes the > pacing/ATP/defib programming? Who supervises the clinics and the in- > patient device activations/deactivations for elective procedures? Who > gets called with the problems? Who admits the patients when the ICDs > fire? > > Again, like everything else - it depends on the system in place. > > -michael > > > > On Feb 1, 2009, at 11:48 AM, Hgrmd@aol.com wrote: > >> Michael, >> My guess is you don't have much experience implanting pacemakers. I >> trained in a different era and practice in a different community. >> Here, the >> surgeons still implant the majority of the devices, including >> biventricular ICD's. >> Personally, I only implant pacers. However, I've done literally >> thousands >> over the past 23 years without a single fatality, and only one >> perforation >> requiring a window (92 yo lady developed an effusion on PPOD#2). >> In contrast, >> there's an EP in our community who has had more perforations in the >> few years >> he's been here than all of the cardiac surgeons in my group in >> their entire >> careers. In addition, guess who this hapless EP screams for when >> his ass is >> in a sling? BTW, Michael, aren't you the one who said you stand by >> for the >> EP's in your hospital when they are extracting leads? That's >> crazy. Quite >> frankly, only surgeons should be doing that since massive tamponade >> can develop >> within seconds with that procedure (linear tear in free wall of RA). >> >> Hal >> >> >> In a message dated 2/1/2009 11:39:16 A.M. Eastern Standard Time, >> msfirst@gmail.com writes: >> >> maybe it is a subtle jab that surgeons should not be putting in >> pacemakers? >> >> wow - all of the snow outside my window just melted from the blaze >> of >> fire directed at me. >> >> >> -michael >> >> >> >> >> >> On Feb 1, 2009, at 10:40 AM, hgrmd@aol.com wrote: >> >>> Ani, >>> To be honest, I've really no idea what's going to be reported. I >>> recently >>> attended a meeting with administration at one of my hospitals where >>> they >>> outlined this new system. It's my uhderstanding that it will >>> include AVR, MVR, >>> CABG, and their combinations. Things like Dors, thoracic aortic >>> procedures, >>> and some others will be excluded. I plan to do a few more stand >>> alone CABG's >>> because, probably like you, my last death from an isolated CABG >>> was >>> several >>> years ago. It's all a matter of playing the game. >>> While we're discussing this crap, what about the STS's bone head >>> rule that >>> counts a postop permanent pacemaker as a "bring back for surgery" >>> if it's >>> done in the OR, but not if it's done in the EP lab? Honestly, >>> who's side are >>> they on? >>> >>> Hal >>> >>> >>> In a message dated 2/1/2009 10:29:06 A.M. Eastern Standard Time, >>> anianyanwu@hotmail.com writes: >>> >>> >>> Hal >>> >>> One would only be at a disadvantage if one sees the stats as a >>> means to >>> promote or validate one's status as a top coronary surgeon - to do >>> this one would >>> need a high volume of CABG with low mortality (I assume that has >>> to >>> be the >>> 'outcome' they will look at). However, given that you are not >>> predominantly a >>> coronary surgeon it shouldnt matter much to you. >>> >>> Assuming you do only 10 to 20 isolated CABGs per year then you >>> would likely >>> be excluded from ranking analysis (otherwise if you did 15 with no >>> death, >>> just like I did last year, then you would be ranked as the top >>> coronary surgeon >>> with a zero mortality risk which would make no sense). If one did >>> include >>> your cases in a report the confidence interval would be so wide >>> such as to make >>> your results meaningless. >>> >>> Only surgeons doing say 50 plus or so CABGs per year need worry >>> about data >>> reporting as the ranking and results would be more stable. If a >>> low >>> volume >>> CABG surgeon wants to look good in the reports then one has to get >>> more volume >>> and try and aim to do at least 100 procedures per year for the >>> data >>> to have >>> meaning. (the caveat though is that while a low volume surgeon >>> will >>> not get >>> credited with low mortality, they will still get penalized for >>> high >>> mortality; >>> if one does 10 cases and 5 die then small numbers wont protect >>> from >>> that). >>> >>> What is the stated goal of the Florida reporting exercise? I find >>> it odd >>> that with CABG in decline new reporting systems still emerge to >>> track isolated >>> CABG. I think one will find that cardiac surgery is becoming more >>> like general >>> thoracic where the make up of ones practice is very heterogenous >>> with very >>> few two operations being alike. The days where isolated CABG, >>> isolated AVR and >>> isolated MVR constituted 95% of most practices are long gone. We >>> now have a >>> plethora of operations and hybrids with various manners of >>> combined >>> procedures on an even more heterogenous group of patients which >>> makes it very >>> difficult to define index operations and compare outcomes. >>> >>> Why does the reporting make you plan to do more isolated CABGs? >>> >>> Ani >>> >>> >>> >>> >>> >>> >>>> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] On pump vs >>>> Off> >>> From: hgrmd@aol.com> Date: Sun, 1 Feb 2009 15:00:10 +0000> CC: > > >>> Tea,> I'm not >>> sure, but wouldn't be surprised if the stats make it to the >>> newspaper. >>> Certainly, it will be online. Anyway, I'm at a disadvantage since >>> my case load if >>> over 95 per cent valves.> > Hal> Sent from my Verizon Wireless >>> BlackBerry> > >>> -----Original Message-----> From: Tea Acuff > > >>> Date: Sun, >>> 1 Feb 2009 06:54:40 > To: >>> OpenHeart-L@lists.hsforum.com> >>> Subject: Re: [HSF] On pump vs Off> > > What format will they use >>> for reporting?> Tea> > Sent from my iPhone> > On Feb 1, 2009, at >>> 5:47 AM, >>> Hgrmd@aol.com wrote:> > I whole heartedly agree with you. Even the >>> most die >>> hard on pump surgeon is > bound to eventually encounter a case >>> that >>> he will >>> screw up if he isn't able > to do at least the occasional off >>> pump. >>> Because >>> Florida is now reporting the > mortality statistics of all >>> surgeons >>> (like New >>> York), I plan to do more > isolated CABG's. I suspect at least >>> half >>> will be >>> OPCAB.> > Hal> > > In a message dated 1/31/2009 11:06:20 P.M. >>> Eastern Standard >>> Time, > govindgovind@hotmail.com writes:> > > > > For any surgeon >>> actively >>> engaged in CABG on pump, learning the ropes for off > pump method >>> is a definite >>> advantage.Both methods are eminently successful in > getting good >>> results and >>> we need to apply either judiciouly as per the > clinical >>> problem.There is no >>> need to be a diehard supporter of only one method. If > some of >>> the >>> surgeons >>> are trying to use off pump method from marketing angle > it is not >>> the method >>> which is at fault.