[HSF] adequate flow to use ima-question for Don and Tomas Salerno

Wed Sep 30 16:53:08 EDT 2009

you are saying that many a times despite a perfect anastomosis something were wrong,it was detected by flowmetry,  you corrected it and the final result was much better than what would be without flowmetry.am I right.

erdinc

> Date: Wed, 30 Sep 2009 15:39:28 +0200
> From: grescigno at mac.com
> To: OpenHeart-L at lists.hsforum.com
> Subject: RE: [HSF] adequate flow to use ima-question for Don and Tomas Salerno
> CC: 
> 
> Erdinç I am a strong proponent of flowmetry but you should also be prepared to know that your work is not as perfect as your surgical ego makes you believe.
> 
> Giuseppe
> 
> 
> 
> Giuseppe Rescigno M.D.
> Cardiothoracic Surgeon
> 
> Lancisi Hospital
> Torrette - Ancona
> Italy
> 
> 
> 
> On Wednesday, 30 September, 2009, at 01:32PM, "erdinç naseri" <enaseri at hotmail.com.tr> wrote:
> >
> >giuseppe,
> >
> >I couldn't get.are you a proponent or opponent of medistim
> >
> >erdinc 
> > 
> >> Date: Wed, 30 Sep 2009 13:25:26 +0200
> >> From: grescigno at mac.com
> >> To: OpenHeart-L at lists.hsforum.com
> >> Subject: RE: [HSF] adequate flow to use ima-question for Don and Tomas Salerno
> >> CC: 
> >> 
> >> Don,
> >> 
> >> if someone wish to consider him or herself as an excellent CABG surgeon I suggest this person to avoid flowmetry at all. I have detected so many problems, often not related to the anastomosis itself. Limited kinking, angulation, compression by the Lima passing above, etc are common findings in patients with excellent hemodynamics, a perfect ECG. 
> >> 
> >> Giuseppe
> >> 
> >> 
> >> 
> >> Giuseppe Rescigno M.D.
> >> Cardiothoracic Surgeon
> >> 
> >> Lancisi Hospital
> >> Torrette - Ancona
> >> Italy
> >> 
> >> 
> >> 
> >> On Tuesday, 29 September, 2009, at 08:15PM, "Douville, Chuck" <ecdouville at orclinic.com> wrote:
> >> >I have used the Medistim routinely Don, for years. It has helped me with several OPCABs in particular, with unexplained graft troubles, as Dr. Salerno identified years ago. I trust it; once in a while I have revised a graft and found nothing wrong, but the flow improves. It is a vast improvement over the electromagnetic flow probes of 15 years ago.
> >> > 
> >> >chuck
> >> >
> >> >________________________________
> >> >
> >> >From: openheart-l-bounces at lists.hsforum.com on behalf of Donald Ross
> >> >Sent: Tue 9/29/2009 4:44 AM
> >> >To: OpenHeart-L at lists.hsforum.com
> >> >Subject: Re: [HSF] adequate flow to use ima-question for Don and Tomas Salerno
> >> >
> >> >
> >> >
> >> >I use the Medistim and don't know much about how accurate it is but 
> >> >certainly there is no calibration.
> >> >It reads zero if the graft is clamped and the readings seem to be 
> >> >reproducible over time. Furthermore in my situation where several 
> >> >grafts are fed by one ima the individual flows roughly add up to the 
> >> >net flow in the main feeder.
> >> >Do any of the power users have anything to add?
> >> >BTW I just had my first detected graft failure which was corrected by 
> >> >redoing the anastomosis. Never thought it would happen. Fallibility is 
> >> >so cruel.
> >> >Don
> >> >On 29/09/2009, at 7:24 PM, Roberto Battellini wrote:
> >> >
> >> >>
> >> >> Do the Medistim or Cardiosonix need calibration?
> >> >>
> >> >> Roberto
> >> >>
> >> >>> From: donross at bigpond.com
> >> >>> To: OpenHeart-L at lists.hsforum.com
> >> >>> Subject: Re: [HSF] adequate flow to use ima
> >> >>> Date: Tue, 29 Sep 2009 08:53:30 +1000
> >> >>> CC:
> >> >>>
> >> >>> If the measuring device can't be trusted, why did the forum talk me
> >> >>> into using it?
