[HSF] STS Meeting - MICS Vs Conventional MV surgery

Wed Feb 3 05:59:34 EST 2010

Prasanna,
This is a horrible problem.  It only takes a little to trigger these kinds
of problems.  I think those patients who have had previous brain injuries
may be more prome to having problems.  I think the hardest part is having to
deal with the neurologists for whom everything is "poor prognosis" based
upon (IMHO) little evolution of their field since the original Glasgow Coma
score data.  A couple of years ago I did an AVR in an 80 year who the year
before had a high risk kidney transplant with a base line Cr of 2.5.  Even
worse, he was good family friends with one of our ICU nurses.  One of the
easiest AVR's that I did - the aorta was relatively clean, the annulus was
clean - just bad calcified leaflets, etc.  No air on TEE.  Did him on a
Saturday morning for a variety of reasons (none emergent).  Did great for
about 5 hours - then started seizing in front of his wife - massive gran
mal, the whole 9 yards (american term) - coded, CPR.  I come flying in from
home.  Get him back and stable - prepared for the worse - renal failure,
sternal dehiscence, stroke, peg trach.  He was in a dense coma for 2 weeks -
the CT scan was horrible (I will try to find it and email to you off line -
and showed evidence of an old huge asymptomatic massive stroke that probably
flaired up like we see with ischemic foci for arrythmias).  He slowly woke
up, sternum healed fine, kidney did fine (our PharmD loved all of the crazy
seizure meds and immunosuppressive meds).  Went to rehab for a few weeks
then went home - saw him about 2 months post-op.  Both his wife and his
nurse friend thing he is back to normal.

Hang in there - give it time.........cuz, as we say - dead is dead and at
least now you have an alive patient
Your patient will declare themselves

how old?

-michael

On Tue, Feb 2, 2010 at 9:36 PM, Prasanna Simha M <prasannasimha at gmail.com>wrote:

> Talking of brain injury , I am having a "Big problem". Patient who had a
> mitral valve replacement a few years back (Mechanical and in afib)
> developed
> severe TR and RV dysfunction. Underwent  TR repair with a ring via right
> thoracotomy and fem fem/jugular CPB and I did not do afib surgery as she
> had
> well controlled rate with a small dose of Verapamil (I probably should kick
> myself for that now) underwent a tricuspid repair . Uneventful surgery
> though she developed transient ST's in lead 2 but no air bubbles seen  on
> TEE and which stopped on its own. 5 hours after surgery was awake and to be
> extubated in an hour or so when she developed status epilepticus which
> required huge amount of antiepileptic drugs. Took nearly 48 hours to
> consistently stop seizures and 3 antiepileptics  in addition to Midazolam
> infusion. First CT showed mild cerebral edema when seizures stopped (we
> could not initially shift her to a CT scan facility when she was seizing
> incessantly). She improved her GCS slightly thereafter for 3 days and her
> Bispectral index improved to the 90's with no recurring seizures  but she
> would flex and localize to deep pain and started having mild response to
> calling her name later. She had a trache and was spontaneous;y breathing
> .She then suddenly started to cone on the 4th day and required emergency
> hyperventilation, mannitole etc and she reversed .
> Repeat MRI shows  bilateral lamellar cortical infarcts (? hypoxic
> encephalopathy) and the neurologist  thinks that it portends a bad
> prognosis
> and she is not doing that well and is  DNR. Not sure of the cause. I
> thought  could afib  be the cause ? (some shower of fibring/platelets etc)
> but still not sure.
> Prasanna
>
> On Wed, Feb 3, 2010 at 5:34 AM, Ben Bidstrup
> <benjamin.bidstrup at bigpond.com>wrote:
>
> > Gentlemen (and the ladies who are listening),
> >
> > I beg to differ that stroke - a permanent or reversible neurological
> > deficit and the often subtle neuropsychological changes - are each end of
> a
> > spectrum. Aetiology is multiple - They range from alterations in blood
> flow
> > due to biochemical changes (CO2 for one), elaboration of inflammation in
> the
> > brain which starts at the blood vessel, through to overt occlusion of an
> > (named - sometimes) artery or watershed malperfusion. These lead to
> diffuse
> > changes - I call them sawn off brain often seen in the very hypertensive
> > patient who has CPB - to a focal stroke, and through the
> neuropsychological
> > changes seen by Pamela Shaw, and studied in detail by Ken Taylor's group
> -
> > Peter Smith (Hunterian Professorship Lecture in 1987 or thereabouts),
> Graham
> > Venn, Chris Blauth, work done by Mark Newman and David Stump, Murkin and
> > many others, as well as Baker and Knight from Flinders Medical Center.