> > govindakubal> To: OpenHeart- >>> L@lists.hsforum.com> >>> Subject: Re: [HSF] On pump > vs Off> Date: Sat, 31 Jan 2009 >>> 21:58:57 -0500> From: >>> tdmartin2000@aol.com> > CC: > > Bill> ?Laurie Davies is the >>> principle >>> investigator and has the > manuscript. She was appointed to the >>> Florida Board of >>> Medicine during the study and > was subsequently appointed as >>> Chair >>> of the Board >>> - a big time consuming job. > She has just completed her tenure on >>> the board >>> and will be completing the > paper soon. It shows just what you >>> would >>> suspect but I cannot write it here as it > has not been published >>> and the journals >>> don't like it when you give out the > data.> Let's just say that it >>> has not >>> converted me.> > Tom> > > -----Original > Message-----> From: >>> wftjrtyler@aol.com> To: OpenHeart-L@lists.hsforum.com> > Sent: >>> Fri, >>> 30 Jan 2009 6:57 pm> >>> Subject: Re: [HSF] On pump vs Off> > > > Tom, > several years(and >>> threads) ago, >>> you were randomizing Opcabs vs. Oncab > at > UF. Is your study in >>> progress >>> or did i miss the paper? bill turner> > > In a > message dated >>> 1/29/2009 >>> 8:53:17 P.M. Central Standard Time, > > tdmartin2000@aol.com >>> writes:> > agree> > > >>> -----Original Message-----> From: hgrmd@aol.com> > To: >>> OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:58 pm> >>> Subject: > Re: [HSF] On pump vs >>> Off> > > > Tom,> You and I are essentially on the same > side. Of >>> course Dors >>> and valves don't > apply. However, my perception, based > on >>> personal >>> experience as well as the > literature, is that elderly > >>> vasculopaths with hostile >>> aortas benefit from > OPCAB. > For the average case, it > probably >>> doesn't >>> matter. You and I would agree > that > there are a lot of > >>> surgeons out there >>> trying to use OPCAB for a marketing > angle. > I consider OPCAB > >>> an >>> excellent technique to have in one's armamentarium. In > fact, I >>> was >>>> recently >>> summoned to the OR to take over my junior surgeon's > CABG > when >>> he > >>> unexpectedly encountered a bad aorta. I stepped in and did a 3 > >>> vessel > OPCAB. > The >>> patient did fine.> > Hal> > Hal > Sent from my Verizon Wireless > >>> BlackBerry> >>>> -----Original Message-----> From: tdmartin2000@aol.com> > Date: >>>> Wed, 28 > >>> Jan 2009 23:44:34 > To: > Subject: >>> Re: [HSF] >>>> On pump vs Off> > > Hal> I'm not sure John refuted as much as >>>> attacked it. >>>> His whole premise was on > the > difference between an >>>> administrative and a >>>> clinical data base. The presenter > had?a good rebuttal to John's >>> rebuttal. I > can't wait to see the manuscript > and > review it >>> myself. It's hard to >>> refute > the conclusions of death, stroke, > length > of stay and >>> costs when >>> there is > data on 63,000 pts no matter what kind of > data > >>> base. >>> I also >>> have to?ask > what your definition of a high risk case is and > >>> where > the >>> data is to > confirm your premise. It is hard to do an off pump >>> redo CABG > >>> AVR > or MVR, or a > CABG Dor, or a CABG, ascending, etc.. These >>> would fall >>> into the > > high risk > cases for me. As you know I brought this >>> up for the >>> sake of > dis> cussion > > and controversy.> > Tom> > > > > ----- >>> Original >>> Message-----> From: > hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com >>>> Sent: Wed, >>> 28 Jan 2009 11:25 pm> > Subject: Re: [HSF] On pump vs Off> > > > >>> Tom,> Yes, >>> it was provocative, but I > thought John Puskas pretty much >>> refuted >>> it in > >>> the discussion. As you know, > his own group at Emory as well as >>> thorough > >>> exam of > > the STS database > comes to the opposite conclusions. >>> Again, I >>> don't think > the 2 > approaches ar> > e that distinguishable for >>> low risk >>> cases. However, most high risk > > > subsets do better.> > Hal> >>> ------Original >>> Message------> From: > tdmartin2000@aol.com> Sender: >>> openheart-l-bounces@lists.hsforum.com> To: > >> OpenHeart-L@lists.hsforum.com >>>> ReplyTo: >>> OpenHeart-L@lists.hsforum.com> Sent: Jan 28, 2009 11:18 PM> > >>> Subject: [HSF] On pump vs Off> > >>> I really hate to get this going again but I > REALLY don't believe >>> that off >>> is > better than on in any group except pts > with significant >>> aortic >>> calcification > or > atheroma. There was an interesting > paper >>> just presented here >>> at the STS that > created a sig controversy.> > > On-pump vs Off- >>> Pump >>> Coronary Artery Bypass Surgery in a Cohort of 63,000 > > >>> Patients-? >>> from Baylor and >>> Texas Heart- reviewing the 2004 Nationwide > Inpatient > Sample >>> database- >>> admittedly an administrative database but with some > really > >>> good >>>>> >>> statistics.> Conclusions- 1. Opcab does not produce lower > >>> mortality or stroke 2. >>> Opcab > has > longer hospital stays and higher costs ($1500) > 3. >>> Performing >>> Opcab in all > candidates for myocardial revascularization may > >>> not be >>> justifiable.> > Comments> > Tom Martin> U of Florida> >>> Gainesville> > >>> _______________________________________________> 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 >>>>> >>> -----------------------------------------> > > Sent from my Verizon >>> Wireless > >>> Black> Berry> > > > >>> _______________________________________________> 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 ma> >>> iling 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>> >>> -----------------------------------------> > > **************A Good >>> Credit > Score is 700 or Above. See yours in >>> just 2 easy > steps! > > >>> >> (http://pr.atwola.com/promoclk/100000075x1215855013x1201028747/aol?redir=http://www.freecreditreport >>> .> >>> com/pm/default.aspx?sc=668072%26hmpgID=62%26bcd=De> >>> cemailfooterNO62)> > >>> _______________________________________________> OpenHeart-L >>> mailing list> > Send > postings to:> OpenHe> >>> art-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>> >>> -----------------------------------------> >>> _________________________________________________________________> >>> Wish to >>> Marry Now? Join MSN Matrimony FREE!> >>> >> http://www.in.msn.com/matrimony_______________________________________________ >>>> 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 >>> Wall Street to Main Street >>> and everywhere in between, stay > up-to-date with the latest news. >>> (http://aol.com?ncid=emlcntaolcom00000023)> >>> _______________________________________________> 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 >>>> >>> ----------------------------------------- >>> _________________________________________________________________ >>> Check out the new and improved services from Windows Live. Learn >>> more! >>> >> http://clk.atdmt.com/UKM/go/132630768/direct/01/______________________________ >>> _________________ >>> 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 Wall Street to Main Street and everywhere in >>> between, stay >>> up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 >>> ) >>> _______________________________________________ >>> 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 Wall Street to Main Street and everywhere in >> between, stay >> up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 >> ) >> _______________________________________________ >> 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 > ----------------------------------------- From rwmfglycar at aol.com Sun Feb 1 14:50:29 2009 From: rwmfglycar at aol.com (rwmfglycar@aol.com) Date: Sun Feb 1 14:51:38 2009 Subject: [HSF] Re:TR In-Reply-To: <8CB5211385E40F6-1458-B46@webmail-de01.sysops.aol.com> References: <89c4ed2d0901301736w66188d28l90846f482ed4951c@mail.gmail.com> <8CB5211385E40F6-1458-B46@webmail-de01.sysops.aol.com> Message-ID: <8CB52BD78223774-1244-2648@webmail-me02.sysops.aol.com> Good experiment Cary. I have a bunch of 35 mm slides of a case in which a few minutes after coming off bypass the RV dilated acutely.RV and RA pressures were equal and were superimposable.