> >> >>> On 29/09/2009, at 12:22 AM, Roberto Battellini wrote:
> >> >>>
> >> >>>>
> >> >>>> Don,
> >> >>>>
> >> >>>>
> >> >>>>
> >> >>>> I have had sometimes flows of 120 and always thought the Medistim
> >> >>>> was wrong.
> >> >>>>
> >> >>>> That is the flow I get in a carotid endarterectomy for a 5 mm 
> >> >>>> Carotid.
> >> >>>>
> >> >>>> Roberto
> >> >>>>
> >> >>>>> From: donross at bigpond.com
> >> >>>>> To: OpenHeart-L at lists.hsforum.com
> >> >>>>> Subject: Re: [HSF] adequate flow to use ima
> >> >>>>> Date: Mon, 28 Sep 2009 18:48:51 +1000
> >> >>>>> CC:
> >> >>>>>
> >> >>>>> Roberto,
> >> >>>>> I just did a little old Chinese man who's ima flowed nil and radial
> >> >>>>> couldn't even be flushed.
> >> >>>>> I retrogradely infused verapamil into the ima and after the passage
> >> >>>>> of
> >> >>>>> a 1mm probe the radial could also be flushed with dilator.
> >> >>>>> After his two grafts: ima to lad ,T radial to pda. his net ima flow
> >> >>>>> was 120 ml/min.
> >> >>>>> Don
> >> >>>>> On 27/09/2009, at 2:57 AM, Roberto Battellini wrote:
> >> >>>>>
> >> >>>>>>
> >> >>>>>> Tea, I would discard it if the flow is less than 30 ml/min
> >> >>>>>>
> >> >>>>>>
> >> >>>>>>
> >> >>>>>> Tea, when do you arrive at Frankfurt?
> >> >>>>>>
> >> >>>>>>
> >> >>>>>>
> >> >>>>>>> Date: Sat, 26 Sep 2009 05:38:12 -0700
> >> >>>>>>> From: tacuff at swbell.net
> >> >>>>>>> Subject: Re: [HSF] Stented subclavian stenosis-for Ani
> >> >>>>>>> To: OpenHeart-L at lists.hsforum.com
> >> >>>>>>> CC:
> >> >>>>>>>
> >> >>>>>>> If you have pulsitile flow, at what measurement would you discard
> >> >>>>>>> it? If you leave attached to measure is that approriate 
> >> >>>>>>> considering
> >> >>>>>>> the effect of outflow and competitive flow.
> >> >>>>>>>
> >> >>>>>>> Try this test instead: as you hold the Lima and watch the end 
> >> >>>>>>> flow,
> >> >>>>>>> the Lima will appear to you to have one behavior. Let go of it 
> >> >>>>>>> and
> >> >>>>>>> see if your mind changes!
> >> >>>>>>>
> >> >>>>>>> Tea
> >> >>>>>>>
> >> >>>>>>> Sent from my iPhone
> >> >>>>>>>
> >> >>>>>>> On Sep 26, 2009, at 5:48 AM, Roberto Battellini <robertobattellini at hotmail.com
> >> >>>>>>>> wrote:
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>> Tea,
> >> >>>>>>>
> >> >>>>>>> if you do that, take a flowmeter, prepare 5 cm of LIMA, and 
> >> >>>>>>> measure
> >> >>>>>>> the flow.I have discarded twice those Lima´s which having for a
> >> >>>>>>> long time receiving almost no flow
> >> >>>>>>>
> >> >>>>>>> from LSA , looked hypoplastic.
> >> >>>>>>>
> >> >>>>>>> And why to risK???
> >> >>>>>>>
> >> >>>>>>> Roberto
> >> >>>>>>>
> >> >>>>>>> Date: Fri, 25 Sep 2009 18:46:53 -0700
> >> >>>>>>> From: tacuff at swbell.net
> >> >>>>>>> Subject: Re: [HSF] Stented subclavian stenosis-for Ani
> >> >>>>>>> To: OpenHeart-L at lists.hsforum.com
> >> >>>>>>> CC:
> >> >>>>>>>
> >> >>>>>>> I would use the pedicle Lima as I said, but I am no rocket
> >> >>>>>>> scientist!