> > Nothing is new. Lee (from Maloney's group. Surgery 1961:50;29) described
> > changes in the brain in 1961. Many other alterations in physiology (akin
> to
> > Prasanna's 3rd degree burns) have been associated with CPB. Someone
> referred
> > recently to MRIs done shortly after CPB. This was done at the Hammersmith
> > again by Taylor's group and published in the Lancet 1993 (Harris et
> > al:342;586). This showed diffuse brain swelling in the first hour after
> CPB.
> >
> > Air is but one cause. Maybe CO2 is dangerous. There are many other
> > reactions occurring in surgery and in particular after CPB. Whether the
> MICS
> > approach vs median sternotomy is a risk factor, I suspect would take a
> huge
> > study to meet the statistical criteria that should be applied.
> > TEE can help, but will only show part of the 'problem.' I have watched
> many
> > methods of de-airing ranging from the sublime to the ridiculous, TEE
> (very
> > rare a  few years ago but now in Australia if trained it is another
> billing
> > item, no TEE (common), CO2, no CO2, etc etc, and it seems, again not
> > statistically valid but most of are musings are the same, that the rate
> of
> > neurological damage is about the same.
> >
> > The strokes I have had often have a identifiable cause - bad aorta or
> > valve, difficult procedure, long bypass time etc. I hesitate to suggest
> this
> > but as Bruce Keough stated in a recent lecture regarding outcomes, the
> role
> > of the rest of the team becomes more important as the complexity
> increases.
> > Do you know exactly what the anaesthetist or perfusionist is doing at
> every
> > point during the operation. What drugs are given ate what time point what
> is
> > the exact flow, how good is the de-airing of the extracorporeal circuit,
> > what about other matter in it, etc etc.  We trust these people and we
> take
> > the blame.
> >
> > So not a simple issue as a cut at the front vs the side.
> >
> >
> >
> >
> >
> > On 03/02/2010, at 8:05 AM, Ani Anyanwu wrote:
> >
> >
> >> Dr Frater:
> >>
> >>
> >>
> >> Yes I do remember your old posts so picked my words carefully! Air
> >> certainly does cause global neurological injury of varying severity from
> >> subclinical and subtle change to catastrophic injury.
> >>
> >>
> >>
> >> I was speaking strictly in the terms of what was being discussed which
> is
> >> stroke as defined by STS and that includes only those with 'permanent
> >> neurological deficit.' What I was saying is that for stroke as defined
> by
> >> Gammie's study, air is not likely to be the principal etiologic
> mechanism in
> >> either MICS or conventional surgery groups. I do not say that micro
> bubbles
> >> are not harmful, but that the usual effect is not 'stroke' as we
> commonly
> >> define. I am sure though if we objectively sought neurological damage,
> >> including subtle changes, the results of this study would be even more
> >> alarming (both for MICS and conventional surgery groups).
> >>
> >>
> >>
> >> I am certainly not suggesting we ignore TEE while deairing - rather in
> >> contrary I believe deairing with TEE should be standard in all cases - I
> was
> >> merely using the example as an illustration.
> >>
> >>
> >>
> >> Ani
> >>
> >>  From: Rwmfglycar at aol.com
> >>> Date: Tue, 2 Feb 2010 16:47:08 -0500
> >>> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery
> >>> To: OpenHeart-L at lists.hsforum.com
> >>> CC:
> >>>
> >>> We should not be conflating stroke with diffuse cerebral damage. They
> are
> >>> two distinct phenomena with very little overlap. I found ,
> miraculously,
> >>> seven posts of mine on air embolism from 2007 and 2008. I enjoyed
> >>> rereading
> >>> them (vanity , vanity, all is vanity, Eclesiastes). They are too long
> to
> >>> reproduce in this post but I think the principles are worth repeating.