(we had paper recordsof everything).??I saw air in the RV surface vessels. I went back on bypass made multiple needle?pricks?out of which the air fizzed, kept the systemic pressure high for about ten minutes and was able to? wean her with no tricuspid insufficiency on minimal inotropes 20 to 30 minutes after the episode started. She had no further trouble. Each anecdote stands by itself Bob -----Original Message----- From: cspassik@aol.com To: OpenHeart-L@lists.hsforum.com Sent: Sun, 1 Feb 2009 1:17 am Subject: [HSF] Re:TR Ok so here's the experiment.? Two groups of animals- use aged dogs- perhaps? equivalent to 80 year old humans-Group1- cross clamp for a couple of hours with usual myocardial protection, then give a usual bolus of air in the aorta and down the RCA, take the clamp off, and let the heart recover and let? the RV dilatation and secondary TR from the RV not moving get better over the next twenty minutes. ? Group 2- Do the same thing to the heart and during the 20 minutes of recovery put in a tricuspid ring,( or a breast enlargement or a tummy tuck or anything else)? See if it makes any difference. Cary Passik -----Original Message----- From: Prasanna Simha M To: OpenHeart-L@lists.hsforum.com Sent: Fri, 30 Jan 2009 8:36 pm Subject: Re: [HSF] to AVR or not to AVR I am not able to explain the mechanism of this TR but it occurs. Does anyone have an explanation of new onset TR that occasionaly occurs with aortic valve replacement ? Incidentaly Hal the statement made by Dr Frater is in a way tru. I have seen umpteen times people hesitate to repair moderate TR saying it will disappear with correction of the left sided lesion and most hesitate to put another incision. Just think , people dont eant to do biatrial lesions in a maze very welll knowing that the conversion rate drops 20-30 %. That is human nature or shall we say laziness ?. Prasanna On Sat, Jan 31, 2009 at 6:51 AM, wrote: > Bob, > Use of the interstrial groove to expose the mitral valve should in no way > inhibit addressing the tricuspid valve. If it does, that's ridiculous. > They > are just 2 separate incisions that need to be closed. The case I did > today > illustrates the value of repairing the tricuspid valve. The 81 yo lady > had > functional class 4 symptoms from mod AI, severe MR (no prolapse, large > central > jet on TEE), no TR or tricuspid annular dilatation, ostial RCA dz, and and > EF of 60% with massive LVH. Of note the LVOT had a pronounced bulge at > the > basilar septum. I did a vein graft to the RCA, ventricular septal > myomectomy, > AVR (19mm Magna), and a mitral repair (closure P1-P2 cleft, 24 mm Physio). > Coming off CPB, the hemodynamics were marginal. There was gross > dilatation of > the RA and severe TR. Going back on CPB with the heart warm and beating, > I > quickly (16 minutes additional CPB) installed a 26 mm MC3 ring. This > time, > coming off CPB was a breeze. The RA was less than half it's original size > with excellent contractility. No TR, trace MR, no AI, no SAM or LVOTO. > EF > 60%. I just checked, she's warm, awake, and weaning from the vent. > The point of this post is that recognizing and repairing important new TR > can make the difference between an easy wean and limping out on major > drips > with an IABP. > > Hal > > > In a message dated 1/30/2009 3:16:20 P.M. Eastern Standard Time, > rwmfglycar@aol.com writes: > > You are right Ani. Another example is the use of the interatrial groove > exposure of the mitral valve which has inhibited msny surgeons from > performing > therapeutic tricuspid surgery let alone prophylactic procedures. > Bob > > > -----Original Message----- > From: Ani Anyanwu > To: open heart list > Sent: Fri, 30 Jan 2009 5:58 pm > Subject: RE: [HSF] to AVR or not to AVR > > > > > This is a problem imposed by a philosophy of avoidance of the pump and > attaching > a sacrilegiousness to the clamping of the aorta as it may bias us in our > decision making when faced with situations such as how to deal with > coexisting > non-severe aortic stenosis. > > I bet you if one did a study to find how such a patient was managed by a > cohort > of ON-pump as compared to Off-pump surgeons one would find more > replacements > of > the aortic valve in the on-pump surgeons as compared to the off-pump > surgeons. > This is not to say though that replacement of the valve is the right > decision to > make but just to illustrate how our biases affect the decisi ons we make. > Another > example would be the attitude to moderate ischemic MR - off-pump surgeons > are > more likely to ignore this while many on-pump surgeons would add in a > ring. > > One way or the other, patients suffer from over-intervention, or lack of > complete treatment, because of our strong biases regarding the heart-lung > machine and other technical aspects of cardiac surgery. As Tea often > suggests we > have to move away from a one construct fits all approach to deciding the > best > treatment for the individual patient within more broadly accepted > constructs. > > Ani > > > From: ebender001@me.com> To: OpenHeart-L@lists.hsforum.com> Subject: > Re: > [HSF] > to AVR or not to AVR> Date: Fri, 30 Jan 2009 07:48:27 -0600> CC: > > > Either > now > or as a redo in a few years.> > Ed Bender, MD> > Sent from my iPhone> > On > Jan > 29, 2009, at 11:10 PM, Donald Ross wrote:> > > 70y > female, > no co-morbidities, angina, severe TVD and mild aortic > > stenosis (Mobile > trileaflet valve with gradient of 25)> > Prophylactic AVR?