> >> >>>>>>>
> >> >>>>>>> tea
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>> ________________________________
> >> >>>>>>> From: Prasanna Simha M <prasannasimha at gmail.com>
> >> >>>>>>> To: OpenHeart-L at lists.hsforum.com
> >> >>>>>>> Sent: Friday, September 25, 2009 8:29:46 PM
> >> >>>>>>> Subject: Re: [HSF] Stented subclavian stenosis-for Ani
> >> >>>>>>>
> >> >>>>>>> Putting it in this 3 point analysis what would you answer be in
> >> >>>>>>> each case ?
> >> >>>>>>> (I presume if asked as point 1 it would be go ahead with 
> >> >>>>>>> LIMA) .For
> >> >>>>>>> point 2 and 3 ?
> >> >>>>>>> (Incidentally stent was already deployed and the patient did have
> >> >>>>>>> Ischemic symptoms which could be blamed as due to arm Ischemia
> >> >>>>>>> (pulses
> >> >>>>>>> were evaluated and noted) and had a strongly positive stress
> >> >>>>>>> test ).
> >> >>>>>>> Even if the pathway was Plan 1 if the plan is "wrong" (ie 
> >> >>>>>>> choosing
> >> >>>>>>> LIMA after stenting) there is still an opportunity to change
> >> >>>>>>> plans .
> >> >>>>>>> I still would not hesitate to ask the question for any one of the
> >> >>>>>>> above as - its simple - I am not sure of the available evidence
> >> >>>>>>> regarding the correct strategy- so I asked !!
> >> >>>>>>> I am sure we can ask -"Is it the right thing" or "Am I doing the
> >> >>>>>>> right thing" or Is it this plan being pursued the right thing" !!
> >> >>>>>>> (Mid course corrections are used even in rocketry !!)
> >> >>>>>>> Prasanna
> >> >>>>>>>
> >> >>>>>>> On Sat, Sep 26, 2009 at 1:02 AM, Roberto Battellini
> >> >>>>>>> <robertobattellini at hotmail.com> wrote:
> >> >>>>>>>
> >> >>>>>>> great, Ani
> >> >>>>>>>
> >> >>>>>>> Roberto
> >> >>>>>>>
> >> >>>>>>> From: anianyanwu at hotmail.com
> >> >>>>>>> To: openheart-l at lists.hsforum.com
> >> >>>>>>> Subject: RE: [HSF] Stented subclavian stenosis
> >> >>>>>>> Date: Fri, 25 Sep 2009 18:12:23 +0000
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>> "If though he had symptomatic subclavian stenosis, may change
> >> >>>>>>> things
> >> >>>>>>> somewhat." since now he has a stented sublcavian with good run 
> >> >>>>>>> off
> >> >>>>>>> how
> >> >>>>>>> would things now differ ?
> >> >>>>>>> Prasanna
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>> Things differ because the questions are different, and so will be
> >> >>>>>>> the answers.
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>> The question from the first scenario is: I have a patient with
> >> >>>>>>> coronary disease and found a stenosed left subcalvian. I placed a
> >> >>>>>>> stent in the vessel yesterday with a view to performing LIMA
> >> >>>>>>> grafting next week - what do you think of my plan?
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>> The second scenario's question is: I have a patient who had a
> >> >>>>>>> subclavian stent yesterday for arm ischemia and I plan to do CABG
> >> >>>>>>> next week. Should I use the LIMA?
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>> And there is the third unasked question - probably the real
> >> >>>>>>> question here - which has been overtaken by events (hence muting
> >> >>>>>>> responses): I have a patient with coronary artery disease and a
> >> >>>>>>> stenosed left subcalvian artery who needs CABG. How do I manage 
> >> >>>>>>> it?
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>> Although all looking at the same scenario the answers we get 
> >> >>>>>>> can be
> >> >>>>>>> very divergent depending on which question we ask. As humans we 
> >> >>>>>>> are
> >> >>>>>>> biased by the answers people asking the question already seem to
> >> >>>>>>> have given to their question. Its like your friendly cardiologist
> >> >>>>>>> calls you to the lab and says to you "i have this guy with short
> >> >>>>>>> isolated mid left main disease, I already have a wire in the 
> >> >>>>>>> artery
> >> >>>>>>> and looks like it is easy to balloon and stent - will take five
> >> >>>>>>> minutes but I just wanted you to take a quick look at the film
> >> >>>>>>> first?" (and as you look a tech is showing him various sizes of
> >> >>>>>>> stents). Very different question from "I have this patient with
> >> >>>>>>> left main disease - how should we manage it?".