> >>> Prasanna your reference to a different mechanism for the formation of
> oil
> >>> floating in the pericardium is interesting and important, but I do not
> >>> agree with your comment "we would be swimming in fat embolism cases".
> >>> Maybe we
> >>> are, but not in the form of stroke; more likely in the form of diffuse
> >>> damage. We are poor at detecting this and very poor at applying what
> >>> modern
> >>> technology there is to help us detect it. In the early days I used the
> NY
> >>> Times test, not the crossword, but merely being able and interested
> >>> enough to
> >>> read the front page on postop day 2. Obviously we could make a list 3
> >>> pages long of all the possible mechanisms of cerebral damage during
> open
> >>> heart
> >>> surgery. We are obliged to avoid all the possible mechanisms that we
> >>> know.
> >>> In 1956 guess what John Kirklin was doing with blood in the pericardial
> >>> cavity? He was assiduously discarding it and would not allow it to be
> >>> returned
> >>> to the pump. (Prasanna can probably supply a reference from the last
> 5-10
> >>> years confirming a beneficial result of this old practice).
> >>> I agree with you Ani, that the "snowstorm" like echo appearances that
> >>> were
> >>> ignored at Harefield when you were there probably did not cause
> strokes.
> >>> I
> >>> once was the moderator of a conference on the brain and heart surgery
> >>> held
> >>> at Oxford University in which several surgeons showed snowstorm echo's
> in
> >>> patients coming off bypass as though this was a normal state which
> >>> corrected
> >>> itself without harm. My response to this kind of thinking at that
> meeting
> >>> was to say prove to me that it does no harm and don't tell me that it
> >>> does
> >>> no harm because you did not notice stroke as a postoperative
> >>> complication.
> >>> Air bubbles visible on echo are big enough to plug endarterioles. The
> >>> question is what happens when they block Central Nervous System
> >>> arterioles?
> >>> When residents would argue that other surgeons let these echo visible
> >>> bubbles
> >>> into the ascending aorta without grossly detectable effects I would say
> >>> would you be prepared to take 1cc of air into your carotid artery? The
> >>> answer was always "no".
> >>> There is a long list of perturbations and circumstances accompanying
> >>> cardiac surgery that could harm the central nervous system. If we
> cannot
> >>> say
> >>> that any one of these is NOT harmful, then we are duty bound not to
> allow
> >>> it
> >>> to occur.
> >>> Bob
> >>>
> >>>
> >>>
> >>> In a message dated 2/2/2010 2:37:50 P.M. South Africa Standard Time,
> >>> jbflegejr at aol.com writes:
> >>>
> >>> Fat embolism can be associated with long bone fractures. A sternotomy
> is
> >>> something like a long bone fracture. John Flege
> >>> On Feb 2, 2010, at 12:22 AM, Ani Anyanwu wrote:
> >>>
> >>>
> >>>> Roberto
> >>>>
> >>>>
> >>>>
> >>>> Yes I have done mitral MICS. What I say about view from camera's is
> from
> >>>>
> >>> personal observation where I have sometimes seen debris (under direct
> >>> vision) in the atrium in an area that was not in camera's view (which
> is
> >>> focused on the valve). I think valve repair without TEE is rarely, if
> >>> ever
> >>> practiced.
> >>>
> >>>>
> >>>>
> >>>>
> >>>> I found it strange at STS all discussants (Mohr included ) seemed to
> >>>>
> >>> give *impression* strokes were no longer seen in MICS and the problem
> had
> >>> been
> >>> 'solved' with CO2, deairing, changes to perfusion and clamping etc.
> Heck
> >>> we see stroke with sternotomy - indeed in 2008 you may recall I posted
> >>> for
> >>> advice on the forum after having two patients in a month with
> devastating
> >>> strokes after mitral repair via sternotomy - so what is strange about
> >>> saying
> >>> strokes occur after MICS? Any surgeon who says he has not seen strokes
> in
> >>> mitral repair needs to do more and sooner or later willl have a stroke
> >>> come
> >>> to visit. Those who do MICS will have those visits a bit more
> frequently.
