From prasannasimha at gmail.com Mon Mar 1 10:41:04 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Mon Mar 1 00:38:18 2010 Subject: [HSF] Reporting and analyzing ABGs In-Reply-To: References: <63747eb91002260558kd53354cv292178ec4af532bc@mail.gmail.com> <89c4ed2d1002270448t2630441as238ca905e0b9c999@mail.gmail.com> Message-ID: <89c4ed2d1002282111k4f596357qa54459cf2da9b309@mail.gmail.com> Of course relevant data presentation is ideal but when you have different levels of reporters of the said data it is better that it is given in a structured manner so that the person reporting does not err and fail to report some data that is relevant. Prasanna On 2/27/10, Ani Anyanwu wrote: > > > >Why is it important to give a> structured information- If the blocks fall > in place it> is easier to construct that mental image. > > Prasanna > > > > It depends on the structure in the recipients brain. If one's brain has a > fixed structure such that he can assimilate data unless in a specific order > then he or she has to creat a system whereby data is presented in a > particular order to fit one's brain structure. If one's brain does not have > a specific structure the it does not matter what order data is presented. > Personally, I dont find routine regurgitation of information helpful and ask > specific questions depending on the clinical problem being presented: when > 'all' the information is rambled in a specific order (if one exists) I would > end up asking again for specific data from the rambling which are relavant > for me to formulate an idea. Personally I dont care what ordeer any > information is given - there are in my opinion far more important things to > bother about. > > > > Ani > > > > From: prasannasimha@gmail.com > > Date: Sat, 27 Feb 2010 18:18:09 +0530 > > Subject: Re: [HSF] Reporting and analyzing ABGs > > To: OpenHeart-L@lists.hsforum.com > > CC: > > > > The first and most important thing is pH it tells a net statement of the > > mileau and generally alerts the nterpreter to problems ahead that are not > > being compensated. Generally the next s pO2 as it deals with oxygenation > and > > thereafter pCO2 as an index of ventilation and then the standard bicarb > as > > it helps tease out any respiratory veruss metabolic componen. The idea of > > reporting is an art -conveying to the surgeon who is not there a clinical > > picture that he is developing in his mind requires a tango. For eg the > first > > sentence is - all patients are OK (Or eldse there is a problem with this > > particular patient) Now if there is a problem with a patient the first > > statment - is he alive or dead (ie undergoing CPR) as that is the first > > vital information needed and then anyone can go blah blah blah with > > information. (I am not remotely sounding condescending but actually teach > > new residents to give info that way) Why is it important to give a > > structured information- imagine (and I would ask you to imagine the > plight > > of the surgeon or whoever is sitting on the other side of the phone) to > > mentally construct a picture of the patient.If the blocks fall in place > it > > is easier to construct that mental image. I would suggest that you play a > > game with one of your colleagues and you sit on the other end while the > > clinical status and ABG is reported to you and try to construct the > patient > > in your mind. It is a good exercise to do and helps in systematic > transfer > > of information. > > I am having poor internet acces till the ist as I am out of town so I > cannot > > give a further detailed response but I hope you get the Idea > > Prasanna > > > > On Fri, Feb 26, 2010 at 7:28 PM, Kevin Floyd wrote: > > > > > Hi, > > > > > > Recently it has been requested that we change the order the way our ABG > are > > > reported both verbally and in the EMR. WE have been reporting them in > this > > > order: PaO2, Sat, PCO2, pH, HCO3, and BE. The physicians have stated > this > > > is not the order that they were trained in having blood gases reported > and > > > feel it could lead to possible mistreatment. > > > > > > My question is there a standard order in which your blood gases are > > > reported? > > > > > > What is the rationale? > > > > > > I have attempted a lit search and have not found anything. > > > > > > Thank you > > > > > > Kevin > > > > > > > > > -- > > > Kevin Floyd RN, BSN, CCRN > > > Critical Care Educator > > > UC Davis Medical Center > > > kevin.floyd@ucdmc.ucdavis.edu > > > chewie@softcom.net > > > _______________________________________________ > > > OpenHeart-L mailing list > > > > > > Send postings to: > > > OpenHeart-L@lists.hsforum.com > > > > > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > > > http://mmp.cjp.com/mailman/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 > > ----------------------------------------- > > _________________________________________________________________ > Send us your Hotmail stories and be featured in our newsletter > > http://clk.atdmt.com/UKM/go/195013117/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 > ----------------------------------------- > -- Prasanna Simha M From toruasai at belle.shiga-med.ac.jp Mon Mar 1 15:46:05 2010 From: toruasai at belle.shiga-med.ac.jp (Tohru Asai) Date: Mon Mar 1 01:46:36 2010 Subject: [HSF] RGEA rejection In-Reply-To: <164315.45274.qm@web24712.mail.ird.yahoo.com> Message-ID: Dear David, the coagulating shears. It is beneficial to treat fragile small branches of GEA. Please read my article of How-to-Do-It. Worth while trying it. Tohru Asai, T., Tabata S.: Skeletonization of the Right Gastroepiploic Artery Using an Ultrasonic Scalpel. Ann Thorac Surg 2002 74: 1715-1717 I can send you PDF version if you want. > Tohru, what kind of harmonic do you use? PS The sushi and sashimi in Cape Town > is great-but as expensive as Europe (everything else is cheaper). Dave From otto at iafrica.com Mon Mar 1 09:37:22 2010 From: otto at iafrica.com (Otto Thaning) Date: Mon Mar 1 02:39:25 2010 Subject: [HSF] CTSNet Wiki References: Message-ID: <284C39E7723945178EF94B0A3DE3337D@private799f148> Ed, Your Cardiac Risk application for iPhone is excellent. The concept of access the the CTSNet Wiki is another great idea and I would support it wholeheartedly. When will it be available? OTTO THANING Cape Town ----- Original Message ----- From: "Edward Bender" To: "HSF List" Sent: Monday, March 01, 2010 1:16 AM Subject: [HSF] CTSNet Wiki Does anybody out there look at or even know about the CTSNetWiki? It can be fount at http://wiki.ctsnet.org/ The reason I ask, is that, although it is user edited, it is an excellent source for general information for our specialty. I have developed an app for the iPhone that allows the user access it in convenient form wherever there is a cellular or wifi signal. I have been corresponding with Mark Turina (the current editor of the CTSNet), but he?s in Switzerland and I?m not and he?s very busy. If people might find some use for this, and perhaps it may stimulate more active editing of it, I would appreciate an indication one way or another. (It would, of course be free, but you would not be able to edit it from the iPhone). Thanks, 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 otto at iafrica.com Mon Mar 1 09:39:44 2010 From: otto at iafrica.com (Otto Thaning) Date: Mon Mar 1 02:40:19 2010 Subject: [HSF] RGEA rejection References: Message-ID: <2E88EFD89E554B0CBC4168D7B72E3764@private799f148> Dear Tohru Please send me a PDF version of your "Skeletonization" article. OTTO THANING otto@iafrica.com ----- Original Message ----- From: "Tohru Asai" To: Sent: Monday, March 01, 2010 8:46 AM Subject: Re: [HSF] RGEA rejection > Dear David, the coagulating shears. It is beneficial to treat fragile > small > branches of GEA. Please read my article of How-to-Do-It. Worth while > trying > it. Tohru > > Asai, T., Tabata S.: Skeletonization of the Right Gastroepiploic Artery > Using an Ultrasonic Scalpel. Ann Thorac Surg 2002 74: 1715-1717 > > I can send you PDF version if you want. > > >> Tohru, what kind of harmonic do you use? PS The sushi and sashimi in Cape >> Town >> is great-but as expensive as Europe (everything else is cheaper). Dave > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 drdharris at yahoo.co.uk Mon Mar 1 10:44:31 2010 From: drdharris at yahoo.co.uk (David Harris) Date: Mon Mar 1 05:46:15 2010 Subject: [HSF] Asc Aorta and Bicuspid Valve Message-ID: <56125.35099.qm@web24707.mail.ird.yahoo.com> I have a similar 32 year old, ascending 49mm since 2005. Now 50mm. Valve is normal. Sinuses possibly dilated. How long should one keep scanning? In a young patient who is exposed to lifelong risk of dissection or rupture should one operate earlier? As the existence of a tube graft has less risks then a valve prosthesis, in which case surgery would be delayed until symptoms (if AS) From Scott.Silvestry at jefferson.edu Mon Mar 1 07:15:15 2010 From: Scott.Silvestry at jefferson.edu (Scott Silvestry) Date: Mon Mar 1 07:18:53 2010 Subject: [HSF] are surgeons necessary...Go Team USA... Message-ID: <20100301071515.AFZ62286@parkcity.jefferson.edu> Michael ?I would appreciate it if the doctor would address (Jessup) as Colonel or Sir. I believe he's earned it.? Scott ---- Original message ---- >Date: Sun, 28 Feb 2010 16:41:29 -0500 >From: Michael Firstenberg >Subject: Re: [HSF] are surgeons necessary...Go Team USA... >To: OpenHeart-L@lists.hsforum.com > >Just like Nathan Jessup said - >We are needed on that fence. >As long as people (presumably physicians) continue to put things into blood vessels (stents, catheters, wires, bullets, knives) or try to take them out (pacemaker leads, catheters also) then someone is going to need to fix the major misadventures/problems..... a reality that is probably (unfortunately) more and more true as others become more and more aggressive........ > >of course the irony is that we are one of the few businesses that does whatever we can to avoid repeat business (hmmmmmm.... there might be something to "staged" procedures?? ??) while overall trying to put ourselves out of business. > >but let us not forget the concept that gee, maybe something are in fact more appropriately treated with surgery in the first place. I would not be surprise that with the evolution of health care "reform" in the USA that some of these high tech (read: expensive and 'noninferior' treatments) may get brushed aside in favor of a cheaper gold-standard like surgery. Carotid stenting anyone? Remember, anything more than 1.4 (give or take a little) and a hospital looses money on a DES DRG vs CABG. > >nothing would please me more than there being a cure for surgical heart disease and being able to retire to some warm beach - but as people proclaim our extinction, I find we are spending more and more time in the hospital. > >bill - need a farm hand? > > > >-michael > > > > >On Feb 28, 2010, at 2:51 PM, wftjrtyler@aol.com wrote: > >> of which i will ponder while clearing brush at turnertown ranch.......bill >> >> >> In a message dated 2/27/2010 10:50:39 P.M. Central Standard Time, >> tacuff@swbell.net writes: >> >> Of course on reflection I found this a question of metaphysical >> significance. >> >> _____________________________________ __________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/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 Mon Mar 1 10:08:24 2010 From: msfirst at gmail.com (Michael Firstenberg) Date: Mon Mar 1 10:08:59 2010 Subject: [HSF] are surgeons necessary...Go Team USA... In-Reply-To: <20100301071515.AFZ62286@parkcity.jefferson.edu> References: <20100301071515.AFZ62286@parkcity.jefferson.edu> Message-ID: Scott - I agree completely and beyond it being a great movie - clearly he deserves in my mind to be called Colonel or Sir. I think the world needs more people willing to put their feet down and take a stand on something they believe in. -michael On Mon, Mar 1, 2010 at 7:15 AM, Scott Silvestry < Scott.Silvestry@jefferson.edu> wrote: > Michael > > I would appreciate it if the doctor would > address (Jessup) as Colonel or Sir. I believe > he's earned it. > > Scott > > ---- Original message ---- > >Date: Sun, 28 Feb 2010 16:41:29 -0500 > >From: Michael Firstenberg > > >Subject: Re: [HSF] are surgeons > necessary...Go Team USA... > >To: OpenHeart-L@lists.hsforum.com > > > >Just like Nathan Jessup said - > >We are needed on that fence. > >As long as people (presumably physicians) > continue to put things into blood vessels > (stents, catheters, wires, bullets, knives) or try > to take them out (pacemaker leads, catheters > also) then someone is going to need to fix the > major misadventures/problems..... a reality that > is probably (unfortunately) more and more true > as others become more and more > aggressive........ > > > >of course the irony is that we are one of the > few businesses that does whatever we can to > avoid repeat business (hmmmmmm.... there > might be something to "staged" procedures?? > ??) while overall trying to put ourselves out of > business. > > > >but let us not forget the concept that gee, > maybe something are in fact more > appropriately treated with surgery in the first > place. I would not be surprise that with the > evolution of health care "reform" in the USA > that some of these high tech (read: expensive > and 'noninferior' treatments) may get brushed > aside in favor of a cheaper gold-standard like > surgery. Carotid stenting anyone? > Remember, anything more than 1.4 (give or > take a little) and a hospital looses money on a > DES DRG vs CABG. > > > >nothing would please me more than there > being a cure for surgical heart disease and > being able to retire to some warm beach - but > as people proclaim our extinction, I find we are > spending more and more time in the hospital. > > > >bill - need a farm hand? > > > > > > > >-michael > > > > > > > > > >On Feb 28, 2010, at 2:51 PM, > wftjrtyler@aol.com wrote: > > > >> of which i will ponder while clearing brush > at turnertown ranch.......bill > >> > >> > >> In a message dated 2/27/2010 10:50:39 > P.M. Central Standard Time, > >> tacuff@swbell.net writes: > >> > >> Of course on reflection I found this a > question of metaphysical > >> significance. > >> > >> > _____________________________________ > __________ > >> OpenHeart-L mailing list > >> > >> Send postings to: > >> OpenHeart-L@lists.hsforum.com > >> > >> To UNSUBSCRIBE, to CHANGE email > address, or to view archives: > >> > http://mmp.cjp.com/mailman/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 Mon Mar 1 15:53:43 2010 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Mon Mar 1 15:54:35 2010 Subject: [HSF] are surgeons necessary Message-ID: <27a87.19cf47f9.38bd8357@aol.com> Dear Tea , I debated this in the past in the context of how could we make medicine a mass production industry. Running a surgical research lab suggested possibilities. In surgical research labs it is common to find an individual with minimal academic credentials who learns how to do a tricky operation in a tiny animal with minimal risk. At Mayo, in the early days, a local farm boy called "Curly" with a couple of years of apprenticeship amassed a massive experience in cardiac anesthesia: a doctor who had seen him in action would choose Curly to put him to sleep. Nurses in intensive care learned not just to record information on a chart but to become experts in integrating multiple varied inputs and come up with a reliable picture of what was happening to the patient. I am talking about smart people without medical degrees who, given a part of the overall job of fixing patients can be more expert than any multitasking doctor. But who is to be the conductor of this orchestra/? What about the whole patient? Should we also have purveyors of patient confidence, anxiety smoothers? Who trains the conductor? Who determines and explores new directions? Who gathers and transfers the knowledge? The experience that Mitch alludes to must be possessed by someone. Cardiac surgeons have traditionally been the most widely educated and experienced of surgeons are clearly the right people to lead a group of non surgeons in providing surgical care. I believe the best medical practise will come about by arranging care givers into disease related teams cutting across all conventional boundaries. For such a team to be good, all must be skilled, all must want to be good and better, all must understand that the joy of working in a good team is as good as it gets. The last remnants of neolithic hunters work in groups of about ten; that seems about right for a disease team. The patient coming into the hands of such a team will receive whatever is the best for the particular variation of disease that he has. Bob In a message dated 2/28/2010 6:50:39 A.M. South Africa Standard Time, tacuff@swbell.net writes: I have changed the topic as I think that it is a slow HSF night, I have had a couple of drinks and while we have still not dealt with issues of training (which is a sub issue of what is a master), you point to an interesting question. I think it is one in my mind in which I continuly wrestle with Ani and his population medicine, protocols are better than doctors,etc. The fact that he is not much interested in regurgitation of data gives me hope for him and shows that he is a complex (complicated) thinker. The question, as all are aware, is: are surgeons necessary? It will be hard for me to stay on track as this is actually a global question found every where. I recently gave a deposition as a medical expert! I will not deal with the case as it is pending, but as I reread my "expert opinion" the lawyer for the other side seemed to be baiting me about what I was willing to be critical about since I was a defense witness. I would not agree (as you might imagine) as to this qualifier demands this or that finding demands that. Essentially the lawyer asked, "Can you give an expert opinion without actually being there to see for yourself." Of course on reflection I found this a question of metaphysical significance. Let me say as a practical manner I often believe that my PA could do 95% of what I do if we gave her time to move the other side of the table for a while. Lets call this 3 sigma. I also commonly say, when faced with the hyper obsessive personalities that make up our specialty that 98(.5)% is good enough for me which is of course 4 sigma. Many of you are 99%ers (5sigmas) or worse (sorry, I mean better). That means I "only" add one sigma. What is that worth or is that the way to "measure" a surgeon? So rather than answer, are there any takers? Is a surgeon necessary? If we have althe data that the EMR requires other than "hands" or to sign the order in the middle of the night is a surgeon useful and necessary? I have way too much to say about this, but I'll wait. tea ________________________________ From: Michael Firstenberg To: OpenHeart-L@lists.hsforum.com Sent: Sat, February 27, 2010 11:25:28 AM Subject: Re: [HSF] Reporting and analyzing ABGs Tea, My only disagreement with your statement is that with some degree of memorization or regurgitation of data there is some hope that there might be some critical processing and consideration of the data at hand. A huge selling point of these new EMR systems is the ability to autopopulate data fields - basically bypassing the human brain (for better or for worse) altogether. I have seen excellent EMR systems create critical care notes populated automatically with data. These note are "generated/created" by a high school graduate - and all an attending needs to do is cut and paste a phrase "seen and agreed and independently blah blah blah" to finalize and bill for the service. Important data may never actually make it to a high cortical thinking center to be acted upon. Impressive - and we wonder why CMS is cutting physician payments......... -michael On Feb 27, 2010, at 11:03 AM, Tea Acuff wrote: > Ani wrote: > Personally, I dont find routine regurgitation of information helpful and ask specific questions depending on the clinical problem being presented: when 'all' the information is rambled in a specific order (if one exists) I would end up asking again for specific data from the rambling which are relavant for me to formulate an idea. > > > > I find memorizing lab a silly game also and this is different than a "syntax" for a specific idea or picture. All languages have syntax or order which codes how to read the message (English may be one of the most flexible and thus both rich and ambiguous and difficult to master.) The patterns code the way we think about the more complex realtions that we deal with. Altering the patterns and codes is one of the tools that I use to rethink our way using ideas. As anyone who has tried to follow my (perhaps faulty) peculiar logic knows how important common orientation can be to communication. On the other hand it underlies the limitations it imposes on alternative explanations. > > Tea > > Tea > Sent from my iPhone > > On Feb 27, 2010, at 8:02 AM, Ani Anyanwu wrote: > > Personally, I dont find routine regurgitation of information helpful and ask specific questions depending on the clinical problem being presented: when 'all' the information is rambled in a specific order (if one exists) I would end up asking again for specific data from the rambling which are relavant for me to formulate an idea. Personally > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 ebender001 at me.com Mon Mar 1 15:25:00 2010 From: ebender001 at me.com (Edward Bender) Date: Mon Mar 1 16:29:37 2010 Subject: [HSF] CTSNet Wiki In-Reply-To: <284C39E7723945178EF94B0A3DE3337D@private799f148> Message-ID: Thanks, Otto. Give a couple of weeks, and I will let you know when it is available. Ed Bender, MD On 3/1/10 1:37 AM, "Otto Thaning" wrote: > Ed, > > Your Cardiac Risk application for iPhone is excellent. > > The concept of access the the CTSNet Wiki is another great idea and I would > support it wholeheartedly. > > When will it be available? > > OTTO THANING > Cape Town > ----- Original Message ----- > From: "Edward Bender" > To: "HSF List" > Sent: Monday, March 01, 2010 1:16 AM > Subject: [HSF] CTSNet Wiki > > > Does anybody out there look at or even know about the CTSNetWiki? It can be > fount at http://wiki.ctsnet.org/ > > The reason I ask, is that, although it is user edited, it is an excellent > source for general information for our specialty. I have developed an app > for the iPhone that allows the user access it in convenient form wherever > there is a cellular or wifi signal. I have been corresponding with Mark > Turina (the current editor of the CTSNet), but he?s in Switzerland and I?m > not and he?s very busy. If people might find some use for this, and perhaps > it may stimulate more active editing of it, I would appreciate an indication > one way or another. (It would, of course be free, but you would not be able > to edit it from the iPhone). > > Thanks, > > 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 Tue Mar 2 17:03:17 2010 From: tacuff at swbell.net (Tea Acuff) Date: Tue Mar 2 20:03:48 2010 Subject: [HSF] are surgeons necessary In-Reply-To: <27a87.19cf47f9.38bd8357@aol.com> References: <27a87.19cf47f9.38bd8357@aol.com> Message-ID: <790394.61105.qm@web81604.mail.mud.yahoo.com> It is interesting that you use the phrase "mass production" as you describe your possibilities, Bob. There is a special irony that those like you, self described as Hunterian, but whom I place in the analytical math group?of thinkers are open to multiple choices, while population thinkers who are forced to describe their findings in stochastic or probabilistic math prefer to enforce a single solution. It is amazing how often we apply?the opposite meaning of the message from the data that we use for our adgendae. We are in a civil war between population appliers and individual appliers of scientific information while we have both little?insight into how?our mathematical tools distort the conclusions to which we are able to hold without self delusion. Of course what you suggest is a return to deregulation, or better, local regulation.?Our current leadership traded our laborious climb from a choatic void to a scientific?vista for a place at the regulatory table. Since this was a universal and not a local or special table, everyone else climbed on board using the common currency of our knowledge or "gnosis" with which we planned to control everyone. But the tables were turned and now we are played by the same evidence that everyone is able to "prove" against or more often irrespective of us.And we see, or made to see,?that we are not indeed everything and universal.?This is why I asked, "Are we neceassary?" If we are just some or more of universally?derived knowledge, why do we deserve a special place? ? If it is not then by special knowledge, special evidence, or gnosis, by what shall we be judged? We have generated a new?and peculiar tool, which will seem appropriate for?