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>> Ani
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>> From: prasannasimha at gmail.com
> >> >>>>>>> Date: Fri, 25 Sep 2009 18:16:21 +0530
> >> >>>>>>> Subject: Re: [HSF] Stented subclavian stenosis
> >> >>>>>>> To: OpenHeart-L at lists.hsforum.com
> >> >>>>>>> CC:
> >> >>>>>>>
> >> >>>>>>> He had confusing symptomatology with presentation with left arm
> >> >>>>>>> pain
> >> >>>>>>> on exertion and weak pulses. A coronary angio + left subclavian
> >> >>>>>>> shoot
> >> >>>>>>> was done was done showing the subclavian stenosis - short segment
> >> >>>>>>> and
> >> >>>>>>> good for stenting.. The plan was/is to stent and use the LIMA if
> >> >>>>>>> the
> >> >>>>>>> subclavian stenting gives a good result.(The result is good). I
> >> >>>>>>> discussed this with the cardiologist and also mentioned I would
> >> >>>>>>> take
> >> >>>>>>> an opinion from the group and hence posed the question.
> >> >>>>>>> I did not understand what you meant with your statement
> >> >>>>>>> "If though he had symptomatic subclavian stenosis, may change
> >> >>>>>>> things
> >> >>>>>>> somewhat." since now he has a stented sublcavian with good run 
> >> >>>>>>> off
> >> >>>>>>> how
> >> >>>>>>> would things now differ ?
> >> >>>>>>> Prasanna
> >> >>>>>>>
> >> >>>>>>> On Fri, Sep 25, 2009 at 6:06 PM, Ani Anyanwu
> >> >>>>>>> <anianyanwu at hotmail.com> wrote:
> >> >>>>>>>
> >> >>>>>>> I am confused as to why you ask this question. If he had a stent
> >> >>>>>>> yesterday and CABG planned for next week was the whole intent of
> >> >>>>>>> the stent not to allow LIMA grafting? Otherwise why was 
> >> >>>>>>> subclavian
> >> >>>>>>> stented? If so is this not a fait accomplait or are you just 
> >> >>>>>>> asking
> >> >>>>>>> us to validate a plan already being executed? Given that the
> >> >>>>>>> subclavian is already stented - presumably successfully - there
> >> >>>>>>> does not seem much grounds to not use the IMA (on this basis). If
> >> >>>>>>> though he had symptomatic subclavian stenosis, may change things
> >> >>>>>>> somewhat.
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>> How was the subcalvian stenosis diagnosed and why was a stent
> >> >>>>>>> placed?
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>>
> >> >>>>>>> Ani
> >> >>>>>>>
> >> >>>>>>> From: prasannasimha at gmail.com
> >> >>>>>>> Date: Fri, 25 Sep 2009 17:22:18 +0530
> >> >>>>>>> To: OpenHeart-L at lists.hsforum.com
> >> >>>>>>> CC:
> >> >>>>>>> Subject: [HSF] Stented subclavian stenosis
> >> >>>>>>>
> >> >>>>>>> I have a case - Left main with left subclavian stenosis. Will
> >> >>>>>>> require
> >> >>>>>>> CABG. The left subclavian was stented yesterday and a CABG is
> >> >>>>>>> planned
> >> >>>>>>> for Tuesday (unless he gets symptoms). He is on Aspirin and
> >> >>>>>>> Heparin.
> >> >>>>>>> Since this stenosis is now successfully stented I am debating 
> >> >>>>>>> about
> >> >>>>>>> going ahead with the LIMA. What is the opinion of the group ? or
> >> >>>>>>> should I use a RIMA to LAD ?.Plan is for a radial for OM and vein
> >> >>>>>>> to
> >> >>>>>>> the PDA (70% stenosis). (I do want multiple inflows)
> >> >>>>>>>
> >> >>>>>>> Prasanna Simha M
> >> >>>>>>> _______________________________________________
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