> > Don> > > _______________________________________________> > 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 > anddiscla > imers 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> > ----------------------------------------- > ______________________ ___________________________________________ > Windows Live Messenger just got better .Video display pics, contact > updates > & > more. > > http://www.download.live.com/messenger________________________________________ > _______ > 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 Wall Street to Main Street and everywhere in between, > stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 > ) > _______________________________________________ > 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 and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From Hgrmd at aol.com Sun Feb 1 15:00:35 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Feb 1 15:01:41 2009 Subject: [HSF] CABG reporting. Message-ID: Don, You could be right, but I do take precautions. I wear a full coverage lead apron, thyroid shield, and leaded goggles. In addition, the typical pacer usually requires 1-2 minutes of fluoro time. Unlike the EP's, the vast majority of my pacers are no more than 20 minutes. My skin to skin record for a DDD is 9 minutes (when I was younger). I did one maybe a month ago in 12 minutes. At least where I work, the EP's take a minimum of an hour, and often 2 hours to get a simple DDD done. Making a pocket, suturing, etc. is a big deal to them. As I said before, they are wannabe surgeons only, who can't take care of their own complications. I don't know about you, but I would definitely want my or any family member's device implanted by an experienced surgeon rather than an EP. Hal In a message dated 2/1/2009 2:51:07 P.M. Eastern Standard Time, donross@bigpond.com writes: Hal. Do you realise how much radiation you get hunched over the X-ray machine doing pacers? It is a lot more than for any other procedure and a hellava lot more than the cards get cathing from the groin with plates of lead glass between their eyes & hands and the damn machine. Don On 02/02/2009, at 4:15 AM, hgrmd@aol.com wrote: > The cardiologists take care of all that junk. I'm like the plumber; > I do the installation. Quite frankly, between me and the pacer > reps, there's virtually never a complaint from the cardiologists. > They frequently tell the rep the exact settings they want prior to > the OR. In addition, I know what comprise good numbers when > implanting a DDD pacer. It ain't that hard. The EP's try to make > everyone believe they are the best at implanting. Unfortunately, > they are not thoracic surgeons. They can't fix most of their > complications. > > Hal > Sent from my Verizon Wireless BlackBerry > > -----Original Message----- > From: Michael Firstenberg > > Date: Sun, 1 Feb 2009 12:06:28 > To: > Subject: Re: [HSF] CABG reporting. > > > Hal - > True and your comments do not surprise me. > > But, my comments (not directed at you in particular) is dealing more > with the fine tuning, follow-up, etc that goes into the devices. Who > does the device checks? Monitors the thresholds? Optimizes the > pacing/ATP/defib programming? Who supervises the clinics and the in- > patient device activations/deactivations for elective procedures? Who > gets called with the problems? Who admits the patients when the ICDs > fire? > > Again, like everything else - it depends on the system in place. > > -michael > > > > On Feb 1, 2009, at 11:48 AM, Hgrmd@aol.com wrote: > >> Michael, >> My guess is you don't have much experience implanting pacemakers. I >> trained in a different era and practice in a different community. >> Here, the >> surgeons still implant the majority of the devices, including >> biventricular ICD's. >> Personally, I only implant pacers. However, I've done literally >> thousands >> over the past 23 years without a single fatality, and only one >> perforation >> requiring a window (92 yo lady developed an effusion on PPOD#2). >> In contrast, >> there's an EP in our community who has had more perforations in the >> few years >> he's been here than all of the cardiac surgeons in my group in >> their entire >> careers. In addition, guess who this hapless EP screams for when >> his ass is >> in a sling? BTW, Michael, aren't you the one who said you stand by >> for the >> EP's in your hospital when they are extracting leads? That's >> crazy. Quite >> frankly, only surgeons should be doing that since massive tamponade >> can develop >> within seconds with that procedure (linear tear in free wall of RA). >> >> Hal >> >> >> In a message dated 2/1/2009 11:39:16 A.M. Eastern Standard Time, >> msfirst@gmail.com writes: >> >> maybe it is a subtle jab that surgeons should not be putting in >> pacemakers? >> >> wow - all of the snow outside my window just melted from the blaze >> of >> fire directed at me. >> >> >> -michael >> >> >> >> >> >> On Feb 1, 2009, at 10:40 AM, hgrmd@aol.com wrote: >> >>> Ani, >>> To be honest, I've really no idea what's going to be reported. I >>> recently >>> attended a meeting with administration at one of my hospitals where >>> they >>> outlined this new system. It's my uhderstanding that it will >>> include AVR, MVR, >>> CABG, and their combinations. Things like Dors, thoracic aortic >>> procedures, >>> and some others will be excluded. I plan to do a few more stand >>> alone CABG's >>> because, probably like you, my last death from an isolated CABG >>> was >>> several >>> years ago. It's all a matter of playing the game. >>> While we're discussing this crap, what about the STS's bone head >>> rule that >>> counts a postop permanent pacemaker as a "bring back for surgery" >>> if it's >>> done in the OR, but not if it's done in the EP lab? Honestly, >>> who's side are >>> they on? >>> >>> Hal >>> >>> >>> In a message dated 2/1/2009 10:29:06 A.M. Eastern Standard Time, >>> anianyanwu@hotmail.com writes: >>> >>> >>> Hal >>> >>> One would only be at a disadvantage if one sees the stats as a >>> means to >>> promote or validate one's status as a top coronary surgeon - to do >>> this one would >>> need a high volume of CABG with low mortality (I assume that has >>> to >>> be the >>> 'outcome' they will look at). However, given that you are not >>> predominantly a >>> coronary surgeon it shouldnt matter much to you. >>> >>> Assuming you do only 10 to 20 isolated CABGs per year then you >>> would likely >>> be excluded from ranking analysis (otherwise if you did 15 with no >>> death, >>> just like I did last year, then you would be ranked as the top >>> coronary surgeon >>> with a zero mortality risk which would make no sense). If one did >>> include >>> your cases in a report the confidence interval would be so wide >>> such as to make >>> your results meaningless. >>> >>> Only surgeons doing say 50 plus or so CABGs per year need worry >>> about data >>> reporting as the ranking and results would be more stable. If a >>> low >>> volume >>> CABG surgeon wants to look good in the reports then one has to get >>> more volume >>> and try and aim to do at least 100 procedures per year for the >>> data >>> to have >>> meaning. (the caveat though is that while a low volume surgeon >>> will >>> not get >>> credited with low mortality, they will still get penalized for >>> high >>> mortality; >>> if one does 10 cases and 5 die then small numbers wont protect >>> from >>> that). >>> >>> What is the stated goal of the Florida reporting exercise? I find >>> it odd >>> that with CABG in decline new reporting systems still emerge to >>> track isolated >>> CABG. I think one will find that cardiac surgery is becoming more >>> like general >>> thoracic where the make up of ones practice is very heterogenous >>> with very >>> few two operations being alike. The days where isolated CABG, >>> isolated AVR and >>> isolated MVR constituted 95% of most practices are long gone. We >>> now have a >>> plethora of operations and hybrids with various manners of >>> combined >>> procedures on an even more heterogenous group of patients which >>> makes it very >>> difficult to define index operations and compare outcomes. >>> >>> Why does the reporting make you plan to do more isolated CABGs? >>> >>> Ani >>> >>> >>> >>> >>> >>> >>>> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] On pump vs >>>> Off> >>> From: hgrmd@aol.com> Date: Sun, 1 Feb 2009 15:00:10 +0000> CC: > > >>> Tea,> I'm not >>> sure, but wouldn't be surprised if the stats make it to the >>> newspaper. >>> Certainly, it will be online. Anyway, I'm at a disadvantage since >>> my case load if >>> over 95 per cent valves.