(us) beleaguered?Hunterians: results. We have a database that now defines us. We proclaim this great database the new Arthurian (and authoritarian) sword that will demonstrate our royal blood. But what does a database that defines or demonstrates?us mean? Will we turn this tool upside down upon our knighthood again?? Or did we get it right this time? Or are surgeons and knights both a naive ego? We shall soon see this play out. Any bettors? tea ________________________________ From: "Rwmfglycar@aol.com" To: OpenHeart-L@lists.hsforum.com Sent: Mon, March 1, 2010 2:53:43 PM Subject: Re: [HSF] are surgeons necessary Dear Tea , I debated this in the past in the context of how could we make? medicine a mass production industry. Running a surgical research lab suggested? possibilities. In surgical research labs it is common to find an individual with? minimal academic credentials who learns how to do a tricky operation in a tiny? animal with minimal risk. At Mayo,? in the early days, a local farm? boy called "Curly" with a couple of years of apprenticeship amassed a? massive experience in cardiac anesthesia: a doctor who had seen him in action? would? choose Curly to put him to sleep. Nurses in intensive care learned? not just to record information on a chart but to become experts in? integrating multiple varied inputs and come up with a reliable picture of what? was happening to the patient. I am talking about smart people without medical? degrees who, given a part of the overall job of fixing patients can be more? expert than any multitasking doctor. But who is to be the conductor of this? orchestra/? What about the whole patient? Should we also have purveyors of? patient confidence, anxiety smoothers? Who trains the conductor? Who determines? and explores new directions? Who gathers and transfers the knowledge? The? experience that Mitch alludes to must be possessed by someone. Cardiac? surgeons have traditionally? been the most widely educated and? experienced of surgeons are clearly the right people to lead a group of non? surgeons in providing surgical care. I believe the best medical practise will come about by arranging care? givers into disease related teams cutting across all conventional boundaries.? For such a team to be good, all must be skilled, all must want to be good and better, all must? understand that the joy of working in a good team is? as good as it gets. The last remnants of neolithic hunters work in groups of? about ten; that seems about right for a disease team. The patient coming? into the hands of such a team will receive whatever is the best for the? particular variation of disease that he has. Bob In a message dated 2/28/2010 6:50:39 A.M. South Africa Standard Time,? tacuff@swbell.net writes: I have? changed the topic as I think that it is a slow HSF night, I have had a couple? of drinks and while we have still not dealt with issues of training (which is? a sub issue of what is a master), you point to an interesting question. I? think it is one in my mind in which I continuly wrestle with Ani and his? population medicine, protocols are better than doctors,etc. The fact that he? is not much interested in regurgitation of data gives me hope for him and? shows that he is a complex (complicated) thinker. The question, as? all are aware, is: are surgeons necessary? It will be hard for me to stay on? track as this is actually a global question found every where. I? recently gave a deposition as a medical expert! I will not deal with the case? as it is pending, but as I reread my "expert opinion" the lawyer for the other? side seemed to be baiting me about what I was willing to be critical about? since I was a defense witness. I would not agree (as you might imagine)? as to this qualifier demands this or that finding demands that. Essentially? the lawyer asked, "Can you give an expert opinion without actually being there? to see for yourself." Of course on reflection I found this a? question of metaphysical significance. Let me say as a practical? manner I often believe that my PA could do 95% of what I do if we gave? her time to move the other side of the table for a while. Lets call this 3? sigma. I also commonly say, when faced with the hyper obsessive? personalities that make up our specialty that 98(.5)% is good enough for me? which is of course 4 sigma. Many of you are 99%ers (5sigmas) or worse? (sorry, I mean better). That means I "only" add one sigma. What? is that worth or is that the way to "measure" a surgeon? So rather than? answer, are there any takers? Is a surgeon necessary? If we have althe data? that the EMR requires other than "hands" or to sign the order in the middle of? the night is a surgeon useful and necessary? I have way too much to say? about this, but I'll? wait. tea ________________________________ From:? Michael Firstenberg To:? OpenHeart-L@lists.hsforum.com Sent: Sat, February 27, 2010 11:25:28? AM Subject: Re: [HSF] Reporting and analyzing ABGs Tea, My only? disagreement with your statement is that with some degree of memorization or? regurgitation of data there is some hope that there might be some critical? processing and consideration of the data at hand.? A huge selling point? of these new EMR systems is the ability to autopopulate data fields -? basically bypassing the human brain (for better or for worse)? altogether.? I have seen excellent EMR systems create critical care notes? populated automatically with data.? These note are "generated/created" by? a high school graduate - and all an attending needs to do is cut and paste a? phrase "seen and agreed and independently blah blah blah" to finalize and bill? for the service.? Important data may never actually make it to a high? cortical thinking center to be acted upon.? Impressive - and we wonder? why CMS is cutting physician payments......... -michael On? Feb 27, 2010, at 11:03 AM, Tea Acuff wrote: > Ani wrote: >? Personally, I dont find routine regurgitation of information helpful and ask? specific questions depending on the clinical problem being presented: when? 'all' the information is rambled in a specific order (if one exists) I would? end up asking again for specific data from the rambling which are relavant for? me to formulate an idea. > > > > I find memorizing lab? a silly game also and this is different than a "syntax" for a specific idea or? picture. All languages have syntax or order which codes how to read the? message (English may be one of the most flexible and thus both? rich and? ambiguous? and difficult to master.) The patterns code the way we think? about the more complex realtions that we deal with. Altering the patterns and? codes is one of the tools that I use to rethink our way using ideas. As anyone? who has tried to follow my (perhaps faulty) peculiar logic knows how important? common orientation can be to communication. On the other hand it underlies the? limitations it imposes on alternative explanations. > >? Tea > > Tea? ? > Sent from my iPhone >? > On Feb 27, 2010, at 8:02 AM, Ani Anyanwu? wrote: > > Personally, I dont find? routine regurgitation of information helpful and ask specific questions? depending on the clinical problem being presented: when 'all' the information? is rambled in a specific order (if one exists) I would end up asking again for? specific data from the rambling which are relavant for me to formulate an? idea. Personally > >? _______________________________________________ > OpenHeart-L mailing? list > > Send postings to: >? OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email? address, or to view archives: >? http://mmp.cjp.com/mailman/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 donross at bigpond.com Wed Mar 3 15:27:41 2010 From: donross at bigpond.com (Donald Ross) Date: Tue Mar 2 23:31:04 2010 Subject: [HSF] Intelligent design In-Reply-To: <56125.35099.qm@web24707.mail.ird.yahoo.com> References: <56125.35099.qm@web24707.mail.ird.yahoo.com> Message-ID: After doing an opcab on a patient with dextrocardiia I now realise why a left handed heart and a right handed surgeon is a heaven made design. It also made demonstrated the burden carried by my recent lefty trainee. Don From tacuff at swbell.net Tue Mar 2 20:36:13 2010 From: tacuff at swbell.net (Tea Acuff) Date: Tue Mar 2 23:37:43 2010 Subject: [HSF] Intelligent design Message-ID: <714004.62910.qm@web81607.mail.mud.yahoo.com> So you are no longer a materalist, Don? Tea Sent from my iPhone On Mar 2, 2010, at 10:27 PM, Donald Ross wrote: After doing an opcab on a patient with dextrocardiia I now realise why a left handed heart and a right handed surgeon is a heaven made design. It also made demonstrated the burden carried by my recent lefty trainee. 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 anddisclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From tacuff at swbell.net Tue Mar 2 20:44:04 2010 From: tacuff at swbell.net (Tea Acuff) Date: Tue Mar 2 23:45:33 2010 Subject: [HSF] Intelligent design Message-ID: <638802.86592.qm@web81604.mail.mud.yahoo.com> Also did you step to the other side of the table? It is not completely the same but closer and what a lefty would see: left hand left heart right side; right hand right heart left side. Tea Sent from my iPhone On Mar 2, 2010, at 10:27 PM, Donald Ross wrote: After doing an opcab on a patient with dextrocardiia I now realise why a left handed heart and a right handed surgeon is a heaven made design. It also made demonstrated the burden carried by my recent lefty trainee. 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 anddisclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From donross at bigpond.com Wed Mar 3 16:49:52 2010 From: donross at bigpond.com (Donald Ross) Date: Wed Mar 3 00:53:11 2010 Subject: [HSF] Intelligent design In-Reply-To: <638802.86592.qm@web81604.mail.mud.yahoo.com> References: <638802.86592.qm@web81604.mail.mud.yahoo.com> Message-ID: I did it all from the other side and used the Rima just like the Lima in regular god designed hearts. Some of the suturing was so awkward I used my left hand. And who said I was a materialist? I am a secular fundamentalist! Don On 03/03/2010, at 3:44 PM, Tea Acuff wrote: > Also did you step to the other side of the table? It is not > completely the same but closer and what a lefty would see: left hand > left heart right side; right hand right heart left side. > Tea > > Sent from my iPhone > > On Mar 2, 2010, at 10:27 PM, Donald Ross wrote: > > After doing an opcab on a patient with dextrocardiia I now realise > why a left handed heart and a right handed surgeon is a heaven made > design. > It also made demonstrated the burden carried by my recent lefty > trainee. > 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 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 > ----------------------------------------- From tacuff at swbell.net Tue Mar 2 22:08:31 2010 From: tacuff at swbell.net (Tea Acuff) Date: Wed Mar 3 01:10:03 2010 Subject: [HSF] Intelligent design Message-ID: <911286.28322.qm@web81606.mail.mud.yahoo.com> So both your graft and your targets are arteries and all your anastomoses are side to side why would the direction of yourvsuturing matter? And what is a secular fundamental? Tea Sent from my iPhone On Mar 2, 2010, at 11:49 PM, Donald Ross wrote: I did it all from the other side and used the Rima just like the Lima in regular god designed hearts. Some of the suturing was so awkward I used my left hand. And who said I was a materialist? I am a secular fundamentalist! Don On 03/03/2010, at 3:44 PM, Tea Acuff wrote: Also did you step to the other side of the table? It is not completely the same but closer and what a lefty would see: left hand left heart right side; right hand right heart left side. Tea Sent from my iPhone On Mar 2, 2010, at 10:27 PM, Donald Ross wrote: After doing an opcab on a patient with dextrocardiia I now realise why a left handed heart and a right handed surgeon is a heaven made design. It also made demonstrated the burden carried by my recent lefty trainee. 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 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 ----------------------------------------- _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, 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 ----------------------------------------- From tacuff at swbell.net Tue Mar 2 22:10:44 2010 From: tacuff at swbell.net (Tea Acuff) Date: Wed Mar 3 01:12:03 2010 Subject: [HSF] Intelligent design Message-ID: <965063.29259.qm@web81606.mail.mud.yahoo.com> Oh I forgot. Imagine how confusing it would be if you did the case right side up in the north hemisphere! Tea Sent from my iPhone On Mar 2, 2010, at 11:49 PM, Donald Ross wrote: I did it all from the other side and used the Rima just like the Lima in regular god designed hearts. Some of the suturing was so awkward I used my left hand. And who said I was a materialist? I am a secular fundamentalist! Don On 03/03/2010, at 3:44 PM, Tea Acuff wrote: Also did you step to the other side of the table? It is not completely the same but closer and what a lefty would see: left hand left heart right side; right hand right heart left side. Tea Sent from my iPhone On Mar 2, 2010, at 10:27 PM, Donald Ross wrote: After doing an opcab on a patient with dextrocardiia I now realise why a left handed heart and a right handed surgeon is a heaven made design. It also made demonstrated the burden carried by my recent lefty trainee. 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 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 ----------------------------------------- _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, 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 ----------------------------------------- From Rwmfglycar at aol.com Wed Mar 3 01:24:48 2010 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Wed Mar 3 01:25:52 2010 Subject: [HSF] are surgeons necessary Message-ID: <4dc.4cafbad9.38bf5ab0@aol.com> I used the term "mass production" because there were moans about the cost of healthcare 40 years ago and complaints about its inefficiency and dark hints that doctors were too expensive to produce. Single solutions are proposed by people who have never been there. I wrote a letter to the Lancet at that time pointing out that the Minister of Health dealing with a population must have a different agenda from the doctor dealing one on one with his unique patient. Bob In a message dated 3/3/2010 3:05:28 A.M. South Africa Standard Time, tacuff@swbell.net writes: It is interesting that you use the phrase "mass production" as you describe your possibilities, Bob. There is a special irony that those like you, self described as Hunterian, but whom I place in the analytical math group of thinkers are open to multiple choices, while population thinkers who are forced to describe their findings in stochastic or probabilistic math prefer to enforce a single solution. It is amazing how often we apply the opposite meaning of the message from the data that we use for our adgendae. We are in a civil war between population appliers and individual appliers of scientific information while we have both little insight into how our mathematical tools distort the conclusions to which we are able to hold without self delusion. Of course what you suggest is a return to deregulation, or better, local regulation. Our current leadership traded our laborious climb from a choatic void to a scientific vista for a place at the regulatory table. Since this was a universal and not a local or special table, everyone else climbed on board using the common currency of our knowledge or "gnosis" with which we planned to control everyone. But the tables were turned and now we are played by the same evidence that everyone is able to "prove" against or more often irrespective of us.And we see, or made to see, that we are not indeed everything and universal. This is why I asked, "Are we neceassary?" If we are just some or more of universally derived knowledge, why do we deserve a special place? If it is not then by special knowledge, special evidence, or gnosis, by what shall we be judged? We have generated a new and peculiar tool, which will seem appropriate for (us) beleaguered Hunterians: results. We have a database that now defines us. We proclaim this great database the new Arthurian (and authoritarian) sword that will demonstrate our royal blood. But what does a database that defines or demonstrates us mean? Will we turn this tool upside down upon our knighthood again? Or did we get it right this time? Or are surgeons and knights both a naive ego? We shall soon see this play out. Any bettors? tea ________________________________ From: "Rwmfglycar@aol.com" To: OpenHeart-L@lists.hsforum.com Sent: Mon, March 1, 2010 2:53:43 PM Subject: Re: [HSF] are surgeons necessary Dear Tea , I debated this in the past in the context of how could we make medicine a mass production industry. Running a surgical research lab suggested possibilities. In surgical research labs it is common to find an individual with minimal academic credentials who learns how to do a tricky operation in a tiny animal with minimal risk. At Mayo, in the early days, a local farm boy called "Curly" with a couple of years of apprenticeship amassed a massive experience in cardiac anesthesia: a doctor who had seen him in action would choose Curly to put him to sleep. Nurses in intensive care learned not just to record information on a chart but to become experts in integrating multiple varied inputs and come up with a reliable picture of what was happening to the patient. I am talking about smart people without medical degrees who, given a part of the overall job of fixing patients can be more expert than any multitasking doctor. But who is to be the conductor of this orchestra/? What about the whole patient? Should we also have purveyors of patient confidence, anxiety smoothers? Who trains the conductor? Who determines and explores new directions? Who gathers and transfers the knowledge? The experience that Mitch alludes to must be possessed by someone. Cardiac surgeons have traditionally been the most widely educated and experienced of surgeons are clearly the right people to lead a group of non surgeons in providing surgical care. I believe the best medical practise will come about by arranging care givers into disease related teams cutting across all conventional boundaries. For such a team to be good, all must be skilled, all must want to be good and better, all must understand that the joy of working in a good team is as good as it gets. The last remnants of neolithic hunters work in groups of about ten; that seems about right for a disease team. The patient coming into the hands of such a team will receive whatever is the best for the particular variation of disease that he has. Bob In a message dated 2/28/2010 6:50:39 A.M. South Africa Standard Time, tacuff@swbell.net writes: I have changed the topic as I think that it is a slow HSF night, I have had a couple of drinks and while we have still not dealt with issues of training (which is a sub issue of what is a master), you point to an interesting question. I think it is one in my mind in which I continuly wrestle with Ani and his population medicine, protocols are better than doctors,etc. The fact that he is not much interested in regurgitation of data gives me hope for him and shows that he is a complex (complicated) thinker. The question, as all are aware, is: are surgeons necessary? It will be hard for me to stay on track as this is actually a global question found every where. I recently gave a deposition as a medical expert! I will not deal with the case as it is pending, but as I reread my "expert opinion" the lawyer for the other side seemed to be baiting me about what I was willing to be critical about since I was a defense witness. I would not agree (as you might imagine) as to this qualifier demands this or that finding demands that. Essentially the lawyer asked, "Can you give an expert opinion without actually being there to see for yourself." Of course on reflection I found this a question of metaphysical significance. Let me say as a practical manner I often believe that my PA could do 95% of what I do if we gave her time to move the other side of the table for a while. Lets call this 3 sigma. I also commonly say, when faced with the hyper obsessive personalities that make up our specialty that 98(.5)% is good enough for me which is of course 4 sigma. Many of you are 99%ers (5sigmas) or worse (sorry, I mean better). That means I "only" add one sigma. What is that worth or is that the way to "measure" a surgeon? So rather than answer, are there any takers? Is a surgeon necessary? If we have althe data that the EMR requires other than "hands" or to sign the order in the middle of the night is a surgeon useful and necessary? I have way too much to say about this, but I'll wait. tea ________________________________ From: Michael Firstenberg To: OpenHeart-L@lists.hsforum.com Sent: Sat, February 27, 2010 11:25:28 AM Subject: Re: [HSF] Reporting and analyzing ABGs Tea, My only disagreement with your statement is that with some degree of memorization or regurgitation of data there is some hope that there might be some critical processing and consideration of the data at hand. A huge selling point of these