> >>>
> >>>>
> >>>>
> >>>>
> >>>> I personally have my doubts as to whether air is a predominant cause
> of
> >>>>
> >>> stroke with permanent deficit - the definition used in STS. When I
> worked
> >>> with Yacoub in early days of routine TEE (and no CO2) there was often a
> >>> snowstorm on echo just before coming of bypass - he just put a needle
> in
> >>> aorta
> >>> - like he had in 30 years of practice without TEE tellling him what to
> do
> >>> -
> >>> and came off bypass ignoring the echo (unless big pockets of air).
> Maybe
> >>> there were neuro changes we could not measure, but rarely did the
> >>> patients
> >>> wake up with an STS defined stroke. I think we can blame air for global
> >>> changes like delirium, cognitive dysfunction etc, but when a patient is
> >>> hemiplegic I think we need to first look for, and exclude, other causes
> >>> before we
> >>> blame air.
> >>>
> >>>>
> >>>>
> >>>>
> >>>> Ani
> >>>>
> >>>>  From: robertobattellini at hotmail.com
> >>>>> To: openheart-l at lists.hsforum.com
> >>>>> Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery
> >>>>> Date: Mon, 1 Feb 2010 21:33:02 +0100
> >>>>>
> >>>>>
> >>>>> Ani,
> >>>>>
> >>>>> Have you ever done Mitral Mics to talk like that?
> >>>>>
> >>>>> The view is Superb with cameras, if you have doubts just go to
> leipzig
> >>>>>
> >>>> and look at Mohr doing it.
> >>>
> >>>>
> >>>>> may be the higher stroke problems are with deairing the heart if the
> >>>>>
> >>>> surgeon is not very strict and does
> >>>
> >>>>
> >>>>> not uses TEE.
> >>>>>
> >>>>> For MICS, camera and TEE are obligatory.
> >>>>>
> >>>>> Roberto
> >>>>>
> >>>>>  From: anianyanwu at hotmail.com
> >>>>>> To: openheart-l at lists.hsforum.com
> >>>>>> Subject: RE: [HSF] STS Meeting - MICS Vs Conventional MV surgery
> >>>>>> Date: Wed, 27 Jan 2010 02:13:54 +0000
> >>>>>>
> >>>>>>
> >>>>>> MICS was a risk factor independent of age and endoclamp use was not
> a
> >>>>>>
> >>>>> predictor of stroke if I recall correctly.
> >>>
> >>>>
> >>>>>>
> >>>>>>
> >>>>>> I doubt it is all retrograde perfusion as the MICS cohort were
> largely
> >>>>>>
> >>>>> younger patients with minimal risk factors so should have clean
> aorta.
> >>>
> >>>>
> >>>>>>
> >>>>>> I think poor debris management due to the limited surgical view is
> >>>>>>
> >>>>> certainly a possibility. Dr Gammie mentioned this in passing and I
> >>> believe
> >>> could well be the reason why a higher stroke rate in MICS persists
> >>> regardless
> >>> of age and risk factors. In MICS especially port access or robotic
> >>> variety
> >>> the surgeon's eye is by definition just on a limited area of the
> surgical
> >>> field, and the assistant often sees less. Whereas via big incision the
> >>> surgeon sees most of field and assistant sees areas surgeon doesnt. Jim
> >>> postulated that maybe small bits of fat or valve, annular or
> ventricular
> >>> tissue or
> >>> surgical material could fall into the atrium or pulmonary veins
> unnoticed
> >>> and go on to cause stroke. Whereas in sternotomy, the surgeon or
> >>> assistant
> >>> is more likely to spot that particle of fat or calcium on the atrial
> >>> wall;
> >>> with a robot, one would not see it as can see only the valve (i
> presume).