> > Hal> Sent from my Verizon Wireless >>> BlackBerry> > >>> -----Original Message-----> From: Tea Acuff > > >>> Date: Sun, >>> 1 Feb 2009 06:54:40 > To: >>> OpenHeart-L@lists.hsforum.com> >>> Subject: Re: [HSF] On pump vs Off> > > What format will they use >>> for reporting?> Tea> > Sent from my iPhone> > On Feb 1, 2009, at >>> 5:47 AM, >>> Hgrmd@aol.com wrote:> > I whole heartedly agree with you. Even the >>> most die >>> hard on pump surgeon is > bound to eventually encounter a case >>> that >>> he will >>> screw up if he isn't able > to do at least the occasional off >>> pump. >>> Because >>> Florida is now reporting the > mortality statistics of all >>> surgeons >>> (like New >>> York), I plan to do more > isolated CABG's. I suspect at least >>> half >>> will be >>> OPCAB.> > Hal> > > In a message dated 1/31/2009 11:06:20 P.M. >>> Eastern Standard >>> Time, > govindgovind@hotmail.com writes:> > > > > For any surgeon >>> actively >>> engaged in CABG on pump, learning the ropes for off > pump method >>> is a definite >>> advantage.Both methods are eminently successful in > getting good >>> results and >>> we need to apply either judiciouly as per the > clinical >>> problem.There is no >>> need to be a diehard supporter of only one method. If > some of >>> the >>> surgeons >>> are trying to use off pump method from marketing angle > it is not >>> the method >>> which is at fault.> > govindakubal> To: OpenHeart- >>> L@lists.hsforum.com> >>> Subject: Re: [HSF] On pump > vs Off> Date: Sat, 31 Jan 2009 >>> 21:58:57 -0500> From: >>> tdmartin2000@aol.com> > CC: > > Bill> ?Laurie Davies is the >>> principle >>> investigator and has the > manuscript. She was appointed to the >>> Florida Board of >>> Medicine during the study and > was subsequently appointed as >>> Chair >>> of the Board >>> - a big time consuming job. > She has just completed her tenure on >>> the board >>> and will be completing the > paper soon. It shows just what you >>> would >>> suspect but I cannot write it here as it > has not been published >>> and the journals >>> don't like it when you give out the > data.> Let's just say that it >>> has not >>> converted me.> > Tom> > > -----Original > Message-----> From: >>> wftjrtyler@aol.com> To: OpenHeart-L@lists.hsforum.com> > Sent: >>> Fri, >>> 30 Jan 2009 6:57 pm> >>> Subject: Re: [HSF] On pump vs Off> > > > Tom, > several years(and >>> threads) ago, >>> you were randomizing Opcabs vs. Oncab > at > UF. Is your study in >>> progress >>> or did i miss the paper? bill turner> > > In a > message dated >>> 1/29/2009 >>> 8:53:17 P.M. Central Standard Time, > > tdmartin2000@aol.com >>> writes:> > agree> > > >>> -----Original Message-----> From: hgrmd@aol.com> > To: >>> OpenHeart-L@lists.hsforum.com> Sent: Wed, 28 Jan 2009 11:58 pm> >>> Subject: > Re: [HSF] On pump vs >>> Off> > > > Tom,> You and I are essentially on the same > side. Of >>> course Dors >>> and valves don't > apply. However, my perception, based > on >>> personal >>> experience as well as the > literature, is that elderly > >>> vasculopaths with hostile >>> aortas benefit from > OPCAB. > For the average case, it > probably >>> doesn't >>> matter. You and I would agree > that > there are a lot of > >>> surgeons out there >>> trying to use OPCAB for a marketing > angle. > I consider OPCAB > >>> an >>> excellent technique to have in one's armamentarium. In > fact, I >>> was >>>> recently >>> summoned to the OR to take over my junior surgeon's > CABG > when >>> he > >>> unexpectedly encountered a bad aorta. I stepped in and did a 3 > >>> vessel > OPCAB. > The >>> patient did fine.> > Hal> > Hal > Sent from my Verizon Wireless > >>> BlackBerry> >>>> -----Original Message-----> From: tdmartin2000@aol.com> > Date: >>>> Wed, 28 > >>> Jan 2009 23:44:34 > To: > Subject: >>> Re: [HSF] >>>> On pump vs Off> > > Hal> I'm not sure John refuted as much as >>>> attacked it. >>>> His whole premise was on > the > difference between an >>>> administrative and a >>>> clinical data base. The presenter > had?a good rebuttal to John's >>> rebuttal. I > can't wait to see the manuscript > and > review it >>> myself. It's hard to >>> refute > the conclusions of death, stroke, > length > of stay and >>> costs when >>> there is > data on 63,000 pts no matter what kind of > data > >>> base. >>> I also >>> have to?ask > what your definition of a high risk case is and > >>> where > the >>> data is to > confirm your premise. It is hard to do an off pump >>> redo CABG > >>> AVR > or MVR, or a > CABG Dor, or a CABG, ascending, etc.. These >>> would fall >>> into the > > high risk > cases for me. As you know I brought this >>> up for the >>> sake of > dis> cussion > > and controversy.> > Tom> > > > > ----- >>> Original >>> Message-----> From: > hgrmd@aol.com> To: OpenHeart-L@lists.hsforum.com >>>> Sent: Wed, >>> 28 Jan 2009 11:25 pm> > Subject: Re: [HSF] On pump vs Off> > > > >>> Tom,> Yes, >>> it was provocative, but I > thought John Puskas pretty much >>> refuted >>> it in > >>> the discussion. As you know, > his own group at Emory as well as >>> thorough > >>> exam of > > the STS database > comes to the opposite conclusions. >>> Again, I >>> don't think > the 2 > approaches ar> > e that distinguishable for >>> low risk >>> cases. However, most high risk > > > subsets do better.> > Hal> >>> ------Original >>> Message------> From: > tdmartin2000@aol.com> Sender: >>> openheart-l-bounces@lists.hsforum.com> To: > >> OpenHeart-L@lists.hsforum.com >>>> ReplyTo: >>> OpenHeart-L@lists.hsforum.com> Sent: Jan 28, 2009 11:18 PM> > >>> Subject: [HSF] On pump vs Off> > >>> I really hate to get this going again but I > REALLY don't believe >>> that off >>> is > better than on in any group except pts > with significant >>> aortic >>> calcification > or > atheroma. There was an interesting > paper >>> just presented here >>> at the STS that > created a sig controversy.> > > On-pump vs Off- >>> Pump >>> Coronary Artery Bypass Surgery in a Cohort of 63,000 > > >>> Patients-? >>> from Baylor and >>> Texas Heart- reviewing the 2004 Nationwide > Inpatient > Sample >>> database- >>> admittedly an administrative database but with some > really > >>> good >>>>> >>> statistics.> Conclusions- 1. Opcab does not produce lower > >>> mortality or stroke 2. >>> Opcab > has > longer hospital stays and higher costs ($1500) > 3. >>> Performing >>> Opcab in all > candidates for myocardial revascularization may > >>> not be >>> justifiable.