new EMR systems is the ability to autopopulate data fields - basically bypassing the human brain (for better or for worse) altogether. I have seen excellent EMR systems create critical care notes populated automatically with data. These note are "generated/created" by a high school graduate - and all an attending needs to do is cut and paste a phrase "seen and agreed and independently blah blah blah" to finalize and bill for the service. Important data may never actually make it to a high cortical thinking center to be acted upon. Impressive - and we wonder why CMS is cutting physician payments......... -michael On Feb 27, 2010, at 11:03 AM, Tea Acuff wrote: > Ani wrote: > Personally, I dont find routine regurgitation of information helpful and ask specific questions depending on the clinical problem being presented: when 'all' the information is rambled in a specific order (if one exists) I would end up asking again for specific data from the rambling which are relavant for me to formulate an idea. > > > > I find memorizing lab a silly game also and this is different than a "syntax" for a specific idea or picture. All languages have syntax or order which codes how to read the message (English may be one of the most flexible and thus both rich and ambiguous and difficult to master.) The patterns code the way we think about the more complex realtions that we deal with. Altering the patterns and codes is one of the tools that I use to rethink our way using ideas. As anyone who has tried to follow my (perhaps faulty) peculiar logic knows how important common orientation can be to communication. On the other hand it underlies the limitations it imposes on alternative explanations. > > Tea > > Tea > Sent from my iPhone > > On Feb 27, 2010, at 8:02 AM, Ani Anyanwu wrote: > > Personally, I dont find routine regurgitation of information helpful and ask specific questions depending on the clinical problem being presented: when 'all' the information is rambled in a specific order (if one exists) I would end up asking again for specific data from the rambling which are relavant for me to formulate an idea. Personally > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 donross at bigpond.com Wed Mar 3 17:25:36 2010 From: donross at bigpond.com (Donald Ross) Date: Wed Mar 3 01:29:00 2010 Subject: [HSF] Intelligent design In-Reply-To: <911286.28322.qm@web81606.mail.mud.yahoo.com> References: <911286.28322.qm@web81606.mail.mud.yahoo.com> Message-ID: <7EB39716-BF18-4767-90D5-72365733E81F@bigpond.com> The problem is access and direction all of which favour the left hand in dextrocarda and the right for the standard heart and despite changing the direction of the suture line the "wrong hand" hand is still restricted by overhanging stuff and the direction of the hole to use a crude simile. Richard Dawkins who is a rabid atheist is called a secular fundamentalist by religious fundamentalists which, being steeped in irony, appeals to both him and me. Don On 03/03/2010, at 5:08 PM, Tea Acuff wrote: > So both your graft and your targets are arteries and all your > anastomoses are side to side why would the direction of > yourvsuturing matter? > And what is a secular fundamental? > Tea > > Sent from my iPhone > > On Mar 2, 2010, at 11:49 PM, Donald Ross wrote: > > I did it all from the other side and used the Rima just like the > Lima in regular god designed hearts. > Some of the suturing was so awkward I used my left hand. > And who said I was a materialist? > I am a secular fundamentalist! > Don > On 03/03/2010, at 3:44 PM, Tea Acuff wrote: > > Also did you step to the other side of the table? It is not > completely the same but closer and what a lefty would see: left hand > left heart right side; right hand right heart left side. > Tea > > Sent from my iPhone > > On Mar 2, 2010, at 10:27 PM, Donald Ross wrote: > > After doing an opcab on a patient with dextrocardiia I now realise > why a left handed heart and a right handed surgeon is a heaven made > design. > It also made demonstrated the burden carried by my recent lefty > trainee. > 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 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 > ----------------------------------------- > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, 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 > ----------------------------------------- From benjamin.bidstrup at bigpond.com Wed Mar 3 17:20:10 2010 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Wed Mar 3 02:20:41 2010 Subject: [HSF] Intelligent design In-Reply-To: <7EB39716-BF18-4767-90D5-72365733E81F@bigpond.com> References: <911286.28322.qm@web81606.mail.mud.yahoo.com> <7EB39716-BF18-4767-90D5-72365733E81F@bigpond.com> Message-ID: He happens to be in Australia at present on a talking trip. Most interesting to listen to! Dawkins that is, not Ross who just talks. Ben Bidstrup FRACS FRCSEd FEBCTS Cardiothoracic Surgeon On 03/03/2010, at 4:25 PM, Donald Ross wrote: > The problem is access and direction all of which favour the left hand in dextrocarda and the right for the standard heart and despite changing the direction of the suture line the "wrong hand" hand is still restricted by overhanging stuff and the direction of the hole to use a crude simile. > Richard Dawkins who is a rabid atheist is called a secular fundamentalist by religious fundamentalists which, being steeped in irony, appeals to both him and me. > Don > On 03/03/2010, at 5:08 PM, Tea Acuff wrote: > >> So both your graft and your targets are arteries and all your anastomoses are side to side why would the direction of yourvsuturing matter? >> And what is a secular fundamental? >> Tea >> >> Sent from my iPhone >> >> On Mar 2, 2010, at 11:49 PM, Donald Ross wrote: >> >> I did it all from the other side and used the Rima just like the Lima in regular god designed hearts. >> Some of the suturing was so awkward I used my left hand. >> And who said I was a materialist? >> I am a secular fundamentalist! >> Don >> On 03/03/2010, at 3:44 PM, Tea Acuff wrote: >> >> Also did you step to the other side of the table? It is not completely the same but closer and what a lefty would see: left hand left heart right side; right hand right heart left side. >> Tea >> >> Sent from my iPhone >> >> On Mar 2, 2010, at 10:27 PM, Donald Ross wrote: >> >> After doing an opcab on a patient with dextrocardiia I now realise why a left handed heart and a right handed surgeon is a heaven made design. >> It also made demonstrated the burden carried by my recent lefty trainee. >> 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 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 >> ----------------------------------------- >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, 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 >> ----------------------------------------- > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, 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 > ----------------------------------------- From prasannasimha at gmail.com Wed Mar 3 13:35:04 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Wed Mar 3 03:05:32 2010 Subject: [HSF] Intelligent design In-Reply-To: <7EB39716-BF18-4767-90D5-72365733E81F@bigpond.com> References: <911286.28322.qm@web81606.mail.mud.yahoo.com> <7EB39716-BF18-4767-90D5-72365733E81F@bigpond.com> Message-ID: <89c4ed2d1003030005l3ebd02b1w6d21445137770e0c@mail.gmail.com> We do get a fair amount of patients with an assortment of lesions ranging from congenital ,valve and coronary and the novelty in them is the positioning etc but otherwise they are fairly doable.Some do not require reversal of positions but some like an MVR or transatrial corrections require reversal of operator/assistant positions.Incidentally the OM graft is pretty easy to do in these people using a standard position but looks a little "angulated" as we are used to peeping over the volume of the heart. Prasanna On 3/3/10, Donald Ross wrote: > The problem is access and direction all of which favour the left hand > in dextrocarda and the right for the standard heart and despite > changing the direction of the suture line the "wrong hand" hand is > still restricted by overhanging stuff and the direction of the hole to > use a crude simile. > Richard Dawkins who is a rabid atheist is called a secular > fundamentalist by religious fundamentalists which, being steeped in > irony, appeals to both him and me. > Don > On 03/03/2010, at 5:08 PM, Tea Acuff wrote: > >> So both your graft and your targets are arteries and all your >> anastomoses are side to side why would the direction of >> yourvsuturing matter? >> And what is a secular fundamental? >> Tea >> >> Sent from my iPhone >> >> On Mar 2, 2010, at 11:49 PM, Donald Ross wrote: >> >> I did it all from the other side and used the Rima just like the >> Lima in regular god designed hearts. >> Some of the suturing was so awkward I used my left hand. >> And who said I was a materialist? >> I am a secular fundamentalist! >> Don >> On 03/03/2010, at 3:44 PM, Tea Acuff wrote: >> >> Also did you step to the other side of the table? It is not >> completely the same but closer and what a lefty would see: left hand >> left heart right side; right hand right heart left side. >> Tea >> >> Sent from my iPhone >> >> On Mar 2, 2010, at 10:27 PM, Donald Ross wrote: >> >> After doing an opcab on a patient with dextrocardiia I now realise >> why a left handed heart and a right handed surgeon is a heaven made >> design. >> It also made demonstrated the burden carried by my recent lefty >> trainee. >> 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 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 >> ----------------------------------------- >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, 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 >> ----------------------------------------- > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 hgrmd at aol.com Wed Mar 3 10:00:17 2010 From: hgrmd at aol.com (hgrmd@aol.com) Date: Wed Mar 3 05:05:18 2010 Subject: [HSF] Intelligent design Message-ID: <2049095138-1267610628-cardhu_decombobulator_blackberry.rim.net-1723112486-@bda730.bisx.prod.on.blackberry> RG9uLA0KICBBcyBhIGhhcmRjb3JlICJMZWZ0eSIsIEkgdW5kZXJzdGFuZCB5b3VyIGNvbW1lbnRz LCBidXQgSSBjYW4gYXNzdXJlIHlvdSB0aGF0IHRoZSBpbXBlZGltZW50IGNhbiBiZSBtYW5hZ2Vk Lg0KDQpIYWwNCi0tLS0tLU9yaWdpbmFsIE1lc3NhZ2UtLS0tLS0NCkZyb206IERvbmFsZCBSb3Nz DQpTZW5kZXI6IG9wZW5oZWFydC1sLWJvdW5jZXNAbGlzdHMuaHNmb3J1bS5jb20NClRvOiBPcGVu SGVhcnQtTEBsaXN0cy5oc2ZvcnVtLmNvbQ0KUmVwbHlUbzogT3BlbkhlYXJ0LUxAbGlzdHMuaHNm b3J1bS5jb20NClN1YmplY3Q6IFJlOiBbSFNGXSBJbnRlbGxpZ2VudCBkZXNpZ24NClNlbnQ6IE1h ciAyLCAyMDEwIDExOjI3IFBNDQoNCkFmdGVyIGRvaW5nIGFuIG9wY2FiIG9uIGEgcGF0aWVudCB3 aXRoIGRleHRyb2NhcmRpaWEgSSBub3cgcmVhbGlzZSB3aHkgIA0KYSBsZWZ0IGhhbmRlZCBoZWFy dCBhbmQgYSByaWdodCBoYW5kZWQgc3VyZ2VvbiBpcyBhIGhlYXZlbiBtYWRlIGRlc2lnbi4NCkl0 IGFsc28gbWFkZSBkZW1vbnN0cmF0ZWQgIHRoZSBidXJkZW4gY2FycmllZCBieSAgbXkgcmVjZW50 IGxlZnR5ICANCnRyYWluZWUuDQpEb24gDQpfX19fX19fX19fX19fX19fX19fX19fX19fX19fX19f X19fX19fX19fX19fX19fXw0KT3BlbkhlYXJ0LUwgbWFpbGluZyBsaXN0DQoNClNlbmQgcG9zdGlu Z3MgdG86DQogT3BlbkhlYXJ0LUxAbGlzdHMuaHNmb3J1bS5jb20NCg0KVG8gVU5TVUJTQ1JJQkUs IHRvIENIQU5HRSBlbWFpbCBhZGRyZXNzLCBvciB0byB2aWV3IGFyY2hpdmVzOg0KaHR0cDovL21t cC5janAuY29tL21haWxtYW4vbGlzdGluZm8vb3BlbmhlYXJ0LWwNCg0KQWxsIG1lc3NhZ2VzIHRy YW5zbWl0dGVkIGJ5IHRoZSBPcGVuSGVhcnQtTCBhcmUgc3ViamVjdCB0byB0aGUgcG9saWNpZXMg YW5kIA0KZGlzY2xhaW1lcnMgcG9zdGVkIGF0Og0KaHR0cDovL3d3dy5oc2ZvcnVtLmNvbS9saXN0 ZGlzY2xhaW0NCi0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tDQoNCg0K U2VudCBmcm9tIG15IFZlcml6b24gV2lyZWxlc3MgQmxhY2tCZXJyeQ== From hgrmd at aol.com Wed Mar 3 10:07:10 2010 From: hgrmd at aol.com (hgrmd@aol.com) Date: Wed Mar 3 05:05:29 2010 Subject: [HSF] Intelligent design Message-ID: <2049095138-1267610638-cardhu_decombobulator_blackberry.rim.net-851322516-@bda730.bisx.prod.on.blackberry> RG9uLA0KICBBcyBhIGhhcmRjb3JlICJMZWZ0eSIsIEkgdW5kZXJzdGFuZCB5b3VyIGNvbW1lbnRz LCBidXQgSSBjYW4gYXNzdXJlIHlvdSB0aGF0IHRoZSBpbXBlZGltZW50IGNhbiBiZSBtYW5hZ2Vk Lg0KDQpIYWwNCi0tLS0tLU9yaWdpbmFsIE1lc3NhZ2UtLS0tLS0NCkZyb206IERvbmFsZCBSb3Nz 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YW5kIA0KZGlzY2xhaW1lcnMgcG9zdGVkIGF0Og0KaHR0cDovL3d3dy5oc2ZvcnVtLmNvbS9saXN0 ZGlzY2xhaW0NCi0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tDQoNCg0K U2VudCBmcm9tIG15IFZlcml6b24gV2lyZWxlc3MgQmxhY2tCZXJyeQ== From prasannasimha at gmail.com Wed Mar 3 16:48:03 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Wed Mar 3 06:18:32 2010 Subject: [HSF] Intelligent design In-Reply-To: <2049095138-1267610628-cardhu_decombobulator_blackberry.rim.net-1723112486-@bda730.bisx.prod.on.blackberry> References: <2049095138-1267610628-cardhu_decombobulator_blackberry.rim.net-1723112486-@bda730.bisx.prod.on.blackberry> Message-ID: <89c4ed2d1003030318h32fb12c3w19c392fc293436ae@mail.gmail.com> I tie my knots with the left and actually find it easier. Prasanna On Wed, Mar 3, 2010 at 3:30 PM, wrote: > Don, > As a hardcore "Lefty", I understand your comments, but I can assure you > that the impediment can be managed. > > Hal > ------Original Message------ > From: Donald Ross > Sender: openheart-l-bounces@lists.hsforum.com > To: OpenHeart-L@lists.hsforum.com > ReplyTo: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] Intelligent design > Sent: Mar 2, 2010 11:27 PM > > After doing an opcab on a patient with dextrocardiia I now realise why > a left handed heart and a right handed surgeon is a heaven made design. > It also made demonstrated the burden carried by my recent lefty > trainee. > 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 and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > > > Sent from my Verizon Wireless BlackBerry > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 donross at bigpond.com Wed Mar 3 22:37:38 2010 From: donross at bigpond.com (Donald Ross) Date: Wed Mar 3 06:41:58 2010 Subject: [HSF] Intelligent design In-Reply-To: <2049095138-1267610638-cardhu_decombobulator_blackberry.rim.net-851322516-@bda730.bisx.prod.on.blackberry> References: <2049095138-1267610638-cardhu_decombobulator_blackberry.rim.net-851322516-@bda730.bisx.prod.on.blackberry> Message-ID: <1B1D5C1C-0D2E-415C-9095-D5BF60A3FDDE@bigpond.com> I am sure there are a lot of lefty heart surgeons but I bet left handed gynaecologists don't stand on the patient's right. Also,Hal, I did a double take of "hardcore lefty" till I realised you weren't referring to politics. Don On 03/03/2010, at 9:07 PM, Hgrmd@aol.com wrote: > Don, > As a hardcore "Lefty", I understand your comments, but I can assure > you that the impediment can be managed. > > Hal > ------Original Message------ > From: Donald Ross > Sender: openheart-l-bounces@lists.hsforum.com > To: OpenHeart-L@lists.hsforum.com > ReplyTo: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] Intelligent design > Sent: Mar 2, 2010 11:27 PM > > After doing an opcab on a patient with dextrocardiia I now realise why > a left handed heart and a right handed surgeon is a heaven made > design. > It also made demonstrated the burden carried by my recent lefty > trainee. > 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 and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > > > Sent from my Verizon Wireless > BlackBerry_______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 Wed Mar 3 07:45:30 2010 From: msfirst at gmail.com (Michael Firstenberg) Date: Wed Mar 3 07:45:58 2010 Subject: [HSF] are surgeons necessary In-Reply-To: <4dc.4cafbad9.38bf5ab0@aol.com> References: <4dc.4cafbad9.38bf5ab0@aol.com> Message-ID: sounds like the same issues going on now. The irony of course is the same people screaming for personalized health care are the same advocate for a "mass production" mentality. Yes, there a certain aspects that clearly can be optimized, but we see time and time again the negative effects from applying "protocols" and "EBM" and whatever to clinical situations that are not appropriate. Part of the problem is there are too many variables. As we are seeing in the auto industry, the concept of mass production can also lead to mass destruction with one small blip in the pathways - and who in the healthcare industry is going to stand up and take responsibility? Probably no one. -michael On Wed, Mar 3, 2010 at 1:24 AM, wrote: > I used the term "mass production" because there were moans about the cost > of healthcare 40 years ago and complaints about its inefficiency and dark > hints that doctors were too expensive to produce. > Single solutions are proposed by people who have never been there. I wrote > a letter to the Lancet at that time pointing out that the Minister of > Health dealing with a population must have a different agenda from the > doctor > dealing one on one with his unique patient. > Bob > > > In a message dated 3/3/2010 3:05:28 A.M. South Africa Standard Time, > tacuff@swbell.net writes: > > It is interesting that you use the phrase "mass production" as you > describe your possibilities, Bob. There is a special irony that those like > you, > self described as Hunterian, but whom I place in the analytical math group > of > thinkers are open to multiple choices, while population thinkers who are > forced to describe their findings in stochastic or probabilistic math > prefer > to enforce a single solution. It is amazing how often we apply the > opposite meaning of the message from the data that we use for our adgendae. > We are in a civil war between population appliers and individual appliers > of scientific information while we have both little insight into how our > mathematical tools distort the conclusions to which we are able to hold > without self delusion. > > Of course what you suggest is a return to deregulation, or better, local > regulation. Our current leadership traded our laborious climb from a > choatic > void to a scientific vista for a place at the regulatory table. Since this > was a universal and not a local or special table, everyone else climbed on > board using the common currency of our knowledge or "gnosis" with which we > planned to control everyone. But the tables were turned and now we are > played by the same evidence that everyone is able to "prove" against or > more > often irrespective of us.And we see, or made to see, that we are not > indeed > everything and universal. This is why I asked, "Are we neceassary?" If we > are just some or more of universally derived knowledge, why do we deserve > a > special place? > > If it is not then by special knowledge, special evidence, or gnosis, by > what shall we be judged? We have generated a new and peculiar tool, which > will seem appropriate for (us) beleaguered Hunterians: results. We have a > database that now defines us. We proclaim this great database the new > Arthurian > (and authoritarian) sword that will demonstrate our royal blood. But what > does a database that defines or demonstrates us mean? Will we turn this > tool upside down upon our knighthood again? Or did we get it right this > time? > Or are surgeons and knights both a naive ego? We shall soon see this play > out. Any bettors? > > tea > > > > > > ________________________________ > From: "Rwmfglycar@aol.com" > To: OpenHeart-L@lists.hsforum.com > Sent: Mon, March 1, 2010 2:53:43 PM > Subject: Re: [HSF] are surgeons necessary > > Dear Tea , > I debated this in the past in the context of how could we make medicine a > mass production industry. Running a surgical research lab suggested > possibilities. In surgical research labs it is common to find an > individual with > minimal academic credentials who learns how to do a tricky operation in a > tiny animal with minimal risk. At Mayo, in the early days, a local farm > boy > called "Curly" with a couple of years of apprenticeship amassed a massive > experience in cardiac anesthesia: a doctor who had seen him in action > would > choose Curly to put him to sleep. Nurses in intensive care learned not > just to record information on a chart but to become experts in > integrating > multiple varied inputs and come up with a reliable picture of what was > happening to the patient. I am talking about smart people without medical > degrees > who, given a part of the overall job of fixing patients can be more > expert > than any multitasking doctor. But who is to be the conductor of this > orchestra/? What about the whole patient? Should we also have purveyors of > > patient confidence, anxiety smoothers? Who trains the conductor? Who > determines > and explores new directions? Who gathers and transfers the knowledge? The > > experience that Mitch alludes to must be possessed by someone. Cardiac > surgeons have traditionally been the most widely educated and > experienced of > surgeons are clearly the right people to lead a group of non surgeons in > providing surgical care. > I believe the best medical practise will come about by arranging care > givers into disease related teams cutting across all conventional > boundaries. > For such a team to be good, all must be skilled, all must want to be good > and > better, all must understand that the joy of working in a good team is as > good as it gets. The last remnants of neolithic hunters work in groups of > about ten; that seems about right for a disease team. The patient coming > into the hands of such a team will receive whatever is the best for the > particular variation of disease that he has. > Bob > > In a message dated 2/28/2010 6:50:39 A.M. South Africa Standard Time, > tacuff@swbell.net writes: > > I have changed the topic as I think that it is a slow HSF night, I have > had a couple of drinks and while we have still not dealt with issues of > training (which is a sub issue of what is a master), you point to an > interesting > question. I think it is one in my mind in which I continuly wrestle with > Ani and his population medicine, protocols are better than doctors,etc. > The > fact that he is not much interested in regurgitation of data gives me > hope > for him and shows that he is a complex (complicated) thinker. > > The question, as all are aware, is: are surgeons necessary? It will be > hard for me to stay on track as this is actually a global question found > every > where. > > I recently gave a deposition as a medical expert! I will not deal with > the > case as it is pending, but as I reread my "expert opinion" the lawyer for > the other side seemed to be baiting me about what I was willing to be > critical about since I was a defense witness. I would not agree (as you > might > imagine) as to this qualifier demands this or that finding demands that. > Essentially the lawyer asked, "Can you give an expert opinion without > actually > being there to see for yourself." Of course on reflection I found this a > question of metaphysical significance. > > Let me say as a practical manner I often believe that my PA could do 95% > of what I do if we gave her time to move the other side of the table for > a > while. Lets call this 3 sigma. I also commonly say, when faced with the > hyper obsessive personalities that make up our specialty that 98(.5)% is > good > enough for me which is of course 4 sigma. Many of you are 99%ers > (5sigmas) > or worse (sorry, I mean better). That means I "only" add one sigma. > What is that worth or is that the way to "measure" a surgeon? > > So rather than answer, are there any takers? Is a surgeon necessary? If > we > have althe data that the EMR requires other than "hands" or to sign the > order in the middle of the night is a surgeon useful and necessary? I > have > way too much to say about this, but I'll wait. > > tea > > > > > > > ________________________________ > From: Michael Firstenberg > To: OpenHeart-L@lists.hsforum.com > Sent: Sat, February 27, 2010 11:25:28 AM > Subject: Re: [HSF] Reporting and analyzing ABGs > > Tea, > My only disagreement with your statement is that with some degree of > memorization or regurgitation of data there is some hope that there might > be > some critical processing and consideration of the data at hand. A huge > selling point of these new EMR systems is the ability to autopopulate > data fields > - basically bypassing the human brain (for better or for worse) > altogether. I have seen excellent EMR systems create critical care notes > populated > automatically with data. These note are "generated/created" by a high > school graduate - and all an attending needs to do is cut and paste a > phrase > "seen and agreed and independently blah blah blah" to finalize and bill > for > the service. Important data may never actually make it to a high > cortical > thinking center to be acted upon. Impressive - and we wonder why CMS is > cutting physician payments......... > > -michael > > > On Feb 27, 2010, at 11:03 AM, Tea Acuff wrote: > > > Ani wrote: > > Personally, I dont find routine regurgitation of information helpful > and > ask specific questions depending on the clinical problem being presented: > when 'all' the information is rambled in a specific order (if one exists) > I > would end up asking again for specific data from the rambling which are > relavant for me to formulate an idea. > > > > > > > I find memorizing lab a silly game also and this is different than a > "syntax" for a specific idea or picture. All languages have syntax or > order > which codes how to read the message (English may be one of the most > flexible > and thus both rich and ambiguous and difficult to master.) The patterns > code the way we think about the more complex realtions that we deal with. > Altering the patterns and codes is one of the tools that I use to rethink > our > way using ideas. As anyone who has tried to follow my (perhaps faulty) > peculiar logic knows how important common orientation can be to > communication. > On the other hand it underlies the limitations it imposes on alternative > explanations. > > > > Tea > > > > Tea > > Sent from my iPhone > > > > On Feb 27, 2010, at 8:02 AM, Ani Anyanwu > wrote: > > > > Personally, I dont find routine regurgitation of information helpful > and > ask specific questions depending on the clinical problem being presented: > when 'all' the information is rambled in a specific order (if one exists) > I > would end up asking again for specific data from the rambling which are > relavant for me to formulate an idea. Personally > > > > _______________________________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@lists.hsforum.com > > > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > > http://mmp.cjp.com/mailman/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 msfirst at gmail.com Wed Mar 3 07:52:00 2010 From: msfirst at gmail.com (Michael Firstenberg) Date: Wed Mar 3 07:52:18 2010 Subject: [HSF] Intelligent design In-Reply-To: <1B1D5C1C-0D2E-415C-9095-D5BF60A3FDDE@bigpond.com> References: <2049095138-1267610638-cardhu_decombobulator_blackberry.rim.net-851322516-@bda730.bisx.prod.on.blackberry> <1B1D5C1C-0D2E-415C-9095-D5BF60A3FDDE@bigpond.com> Message-ID: Hal, I did not know that you are a fellow Southpaw..... now I am really worried. I will take issue with "intelligent design" of the heart and such - we just live in a right handed world, but once you and your team get used to doing thing a little different then there are no issues. Us left handed people, being in their right minds, are just more adaptive (maybe more evolutionarily advanced???) and flexible then you right handed people who cant operate outside of a comfort zone. In fact, I can argue that you right handed people just do everything backwards to begin with.......... -michael On Wed, Mar 3, 2010 at 6:37 AM, Donald Ross wrote: > I am sure there are a lot of lefty heart surgeons but I bet left handed > gynaecologists don't stand on the patient's right. > Also,Hal, I did a double take of "hardcore lefty" till I realised you > weren't referring to politics. > Don > > On 03/03/2010, at 9:07 PM, Hgrmd@aol.com wrote: > > Don, >> As a hardcore "Lefty", I understand your comments, but I can assure you >> that the impediment can be managed. >> >> Hal >> ------Original Message------ >> From: Donald Ross >> Sender: openheart-l-bounces@lists.hsforum.com >> To: OpenHeart-L@lists.hsforum.com >> ReplyTo: OpenHeart-L@lists.hsforum.com >> Subject: Re: [HSF] Intelligent design >> Sent: Mar 2, 2010 11:27 PM >> >> After doing an opcab on a patient with dextrocardiia I now realise why >> a left handed heart and a right handed surgeon is a heaven made design. >> It also made demonstrated the burden carried by my recent lefty >> trainee. >> 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 >> and >> disclaimers posted at: >> http://www.hsforum.com/listdisclaim >> ----------------------------------------- >> >> >> Sent from my Verizon Wireless >> BlackBerry_______________________________________________ >> >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/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 > anddisclaimers posted at: > > http://www.hsforum.com/listdisclaim > ----------------------------------------- > From gabuin at intramed.net Wed Mar 3 13:32:48 2010 From: gabuin at intramed.net (gustavo abuin) Date: Wed Mar 3 08:32:50 2010 Subject: [HSF] Intelligent design References: <2049095138-1267610638-cardhu_decombobulator_blackberry.rim.net-851322516-@bda730.bisx.prod.on.blackberry><1B1D5C1C-0D2E-415C-9095-D5BF60A3FDDE@bigpond.com> Message-ID: <003101cad331$fe175280$719312be@toshibauser> When I was a resident of general surgery, the whole staff said during my first week at the Hospital: "Ok baldy man, you have one month to became right handed.... if you don?t, you can consider to do endoscopic diagnosis for the rest of your life". After that suggestion, I started a protocol of experimental acute pancreatitis (no matter the details). I operated 50 dogs only with my right hand. It was very useful, because now I can use (badly) both hands and I can finish my four year residence in general surgery.... When I started cardiac surgery there was another challenge. Learn the delicate movements of coronary surgery with right-handed designed scissor, right handed needle holders in a completely right handed cardiac surgery staff.... It was hard, very hard. Can you imagine my first proximal anastomosis with my left hand assisted by an ALWAYS right handed surgeon? Now I do my surgeries with a left handed surgeon!!!!!! gustavo. ----- Original Message ----- From: "Michael Firstenberg" To: Sent: Wednesday, March 03, 2010 9:52 AM Subject: Re: [HSF] Intelligent design > Hal, > I did not know that you are a fellow Southpaw..... now I am really > worried. > > I will take issue with "intelligent design" of the heart and such - we > just > live in a right handed world, but once you and your team get used to doing > thing a little different then there are no issues. Us left handed people, > being in their right minds, are just more adaptive (maybe more > evolutionarily advanced???) and flexible then you right handed people who > cant operate outside of a comfort zone. In fact, I can argue that you > right > handed people just do everything backwards to begin with.......... > > -michael > > > > On Wed, Mar 3, 2010 at 6:37 AM, Donald Ross wrote: > >> I am sure there are a lot of lefty heart surgeons but I bet left handed >> gynaecologists don't stand on the patient's right. >> Also,Hal, I did a double take of "hardcore lefty" till I realised you >> weren't referring to politics. >> Don >> >> On 03/03/2010, at 9:07 PM, Hgrmd@aol.com wrote: >> >> Don, >>> As a hardcore "Lefty", I understand your comments, but I can assure you >>> that the impediment can be managed. >>> >>> Hal >>> ------Original Message------ >>> From: Donald Ross >>> Sender: openheart-l-bounces@lists.hsforum.com >>> To: OpenHeart-L@lists.hsforum.com >>> ReplyTo: OpenHeart-L@lists.hsforum.com >>> Subject: Re: [HSF] Intelligent design >>> Sent: Mar 2, 2010 11:27 PM >>> >>> After doing an opcab on a patient with dextrocardiia I now realise why >>> a left handed heart and a right handed surgeon is a heaven made design. >>> It also made demonstrated the burden carried by my recent lefty >>> trainee. >>> 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 >>> and >>> disclaimers posted at: >>> http://www.hsforum.com/listdisclaim >>> ----------------------------------------- >>> >>> >>> Sent from my Verizon Wireless >>> BlackBerry_______________________________________________ >>> >>> OpenHeart-L mailing list >>> >>> Send postings to: >>> OpenHeart-L@lists.hsforum.com >>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>> http://mmp.cjp.com/mailman/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 >> 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 > ----------------------------------------- From tacuff at swbell.net Wed Mar 3 07:19:08 2010 From: tacuff at swbell.net (Tea Acuff) Date: Wed Mar 3 10:20:37 2010 Subject: [HSF] Intelligent design Message-ID: <105823.25055.qm@web81606.mail.mud.yahoo.com> Yes hard core lefties do want to manage everything. Are you sure you know which side that you are on, Don? Tea Sent from my iPhone On Mar 3, 2010, at 5:37 AM, Donald Ross wrote: I am sure there are a lot of lefty heart surgeons but I bet left handed gynaecologists don't stand on the patient's right. Also,Hal, I did a double take of "hardcore lefty" till I realised you weren't referring to politics. Don On 03/03/2010, at 9:07 PM, Hgrmd@aol.com wrote: Don, As a hardcore "Lefty", I understand your comments, but I can assure you that the impediment can be managed. Hal ------Original Message------ From: Donald Ross Sender: openheart-l-bounces@lists.hsforum.com To: OpenHeart-L@lists.hsforum.com ReplyTo: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Intelligent design Sent: Mar 2, 2010 11:27 PM After doing an opcab on a patient with dextrocardiia I now realise why a left handed heart and a right handed surgeon is a heaven made design. It also made demonstrated the burden carried by my recent lefty trainee. 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 and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- Sent from my Verizon Wireless BlackBerry_______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/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 anddisclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From TSalerno at med.miami.edu Wed Mar 3 10:22:38 2010 From: TSalerno at med.miami.edu (Salerno, Tomas) Date: Wed Mar 3 10:23:06 2010 Subject: [HSF] Intelligent design In-Reply-To: <105823.25055.qm@web81606.mail.mud.yahoo.com> References: <105823.25055.qm@web81606.mail.mud.yahoo.com> Message-ID: The hardest thing is to train a lefty resident in CT surgery. I have trained many, there were all excellent. At one time, I was going to write a manuscript as to how to train left-handed CT residents. Never did, however, kind of regret it. Tomas -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Tea Acuff Sent: Wednesday, March 03, 2010 10:19 AM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Intelligent design Yes hard core lefties do want to manage everything. Are you sure you know which side that you are on, Don? Tea Sent from my iPhone On Mar 3, 2010, at 5:37 AM, Donald Ross wrote: I am sure there are a lot of lefty heart surgeons but I bet left handed gynaecologists don't stand on the patient's right. Also,Hal, I did a double take of "hardcore lefty" till I realised you weren't referring to politics. Don On 03/03/2010, at 9:07 PM, Hgrmd@aol.com wrote: Don, As a hardcore "Lefty", I understand your comments, but I can assure you that the impediment can be managed. Hal ------Original Message------ From: Donald Ross Sender: openheart-l-bounces@lists.hsforum.com To: OpenHeart-L@lists.hsforum.com ReplyTo: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Intelligent design Sent: Mar 2, 2010 11:27 PM After doing an opcab on a patient with dextrocardiia I now realise why a left handed heart and a right handed surgeon is a heaven made design. It also made demonstrated the burden carried by my recent lefty trainee. 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 and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- Sent from my Verizon Wireless BlackBerry_______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/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 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 ----------------------------------------- From tacuff at swbell.net Wed Mar 3 07:34:57 2010 From: tacuff at swbell.net (Tea Acuff) Date: Wed Mar 3 10:35:25 2010 Subject: [HSF] Intelligent design Message-ID: <594199.36029.qm@web81604.mail.mud.yahoo.com> There is still time! Tea Sent from my iPhone On Mar 3, 2010, at 9:22 AM, "Salerno, Tomas" wrote: The hardest thing is to train a lefty resident in CT surgery. I have trained many, there were all excellent. At one time, I was going to write a manuscript as to how to train left-handed CT residents. Never did, however, kind of regret it. Tomas -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Tea Acuff Sent: Wednesday, March 03, 2010 10:19 AM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Intelligent design Yes hard core lefties do want to manage everything. Are you sure you know which side that you are on, Don? Tea Sent from my iPhone On Mar 3, 2010, at 5:37 AM, Donald Ross wrote: I am sure there are a lot of lefty heart surgeons but I bet left handed gynaecologists don't stand on the patient's right. Also,Hal, I did a double take of "hardcore lefty" till I realised you weren't referring to politics. Don On 03/03/2010, at 9:07 PM, Hgrmd@aol.com wrote: Don, As a hardcore "Lefty", I understand your comments, but I can assure you that the impediment can be managed. Hal ------Original Message------ From: Donald Ross Sender: openheart-l-bounces@lists.hsforum.com To: OpenHeart-L@lists.hsforum.com ReplyTo: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Intelligent design Sent: Mar 2, 2010 11:27 PM After doing an opcab on a patient with dextrocardiia I now realise why a left handed heart and a right handed surgeon is a heaven made design. It also made demonstrated the burden carried by my recent lefty trainee. 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 and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- Sent from my Verizon Wireless BlackBerry_______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/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 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 ----------------------------------------- _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/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 Wed Mar 3 07:37:21 2010 From: tacuff at swbell.net (Tea Acuff) Date: Wed Mar 3 10:37:51 2010 Subject: [HSF] Intelligent design Message-ID: <502183.32851.qm@web81608.mail.mud.yahoo.com> You can argue the left handed means right brained but that is a "sinister" argument as it is more often wrong. ; ) Tea Sent from my iPhone On Mar 3, 2010, at 6:52 AM, Michael Firstenberg wrote: Hal, I did not know that you are a fellow Southpaw..... now I am really worried. I will take issue with "intelligent design" of the heart and such - we just live in a right handed world, but once you and your team get used to doing thing a little different then there are no issues. Us left handed people, being in their right minds, are just more adaptive (maybe more evolutionarily advanced???) and flexible then you right handed people who cant operate outside of a comfort zone. In fact, I can argue that you right handed people just do everything backwards to begin with.......... -michael On Wed, Mar 3, 2010 at 6:37 AM, Donald Ross wrote: I am sure there are a lot of lefty heart surgeons but I bet left handed gynaecologists don't stand on the patient's right. Also,Hal, I did a double take of "hardcore lefty" till I realised you weren't referring to politics. Don On 03/03/2010, at 9:07 PM, Hgrmd@aol.com wrote: Don, As a hardcore "Lefty", I understand your comments, but I can assure you that the impediment can be managed. Hal ------Original Message------ From: Donald Ross Sender: openheart-l-bounces@lists.hsforum.com To: OpenHeart-L@lists.hsforum.com ReplyTo: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Intelligent design Sent: Mar 2, 2010 11:27 PM After doing an opcab on a patient with dextrocardiia I now realise why a left handed heart and a right handed surgeon is a heaven made design. It also made demonstrated the burden carried by my recent lefty trainee. 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 and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- Sent from my Verizon Wireless BlackBerry_______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/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 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 ----------------------------------------- From Rwmfglycar at aol.com Wed Mar 3 11:39:15 2010 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Wed Mar 3 11:40:22 2010 Subject: [HSF] Intelligent design OTT Message-ID: <1775e.47408e0a.38bfeab3@aol.com> Unlike in sports which involve hitting a thrown ball with an implement, where left handers appear at the top levels in disproprtionate numbers, and opponents need to make adjustments, I don't suppose the patients are affected one way or another Bob In a message dated 3/3/2010 5:39:18 P.M. South Africa Standard Time, tacuff@swbell.net writes: You can argue the left handed means right brained but that is a "sinister" argument as it is more often wrong. ; ) Tea Sent from my iPhone On Mar 3, 2010, at 6:52 AM, Michael Firstenberg wrote: Hal, I did not know that you are a fellow Southpaw..... now I am really worried. I will take issue with "intelligent design" of the heart and such - we just live in a right handed world, but once you and your team get used to doing thing a little different then there are no issues. Us left handed people, being in their right minds, are just more adaptive (maybe more evolutionarily advanced???) and flexible then you right handed people who cant operate outside of a comfort zone. In fact, I can argue that you right handed people just do everything backwards to begin with.......... -michael On Wed, Mar 3, 2010 at 6:37 AM, Donald Ross wrote: I am sure there are a lot of lefty heart surgeons but I bet left handed gynaecologists don't stand on the patient's right. Also,Hal, I did a double take of "hardcore lefty" till I realised you weren't referring to politics. Don On 03/03/2010, at 9:07 PM, Hgrmd@aol.com wrote: Don, As a hardcore "Lefty", I understand your comments, but I can assure you that the impediment can be managed. Hal ------Original Message------ From: Donald Ross Sender: openheart-l-bounces@lists.hsforum.com To: OpenHeart-L@lists.hsforum.com ReplyTo: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Intelligent design Sent: Mar 2, 2010 11:27 PM After doing an opcab on a patient with dextrocardiia I now realise why a left handed heart and a right handed surgeon is a heaven made design. It also made demonstrated the burden carried by my recent lefty trainee. 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 and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- Sent from my Verizon Wireless BlackBerry_______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/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 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 ----------------------------------------- _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/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 Wed Mar 3 08:45:42 2010 From: tacuff at swbell.net (Tea Acuff) Date: Wed Mar 3 11:46:12 2010 Subject: [HSF] Intelligent design OTT Message-ID: <970053.55907.qm@web81602.mail.mud.yahoo.com> We so often fail to note that gamesmanship changes the game. .. To reflect back to my database question. Tea Sent from my iPhone On Mar 3, 2010, at 10:39 AM, Rwmfglycar@aol.com wrote: Unlike in sports which involve hitting a thrown ball with an implement, where left handers appear at the top levels in disproprtionate numbers, and opponents need to make adjustments, I don't suppose the patients are affected one way or another Bob In a message dated 3/3/2010 5:39:18 P.M. South Africa Standard Time, tacuff@swbell.net writes: You can argue the left handed means right brained but that is a "sinister" argument as it is more often wrong. ; ) Tea Sent from my iPhone On Mar 3, 2010, at 6:52 AM, Michael Firstenberg wrote: Hal, I did not know that you are a fellow Southpaw..... now I am really worried. I will take issue with "intelligent design" of the heart and such - we just live in a right handed world, but once you and your team get used to doing thing a little different then there are no issues. Us left handed people, being in their right minds, are just more adaptive (maybe more evolutionarily advanced???) and flexible then you right handed people who cant operate outside of a comfort zone. In fact, I can argue that you right handed people just do everything backwards to begin with.......... -michael On Wed, Mar 3, 2010 at 6:37 AM, Donald Ross wrote: I am sure there are a lot of lefty heart surgeons but I bet left handed gynaecologists don't stand on the patient's right. Also,Hal, I did a double take of "hardcore lefty" till I realised you weren't referring to politics. Don On 03/03/2010, at 9:07 PM, Hgrmd@aol.com wrote: Don, As a hardcore "Lefty", I understand your comments, but I can assure you that the impediment can be managed. Hal ------Original Message------ From: Donald Ross Sender: openheart-l-bounces@lists.hsforum.com To: OpenHeart-L@lists.hsforum.com ReplyTo: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Intelligent design Sent: Mar 2, 2010 11:27 PM After doing an opcab on a patient with dextrocardiia I now realise why a left handed heart and a right handed surgeon is a heaven made design. It also made demonstrated the burden carried by my recent lefty trainee. 