> >>> This explantion, rather than air, could also tie up the observation of
> >>> higher
> >>> strokes with no-clamp methods as with the heart beating and blood in
> the
> >>> field you are probably even less likely to see loose bits of tissue in
> >>> the
> >>> ventricle and around the annulus or leaflets.
> >>>
> >>>>
> >>>>>>
> >>>>>>
> >>>>>> Ani
> >>>>>>
> >>>>>>
> >>>>>>
> >>>>>>
> >>>>>>  Date: Tue, 26 Jan 2010 19:30:40 -0600
> >>>>>>> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery
> >>>>>>> From: ebender001 at me.com
> >>>>>>> To: OpenHeart-L at lists.hsforum.com
> >>>>>>> CC:
> >>>>>>>
> >>>>>>> Besides operating without a cross-clamp and air embolus (which
> >>>>>>>
> >>>>>> obviously
> >>>
> >>>> must be prevented no matter what approach), I assume the increased
> >>>>>>>
> >>>>>> stroke
> >>>
> >>>> risk was due to retrograde perfusion and athero emboli from the
> >>>>>>>
> >>>>>> aorta, plus
> >>>
> >>>> a small number due to malpositioned endo clamp or poor debris
> >>>>>>>
> >>>>>> management
> >>>
> >>>> through a small incision or port approach. Obviously these are
> >>>>>>>
> >>>>>> concerning
> >>>
> >>>> numbers, and stresses the need for a pre-op study of the aorta (most
> >>>>>>>
> >>>>>> use CTA
> >>>
> >>>> through the femorals) Did Jim break down the age groups? I guess one
> >>>>>>>
> >>>>>> could
> >>>
> >>>> use age as a surrogate for plaque build up in the aorta.
> >>>>>>>
> >>>>>>> Thanks for the feedback.
> >>>>>>>
> >>>>>>> Ed Bender, MD
> >>>>>>>
> >>>>>>>
> >>>>>>> On 1/26/10 6:31 PM, "Ani Anyanwu" <anianyanwu at hotmail.com> wrote:
> >>>>>>>
> >>>>>>>
> >>>>>>>> redos were excluded from this analysis
> >>>>>>>>
> >>>>>>>>  Date: Tue, 26 Jan 2010 18:28:44 -0600
> >>>>>>>>> Subject: Re: [HSF] STS Meeting - MICS Vs Conventional MV surgery
> >>>>>>>>> From: ebender001 at me.com
> >>>>>>>>> To: OpenHeart-L at lists.hsforum.com
> >>>>>>>>> CC:
> >>>>>>>>>
> >>>>>>>>> Very interesting. I would, as you stated, be cautious in using
> >>>>>>>>>
> >>>>>>>> peripheral
> >>>
> >>>> cannulation as a proxy for MICS. I use it liberally for redo
> >>>>>>>>>
> >>>>>>>> approaches with
> >>>
> >>>> a full sternotomy (as at least one other person on this forum
> >>>>>>>>>
> >>>>>>>> does). Could
> >>>
> >>>> it be that the reop rate might reflect a redo staus rather than a
> >>>>>>>>>
> >>>>>>>> MICS?
> >>>
> >>>>
> >>>>>>>>> Ed Bender, MD
> >>>>>>>>>
> >>>>>>>>>
> >>>>>>>>> On 1/26/10 6:04 PM, "Ani Anyanwu" <anianyanwu at hotmail.com>
> wrote:
> >>>>>>>>>
> >>>>>>>>>
> >>>>>>>>>> I was at the STS for just a day. Only one paper caught my
> >>>>>>>>>>
> >>>>>>>>> interest. Dr
> >>>
> >>>> Gammie
> >>>>>>>>>> presented an excellent analysis of mitral valve surgery reported
> >>>>>>>>>>
> >>>>>>>>> to the STS
> >>>
> >>>> database to compare analysis of conventional mitral valve surgery
> >>>>>>>>>>
> >>>>>>>>> vs
> >>>
> >>>> minimally
> >>>>>>>>>> invasive cardiac surgery. Becausesurgical incision is not
> >>>>>>>>>>
> >>>>>>>>> collected by STS,
> >>>
> >>>> Gammie and colleagues used cannulation strategy as surrogate for
> >>>>>>>>>> invasiveness.