> > Comments> > Tom Martin> U of Florida> >>> Gainesville> > >>> _______________________________________________> 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 >>>>> >>> -----------------------------------------> > > Sent from my Verizon >>> Wireless > >>> Black> Berry> > > > >>> _______________________________________________> 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 ma> >>> iling 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>> >>> -----------------------------------------> > > **************A Good >>> Credit > Score is 700 or Above. See yours in >>> just 2 easy > steps! > > >>> >> (http://pr.atwola.com/promoclk/100000075x1215855013x1201028747/aol?redir=http://www.freecreditreport >>> .> >>> com/pm/default.aspx?sc=668072%26hmpgID=62%26bcd=De> >>> cemailfooterNO62)> > >>> _______________________________________________> OpenHeart-L >>> mailing list> > Send > postings to:> OpenHe> >>> art-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>> >>> -----------------------------------------> >>> _________________________________________________________________> >>> Wish to >>> Marry Now? Join MSN Matrimony FREE!> >>> >> http://www.in.msn.com/matrimony_______________________________________________ >>>> 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 >>> Wall Street to Main Street >>> and everywhere in between, stay > up-to-date with the latest news. >>> (http://aol.com?ncid=emlcntaolcom00000023)> >>> _______________________________________________> 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 >>>> >>> ----------------------------------------- >>> _________________________________________________________________ >>> Check out the new and improved services from Windows Live. Learn >>> more! >>> >> http://clk.atdmt.com/UKM/go/132630768/direct/01/______________________________ >>> _________________ >>> 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 Wall Street to Main Street and everywhere in >>> between, stay >>> up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 >>> ) >>> _______________________________________________ >>> 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 Wall Street to Main Street and everywhere in >> between, stay >> up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023 >> ) >> _______________________________________________ >> 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 > ----------------------------------------- _______________________________________________ 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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) From rwmfglycar at aol.com Sun Feb 1 15:02:14 2009 From: rwmfglycar at aol.com (rwmfglycar@aol.com) Date: Sun Feb 1 15:03:19 2009 Subject: [HSF] Re:TR In-Reply-To: References: Message-ID: <8CB52BF1C04E9A0-1244-26B6@webmail-me02.sysops.aol.com> We need Tea to help us here. In the preecho days pricking the most distal visible vessels to let the air out was a standard operating procedure. Nobody ever wrote it up because every body knew what to do if one saw air in the surface vessels. Why does simple knowledge disappear? Why would someone teaching students about perioperative air embolism not end with a sentence about pricking the vessels. A surgical needle will do the trick; the air comes out of the hole in the artery. Bob -----Original Message----- From: Hgrmd@aol.com To: OpenHeart-L@lists.hsforum.com Sent: Sun, 1 Feb 2009 1:49 pm Subject: Re: [HSF] Re:TR Cary, I knew you were kidding. Your tip to nick the acute marginals is excellent. What do you use, a 27 gauge needle? Hal In a message dated 2/1/2009 12:31:53 A.M. Eastern Standard Time, CSPassik@aol.com writes: Hal, Actually, you're comments are fascinating, particularly the fact that the RV seemed to be moving well. I would have expected the RV to be big and suffering in appearance. This perhaps speaks for another mechanism- do you think it may be possible for regional RV wall motion abnormalities to cause TR from asynergy- just like regional LV abnormalities can cause transient bad MR with an overall good ventricle? Even in the absence of much air on TEE, I very frequently see air bubbles come right down the acute marginals after unclamping- this certainly gives global and perhaps regional RV abnormalities. The native RCA always takes the hit before the RCA graft. A useful technique that I use in this situation( and reported in a letter commenting on a paper by Salerno in the Annals in 1996) is to nick 1 or 2 small acute marginals to let the air escape- the RV returns very quickly. Now I will start to look at what happens to the tricuspid with this maneuver. The tummy tuck or breast enlargement is optional and purely facetious. Cary **************Great Deals on Dell Laptops. Starting at $499. (http://pr.atwola.com/promoclk/100000075x1217883258x1201191827/aol?redir=http: //www.dell.com/co ntent/products/features.aspx/laptops_great_deals?c=us%26cs=19%26l=en%26s=d hs%26~ck=anavml) _______________________________________________ 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 Wall Stre et to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) _______________________________________________ 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 Sun Feb 1 15:08:25 2009 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Feb 1 15:09:00 2009 Subject: [HSF] Re:TR Message-ID: Bob, I'm embarrassed to say I've never pricked a coronary to deair it. I have always just made sure the perfusion pressure was at least 70 mm and waited it out. I will definitely use this technique in the future. I think I like your recommendation with a needle better than the eleven blade. That way, the coronary shouldn't be permanently damaged. Hal In a message dated 2/1/2009 3:04:30 P.M. Eastern Standard Time, rwmfglycar@aol.com writes: We need Tea to help us here. In the preecho days pricking the most distal visible vessels to let the air out was a standard operating procedure. Nobody ever wrote it up because every body knew what to do if one saw air in the surface vessels. Why does simple knowledge disappear? Why would someone teaching students about perioperative air embolism not end with a sentence about pricking the vessels. A surgical needle will do the trick; the air comes out of the hole in the artery. Bob -----Original Message----- From: Hgrmd@aol.com To: OpenHeart-L@lists.hsforum.com Sent: Sun, 1 Feb 2009 1:49 pm Subject: Re: [HSF] Re:TR Cary, I knew you were kidding. Your tip to nick the acute marginals is excellent. What do you use, a 27 gauge needle? Hal In a message dated 2/1/2009 12:31:53 A.M. Eastern Standard Time, CSPassik@aol.com writes: Hal, Actually, you're comments are fascinating, particularly the fact that the RV seemed to be moving well. I would have expected the RV to be big and suffering in appearance. This perhaps speaks for another mechanism- do you think it may be possible for regional RV wall motion abnormalities to cause TR from asynergy- just like regional LV abnormalities can cause transient bad MR with an overall good ventricle? Even in the absence of much air on TEE, I very frequently see air bubbles come right down the acute marginals after unclamping- this certainly gives global and perhaps regional RV abnormalities. The native RCA always takes the hit before the RCA graft. A useful technique that I use in this situation( and reported in a letter commenting on a paper by Salerno in the Annals in 1996) is to nick 1 or 2 small acute marginals to let the air