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 and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- Sent from my Verizon Wireless BlackBerry_______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/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 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 ----------------------------------------- _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/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 edman63 at hotmail.com Wed Mar 3 11:52:30 2010 From: edman63 at hotmail.com (edgar manrique) Date: Wed Mar 3 11:53:11 2010 Subject: [HSF] subaortic stenosis Message-ID: what is the principal point for obtain few re-stenosis ? in subaortic membrane ?? specific anatomical for resecction?, or? thanks edgar j manrique _________________________________________________________________ Hotmail: Trusted email with powerful SPAM protection. https://signup.live.com/signup.aspx?id=60969 From prasannasimha at gmail.com Wed Mar 3 22:28:17 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Wed Mar 3 11:58:45 2010 Subject: [HSF] subaortic stenosis In-Reply-To: References: Message-ID: <89c4ed2d1003030858r6a7a9beem5d7af82d3497230c@mail.gmail.com> It varies. The membrane can reoccur or there may have been inadequate resection or annular narrowing. You need to reevaluate and consider a reresection and a mini Konno for this if there are no annular issues. Prasanna On Wed, Mar 3, 2010 at 10:22 PM, edgar manrique wrote: > > what is the principal point for obtain few re-stenosis ? in subaortic > membrane ?? > > specific anatomical for resecction?, or? > > thanks > > edgar j manrique > > _________________________________________________________________ > Hotmail: Trusted email with powerful SPAM protection. > > https://signup.live.com/signup.aspx?id=60969_______________________________________________ > OpenHeart-Lmailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 Rwmfglycar at aol.com Wed Mar 3 11:58:35 2010 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Wed Mar 3 11:59:11 2010 Subject: [HSF] Intelligent design Message-ID: <18fbc.349c6788.38bfef3b@aol.com> Denton Cooley (right handed) did mitral valves from the patient's right and aortic valves from the patient's left, and changed sides when doing a double valve.. To me left and right didn't seem much of an issue long as one was equally comfortable with stitching forehand and backhand , understood the value of moving the patient's body around by tilting and tipping the table and changing to the other side of the patient to get under a shelf, Bob In a message dated 3/3/2010 5:22:17 P.M. South Africa Standard Time, tacuff@swbell.net writes: Yes hard core lefties do want to manage everything. Are you sure you know which side that you are on, Don? Tea Sent from my iPhone On Mar 3, 2010, at 5:37 AM, Donald Ross wrote: I am sure there are a lot of lefty heart surgeons but I bet left handed gynaecologists don't stand on the patient's right. Also,Hal, I did a double take of "hardcore lefty" till I realised you weren't referring to politics. Don On 03/03/2010, at 9:07 PM, Hgrmd@aol.com wrote: Don, As a hardcore "Lefty", I understand your comments, but I can assure you that the impediment can be managed. Hal ------Original Message------ From: Donald Ross Sender: openheart-l-bounces@lists.hsforum.com To: OpenHeart-L@lists.hsforum.com ReplyTo: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Intelligent design Sent: Mar 2, 2010 11:27 PM After doing an opcab on a patient with dextrocardiia I now realise why a left handed heart and a right handed surgeon is a heaven made design. It also made demonstrated the burden carried by my recent lefty trainee. 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 and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- Sent from my Verizon Wireless BlackBerry_______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/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 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 ----------------------------------------- From Rwmfglycar at aol.com Wed Mar 3 12:39:58 2010 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Wed Mar 3 12:41:09 2010 Subject: [HSF] subaortic stenosis Message-ID: <1bc00.7e8443b.38bff8ee@aol.com> Excise the membrane completely, in one piece if you can. The pecimen should be a circle or sometimes a U. If there is subaortic muscular hypertrophy do a formal myomectomy at the same time. Bob In a message dated 3/3/2010 6:54:41 P.M. South Africa Standard Time, edman63@hotmail.com writes: what is the principal point for obtain few re-stenosis ? in subaortic membrane ?? specific anatomical for resecction?, or? thanks edgar j manrique _________________________________________________________________ Hotmail: Trusted email with powerful SPAM protection. https://signup.live.com/signup.aspx?id=60969________________________________ _______________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/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 Wed Mar 3 23:17:26 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Wed Mar 3 12:53:06 2010 Subject: [HSF] John Flege ? Message-ID: <89c4ed2d1003030947l7ac50d18t3542a95a22b92c30@mail.gmail.com> John Flege did you publish an article in 1967 wrt transventricular repair of Tetralogy of Fallot along with Johann Ehrenhaft ? Prasanna -- Prasanna Simha M From prasannasimha at gmail.com Wed Mar 3 22:29:16 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Wed Mar 3 13:02:57 2010 Subject: [HSF] subaortic stenosis In-Reply-To: <89c4ed2d1003030858r6a7a9beem5d7af82d3497230c@mail.gmail.com> References: <89c4ed2d1003030858r6a7a9beem5d7af82d3497230c@mail.gmail.com> Message-ID: <89c4ed2d1003030859w939e3c9j2dd8bfd80476736c@mail.gmail.com> Most of us do a small wedge resection of the septum to specifically avoid recurrence. Some would also do a trigonal release as described by Yacoub but I havent really done that over the right trigone though the left is easier. Prasanna 2010/3/3 Prasanna Simha M > It varies. The membrane can reoccur or there may have been inadequate > resection or annular narrowing. You need to reevaluate and consider a > reresection and a mini Konno for this if there are no annular issues. > Prasanna > > On Wed, Mar 3, 2010 at 10:22 PM, edgar manrique wrote: > >> >> what is the principal point for obtain few re-stenosis ? in subaortic >> membrane ?? >> >> specific anatomical for resecction?, or? >> >> thanks >> >> edgar j manrique >> >> _________________________________________________________________ >> Hotmail: Trusted email with powerful SPAM protection. >> >> https://signup.live.com/signup.aspx?id=60969_______________________________________________ >> OpenHeart-Lmailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/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 ichfno at aol.com Wed Mar 3 14:06:18 2010 From: ichfno at aol.com (William M. Novick, M.D.) Date: Wed Mar 3 14:07:04 2010 Subject: [HSF] subaortic stenosis In-Reply-To: References: Message-ID: <8CC891BBD651F72-62F4-3319@webmail-m008.sysops.aol.com> Edgar; It depends, was the original lesion only subaortic stenosis? If yes, then recurrence can occur in up to 15% of the patients. Typically it is secondary to 1- Inadequate primary operation with some of the membrane left behind or 2- the surgeon did not perform septal myomectomy, which has been shown to be important for preventing recurrence. If the LVOT is small then recurrence is more likely and a Modified Konno operation will be necessary to prevent another recurrence. Sincerely, William M. Novick, M.D. Founder, Medical Director, International Children's Heart Foundation 901-869-4243 office 901-432-4243 fax 901-438-9413 cell -----Original Message----- From: edgar manrique To: openheart-l@lists.hsforum.com Sent: Wed, Mar 3, 2010 10:52 am Subject: [HSF] subaortic stenosis hat is the principal point for obtain few re-stenosis ? in subaortic membrane ? specific anatomical for resecction?, or? thanks edgar j manrique ________________________________________________________________ otmail: Trusted email with powerful SPAM protection. ttps://signup.live.com/signup.aspx?id=60969_______________________________________________ penHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: ttp://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and isclaimers posted at: ttp://www.hsforum.com/listdisclaim ---------------------------------------- From msfirst at gmail.com Wed Mar 3 17:43:11 2010 From: msfirst at gmail.com (Michael Firstenberg) Date: Wed Mar 3 17:43:41 2010 Subject: [HSF] Intelligent design In-Reply-To: References: <105823.25055.qm@web81606.mail.mud.yahoo.com> Message-ID: I know how you feel - not easy to train right handed surgeons. -m On Wed, Mar 3, 2010 at 10:22 AM, Salerno, Tomas wrote: > The hardest thing is to train a lefty resident in CT surgery. I have > trained many, there were all excellent. At one time, I was going to write a > manuscript as to how to train left-handed CT residents. Never did, however, > kind of regret it. > > Tomas > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com [mailto: > openheart-l-bounces@lists.hsforum.com] On Behalf Of Tea Acuff > Sent: Wednesday, March 03, 2010 10:19 AM > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] Intelligent design > > Yes hard core lefties do want to manage everything. Are you sure you know > which side that you are on, Don? > Tea > > Sent from my iPhone > > On Mar 3, 2010, at 5:37 AM, Donald Ross wrote: > > I am sure there are a lot of lefty heart surgeons but I bet left handed > gynaecologists don't stand on the patient's right. > Also,Hal, I did a double take of "hardcore lefty" till I realised you > weren't referring to politics. > Don > On 03/03/2010, at 9:07 PM, Hgrmd@aol.com wrote: > > Don, > As a hardcore "Lefty", I understand your comments, but I can assure you > that the impediment can be managed. > > Hal > ------Original Message------ > From: Donald Ross > Sender: openheart-l-bounces@lists.hsforum.com > To: OpenHeart-L@lists.hsforum.com > ReplyTo: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] Intelligent design > Sent: Mar 2, 2010 11:27 PM > > After doing an opcab on a patient with dextrocardiia I now realise why > a left handed heart and a right handed surgeon is a heaven made design. > It also made demonstrated the burden carried by my recent lefty > trainee. > 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 and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > > > Sent from my Verizon Wireless > BlackBerry_______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 > 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 > ----------------------------------------- > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 TSalerno at med.miami.edu Wed Mar 3 17:48:09 2010 From: TSalerno at med.miami.edu (Salerno, Tomas) Date: Wed Mar 3 17:48:42 2010 Subject: [HSF] Intelligent design In-Reply-To: References: <105823.25055.qm@web81606.mail.mud.yahoo.com> Message-ID: Agreed It is hard no matter what hand dominance but rewarding to see them mature and some become leaders Tomas Sent from my iPhone On Mar 3, 2010, at 5:44 PM, "Michael Firstenberg" wrote: > I know how you feel - not easy to train right handed surgeons. > > -m > > > > On Wed, Mar 3, 2010 at 10:22 AM, Salerno, Tomas >wrote: > >> The hardest thing is to train a lefty resident in CT surgery. I have >> trained many, there were all excellent. At one time, I was going to >> write a >> manuscript as to how to train left-handed CT residents. Never did, >> however, >> kind of regret it. >> >> Tomas >> >> -----Original Message----- >> From: openheart-l-bounces@lists.hsforum.com [mailto: >> openheart-l-bounces@lists.hsforum.com] On Behalf Of Tea Acuff >> Sent: Wednesday, March 03, 2010 10:19 AM >> To: OpenHeart-L@lists.hsforum.com >> Subject: Re: [HSF] Intelligent design >> >> Yes hard core lefties do want to manage everything. Are you sure >> you know >> which side that you are on, Don? >> Tea >> >> Sent from my iPhone >> >> On Mar 3, 2010, at 5:37 AM, Donald Ross wrote: >> >> I am sure there are a lot of lefty heart surgeons but I bet left >> handed >> gynaecologists don't stand on the patient's right. >> Also,Hal, I did a double take of "hardcore lefty" till I realised you >> weren't referring to politics. >> Don >> On 03/03/2010, at 9:07 PM, Hgrmd@aol.com wrote: >> >> Don, >> As a hardcore "Lefty", I understand your comments, but I can assure >> you >> that the impediment can be managed. >> >> Hal >> ------Original Message------ >> From: Donald Ross >> Sender: openheart-l-bounces@lists.hsforum.com >> To: OpenHeart-L@lists.hsforum.com >> ReplyTo: OpenHeart-L@lists.hsforum.com >> Subject: Re: [HSF] Intelligent design >> Sent: Mar 2, 2010 11:27 PM >> >> After doing an opcab on a patient with dextrocardiia I now realise >> why >> a left handed heart and a right handed surgeon is a heaven made >> design. >> It also made demonstrated the burden carried by my recent lefty >> trainee. >> 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 and >> disclaimers posted at: >> http://www.hsforum.com/listdisclaim >> ----------------------------------------- >> >> >> Sent from my Verizon Wireless >> BlackBerry_______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/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 >> 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 >> ----------------------------------------- >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/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 toruasai at belle.shiga-med.ac.jp Thu Mar 4 10:17:15 2010 From: toruasai at belle.shiga-med.ac.jp (Tohru Asai) Date: Wed Mar 3 20:17:46 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: Message-ID: Dear members I have a 64 year old female s/p mechanical AVR twice, 7 years ago and 8 years ago. She presented with increased paravalvular leak and partial dehesience.She has been taking steroid. The second operation was done by me. I put SJM prosthesis with usual intraannular technique. I am going to operate on her next week. Any caution or experience, or comments? Tohru From msfirst at gmail.com Wed Mar 3 20:23:33 2010 From: msfirst at gmail.com (Michael Firstenberg) Date: Wed Mar 3 20:24:05 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: References: Message-ID: <64A9C14D-D9D8-48D1-B1D4-E65F69FAE0A4@gmail.com> where is the leak? -michael On Mar 3, 2010, at 8:17 PM, Tohru Asai wrote: > Dear members > > I have a 64 year old female s/p mechanical AVR twice, 7 years ago and 8 > years ago. She presented with increased paravalvular leak and partial > dehesience.She has been taking steroid. The second operation was done by me. > I put SJM prosthesis with usual intraannular technique. > > I am going to operate on her next week. Any caution or experience, or > comments? > > Tohru > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 Thu Mar 4 01:45:52 2010 From: hgrmd at aol.com (hgrmd@aol.com) Date: Wed Mar 3 20:43:52 2010 Subject: [HSF] (OT)lntelligent design In-Reply-To: <1B1D5C1C-0D2E-415C-9095-D5BF60A3FDDE@bigpond.com> References: <2049095138-1267610638-cardhu_decombobulator_blackberry.rim.net-851322516-@bda730.bisx.prod.on.blackberry><1B1D5C1C-0D2E-415C-9095-D5BF60A3FDDE@bigpond.com> Message-ID: <2018131455-1267666944-cardhu_decombobulator_blackberry.rim.net-1480836317-@bda730.bisx.prod.on.blackberry> 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References: <64A9C14D-D9D8-48D1-B1D4-E65F69FAE0A4@gmail.com> Message-ID: <3E7869A2-4B28-4AA0-82F1-DF7DA7915A24@med.miami.edu> If there is no endocarditis we are closing this leak percutaneously with cardiologist Tomas Sent from my iPhone On Mar 3, 2010, at 8:24 PM, "Michael Firstenberg" wrote: > where is the leak? > > -michael > > On Mar 3, 2010, at 8:17 PM, Tohru Asai wrote: > >> Dear members >> >> I have a 64 year old female s/p mechanical AVR twice, 7 years ago >> and 8 >> years ago. She presented with increased paravalvular leak and partial >> dehesience.She has been taking steroid. The second operation was >> done by me. >> I put SJM prosthesis with usual intraannular technique. >> >> I am going to operate on her next week. Any caution or experience, or >> comments? >> >> Tohru >> >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/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 prasannasimha at gmail.com Thu Mar 4 07:52:09 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Wed Mar 3 21:22:37 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: References: Message-ID: <89c4ed2d1003031822t57853bd6xc61a84fff9518a25@mail.gmail.com> Endocarditis ? I have operated on patients with aortoarteritis but havent really seen this problem.Probably may need multiple single sutures.Was the valve that was placed small compared to the annulus (ie very dilated annulus) ? Prasanna 2010/3/4 Tohru Asai > Dear members > > I have a 64 year old female s/p mechanical AVR twice, 7 years ago and 8 > years ago. She presented with increased paravalvular leak and partial > dehesience.She has been taking steroid. The second operation was done by > me. > I put SJM prosthesis with usual intraannular technique. > > I am going to operate on her next week. Any caution or experience, or > comments? > > Tohru > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 ebender001 at me.com Wed Mar 3 20:19:34 2010 From: ebender001 at me.com (Edward Bender) Date: Wed Mar 3 21:24:07 2010 Subject: [HSF] Aberrant RCA Message-ID: I have a 69 year old male with angina, no longer stable, but getting more frequent with less activity. Stress shows inferior EKG changes associated with pain, and reversible inferior ischemia. Cath shows aberrant RCA off the left main, a few mm from ostium, coursing anteriorly between the aorta and PA, then crossing the RVOT to the right AV groove. It is a hyper dominant RCA, and has trivial obstructive disease. I have been asked to do CABG, since cardiologist does not feel PCI would help him. What to do about the native proximal vessel? Should I ligate it? If I do ligate it, I don?t think that an IMA will support the distal circulation acutely, in the same way that a LIMA will not safely replace a patent SVG to the LAD in a redo CABG. Should I just put a very short segment SVG from aorta to coronary and suppose a long term patency? Thanks, Ed Bender, MD From prasannasimha at gmail.com Thu Mar 4 08:06:09 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Wed Mar 3 21:42:27 2010 Subject: [HSF] Aberrant RCA In-Reply-To: <89c4ed2d1003031828j5b0e6a79o58d6b6516f2f25b5@mail.gmail.com> References: <89c4ed2d1003031828j5b0e6a79o58d6b6516f2f25b5@mail.gmail.com> Message-ID: <89c4ed2d1003031836j358a494cl9a755366d06d5bea@mail.gmail.com> Another option is to rerout the RCA ostium but in htis case it would be probably difficult since it is very close to the left main (and from lessons from the arterial switch is a difficult one to transpose) Prasanna On Thu, Mar 4, 2010 at 7:58 AM, Prasanna Simha M wrote: > Actually stenting works very well in this scenario. You can put a graft and > ligate/narrow the proximal RCA.IMA's have also been put to these. This is > often a cause of sudden death in young athletes. > Prasanna > > > On Thu, Mar 4, 2010 at 7:49 AM, Edward Bender wrote: > >> I have a 69 year old male with angina, no longer stable, but getting more >> frequent with less activity. Stress shows inferior EKG changes associated >> with pain, and reversible inferior ischemia. Cath shows aberrant RCA off >> the >> left main, a few mm from ostium, coursing anteriorly between the aorta and >> PA, then crossing the RVOT to the right AV groove. It is a hyper dominant >> RCA, and has trivial obstructive disease. I have been asked to do CABG, >> since cardiologist does not feel PCI would help him. >> >> What to do about the native proximal vessel? Should I ligate it? If I do >> ligate it, I don?t think that an IMA will support the distal circulation >> acutely, in the same way that a LIMA will not safely replace a patent SVG >> to >> the LAD in a redo CABG. Should I just put a very short segment SVG from >> aorta to coronary and suppose a long term patency? >> >> Thanks, >> >> 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 > -- Prasanna Simha M From prasannasimha at gmail.com Thu Mar 4 08:07:47 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Wed Mar 3 22:06:46 2010 Subject: [HSF] Aberrant RCA In-Reply-To: References: Message-ID: <89c4ed2d1003031837x1b80d692l17f2a7d2c499a7e6@mail.gmail.com> http://ats.ctsnetjournals.org/cgi/content/abstract/88/3/844 Prasanna On Thu, Mar 4, 2010 at 7:49 AM, Edward Bender wrote: > I have a 69 year old male with angina, no longer stable, but getting more > frequent with less activity. Stress shows inferior EKG changes associated > with pain, and reversible inferior ischemia. Cath shows aberrant RCA off > the > left main, a few mm from ostium, coursing anteriorly between the aorta and > PA, then crossing the RVOT to the right AV groove. It is a hyper dominant > RCA, and has trivial obstructive disease. I have been asked to do CABG, > since cardiologist does not feel PCI would help him. > > What to do about the native proximal vessel? Should I ligate it? If I do > ligate it, I don?t think that an IMA will support the distal circulation > acutely, in the same way that a LIMA will not safely replace a patent SVG > to > the LAD in a redo CABG. Should I just put a very short segment SVG from > aorta to coronary and suppose a long term patency? > > Thanks, > > 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 donross at bigpond.com Thu Mar 4 14:10:52 2010 From: donross at bigpond.com (Donald Ross) Date: Wed Mar 3 22:15:17 2010 Subject: [HSF] Aberrant RCA In-Reply-To: References: Message-ID: <3EE19B40-734B-436B-A38C-9DA8F9B44063@bigpond.com> Either a dreaded SVG or a rima plus partial occlusion of R main under flow probe control. I think I wound do the former even with my eccentric propensity. Don On 04/03/2010, at 1:19 PM, Edward Bender wrote: > I have a 69 year old male with angina, no longer stable, but getting > more > frequent with less activity. Stress shows inferior EKG changes > associated > with pain, and reversible inferior ischemia. Cath shows aberrant RCA > off the > left main, a few mm from ostium, coursing anteriorly between the > aorta and > PA, then crossing the RVOT to the right AV groove. It is a hyper > dominant > RCA, and has trivial obstructive disease. I have been asked to do > CABG, > since cardiologist does not feel PCI would help him. > > What to do about the native proximal vessel? Should I ligate it? If > I do > ligate it, I don?t think that an IMA will support the distal > circulation > acutely, in the same way that a LIMA will not safely replace a > patent SVG to > the LAD in a redo CABG. Should I just put a very short segment SVG > from > aorta to coronary and suppose a long term patency? > > Thanks, > > 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 edman63 at hotmail.com Wed Mar 3 22:18:50 2010 From: edman63 at hotmail.com (edgar manrique) Date: Wed Mar 3 22:19:18 2010 Subject: [HSF] subaortic stenosis In-Reply-To: <8CC891BBD651F72-62F4-3319@webmail-m008.sysops.aol.com> References: , <8CC891BBD651F72-62F4-3319@webmail-m008.sysops.aol.com> Message-ID: Bill yes is a second surgery but the first was in other institution so, we have not information but your opinion are helpfull thanks edgar j manrique > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] subaortic stenosis > Date: Wed, 3 Mar 2010 14:06:18 -0500 > From: ichfno@aol.com > CC: > > > Edgar; > > It depends, was the original lesion only subaortic stenosis? If