> >>>>>>>>>> If patient was cannulated centrally (aorta, right atrium) was
> >>>>>>>>>>
> >>>>>>>>> assumed a
> >>>
> >>>> conventional appproach, if cannulated femoro-femoral, then was
> >>>>>>>>>>
> >>>>>>>>> assumed to be
> >>>
> >>>> minimally invasive approach. Other permutations of cannulation
> >>>>>>>>>>
> >>>>>>>>> were excluded
> >>>
> >>>> from analysis. Isolated MV only (?). They reviewed over 20,000
> >>>>>>>>>>
> >>>>>>>>> operations
> >>>
> >>>> performed in US between 2004-2008.
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>> Summary of findings
> >>>>>>>>>>
> >>>>>>>>>> .
> >>>>>>>>>>
> >>>>>>>>>> About 15% of all mitral operations were done with MICS as
> defined.
> >>>>>>>>>>
> >>>>>>>>> Frequency
> >>>
> >>>> increased from 10% in 2004 to 20% in 2008.
> >>>>>>>>>>
> >>>>>>>>>> 35% of MICS robot assisted.
> >>>>>>>>>>
> >>>>>>>>>> Median number of MICS cases per center was 3. Over 75% of
> >>>>>>>>>>
> >>>>>>>>> procedures in US
> >>>
> >>>> were done by institutions doing less than 5 procedures a year.
> >>>>>>>>>>
> >>>>>>>>>> Endoaortic balloon used in 35%.
> >>>>>>>>>>
> >>>>>>>>>> More valve repair in MICS group (85% Vs 67%)
> >>>>>>>>>>
> >>>>>>>>>> Clamp and bypass times 20 and 27 min longer in MICS group.
> >>>>>>>>>>
> >>>>>>>>>> 41% transfusion rate in MICS (51% conventional).
> >>>>>>>>>>
> >>>>>>>>>> More (yes - more) reoperations for bleeding with MICS (Odds
> ratio
> >>>>>>>>>>
> >>>>>>>>> 1.22).
> >>>
> >>>>
> >>>>>>>>>> Shorter length of saty and ventilation with MICS.
> >>>>>>>>>>
> >>>>>>>>>> Mortality same.
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>> KEY FINDING: Twice more strokes with MICS (Odds Ratio 1.96).
> >>>>>>>>>>
> >>>>>>>>> Strokes defined
> >>>
> >>>> as stroke with permanent deficit. Higher stroke rate with MICS
> >>>>>>>>>>
> >>>>>>>>> seen in all
> >>>
> >>>> groups examined, regardless of risk factors, center case volume,
> >>>>>>>>>>
> >>>>>>>>> use of
> >>>
> >>>> endocclamp, use of clamp. However, highest rate of stroke was seen
> >>>>>>>>>>
> >>>>>>>>> in those
> >>>
> >>>> cases done without a cross clamp (beating or fibrillation)
> >>>>>>>>>>
> >>>>>>>>> associated with
> >>>
> >>>> odds ratio of 3.
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>> Limitations: Definition of MICS based on cannulaation strategy
> >>>>>>>>>>
> >>>>>>>>> likely
> >>>
> >>>> misscalssified some patients. While very likely almost all
> >>>>>>>>>>
> >>>>>>>>> femorofemoral
> >>>
> >>>> approachs were truly MICS procedures, a lot of MICS would have
> >>>>>>>>>>
> >>>>>>>>> been called
> >>>
> >>>> conventional if centrally cannulated. Of importance because some
> >>>>>>>>>>
> >>>>>>>>> high volume
> >>>
> >>>> MICS centers like NYU, Cleveland, BWH I believe use central
> >>>>>>>>>>
> >>>>>>>>> cannulation
> >>>
> >>>> liberally for thoracotomy or hemisternotomy approach. Also hybrids
> >>>>>>>>>>
> >>>>>>>>> eg
> >>>
> >>>> femoral
> >>>>>>>>>> artery and central venous cannulation, used by some, were
> >>>>>>>>>> excluded.