escape- the RV returns very quickly. Now I will start to look at what happens to the tricuspid with this maneuver. The tummy tuck or breast enlargement is optional and purely facetious. Cary **************Great Deals on Dell Laptops. Starting at $499. (http://pr.atwola.com/promoclk/100000075x1217883258x1201191827/aol?redir=http: //www.dell.com/co ntent/products/features.aspx/laptops_great_deals?c=us%26cs=19%26l=en%26s=d hs%26~ck=anavml) _______________________________________________ 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 Wall Stre et to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) _______________________________________________ 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 Wall Street to Main Street and everywhere in between, stay up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) From ebender001 at me.com Sun Feb 1 14:23:39 2009 From: ebender001 at me.com (Edward Bender) Date: Sun Feb 1 15:24:11 2009 Subject: [HSF] Re:TR In-Reply-To: <8CB52BF1C04E9A0-1244-26B6@webmail-me02.sysops.aol.com> Message-ID: This is very interesting. I always hearken back to Kuhn's "Structure of Scientific Revolution" concept of paradigm shifts occurring because proponents of older theories (read: techniques) retiring, etc. What you are describing is lost knowledge becoming lost because no one really taught it that much. I know that I was never taught this, nor did I ever hear of it or see it used. My trainer was Bob Karp and his trainer was John Kirklin. I did plenty of cases with Karp, and he never opened a coronary to evacuate air. Did Kirklin? Can a technique be so mundane that it is not passed down? Ed Bender, MD On 2/1/09 2:02 PM, "rwmfglycar@aol.com" wrote: > We need Tea to help us here. In the preecho days pricking the most distal > visible vessels to let the air out was a standard operating procedure. > Nobody ever wrote it up because every body knew what to do if one saw air in > the surface vessels. > Why does simple knowledge disappear? Why would someone teaching students about > perioperative air embolism not end with a sentence about pricking the vessels. > A surgical needle will do the trick; the air comes out of the hole in the > artery. > Bob > > -----Original Message----- > From: Hgrmd@aol.com > To: OpenHeart-L@lists.hsforum.com > Sent: Sun, 1 Feb 2009 1:49 pm > Subject: Re: [HSF] Re:TR > > > > Cary, > I knew you were kidding. Your tip to nick the acute marginals is > excellent. What do you use, a 27 gauge needle? > > Hal > > > In a message dated 2/1/2009 12:31:53 A.M. Eastern Standard Time, > CSPassik@aol.com writes: > > Hal, > Actually, you're comments are fascinating, particularly the fact that the > RV > seemed to be moving well. I would have expected the RV to be big and > suffering in appearance. This perhaps speaks for another mechanism- do you > think it > may be possible for regional RV wall motion abnormalities to cause TR > from > asynergy- just like regional LV abnormalities can cause transient bad MR > with an overall good ventricle? Even in the absence of much air on TEE, > I > very frequently see air bubbles come right down the acute marginals after > unclamping- this certainly gives global and perhaps regional RV > abnormalities. > The native RCA always takes the hit before the RCA graft. A useful > technique > that I use in this situation( and reported in a letter commenting on a > paper > by Salerno in the Annals in 1996) is to nick 1 or 2 small acute marginals > to let the air escape- the RV returns very quickly. Now I will start to > look > at what happens to the tricuspid with this maneuver. The tummy tuck or > breast > enlargement is optional and purely facetious. > Cary > **************Great Deals on Dell Laptops. Starting at $499. > (http://pr.atwola.com/promoclk/100000075x1217883258x1201191827/aol?redir=http: > //www.dell.com/co > ntent/products/features.aspx/laptops_great_deals?c=us%26cs=19%26l=en%26s=d > hs%26~ck=anavml) > _______________________________________________ > 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 Wall Stre > et to Main Street and everywhere in between, stay > up-to-date with the latest news. (http://aol.com?ncid=emlcntaolcom00000023) > _______________________________________________ > 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 msfirst at gmail.com Sun Feb 1 15:42:50 2009 From: msfirst at gmail.com (Michael Firstenberg) Date: Sun Feb 1 15:51:30 2009 Subject: [HSF] Re:TR In-Reply-To: References: Message-ID: Without getting into too much of a discussion about surgical education - particularly in the context of the 80 hr era. Unfortunately, I am as much to blame as anyone, as we become more reliant on modern technology the basics and tricks get lost in time - particularly in the "pre youtube/internet era". You point is well taken - as is all of your points. these days, far easier to load up with milrinone, nitric, maybe even an RVAD than the simple stuff. For my high risk cases, I have gotten into the habit of using ice patties (raytek wrapped in ice) and resting on top of the RV for better protection - everyone thinks I am crazy and I probably am, but since I have been doing it, I have be much happier with my RV post-pump function. You are my hero. -michael On Sun, Feb 1, 2009 at 3:08 PM, wrote: > Bob, > I'm embarrassed to say I've never pricked a coronary to deair it. I have > always just made sure the perfusion pressure was at least 70 mm and waited > it > out. I will definitely use this technique in the future. I think I like > your recommendation with a needle better than the eleven blade. That way, > the > coronary shouldn't be permanently damaged. > > Hal > > > In a message dated 2/1/2009 3:04:30 P.M. Eastern Standard Time, > rwmfglycar@aol.com writes: > > We need Tea to help us here. In the preecho days pricking the most distal > visible vessels to let the air out was a standard operating procedure. > Nobody ever wrote it up because every body knew what to do if one saw air > in > the surface vessels. > Why does simple knowledge disappear? Why would someone teaching students > about perioperative air embolism not end with a sentence about pricking > the > vessels. A surgical needle will do the trick; the air comes out of the > hole in > the artery. > Bob > > -----Original Message----- > From: Hgrmd@aol.com > To: OpenHeart-L@lists.hsforum.com > Sent: Sun, 1 Feb 2009 1:49 pm > Subject: Re: [HSF] Re:TR > > > > Cary, > I knew you were kidding. Your tip to nick the acute marginals is > excellent. What do you use, a 27 gauge needle? > > Hal > > > In a message dated 2/1/2009 12:31:53 A.M. Eastern Standard Time, > CSPassik@aol.com writes: > > Hal, > Actually, you're comments are fascinating, particularly the fact that the > RV > seemed to be moving well. I would have expected the RV to be big and > suffering in appearance. This perhaps speaks for another mechanism- do > you > > think it > may be possible for regional RV wall motion abnormalities to cause TR > from > asynergy- just like regional LV abnormalities can cause transient bad MR > with an overall good ventricle? Even in the absence of much air on > TEE, > I > very frequently see air bubbles come right