yes, then recurrence can occur in up to 15% of the patients. Typically it is secondary to 1- Inadequate primary operation with some of the membrane left behind or 2- the surgeon did not perform septal myomectomy, which has been shown to be important for preventing recurrence. > > If the LVOT is small then recurrence is more likely and a Modified Konno operation will be necessary to prevent another recurrence. > > Sincerely, > > > > William M. Novick, M.D. > Founder, Medical Director, International Children's Heart Foundation > 901-869-4243 office > 901-432-4243 fax > 901-438-9413 cell > > > > > > -----Original Message----- > From: edgar manrique > To: openheart-l@lists.hsforum.com > Sent: Wed, Mar 3, 2010 10:52 am > Subject: [HSF] subaortic stenosis > > > > hat is the principal point for obtain few re-stenosis ? in subaortic membrane > ? > specific anatomical for resecction?, or? > thanks > edgar j manrique > > ________________________________________________________________ > otmail: Trusted email with powerful SPAM protection. > ttps://signup.live.com/signup.aspx?id=60969_______________________________________________ > penHeart-L mailing list > Send postings to: > OpenHeart-L@lists.hsforum.com > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > ttp://mmp.cjp.com/mailman/listinfo/openheart-l > All messages transmitted by the OpenHeart-L are subject to the policies and > isclaimers posted at: > ttp://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 > ----------------------------------------- _________________________________________________________________ Your E-mail and More On-the-Go. Get Windows Live Hotmail Free. https://signup.live.com/signup.aspx?id=60969 From edman63 at hotmail.com Wed Mar 3 22:20:27 2010 From: edman63 at hotmail.com (edgar manrique) Date: Wed Mar 3 22:20:54 2010 Subject: [HSF] subaortic stenosis In-Reply-To: <8CC891BBD651F72-62F4-3319@webmail-m008.sysops.aol.com> References: , <8CC891BBD651F72-62F4-3319@webmail-m008.sysops.aol.com> Message-ID: Bill yes is a second surgery but the first was in other institution so, we have not information but your opinion are helpfull thanks edgar j manrique > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] subaortic stenosis > Date: Wed, 3 Mar 2010 14:06:18 -0500 > From: ichfno@aol.com > CC: > > > Edgar; > > It depends, was the original lesion only subaortic stenosis? If yes, then recurrence can occur in up to 15% of the patients. Typically it is secondary to 1- Inadequate primary operation with some of the membrane left behind or 2- the surgeon did not perform septal myomectomy, which has been shown to be important for preventing recurrence. > > If the LVOT is small then recurrence is more likely and a Modified Konno operation will be necessary to prevent another recurrence. > > Sincerely, > > > > William M. Novick, M.D. > Founder, Medical Director, International Children's Heart Foundation > 901-869-4243 office > 901-432-4243 fax > 901-438-9413 cell > > > > > > -----Original Message----- > From: edgar manrique > To: openheart-l@lists.hsforum.com > Sent: Wed, Mar 3, 2010 10:52 am > Subject: [HSF] subaortic stenosis > > > > hat is the principal point for obtain few re-stenosis ? in subaortic membrane > ? > specific anatomical for resecction?, or? > thanks > edgar j manrique > > ________________________________________________________________ > otmail: Trusted email with powerful SPAM protection. > ttps://signup.live.com/signup.aspx?id=60969_______________________________________________ > penHeart-L mailing list > Send postings to: > OpenHeart-L@lists.hsforum.com > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > ttp://mmp.cjp.com/mailman/listinfo/openheart-l > All messages transmitted by the OpenHeart-L are subject to the policies and > isclaimers posted at: > ttp://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 > ----------------------------------------- _________________________________________________________________ Hotmail: Powerful Free email with security by Microsoft. https://signup.live.com/signup.aspx?id=60969 From jbflegejr at aol.com Wed Mar 3 22:11:30 2010 From: jbflegejr at aol.com (John Flege) Date: Wed Mar 3 22:31:32 2010 Subject: [HSF] Aberrant RCA In-Reply-To: References: Message-ID: <827BE26C-DD73-4E78-BC17-1EB8F098230E@aol.com> Ed, I would go for your final suggestion-SVG from aorta to RCA and don't ligate. Like you, I would not use IMA and ligate RCA proximally. You could probably implant the RCA to the aorta but why chance it at this age. In a young patient maybe. John On Mar 3, 2010, at 9:19 PM, Edward Bender wrote: > I have a 69 year old male with angina, no longer stable, but getting more > frequent with less activity. Stress shows inferior EKG changes associated > with pain, and reversible inferior ischemia. Cath shows aberrant RCA off the > left main, a few mm from ostium, coursing anteriorly between the aorta and > PA, then crossing the RVOT to the right AV groove. It is a hyper dominant > RCA, and has trivial obstructive disease. I have been asked to do CABG, > since cardiologist does not feel PCI would help him. > > What to do about the native proximal vessel? Should I ligate it? If I do > ligate it, I don?t think that an IMA will support the distal circulation > acutely, in the same way that a LIMA will not safely replace a patent SVG to > the LAD in a redo CABG. Should I just put a very short segment SVG from > aorta to coronary and suppose a long term patency? > > Thanks, > > 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 jbflegejr at aol.com Wed Mar 3 22:02:53 2010 From: jbflegejr at aol.com (John Flege) Date: Wed Mar 3 22:31:53 2010 Subject: [HSF] John Flege ? In-Reply-To: <89c4ed2d1003030947l7ac50d18t3542a95a22b92c30@mail.gmail.com> References: <89c4ed2d1003030947l7ac50d18t3542a95a22b92c30@mail.gmail.com> Message-ID: <8E6E2212-4150-4C60-B4AB-90C010D05C0A@aol.com> Yes, Prasanna, I was with Dr. Ehrenhaft at that time. incidentally he died last year at the age of 93. John. On Mar 3, 2010, at 12:47 PM, Prasanna Simha M wrote: > John Flege did you publish an article in 1967 wrt transventricular repair of > Tetralogy of Fallot along with Johann Ehrenhaft ? > Prasanna > > -- > 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 prasannasimha at gmail.com Thu Mar 4 07:58:12 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Thu Mar 4 00:06:43 2010 Subject: [HSF] Aberrant RCA In-Reply-To: References: Message-ID: <89c4ed2d1003031828j5b0e6a79o58d6b6516f2f25b5@mail.gmail.com> Actually stenting works very well in this scenario. You can put a graft and ligate/narrow the proximal RCA.IMA's have also been put to these. This is often a cause of sudden death in young athletes. Prasanna On Thu, Mar 4, 2010 at 7:49 AM, Edward Bender wrote: > I have a 69 year old male with angina, no longer stable, but getting more > frequent with less activity. Stress shows inferior EKG changes associated > with pain, and reversible inferior ischemia. Cath shows aberrant RCA off > the > left main, a few mm from ostium, coursing anteriorly between the aorta and > PA, then crossing the RVOT to the right AV groove. It is a hyper dominant > RCA, and has trivial obstructive disease. I have been asked to do CABG, > since cardiologist does not feel PCI would help him. > > What to do about the native proximal vessel? Should I ligate it? If I do > ligate it, I don?t think that an IMA will support the distal circulation > acutely, in the same way that a LIMA will not safely replace a patent SVG > to > the LAD in a redo CABG. Should I just put a very short segment SVG from > aorta to coronary and suppose a long term patency? > > Thanks, > > 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 Rwmfglycar at aol.com Thu Mar 4 01:12:47 2010 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Thu Mar 4 01:14:00 2010 Subject: [HSF] redo redo AVR for aortitis Message-ID: <473cd.716b1776.38c0a95f@aol.com> How many sutures were placed? Exactly what type were they? We know the valve is intraannular, but: simple?, figure of eight?, horizontal mattress?, everting?, inverting?, pledgets?. How deep were the sutures? i.e. how much tissue did they encircle? Was calcium completely excised the first time?, the second time? Were both ops for paravalvular leak? If so, is the leak now in the same site as the first time? In the absence of endocarditis paravalvar leaks can be attributed to 1)Technique, technique, technique, 2) tissue quality, 3) host healing (in order of importance). If this is a recurrent leak at the same site as it occurred before then I found using a strip of bovine pericardium through which all the sutures are passed before they pass through the tissue (there are several ways to do this) would produce a permanent fix. Bob In a message dated 3/4/2010 3:25:31 A.M. South Africa Standard Time, msfirst@gmail.com writes: where is the leak? -michael On Mar 3, 2010, at 8:17 PM, Tohru Asai wrote: > Dear members > > I have a 64 year old female s/p mechanical AVR twice, 7 years ago and 8 > years ago. She presented with increased paravalvular leak and partial > dehesience.She has been taking steroid. The second operation was done by me. > I put SJM prosthesis with usual intraannular technique. > > I am going to operate on her next week. Any caution or experience, or > comments? > > Tohru > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 donross at bigpond.com Thu Mar 4 17:21:18 2010 From: donross at bigpond.com (Donald Ross) Date: Thu Mar 4 01:25:39 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: <473cd.716b1776.38c0a95f@aol.com> References: <473cd.716b1776.38c0a95f@aol.com> Message-ID: <6388DB95-EDA8-4EB9-AE01-5B0056C919B0@bigpond.com> Bob, Have you ever seen patients dying from repeated para-valvular leaks? I recall one in my training where this happened after the third op and it was attributed to an undetectable infection of some sort. Don On 04/03/2010, at 5:12 PM, Rwmfglycar@aol.com wrote: > How many sutures were placed? > Exactly what type were they? We know the valve is intraannular, but: > simple?, figure of eight?, horizontal mattress?, everting?, > inverting?, > pledgets?. > How deep were the sutures? i.e. how much tissue did they encircle? > Was calcium completely excised the first time?, the second time? > Were both ops for paravalvular leak? > If so, is the leak now in the same site as the first time? > In the absence of endocarditis paravalvar leaks can be attributed to > 1)Technique, technique, technique, 2) tissue quality, 3) host > healing (in > order of importance). > If this is a recurrent leak at the same site as it occurred before > then I > found using a strip of bovine pericardium through which all the > sutures are > passed before they pass through the tissue (there are several ways > to do > this) would produce a permanent fix. > Bob > > > In a message dated 3/4/2010 3:25:31 A.M. South Africa Standard Time, > msfirst@gmail.com writes: > > where is the leak? > > -michael > > On Mar 3, 2010, at 8:17 PM, Tohru Asai wrote: > >> Dear members >> >> I have a 64 year old female s/p mechanical AVR twice, 7 years ago >> and 8 >> years ago. She presented with increased paravalvular leak and >> partial >> dehesience.She has been taking steroid. The second operation was >> done by > me. >> I put SJM prosthesis with usual intraannular technique. >> >> I am going to operate on her next week. Any caution or experience, >> or >> comments? >> >> Tohru >> >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/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 Thu Mar 4 01:45:56 2010 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Thu Mar 4 01:46:52 2010 Subject: [HSF] redo redo AVR for aortitis Message-ID: <47cfd.62d75b66.38c0b124@aol.com> No but I have seen patients being operated on 3 times for the same leak before it was finally fixed. One problem is that the patient goes somewhere else or to another surgeon for the next operation.. I have seen inadequate calcium removal as a cause. Too few sutures was a definite mechanism. The only way to deal with poor tissue given the limitation on depth of suture imposed by nearby vital structures is to use more sutures then usual and reinforce the tissue. My preference for reinforcement was strong biological tissue that encourages host healing (pericardium of course). I saw one total valve dehiscence in which one continuous suture had been was used with one knot. Bob. In a message dated 3/4/2010 8:27:03 A.M. South Africa Standard Time, donross@bigpond.com writes: Bob, Have you ever seen patients dying from repeated para-valvular leaks? I recall one in my training where this happened after the third op and it was attributed to an undetectable infection of some sort. Don On 04/03/2010, at 5:12 PM, Rwmfglycar@aol.com wrote: > How many sutures were placed? > Exactly what type were they? We know the valve is intraannular, but: > simple?, figure of eight?, horizontal mattress?, everting?, > inverting?, > pledgets?. > How deep were the sutures? i.e. how much tissue did they encircle? > Was calcium completely excised the first time?, the second time? > Were both ops for paravalvular leak? > If so, is the leak now in the same site as the first time? > In the absence of endocarditis paravalvar leaks can be attributed to > 1)Technique, technique, technique, 2) tissue quality, 3) host > healing (in > order of importance). > If this is a recurrent leak at the same site as it occurred before > then I > found using a strip of bovine pericardium through which all the > sutures are > passed before they pass through the tissue (there are several ways > to do > this) would produce a permanent fix. > Bob > > > In a message dated 3/4/2010 3:25:31 A.M. South Africa Standard Time, > msfirst@gmail.com writes: > > where is the leak? > > -michael > > On Mar 3, 2010, at 8:17 PM, Tohru Asai wrote: > >> Dear members >> >> I have a 64 year old female s/p mechanical AVR twice, 7 years ago >> and 8 >> years ago. She presented with increased paravalvular leak and >> partial >> dehesience.She has been taking steroid. The second operation was >> done by > me. >> I put SJM prosthesis with usual intraannular technique. >> >> I am going to operate on her next week. Any caution or experience, >> or >> comments? >> >> Tohru >> >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/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 toruasai at belle.shiga-med.ac.jp Thu Mar 4 19:07:48 2010 From: toruasai at belle.shiga-med.ac.jp (Tohru Asai) Date: Thu Mar 4 05:08:10 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: <473cd.716b1776.38c0a95f@aol.com> Message-ID: Michael, Prasanna, Tomas, Don and Bob Thanks for prompt comments. The patient is small Japanese woman (146 cm, 50 kg) known to have Aortitis syndrome (Takayasu's disease) involving total occlusion of the right common carotid artery prior to the first AVR for AR and CHF. The first Surgery was performed with Carbomedicus Tophat 21 or 23 mm by the other surgeon. Perivalvular leak, mainly from the RCC annulus area, became rapidly increased in 4 months, when I was referred for the urgent second operation. The prosthesis was a third dehiscence but the annular tissue looked OK. I thought it was a simply technical problem and replaced with SJM 23 mm prosthesis. No obvious calcification present or no sign of endocarditis. My AVR method: I always go very proximal aortotomy, about 5 to 10 mm above the RCA orifice and very meticulously and completely clean up the annulus if calcium is present ( not in this case). And I choose very large size of prosthesis sometime even cutting down ST junction. Everting mattress sutures with spaghettie (pledget-ike thing) is used for mechanical prosthesis (mostly SJM) and total 12 or more sutures are used usually.I put the suture quite deep to get a part of aortic tissue, In my small series of 400 cases in past 8 years, I have not experienced paravalvular leak more than mild except for this case. After my second AVR, The echo report demonstrated a trivial AR ( not structural). Since then, it took 7 years. She has been on 7.5 mg of Predonisolone PO. No obvious episode of IE, Now she presented with SOB and enlarged CTR, severe AR especially from RCC annulus area ( it was mild AR in last year echo),estimated PASP 41, moderate MR, mild TR. LAD 49 mm, Aortic annulus and ascending is not enlarged too much, although some calcification is seen in the ascending aorta. WBC 10,000, CRP0.7 to 1.2 How would you handle this problem? How would you reinforce the RCC annulus, if it is too fragile, where the conduction tissue running nearby? Mattress suture from outside of aorta in this area? Tohru > How many sutures were placed? > Exactly what type were they? We know the valve is intraannular, but: > simple?, figure of eight?, horizontal mattress?, everting?, inverting?, > pledgets?. > How deep were the sutures? i.e. how much tissue did they encircle? > Was calcium completely excised the first time?, the second time? > Were both ops for paravalvular leak? > If so, is the leak now in the same site as the first time? > In the absence of endocarditis paravalvar leaks can be attributed to > 1)Technique, technique, technique, 2) tissue quality, 3) host healing (in > order of importance). > If this is a recurrent leak at the same site as it occurred before then I > found using a strip of bovine pericardium through which all the sutures are > passed before they pass through the tissue (there are several ways to do > this) would produce a permanent fix. From prasannasimha at gmail.com Thu Mar 4 18:16:41 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Thu Mar 4 07:47:10 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: References: <473cd.716b1776.38c0a95f@aol.com> Message-ID: <89c4ed2d1003040446n5aa9bbdapf4cd8f1b075653bb@mail.gmail.com> Release the aorta, take sutures from outside in or patch the paravalvar leak with goretex/pericardium. Prasanna 2010/3/4 Tohru Asai > Michael, Prasanna, Tomas, Don and Bob > Thanks for prompt comments. > > The patient is small Japanese woman (146 cm, 50 kg) known to have Aortitis > syndrome (Takayasu's disease) involving total occlusion of the right common > carotid artery prior to the first AVR for AR and CHF. The first Surgery was > performed with Carbomedicus Tophat 21 or 23 mm by the other surgeon. > Perivalvular leak, mainly from the RCC annulus area, became rapidly > increased in 4 months, when I was referred for the urgent second operation. > > The prosthesis was a third dehiscence but the annular tissue looked OK. I > thought it was a simply technical problem and replaced with SJM 23 mm > prosthesis. No obvious calcification present or no sign of endocarditis. > My AVR method: I always go very proximal aortotomy, about 5 to 10 mm above > the RCA orifice and very meticulously and completely clean up the annulus > if > calcium is present ( not in this case). And I choose very large size of > prosthesis sometime even cutting down ST junction. Everting mattress > sutures > with spaghettie (pledget-ike thing) is used for mechanical prosthesis > (mostly SJM) and total 12 or more sutures are used usually.I put the suture > quite deep to get a part of aortic tissue, In my small series of 400 cases > in past 8 years, I have not experienced paravalvular leak more than mild > except for this case. > > After my second AVR, The echo report demonstrated a trivial AR ( not > structural). Since then, it took 7 years. She has been on 7.5 mg of > Predonisolone PO. No obvious episode of IE, Now she presented with SOB and > enlarged CTR, severe AR especially from RCC annulus area ( it was mild AR > in > last year echo),estimated PASP 41, moderate MR, mild TR. LAD 49 mm, Aortic > annulus and ascending is not enlarged too much, although some calcification > is seen in the ascending aorta. WBC 10,000, CRP0.7 to 1.2 > > How would you handle this problem? How would you reinforce the RCC annulus, > if it is too fragile, where the conduction tissue running nearby? Mattress > suture from outside of aorta in this area? > > Tohru > > > > How many sutures were placed? > > Exactly what type were they? We know the valve is intraannular, but: > > simple?, figure of eight?, horizontal mattress?, everting?, inverting?, > > pledgets?. > > How deep were the sutures? i.e. how much tissue did they encircle? > > Was calcium completely excised the first time?, the second time? > > Were both ops for paravalvular leak? > > If so, is the leak now in the same site as the first time? > > In the absence of endocarditis paravalvar leaks can be attributed to > > 1)Technique, technique, technique, 2) tissue quality, 3) host healing > (in > > order of importance). > > If this is a recurrent leak at the same site as it occurred before then I > > found using a strip of bovine pericardium through which all the sutures > are > > passed before they pass through the tissue (there are several ways to do > > this) would produce a permanent fix. > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 Thu Mar 4 18:19:19 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Thu Mar 4 07:54:54 2010 Subject: [HSF] John Flege ? In-Reply-To: <8E6E2212-4150-4C60-B4AB-90C010D05C0A@aol.com> References: <89c4ed2d1003030947l7ac50d18t3542a95a22b92c30@mail.gmail.com> <8E6E2212-4150-4C60-B4AB-90C010D05C0A@aol.com> Message-ID: <89c4ed2d1003040449g2a8c49ecn2e892c313aba08c6@mail.gmail.com> Thanks for the info. I was doing some literature search wrt Tetralogy and saw your name !! Prasanna On Thu, Mar 4, 2010 at 8:32 AM, John Flege wrote: > Yes, Prasanna, I was with Dr. Ehrenhaft at that time. incidentally he died > last year at the age of 93. John. > On Mar 3, 2010, at 12:47 PM, Prasanna Simha M wrote: > > > John Flege did you publish an article in 1967 wrt transventricular repair > of > > Tetralogy of Fallot along with Johann Ehrenhaft ? > > Prasanna > > > > -- > > 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 > ----------------------------------------- > -- Prasanna Simha M From msfirst at gmail.com Thu Mar 4 07:58:53 2010 From: msfirst at gmail.com (Michael Firstenberg) Date: Thu Mar 4 08:29:52 2010 Subject: [HSF] John Flege ? In-Reply-To: <89c4ed2d1003040449g2a8c49ecn2e892c313aba08c6@mail.gmail.com> References: <89c4ed2d1003030947l7ac50d18t3542a95a22b92c30@mail.gmail.com> <8E6E2212-4150-4C60-B4AB-90C010D05C0A@aol.com> <89c4ed2d1003040449g2a8c49ecn2e892c313aba08c6@mail.gmail.com> Message-ID: Professor flege As a sign of my utmost respect for your accomplishments - I am obligated to mention that I was not even born at that time. -michael/iPhone On Mar 4, 2010, at 7:49 AM, Prasanna Simha M wrote: > Thanks for the info. I was doing some literature search wrt > Tetralogy and > saw your name !! > Prasanna > > On Thu, Mar 4, 2010 at 8:32 AM, John Flege wrote: > >> Yes, Prasanna, I was with Dr. Ehrenhaft at that time. incidentally >> he died >> last year at the age of 93. John. >> On Mar 3, 2010, at 12:47 PM, Prasanna Simha M wrote: >> >>> John Flege did you publish an article in 1967 wrt transventricular >>> repair >> of >>> Tetralogy of Fallot along with Johann Ehrenhaft ? >>> Prasanna >>> >>> -- >>> 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 >> ----------------------------------------- >> > > > > -- > 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 msfirst at gmail.com Thu Mar 4 09:04:54 2010 From: msfirst at gmail.com (Michael Firstenberg) Date: Thu Mar 4 09:05:06 2010 Subject: [HSF] Burt? Message-ID: <4E192017-91FE-45EF-902D-CEB707F7AC52@gmail.com> Hal You've been quiet. Bandit your patient? -michael/iPhone From grescigno at mac.com Thu Mar 4 14:59:41 2010 From: grescigno at mac.com (Giuseppe Rescigno) Date: Thu Mar 4 09:09:18 2010 Subject: [HSF] John Flege ? In-Reply-To: References: <89c4ed2d1003030947l7ac50d18t3542a95a22b92c30@mail.gmail.com> <8E6E2212-4150-4C60-B4AB-90C010D05C0A@aol.com> <89c4ed2d1003040449g2a8c49ecn2e892c313aba08c6@mail.gmail.com> Message-ID: <662B8AE2-8CD2-435E-AC9D-A8F19A9E1B5B@mac.com> I was 4 yo (very happy period!) Giuseppe Il giorno 04/mar/10, alle ore 13:58, Michael Firstenberg ha scritto: > Professor flege > As a sign of my utmost respect for your accomplishments - I am > obligated to mention that I was not even born at that time. > > -michael/iPhone > > On Mar 4, 2010, at 7:49 AM, Prasanna Simha M > wrote: > >> Thanks for the info. I was doing some literature search wrt >> Tetralogy and >> saw your name !! >> Prasanna >> >> On Thu, Mar 4, 2010 at 8:32 AM, John Flege wrote: >> >>> Yes, Prasanna, I was with Dr. Ehrenhaft at that time. >>> incidentally he died >>> last year at the age of 93. John. >>> On Mar 3, 2010, at 12:47 PM, Prasanna Simha M wrote: >>> >>>> John Flege did you publish an article in 1967 wrt >>>> transventricular repair >>> of >>>> Tetralogy of Fallot along with Johann Ehrenhaft ? >>>> Prasanna >>>> >>>> -- >>>> 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 >>> ----------------------------------------- >>> >> >> >> >> -- >> 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 anddisclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- From hgrmd at aol.com Thu Mar 4 14:49:21 2010 From: hgrmd at aol.com (hgrmd@aol.com) Date: Thu Mar 4 09:47:19 2010 Subject: [HSF] Burt? Message-ID: <1837365371-1267713950-cardhu_decombobulator_blackberry.rim.net-502340623-@bda730.bisx.prod.on.blackberry> Michael, Huh? Hal ------Original Message------ From: Michael Firstenberg Sender: openheart-l-bounces@lists.hsforum.com To: OpenHeart-L@lists.hsforum.com ReplyTo: OpenHeart-L@lists.hsforum.com Subject: [HSF] Burt? Sent: Mar 4, 2010 9:04 AM Hal You've been quiet. Bandit your patient? -michael/iPhone _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/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 BlackBerry From jrodriguezcampos at yahoo.com Thu Mar 4 07:16:07 2010 From: jrodriguezcampos at yahoo.com (Jorge Rodriguez Campos) Date: Thu Mar 4 10:17:36 2010 Subject: [HSF] Aberrant RCA In-Reply-To: <827BE26C-DD73-4E78-BC17-1EB8F098230E@aol.com> References: <827BE26C-DD73-4E78-BC17-1EB8F098230E@aol.com> Message-ID: <616150.8895.qm@web51408.mail.re2.yahoo.com> I am in agreement with John, cut vein segment between the aorta and the coronary right and I am certainly is of long durability in this particular case, high flow, excellent and ample runnoff distal, artery without atherosclerosis, short segment, I have been having a realized similar case 23 years ago and she stays permeable and without injuries. - Dr. Jorge F. Rodriguez Campos ________________________________ De: John Flege Para: OpenHeart-L@lists.hsforum.com Enviado: jue, marzo 4, 2010 1:11:30 AM Asunto: Re: [HSF] Aberrant RCA Ed, I would go for your final suggestion-SVG from aorta to RCA and don't ligate. Like you, I would not use IMA and ligate RCA proximally. You could probably implant the RCA to the aorta but why chance it at this age. In a young patient maybe. John On Mar 3, 2010, at 9:19 PM, Edward Bender wrote: > I have a 69 year old male with angina, no longer stable, but getting more > frequent with less activity. Stress shows inferior EKG changes associated > with pain, and reversible inferior ischemia. Cath shows aberrant RCA off the > left main, a few mm from ostium, coursing anteriorly between the aorta and > PA, then crossing the RVOT to the right AV groove. It is a hyper dominant > RCA, and has trivial obstructive disease. I have been asked to do CABG, > since cardiologist does not feel PCI would help him. > > What to do about the native proximal vessel? Should I ligate it? If I do > ligate it, I don?t think that an IMA will support the distal circulation > acutely, in the same way that a LIMA will not safely replace a patent SVG to > the LAD in a redo CABG. Should I just put a very short segment SVG from > aorta to coronary and suppose a long term patency? > > Thanks, > > 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 ----------------------------------------- ____________________________________________________________________________________ ?Obt?n la mejor experiencia en la web! Descarga gratis el nuevo Internet Explorer 8. http://downloads.yahoo.com/ieak8/?l=e1 From msfirst at gmail.com Thu Mar 4 10:23:32 2010 From: msfirst at gmail.com (Michael Firstenberg) Date: Thu Mar 4 10:30:16 2010 Subject: [HSF] Burt? In-Reply-To: <1837365371-1267713950-cardhu_decombobulator_blackberry.rim.net-502340623-@bda730.bisx.prod.on.blackberry> References: <1837365371-1267713950-cardhu_decombobulator_blackberry.rim.net-502340623-@bda730.bisx.prod.on.blackberry> Message-ID: <650217F5-FE3F-4FD0-A07A-8E8573B8E7BB@gmail.com> Burt reynolds has a cabg in Florida (Miami?) recently. I know you are in FLA broward but to us neophytes that is close enough. -michael/iPhone On Mar 4, 2010, at 9:49 AM, hgrmd@aol.com wrote: > Michael, > Huh? > > Hal > ------Original Message------ > From: Michael Firstenberg > Sender: openheart-l-bounces@lists.hsforum.com > To: OpenHeart-L@lists.hsforum.com > ReplyTo: OpenHeart-L@lists.hsforum.com > Subject: [HSF] Burt? > Sent: Mar 4, 2010 9:04 AM > > Hal > You've been quiet. Bandit your patient? > > -michael/iPhone > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 BlackBerry > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 Thu Mar 4 10:40:52 2010 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Thu Mar 4 10:42:00 2010 Subject: [HSF] John Flege ? Message-ID: <593f3.7227ba24.38c12e84@aol.com> One day Michael, if you continue thinking and questioning and searching for the grail, some youngster will, with awe and respect, say the same about you and you can tell him "I have been so lucky following the road I took. I hope you will have the same". John, I knew Hans and intermittently had most enjoyable exchanges with him. I remember VSD with prolapsing aortic leaflet was a subject we exchanged views on. Was he a good teacher? Bob In a message dated 3/4/2010 3:31:02 P.M. South Africa Standard Time, msfirst@gmail.com writes: Professor flege As a sign of my utmost respect for your accomplishments - I am obligated to mention that I was not even born at that time. -michael/iPhone On Mar 4, 2010, at 7:49 AM, Prasanna Simha M wrote: > Thanks for the info. I was doing some literature search wrt > Tetralogy and > saw your name !! > Prasanna > > On Thu, Mar 4, 2010 at 8:32 AM, John Flege wrote: > >> Yes, Prasanna, I was with Dr. Ehrenhaft at that time. incidentally >> he died >> last year at the age of 93. John. >> On Mar 3, 2010, at 12:47 PM, Prasanna Simha M wrote: >> >>> John Flege did you publish an article in 1967 wrt transventricular >>> repair >> of >>> Tetralogy of Fallot along with Johann Ehrenhaft ? >>> Prasanna >>> >>> -- >>> 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 >> ----------------------------------------- >> > > > > -- > 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 Rwmfglycar at aol.com Thu Mar 4 11:42:31 2010 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Thu Mar 4 11:43:15 2010 Subject: [HSF] redo redo AVR for aortitis Message-ID: <5df55.3e00a131.38c13cf7@aol.com> Dear Tohru, It seems you have a good technique for avoiding perivalvar leak.12 mattress sutures for the size patient you have should be good. In this case tissue quality is the factor. But note that the recurrence is where it was the first time. I have seen this before. Your idea of bringing the sutures through from outside is excellent. You need to get about 3mm of aorta exposed proximal to the RCA orifice to be able to pass the sutures horizontally though the bolster strip and though the base of the sinus into the sewing ring, avoiding the conducting tissue. I don't have to tell you .that this is "tiger" country and it may be impossible to expose properly without removing the whole valve. A soft coronary perfusion catheter in the right coronary will be a help. Once the dissection is done probably 4 or 5 horizontal mattress sutures passed through the bolster strip will produce a cure. My bias in these cases was to avoid removing the valve and just be patient about getting optimal exposure. We probably can declare that tissue quality is dominant in the etiology of the recurrent leak. Your previous suture technique for the rest of the annulus has worked. When the tissue is at fault you need more of it with each bite for the sutures to hold. Perhaps your sutures at the second operation were a little tentative because of your knowledge of the conducting system close by. Nevertheless it worked for 2/3 of the diseased annulus. Why disturb the part that has worked already? This area will demand placing the needles at a different angle on the needle driver for each mattress suture and passage through strip/tissue and ring will be separate actions.Be sure that each suture emerges on the inside well below the coronary orifice. What I am describing worked for me. I do not have large numbers but as surgeon of last resort in my department I would get these cases. Best of luck Bob In a message dated 3/4/2010 12:09:21 P.M. South Africa Standard Time, toruasai@belle.shiga-med.ac.jp writes: Michael, Prasanna, Tomas, Don and Bob Thanks for prompt comments. The patient is small Japanese woman (146 cm, 50 kg) known to have Aortitis syndrome (Takayasu's disease) involving total occlusion of the right common carotid artery prior to the first AVR for AR and CHF. The first Surgery was performed with Carbomedicus Tophat 21 or 23 mm by the other surgeon. Perivalvular leak, mainly from the RCC annulus area, became rapidly increased in 4 months, when I was referred for the urgent second operation. The prosthesis was a third dehiscence but the annular tissue looked OK. I thought it was a simply technical problem and replaced with SJM 23 mm prosthesis. No obvious calcification present or no sign of endocarditis. My AVR method: I always go very proximal aortotomy, about 5 to 10 mm above the RCA orifice and very meticulously and completely clean up the annulus if calcium is present ( not in this case). And I choose very large size of prosthesis sometime even cutting down ST junction. Everting mattress sutures with spaghettie (pledget-ike thing) is used for mechanical prosthesis (mostly SJM) and total 12 or more sutures are used usually.I put the suture quite deep to get a part of aortic tissue, In my small series of 400 cases in past 8 years, I have not experienced paravalvular leak more than mild except for this case. After my second AVR, The echo report demonstrated a trivial AR ( not structural). Since then, it took 7 years. She has been on 7.5 mg of Predonisolone PO. No obvious episode of IE, Now she presented with SOB and enlarged CTR, severe AR especially from RCC annulus area ( it was mild AR in last year echo),estimated PASP 41, moderate MR, mild TR. LAD 49 mm, Aortic annulus and ascending is not enlarged too much, although some calcification is seen in the ascending aorta. WBC 10,000, CRP0.7 to 1.2 How would you handle this problem? How would you reinforce the RCC annulus, if it is too fragile, where the conduction tissue running nearby? Mattress suture from outside of aorta in this area? Tohru > How many sutures were placed? > Exactly what type were they? We know the valve is intraannular, but: > simple?, figure of eight?, horizontal mattress?, everting?, inverting?, > pledgets?. > How deep were the sutures? i.e. how much tissue did they encircle? > Was calcium completely excised the first time?, the second time? > Were both ops for paravalvular leak? > If so, is the leak now in the same site as the first time? > In the absence of endocarditis paravalvar leaks can be attributed to > 1)Technique, technique, technique, 2) tissue quality, 3) host healing (in > order of importance). > If this is a recurrent leak at the same site as it occurred before then I > found using a strip of bovine pericardium through which all the sutures are > passed before they pass through the tissue (there are several ways to do > this) would produce a permanent fix. _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/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 grescigno at mac.com Thu Mar 4 17:33:38 2010 From: grescigno at mac.com (Giuseppe Rescigno) Date: Thu Mar 4 11:43:24 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: <47cfd.62d75b66.38c0b124@aol.com> References: <47cfd.62d75b66.38c0b124@aol.com> Message-ID: Bob, have you any exeperience/opinions on Cormatrix? Our pediatric surgeon is using it liberally with very good results. Giuseppe Il giorno 04/mar/10, alle ore 07:45, Rwmfglycar@aol.com ha scritto: > No but I have seen patients being operated on 3 times for the same > leak > before it was finally fixed. One problem is that the patient goes > somewhere > else or to another surgeon for the next operation.. I have seen > inadequate > calcium removal as a cause. Too few sutures was a definite > mechanism. The > only way to deal with poor tissue given the limitation on depth of > suture > imposed by nearby vital structures is to use more sutures then > usual and > reinforce the tissue. My preference for reinforcement was strong > biological > tissue that encourages host healing (pericardium of course). > I saw one total valve dehiscence in which one continuous suture > had been > was used with one knot. > Bob. > > > In a message dated 3/4/2010 8:27:03 A.M. South Africa Standard Time, > donross@bigpond.com writes: > > Bob, > Have you ever seen patients dying from repeated para-valvular leaks? > I recall one in my training where this happened after the third op > and > it was attributed to an undetectable infection of some sort. > Don > On 04/03/2010, at 5:12 PM, Rwmfglycar@aol.com wrote: > >> How many sutures were placed? >> Exactly what type were they? We know the valve is intraannular, but: >> simple?, figure of eight?, horizontal mattress?, everting?, >> inverting?, >> pledgets?. >> How deep were the sutures? i.e. how much tissue did they encircle? >> Was calcium completely excised the first time?, the second time? >> Were both ops for paravalvular leak? >> If so, is the leak now in the same site as the first time? >> In the absence of endocarditis paravalvar leaks can be attributed to >> 1)Technique, technique, technique, 2) tissue quality, 3) host >> healing (in >> order of importance). >> If this is a recurrent leak at the same site as it occurred before >> then I >> found using a strip of bovine pericardium through which all the >> sutures are >> passed before they pass through the tissue (there are several ways >> to do >> this) would produce a permanent fix. >> Bob >> >> >> In a message dated 3/4/2010 3:25:31 A.M. South Africa Standard Time, >> msfirst@gmail.com writes: >> >> where is the leak? >> >> -michael >> >> On Mar 3, 2010, at 8:17 PM, Tohru Asai wrote: >> >>> Dear members >>> >>> I have a 64 year old female s/p mechanical AVR twice, 7 years ago >>> and 8 >>> years ago. She presented with increased paravalvular leak and >>> partial >>> dehesience.She has been taking steroid. The second operation was >>> done by >> me. >>> I put SJM prosthesis with usual intraannular technique. >>> >>> I am going to operate on her next week. Any caution or experience, >>> or >>> comments? >>> >>> Tohru >>> >>> >>> _______________________________________________ >>> OpenHeart-L mailing list >>> >>> Send postings to: >>> OpenHeart-L@lists.hsforum.com >>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>> http://mmp.cjp.com/mailman/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 ebender001 at me.com Thu Mar 4 10:49:37 2010 From: ebender001 at me.com (Edward Bender) Date: Thu Mar 4 11:50:41 2010 Subject: [HSF] Aberrant RCA In-Reply-To: <616150.8895.qm@web51408.mail.re2.yahoo.com> References: <827BE26C-DD73-4E78-BC17-1EB8F098230E@aol.com> <616150.8895.qm@web51408.mail.re2.yahoo.com> Message-ID: <11116422494694383682102337379562020287-Webmail@me.com> Thanks to all who responded. Did a SVG to RCA. Ed Bender, MD On Thursday, March 04, 2010, at 09:16AM, "Jorge Rodriguez Campos" wrote: >I am in agreement with John, cut vein segment between the aorta and the coronary right and I am certainly is of long durability in this particular case, high flow, excellent and ample runnoff distal, artery without atherosclerosis, short segment, I have been having a realized similar case 23 years ago and she stays permeable and without injuries. - > > Dr. Jorge F. Rodriguez Campos > > > > >________________________________ >De: John Flege >Para: OpenHeart-L@lists.hsforum.com >Enviado: jue, marzo 4, 2010 1:11:30 AM >Asunto: Re: [HSF] Aberrant RCA > >Ed, I would go for your final suggestion-SVG from aorta to RCA and don't ligate. Like you, I would not use IMA and ligate RCA proximally. You could probably implant the RCA to the aorta but why chance it at this age. In a young patient maybe. John >On Mar 3, 2010, at 9:19 PM, Edward Bender wrote: > >> I have a 69 year old male with angina, no longer stable, but getting more >> frequent with less activity. Stress shows inferior EKG changes associated >> with pain, and reversible inferior ischemia. Cath shows aberrant RCA off the >> left main, a few mm from ostium, coursing anteriorly between the aorta and >> PA, then crossing the RVOT to the right AV groove. It is a hyper dominant >> RCA, and has trivial obstructive disease. I have been asked to do CABG, >> since cardiologist does not feel PCI would help him. >> >> What to do about the native proximal vessel? Should I ligate it? If I do >> ligate it, I don?t think that an IMA will support the distal circulation >> acutely, in the same way that a LIMA will not safely replace a patent SVG to >> the LAD in a redo CABG. Should I just put a very short segment SVG from >> aorta to coronary and suppose a long term patency? >> >> Thanks, >> >> 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 >----------------------------------------- > > > > ____________________________________________________________________________________ >?Obt?n la mejor experiencia en la web! >Descarga gratis el nuevo Internet Explorer 8. >http://downloads.yahoo.com/ieak8/?l=e1 >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: > OpenHeart-L@lists.hsforum.com > >To UNSUBSCRIBE, to CHANGE email address, or to view archives: >http://mmp.cjp.com/mailman/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 Thu Mar 4 13:45:12 2010 From: msfirst at gmail.com (Michael Firstenberg) Date: Thu Mar 4 13:50:45 2010 Subject: [HSF] John Flege ? In-Reply-To: <593f3.7227ba24.38c12e84@aol.com> References: <593f3.7227ba24.38c12e84@aol.com> Message-ID: Dr Frater - I hope and will take your comments as a complement as I feel very lucky to stand on the shoulders of such great giants - obviously yourself included! -michael On Thu, Mar 4, 2010 at 10:40 AM, wrote: > One day Michael, if you continue thinking and questioning and searching for > the grail, some youngster will, with awe and respect, say the same about > you and you can tell him "I have been so lucky following the road I took. > I > hope you will have the same". > John, I knew Hans and intermittently had most enjoyable exchanges with him. > I remember VSD with prolapsing aortic leaflet was a subject we exchanged > views on. Was he a good teacher? > Bob > > > In a message dated 3/4/2010 3:31:02 P.M. South Africa Standard Time, > msfirst@gmail.com writes: > > Professor flege > As a sign of my utmost respect for your accomplishments - I am > obligated to mention that I was not even born at that time. > > -michael/iPhone > > On Mar 4, 2010, at 7:49 AM, Prasanna Simha M > wrote: > > > Thanks for the info. I was doing some literature search wrt > > Tetralogy and > > saw your name !! > > Prasanna > > > > On Thu, Mar 4, 2010 at 8:32 AM, John Flege wrote: > > > >> Yes, Prasanna, I was with Dr. Ehrenhaft at that time. incidentally > >> he died > >> last year at the age of 93. John. > >> On Mar 3, 2010, at 12:47 PM, Prasanna Simha M wrote: > >> > >>> John Flege did you publish an article in 1967 wrt transventricular > >>> repair > >> of > >>> Tetralogy of Fallot along with Johann Ehrenhaft ? > >>> Prasanna > >>> > >>> -- > >>> 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 > >> ----------------------------------------- > >> > > > > > > > > -- > > 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 Rwmfglycar at aol.com Thu Mar 4 15:53:14 2010 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Thu Mar 4 15:54:33 2010 Subject: [HSF] redo redo AVR for aortitis Message-ID: <6eeb6.5b66cc0f.38c177ba@aol.com> Not yet. I plan an animal study soon Bob In a message dated 3/4/2010 6:45:53 P.M. South Africa Standard Time, grescigno@mac.com writes: Bob, have you any exeperience/opinions on Cormatrix? Our pediatric surgeon is using it liberally with very good results. Giuseppe Il giorno 04/mar/10, alle ore 07:45, Rwmfglycar@aol.com ha scritto: > No but I have seen patients being operated on 3 times for the same > leak > before it was finally fixed. One problem is that the patient goes > somewhere > else or to another surgeon for the next operation.. I have seen > inadequate > calcium removal as a cause. Too few sutures was a definite > mechanism. The > only way to deal with poor tissue given the limitation on depth of > suture > imposed by nearby vital structures is to use more sutures then > usual and > reinforce the tissue. My preference for reinforcement was strong > biological > tissue that encourages host healing (pericardium of course). > I saw one total valve dehiscence in which one continuous suture > had been > was used with one knot. > Bob. > > > In a message dated 3/4/2010 8:27:03 A.M. South Africa Standard Time, > donross@bigpond.com writes: > > Bob, > Have you ever seen patients dying from repeated para-valvular leaks? > I recall one in my training where this happened after the third op > and > it was attributed to an undetectable infection of some sort. > Don > On 04/03/2010, at 5:12 PM, Rwmfglycar@aol.com wrote: > >> How many sutures were placed? >> Exactly what type were they? We know the valve is intraannular, but: >> simple?, figure of eight?, horizontal mattress?, everting?, >> inverting?, >> pledgets?. >> How deep were the sutures? i.e. how much tissue did they encircle? >> Was calcium completely excised the first time?, the second time? >> Were both ops for paravalvular leak? >> If so, is the leak now in the same site as the first time? >> In the absence of endocarditis paravalvar leaks can be attributed to >> 1)Technique, technique, technique, 2) tissue quality, 