> >>>>>>>>>>
> >>>>>>>>>> Patients in MICS were less sick, younger etc and more likely
> >>>>>>>>>>
> >>>>>>>>> repairable
> >>>
> >>>> hence
> >>>>>>>>>> introducing bias - of concern though is despite lower risk there
> >>>>>>>>>>
> >>>>>>>>> was still
> >>>
> >>>> double stroke incidence.
> >>>>>>>>>>
> >>>>>>>>>> No data on true outcomes of surgery such as results of repair,
> >>>>>>>>>>
> >>>>>>>>> reoperation,
> >>>
> >>>> 12
> >>>>>>>>>> month symptoms or survival.
> >>>>>>>>>>
> >>>>>>>>>> No data on mitral pathology and disease treated.
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>> Response from disscussants (most MICS enthusiasts) largely
> ignored
> >>>>>>>>>>
> >>>>>>>>> or
> >>>
> >>>> dismissed the stroke risk and felt the data were sufficient to
> >>>>>>>>>>
> >>>>>>>>> show that
> >>>
> >>>> MICS
> >>>>>>>>>> 1) is valid approach for MV surgery 2) Does not compromise
> repair
> >>>>>>>>>>
> >>>>>>>>> 3) Is safe
> >>>
> >>>> 4) Has better 'outcomes' but 5) other explanations likely exist
> >>>>>>>>>>
> >>>>>>>>> for higher
> >>>
> >>>> stroke and 6) MV surgery without a clamp should be strongly
> >>>>>>>>>>
> >>>>>>>>> discouraged. One
> >>>
> >>>> discussant cautioned that the stroke risk cannot be ignored as
> >>>>>>>>>>
> >>>>>>>>> this is the
> >>>
> >>>> second mega-analysis of a database presented at STS in recent
> >>>>>>>>>>
> >>>>>>>>> years showing
> >>>
> >>>> higher stroke risk with MICS (the other being a paper by Mehmet Oz
> >>>>>>>>>>
> >>>>>>>>> group 5
> >>>
> >>>> years or so ago I think presented by our Dr Cheema which also
> >>>>>>>>>>
> >>>>>>>>> found doubling
> >>>
> >>>> of incidence of stroke in NY State).
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>> Ani
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>>
> >>>>>>>>>>  From: msfirst at gmail.com
> >>>>>>>>>>> To: OpenHeart-L at lists.hsforum.com
> >>>>>>>>>>> Subject: Re: [HSF] STS Meeting
> >>>>>>>>>>> Date: Tue, 26 Jan 2010 18:23:52 -0500
> >>>>>>>>>>> CC:
> >>>>>>>>>>>
> >>>>>>>>>>> Guess not
> >>>>>>>>>>>
> >>>>>>>>>>> -michael/iPhone
> >>>>>>>>>>>
> >>>>>>>>>>> On Jan 26, 2010, at 4:50 PM, Edward Bender <ebender001 at me.com>
> >>>>>>>>>>>
> >>>>>>>>>> wrote:
> >>>
> >>>>
> >>>>>>>>>>>  Anything new and/or interesting coming out of the STS meeting?
> >>>>>>>>>>>>
> >>>>>>>>>>>> Ed Bender, MD
> >>>>>>>>>>>> _______________________________________________
> >>>>>>>>>>>> OpenHeart-L mailing list
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> >>>>>>>>>>
> >>>
> http://clk.atdmt.com/UKM/go/195013117/direct/01/____________________________
> >>>
> >>>> __
> >>>>>>>>>> _________________
> >>>>>>>>>> OpenHeart-L mailing list
> >>>>>>>>>>
> >>>>>>>>>> Send postings to:
> >>>>>>>>>> OpenHeart-L at lists.hsforum.com
> >>>>>>>>>>
> >>>>>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >>>>>>>>>> http://mmp.cjp.com/mailman/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 at lists.hsforum.com
> >>>>>>>>>
> >>>>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >>>>>>>>> http://mmp.cjp.com/mailman/listinfo/openheart-l
> >>>>>>>>>
> >>>>>>>>> All messages transmitted by the OpenHeart-L are subject to the
> >>>>>>>>>
> >>>>>>>> policies and
> >>>
> >>>> disclaimers posted at:
> >>>>>>>>> http://www.hsforum.com/listdisclaim
> >>>>>>>>> -----------------------------------------
> >>>>>>>>>
> >>>>>>>>
> >>>>>>>> _________________________________________________________________
> >>>>>>>> We want to hear all your funny, exciting and crazy Hotmail
> stories.