down the acute marginals > after > unclamping- this certainly gives global and perhaps regional RV > abnormalities. > The native RCA always takes the hit before the RCA graft. A useful > technique > that I use in this situation( and reported in a letter commenting on a > paper > by Salerno in the Annals in 1996) is to nick 1 or 2 small acute > marginals > to let the air escape- the RV returns very quickly. Now I will start to > look > at what happens to the tricuspid with this maneuver. The tummy tuck or > breast > enlargement is optional and purely facetious. > Cary > **************Great Deals on Dell Laptops. Starting at $499. > ( > http://pr.atwola.com/promoclk/100000075x1217883258x1201191827/aol?redir=http > : > //www.dell.com/co > > ntent/products/features.aspx/laptops_great_deals?c=us%26cs=19%26l=en%26s=d > hs%26~ck=anavml) > _______________________________________________ > 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 Wall Stre > et to Main Street and everywhere in between, stay > up-to-date with the latest news. ( > http://aol.com?ncid=emlcntaolcom00000023 > ) > _______________________________________________ > 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 Wall Street to Main Street and everywhere in between, > stay > up-to-date with the latest news. ( > http://aol.com?ncid=emlcntaolcom00000023 > ) > _______________________________________________ > 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 robertobattellini at hotmail.com Sun Feb 1 21:54:56 2009 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Sun Feb 1 15:55:44 2009 Subject: [HSF] Re-do AVR In-Reply-To: <001701c9848c$8d9c7a20$a8d56e60$@net> References: <654814.79899.qm@web81606.mail.mud.yahoo.com> <1095840663-1233500406-cardhu_decombobulator_blackberry.rim.net-390820265-@bxe016.bisx.prod.on.blackberry> <001701c9848c$8d9c7a20$a8d56e60$@net> Message-ID: Ajit, you mean left thoracotomy, transapical? Tommy Walther has already done his 200 cases in Leipzig, we received this week a patient from Pennsylvania, 92 years old.Went off pump, no blood. All those patients come to my Station, and I see them after Op. Last 100 cases mortality was reduced to 9% in high risk cases. He did also a couple of cases MIDCAB + transapical. Roberto > From: damle@cableone.net> To: OpenHeart-L@lists.hsforum.com> Date: Sun, 1 Feb 2009 10:45:55 -0600> CC: > Subject: [HSF] Re-do AVR> > It sometimes seems that all my AVRs are re-dos after previous CABGs. Here is> the latest one:> > > > 76 M, severe COPD, FEV1 50% of predicted, LIMA-LAD, SVG to OM 1996,> Creatinine 1.6, Asc aorta 4.0. I saw him in 2006, Angio patent LIMA to a> 100% large LAD, SVG occluded, 99% Cx and RCA. AS, valve area 1.0 sq cms. EF> 65%. 3D CT 06 showed LIMA plastered to back of sternum and coursing> medially. His presentation was unstable angina. I recommended surgery and> patient refused.> > > > Now increasing SOB, NYHA class III. EF now 25%, AV area 0.6sq cms, MR++,> wants surgery. PFTs unchanged. I am planning CT, coronary angio, PET scan> and perhaps a Dobutamine ECHO. Because of his coronary disease, he does not> qualify for the percuteneous trial.> > > > I have been doing my re-dos now after Hal's description: CPB and moderate> hypothermia before sternotomy. So although his LIMA has a high chance of> injury, I will be able to deal with it. But overall the problems are> daunting. > > > > Oh, and did I mention he is a Jehovah's Witness?> > > > At STS there was a presentation of AVR through a right thoracotomy. If I can> stent the Cx and RCA, that might be the best option.> > > > What do you think?> > > > Ajit Damle> > > > _______________________________________________> 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 Sun Feb 1 15:47:50 2009 From: msfirst at gmail.com (Michael Firstenberg) Date: Sun Feb 1 17:42:21 2009 Subject: [HSF] Re-do AVR In-Reply-To: References: Message-ID: I am not a big fan of negiotiating with patients Fortunately we do not have too many JW around here - but I have seen/heard of enough problems (including 1 I know getting blood against their wishes - and not exactly sure they needed it). Some of this stuff is hard enough as it is - doing it with 1 hand tied behind your back doesnt help. Maybe Dr Salerno is interested........(he does a lot of JW's right?) -michael On Sun, Feb 1, 2009 at 2:39 PM, wrote: > Dear Ani, > Sorry for mistaking you for Ajit. However, my thoughts are the same. > > Hal > > > In a message dated 2/1/2009 2:22:01 P.M. Eastern Standard Time, > anianyanwu@hotmail.com writes: > > > Hal > > Even after that unfortunate transapical case you saw in paris you would > advocate off-pump apical conduit in this particular patient? I think fair > if the > surgeon does these off-pump apical conduits often, but for the surgeon > with > only occasional experience in apical conduits, off-pump apical cannulation > might not be the best for a Jehovah's witness. > > If that thing bleeds the patient faces a high risk of death. I have done a > number of LVADs off-pump so I am okay with cannulating the apex without > the > heart-lung machine, but the LVAD situation is very different as the LV > pressures once device starts are very low so bleeding rarely a problem, but > with the > apicoaortic conduit and the LV systolic of 150 in many of these patients, > if > that thing bleeds then one may have big problem in a JW which is why I > suspect safety of bypass will be ideal to get absolute hemostasis and > minimize > blood loss. > > I would stick with your earlier view that if the patient does not want > blood > all conventional surgical options are out. I dont think a thoracotomy > changes this much. > > Ani > > > > ---------------------------------------- > > From: Hgrmd@aol.com > > Date: Sun, 1 Feb 2009 14:03:16 -0500 > > Subject: Re: [HSF] Re-do AVR > > To: OpenHeart-L@lists.hsforum.com > > CC: > > > > Last year, I did an off pump aortic valve bypass with Gammie proctoring. > We > > were completely ready to go on pump, but it wasn't necessary. With a > J.W., > > I think staying off pump would definitely be of benefit. Ajit should > contact > > Medtronic for technical support if he decides to pursue this avenue. > > > > Hal > > > > > > In a message dated 2/1/2009 1:39:26 P.M. Eastern Standard Time, > > ebender001@me.com writes: > > > > Ajit's case report mentions MR 2+, but no AI mentioned. I think the > rational > > choice is a conduit. > > Even though Jim Gammie writes that he now prefers to do these cases off > > pump, I think that doing the LV portion on pump, would go a long way > towards > > not needing a blood transfusion - at least not violating any religious > > tenets type of blood transfusion. > > Ed Bender, MD > > > > > > On 2/1/09 12:26 PM, "Harold Roberts" wrote: > > > >> Ajit and Ani, > >> I've injured a handful of mammaries in my time. The last one was > > several > >> years ago. I only recall one fatality which was the first one. I was in > >> training, opening a redo, when I transected the mammary. Of course, I > > wasn't > >> even close to being able to go on bypass. The outcome was predictably > >> horrible. > >> In these cases, I prefer CPB prior to splitting the chest. At th