> >>>>>>>>
> >>>>>>> Tell us
> >>>
> >>>> now
> >>>>>>>>
> >>>>>>>>
> >>>
> http://clk.atdmt.com/UKM/go/195013117/direct/01/______________________________
> >>>
> >>>> _________________
> >>>>>>>> OpenHeart-L mailing list
> >>>>>>>>
> >>>>>>>> Send postings to:
> >>>>>>>> OpenHeart-L at lists.hsforum.com
> >>>>>>>>
> >>>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >>>>>>>> http://mmp.cjp.com/mailman/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 at lists.hsforum.com
> >>>>>>>
> >>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >>>>>>> http://mmp.cjp.com/mailman/listinfo/openheart-l
> >>>>>>>
> >>>>>>> All messages transmitted by the OpenHeart-L are subject to the
> >>>>>>>
> >>>>>> policies and
> >>>
> >>>> disclaimers posted at:
> >>>>>>> http://www.hsforum.com/listdisclaim
> >>>>>>> -----------------------------------------
> >>>>>>>
> >>>>>>
> >>>>>> _________________________________________________________________
> >>>>>> We want to hear all your funny, exciting and crazy Hotmail stories.
> >>>>>>
> >>>>> Tell us now
> >>>
> >>>>
> >>>>>>
> >>>
> http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________
> >>>
> >>>> OpenHeart-L mailing list
> >>>>>>
> >>>>>> Send postings to:
> >>>>>> OpenHeart-L at lists.hsforum.com
> >>>>>>
> >>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >>>>>> http://mmp.cjp.com/mailman/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 at lists.hsforum.com
> >>>>>
> >>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >>>>> http://mmp.cjp.com/mailman/listinfo/openheart-l
> >>>>>
> >>>>> All messages transmitted by the OpenHeart-L are subject to the
> policies
> >>>>>
> >>>> and
> >>>
> >>>> disclaimers posted at:
> >>>>> http://www.hsforum.com/listdisclaim
> >>>>> -----------------------------------------
> >>>>>
> >>>>
> >>>> _________________________________________________________________
> >>>> Got a cool Hotmail story? Tell us now
> >>>>
> >>>>
> >>>
> http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________
> >>>
> >>>> OpenHeart-L mailing list
> >>>>
> >>>> Send postings to:
> >>>> OpenHeart-L at lists.hsforum.com
> >>>>
> >>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >>>> http://mmp.cjp.com/mailman/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 at lists.hsforum.com
> >>>
> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >>> http://mmp.cjp.com/mailman/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 at lists.hsforum.com
> >>>
> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >>> http://mmp.cjp.com/mailman/listinfo/openheart-l
> >>>
> >>> All messages transmitted by the OpenHeart-L are subject to the policies
> >>> and
> >>> disclaimers posted at:
> >>> http://www.hsforum.com/listdisclaim
> >>> -----------------------------------------
> >>>
> >>
> >> _________________________________________________________________
> >> We want to hear all your funny, exciting and crazy Hotmail stories. Tell
> >> us now
> >>
> >>
> http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________
> >> OpenHeart-L mailing list
> >>
> >> Send postings to:
> >> OpenHeart-L at lists.hsforum.com
> >>
> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> >> http://mmp.cjp.com/mailman/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 at lists.hsforum.com
> >
> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> > http://mmp.cjp.com/mailman/listinfo/openheart-l
> >
> > All messages transmitted by the OpenHeart-L are subject to the policies
> > anddisclaimers posted at:
> >
> > http://www.hsforum.com/listdisclaim
> > -----------------------------------------
> >
>
>
>
> --
> Prasanna Simha M
>  _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
>  OpenHeart-L at lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the policies and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------
>