3) host >> healing (in >> order of importance). >> If this is a recurrent leak at the same site as it occurred before >> then I >> found using a strip of bovine pericardium through which all the >> sutures are >> passed before they pass through the tissue (there are several ways >> to do >> this) would produce a permanent fix. >> Bob >> >> >> In a message dated 3/4/2010 3:25:31 A.M. South Africa Standard Time, >> msfirst@gmail.com writes: >> >> where is the leak? >> >> -michael >> >> On Mar 3, 2010, at 8:17 PM, Tohru Asai wrote: >> >>> Dear members >>> >>> I have a 64 year old female s/p mechanical AVR twice, 7 years ago >>> and 8 >>> years ago. She presented with increased paravalvular leak and >>> partial >>> dehesience.She has been taking steroid. The second operation was >>> done by >> me. >>> I put SJM prosthesis with usual intraannular technique. >>> >>> I am going to operate on her next week. Any caution or experience, >>> or >>> comments? >>> >>> Tohru >>> >>> >>> _______________________________________________ >>> OpenHeart-L mailing list >>> >>> Send postings to: >>> OpenHeart-L@lists.hsforum.com >>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>> http://mmp.cjp.com/mailman/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 gabuin at intramed.net Thu Mar 4 19:29:23 2010 From: gabuin at intramed.net (gustavo abuin) Date: Thu Mar 4 17:30:10 2010 Subject: [HSF] redo redo AVR for aortitis References: Message-ID: <002101cabbea$26819b90$3fd9e818@toshibauser> Here are two photos of the heart conduction system from the left side. The lateral wall of the left ventricle is open and we can see the left aspect of the septum, the aortic valve and the anterior mitral valve. In one photo an asterisk is at the level of the membranous septum. LAB AND LPB are the anterior and posterior branches of the left bundle of His (no midle branch in these two sepcimens). The right coronary cusp is far from the conduction tissues. The non coronary sinus is near the left bundle, which is protected by the right fibrous trigone. Hope this help. gustavo. ----- Original Message ----- From: "Tohru Asai" To: Sent: Thursday, March 04, 2010 7:07 AM Subject: Re: [HSF] redo redo AVR for aortitis > Michael, Prasanna, Tomas, Don and Bob > Thanks for prompt comments. > > The patient is small Japanese woman (146 cm, 50 kg) known to have Aortitis > syndrome (Takayasu's disease) involving total occlusion of the right common > carotid artery prior to the first AVR for AR and CHF. The first Surgery was > performed with Carbomedicus Tophat 21 or 23 mm by the other surgeon. > Perivalvular leak, mainly from the RCC annulus area, became rapidly > increased in 4 months, when I was referred for the urgent second operation. > > The prosthesis was a third dehiscence but the annular tissue looked OK. I > thought it was a simply technical problem and replaced with SJM 23 mm > prosthesis. No obvious calcification present or no sign of endocarditis. > My AVR method: I always go very proximal aortotomy, about 5 to 10 mm above > the RCA orifice and very meticulously and completely clean up the annulus if > calcium is present ( not in this case). And I choose very large size of > prosthesis sometime even cutting down ST junction. Everting mattress sutures > with spaghettie (pledget-ike thing) is used for mechanical prosthesis > (mostly SJM) and total 12 or more sutures are used usually.I put the suture > quite deep to get a part of aortic tissue, In my small series of 400 cases > in past 8 years, I have not experienced paravalvular leak more than mild > except for this case. > > After my second AVR, The echo report demonstrated a trivial AR ( not > structural). Since then, it took 7 years. She has been on 7.5 mg of > Predonisolone PO. No obvious episode of IE, Now she presented with SOB and > enlarged CTR, severe AR especially from RCC annulus area ( it was mild AR in > last year echo),estimated PASP 41, moderate MR, mild TR. LAD 49 mm, Aortic > annulus and ascending is not enlarged too much, although some calcification > is seen in the ascending aorta. WBC 10,000, CRP0.7 to 1.2 > > How would you handle this problem? How would you reinforce the RCC annulus, > if it is too fragile, where the conduction tissue running nearby? Mattress > suture from outside of aorta in this area? > > Tohru > > >> How many sutures were placed? >> Exactly what type were they? We know the valve is intraannular, but: >> simple?, figure of eight?, horizontal mattress?, everting?, inverting?, >> pledgets?. >> How deep were the sutures? i.e. how much tissue did they encircle? >> Was calcium completely excised the first time?, the second time? >> Were both ops for paravalvular leak? >> If so, is the leak now in the same site as the first time? >> In the absence of endocarditis paravalvar leaks can be attributed to >> 1)Technique, technique, technique, 2) tissue quality, 3) host healing (in >> order of importance). >> If this is a recurrent leak at the same site as it occurred before then I >> found using a strip of bovine pericardium through which all the sutures are >> passed before they pass through the tissue (there are several ways to do >> this) would produce a permanent fix. > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/listinfo/openheart-l > > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- -------------- next part -------------- A non-text attachment was scrubbed... Name: LEFT BUNDLE AND AORTIC CUSPS FOR TOHRU.jpg Type: image/jpeg Size: 26993 bytes Desc: not available Url : http://mmp.cjp.com/pipermail/openheart-l/attachments/20100304/1c9f5f22/LEFTBUNDLEANDAORTICCUSPSFORTOHRU-0001.jpg -------------- next part -------------- A non-text attachment was scrubbed... Name: PHOTO 2 LEFT BUNDLE GROSSLY DISSECTED.JPG Type: image/jpeg Size: 35699 bytes Desc: not available Url : http://mmp.cjp.com/pipermail/openheart-l/attachments/20100304/1c9f5f22/PHOTO2LEFTBUNDLEGROSSLYDISSECTED-0001.jpe From donross at bigpond.com Fri Mar 5 15:08:59 2010 From: donross at bigpond.com (Donald Ross) Date: Thu Mar 4 23:13:36 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: <5df55.3e00a131.38c13cf7@aol.com> References: <5df55.3e00a131.38c13cf7@aol.com> Message-ID: Tohru, I am interested in your decision to use everting mattress sutures for aortic valve replacement. There was a paper, years ago, testing the strength of various valve replacement suturing techniques and mattress sutures placed from the ventricular side , through the annulus tissue and then the prosthesis proved to be the strongest . They sewed the valves in animals and measured how much force was required to rip them out. How many other members use everting sutures or AVR Don On 05/03/2010, at 3:42 AM, Rwmfglycar@aol.com wrote: > Dear Tohru, > It seems you have a good technique for avoiding perivalvar leak.12 > mattress > sutures for the size patient you have should be good. In this case > tissue > quality is the factor. But note that the recurrence is where it was > the > first time. I have seen this before. Your idea of bringing the > sutures through > from outside is excellent. You need to get about 3mm of aorta > exposed > proximal to the RCA orifice to be able to pass the sutures > horizontally though > the bolster strip and though the base of the sinus into the sewing > ring, > avoiding the conducting tissue. I don't have to tell you .that this > is > "tiger" country and it may be impossible to expose properly without > removing > the whole valve. A soft coronary perfusion catheter in the right > coronary > will be a help. Once the dissection is done probably 4 or 5 > horizontal > mattress sutures passed through the bolster strip will produce a > cure. My bias in > these cases was to avoid removing the valve and just be patient about > getting optimal exposure. We probably can declare that tissue > quality is > dominant in the etiology of the recurrent leak. Your previous > suture technique > for the rest of the annulus has worked. When the tissue is at > fault you need > more of it with each bite for the sutures to hold. Perhaps your > sutures > at the second operation were a little tentative because of your > knowledge of > the conducting system close by. Nevertheless it worked for 2/3 of the > diseased annulus. Why disturb the part that has worked already? > This area will demand placing the needles at a different angle on the > needle driver for each mattress suture and passage through strip/ > tissue and > ring will be separate actions.Be sure that each suture emerges on > the inside > well below the coronary orifice. > What I am describing worked for me. I do not have large numbers > but as > surgeon of last resort in my department I would get these cases. > Best of luck > Bob > > > > In a message dated 3/4/2010 12:09:21 P.M. South Africa Standard Time, > toruasai@belle.shiga-med.ac.jp writes: > > Michael, Prasanna, Tomas, Don and Bob > Thanks for prompt comments. > > The patient is small Japanese woman (146 cm, 50 kg) known to have > Aortitis > syndrome (Takayasu's disease) involving total occlusion of the > right common > carotid artery prior to the first AVR for AR and CHF. The first > Surgery > was > performed with Carbomedicus Tophat 21 or 23 mm by the other surgeon. > Perivalvular leak, mainly from the RCC annulus area, became rapidly > increased in 4 months, when I was referred for the urgent second > operation. > > The prosthesis was a third dehiscence but the annular tissue looked > OK. I > thought it was a simply technical problem and replaced with SJM 23 mm > prosthesis. No obvious calcification present or no sign of > endocarditis. > My AVR method: I always go very proximal aortotomy, about 5 to 10 > mm above > the RCA orifice and very meticulously and completely clean up the > annulus > if > calcium is present ( not in this case). And I choose very large > size of > prosthesis sometime even cutting down ST junction. Everting mattress > sutures > with spaghettie (pledget-ike thing) is used for mechanical prosthesis > (mostly SJM) and total 12 or more sutures are used usually.I put > the suture > quite deep to get a part of aortic tissue, In my small series of > 400 cases > in past 8 years, I have not experienced paravalvular leak more than > mild > except for this case. > > After my second AVR, The echo report demonstrated a trivial AR ( not > structural). Since then, it took 7 years. She has been on 7.5 mg of > Predonisolone PO. No obvious episode of IE, Now she presented with > SOB and > enlarged CTR, severe AR especially from RCC annulus area ( it was > mild AR > in > last year echo),estimated PASP 41, moderate MR, mild TR. LAD 49 mm, > Aortic > annulus and ascending is not enlarged too much, although some > calcification > is seen in the ascending aorta. WBC 10,000, CRP0.7 to 1.2 > > How would you handle this problem? How would you reinforce the RCC > annulus, > if it is too fragile, where the conduction tissue running nearby? > Mattress > suture from outside of aorta in this area? > > Tohru > > >> How many sutures were placed? >> Exactly what type were they? We know the valve is intraannular, but: >> simple?, figure of eight?, horizontal mattress?, everting?, >> inverting?, >> pledgets?. >> How deep were the sutures? i.e. how much tissue did they encircle? >> Was calcium completely excised the first time?, the second time? >> Were both ops for paravalvular leak? >> If so, is the leak now in the same site as the first time? >> In the absence of endocarditis paravalvar leaks can be attributed to >> 1)Technique, technique, technique, 2) tissue quality, 3) host >> healing > (in >> order of importance). >> If this is a recurrent leak at the same site as it occurred before >> then I >> found using a strip of bovine pericardium through which all the >> sutures > are >> passed before they pass through the tissue (there are several ways >> to do >> this) would produce a permanent fix. > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 Thu Mar 4 20:26:00 2010 From: tacuff at swbell.net (Tea Acuff) Date: Thu Mar 4 23:26:27 2010 Subject: [HSF] redo redo AVR for aortitis Message-ID: <572004.36143.qm@web81608.mail.mud.yahoo.com> I do what you describe: subannular, supraannular, then sewing ring. Especially if one uses a valve that sits supraannular the line of force is linear on the suture. If one uses a smaller intraannular valve everting should do the same. However once or twice whether one counts patients or valves out of 400 speaks for itself. Tea Sent from my iPhone On Mar 4, 2010, at 10:08 PM, Donald Ross wrote: Tohru, I am interested in your decision to use everting mattress sutures for aortic valve replacement. There was a paper, years ago, testing the strength of various valve replacement suturing techniques and mattress sutures placed from the ventricular side , through the annulus tissue and then the prosthesis proved to be the strongest . They sewed the valves in animals and measured how much force was required to rip them out. How many other members use everting sutures or AVR Don On 05/03/2010, at 3:42 AM, Rwmfglycar@aol.com wrote: Dear Tohru, It seems you have a good technique for avoiding perivalvar leak.12 mattress sutures for the size patient you have should be good. In this case tissue quality is the factor. But note that the recurrence is where it was the first time. I have seen this before. Your idea of bringing the sutures through from outside is excellent. You need to get about 3mm of aorta exposed proximal to the RCA orifice to be able to pass the sutures horizontally though the bolster strip and though the base of the sinus into the sewing ring, avoiding the conducting tissue. I don't have to tell you .that this is "tiger" country and it may be impossible to expose properly without removing the whole valve. A soft coronary perfusion catheter in the right coronary will be a help. Once the dissection is done probably 4 or 5 horizontal mattress sutures passed through the bolster strip will produce a cure. My bias in these cases was to avoid removing the valve and just be patient about getting optimal exposure. We probably can declare that tissue quality is dominant in the etiology of the recurrent leak. Your previous suture technique for the rest of the annulus has worked. When the tissue is at fault you need more of it with each bite for the sutures to hold. Perhaps your sutures at the second operation were a little tentative because of your knowledge of the conducting system close by. Nevertheless it worked for 2/3 of the diseased annulus. Why disturb the part that has worked already? This area will demand placing the needles at a different angle on the needle driver for each mattress suture and passage through strip/tissue and ring will be separate actions.Be sure that each suture emerges on the inside well below the coronary orifice. What I am describing worked for me. I do not have large numbers but as surgeon of last resort in my department I would get these cases. Best of luck Bob In a message dated 3/4/2010 12:09:21 P.M. South Africa Standard Time, toruasai@belle.shiga-med.ac.jp writes: Michael, Prasanna, Tomas, Don and Bob Thanks for prompt comments. The patient is small Japanese woman (146 cm, 50 kg) known to have Aortitis syndrome (Takayasu's disease) involving total occlusion of the right common carotid artery prior to the first AVR for AR and CHF. The first Surgery was performed with Carbomedicus Tophat 21 or 23 mm by the other surgeon. Perivalvular leak, mainly from the RCC annulus area, became rapidly increased in 4 months, when I was referred for the urgent second operation. The prosthesis was a third dehiscence but the annular tissue looked OK. I thought it was a simply technical problem and replaced with SJM 23 mm prosthesis. No obvious calcification present or no sign of endocarditis. My AVR method: I always go very proximal aortotomy, about 5 to 10 mm above the RCA orifice and very meticulously and completely clean up the annulus if calcium is present ( not in this case). And I choose very large size of prosthesis sometime even cutting down ST junction. Everting mattress sutures with spaghettie (pledget-ike thing) is used for mechanical prosthesis (mostly SJM) and total 12 or more sutures are used usually.I put the suture quite deep to get a part of aortic tissue, In my small series of 400 cases in past 8 years, I have not experienced paravalvular leak more than mild except for this case. After my second AVR, The echo report demonstrated a trivial AR ( not structural). Since then, it took 7 years. She has been on 7.5 mg of Predonisolone PO. No obvious episode of IE, Now she presented with SOB and enlarged CTR, severe AR especially from RCC annulus area ( it was mild AR in last year echo),estimated PASP 41, moderate MR, mild TR. LAD 49 mm, Aortic annulus and ascending is not enlarged too much, although some calcification is seen in the ascending aorta. WBC 10,000, CRP0.7 to 1.2 How would you handle this problem? How would you reinforce the RCC annulus, if it is too fragile, where the conduction tissue running nearby? Mattress suture from outside of aorta in this area? Tohru How many sutures were placed? Exactly what type were they? We know the valve is intraannular, but: simple?, figure of eight?, horizontal mattress?, everting?, inverting?, pledgets?. How deep were the sutures? i.e. how much tissue did they encircle? Was calcium completely excised the first time?, the second time? Were both ops for paravalvular leak? If so, is the leak now in the same site as the first time? In the absence of endocarditis paravalvar leaks can be attributed to 1)Technique, technique, technique, 2) tissue quality, 3) host healing (in order of importance). If this is a recurrent leak at the same site as it occurred before then I found using a strip of bovine pericardium through which all the sutures are passed before they pass through the tissue (there are several ways to do this) would produce a permanent fix. _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/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 anddisclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From toruasai at belle.shiga-med.ac.jp Fri Mar 5 14:08:39 2010 From: toruasai at belle.shiga-med.ac.jp (Tohru Asai) Date: Fri Mar 5 00:09:10 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: <5df55.3e00a131.38c13cf7@aol.com> Message-ID: Dear Bob, Thank you for very informative and educational advices. A few more questions I would like to ask. 1. Everting mattress suturing method may be harmful to this kind of tissue quality related (or suspected) cases? If it is so, maybe supraannular implantation with horizontal mattress or simple interrupted suture technique is better than the everting method? Because I was wondering that the everting method bring the annular tissue more stress, and maybe causing a little tissue cutting compared to other two methods. Should I have avoided the everting method? I learned the everting horizontal mattress for mechanical and non-everting supra-annular for bioprosthesis about 20 years ago for regular cases in my training. Do you do that in the same way? Or simple interruption is more natural, non-stressful to annular tissue? 2. Aortitis Syndrome (Takayasu's disease) may be uncommon in western countries. ( In fact, Dr. Takayasu was Dean of my graduating medical school of Kanazawa University about 100 years ago. He was a ophthalmologist.)So let's change the situation. If tissue factors are suspected with other diseases such as Bachet disease, when you have a patient with dehesiece of prosthetic valve, how would you handle the problem differently? 3. About choice of a prosthesis, as you know the sewing ring of mechanical prosthesis is a flat circle and rigid. On the other hand, stented bioprosthesis has more natural 3 dimentional annular shape, and not as stiff as mechanical valve. And stentless bioprosthesis can be applied with more flexibility of its annular character. Probably homograft is more ideal in this regard. Do you think or know the difference with regard to incidence of dehesience in this kind of setting? Thank you again in advance. Tohru > Dear Tohru, > It seems you have a good technique for avoiding perivalvar leak.12 mattress > sutures for the size patient you have should be good. In this case tissue > quality is the factor. But note that the recurrence is where it was the > first time. I have seen this before. Your idea of bringing the sutures > through > from outside is excellent. You need to get about 3mm of aorta exposed > proximal to the RCA orifice to be able to pass the sutures horizontally though > the bolster strip and though the base of the sinus into the sewing ring, > avoiding the conducting tissue. I don't have to tell you .that this is > "tiger" country and it may be impossible to expose properly without removing > the whole valve. A soft coronary perfusion catheter in the right coronary > will be a help. Once the dissection is done probably 4 or 5 horizontal > mattress sutures passed through the bolster strip will produce a cure. My > bias in > these cases was to avoid removing the valve and just be patient about > getting optimal exposure. We probably can declare that tissue quality is > dominant in the etiology of the recurrent leak. Your previous suture > technique > for the rest of the annulus has worked. When the tissue is at fault you need > more of it with each bite for the sutures to hold. Perhaps your sutures > at the second operation were a little tentative because of your knowledge of > the conducting system close by. Nevertheless it worked for 2/3 of the > diseased annulus. Why disturb the part that has worked already? > This area will demand placing the needles at a different angle on the > needle driver for each mattress suture and passage through strip/tissue and > ring will be separate actions.Be sure that each suture emerges on the inside > well below the coronary orifice. > What I am describing worked for me. I do not have large numbers but as > surgeon of last resort in my department I would get these cases. > Best of luck > Bob From toruasai at belle.shiga-med.ac.jp Fri Mar 5 14:12:36 2010 From: toruasai at belle.shiga-med.ac.jp (Tohru Asai) Date: Fri Mar 5 00:12:54 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: <002101cabbea$26819b90$3fd9e818@toshibauser> Message-ID: Dear Gustavo, Great help. Many thanks. These are great photos.Now I can be confidently take a good bit of suture. Tohru > Here are two photos of the heart conduction system from the left side. > The lateral wall of the left ventricle is open and we can see the left aspect > of the septum, the aortic valve and the anterior mitral valve. > In one photo an asterisk is at the level of the membranous septum. > LAB AND LPB are the anterior and posterior branches of the left bundle of His > (no midle branch in these two sepcimens). > The right coronary cusp is far from the conduction tissues. The non coronary > sinus is near the left bundle, which is protected by the right fibrous > trigone. > Hope this help. > gustavo. From toruasai at belle.shiga-med.ac.jp Fri Mar 5 14:18:27 2010 From: toruasai at belle.shiga-med.ac.jp (Tohru Asai) Date: Fri Mar 5 00:19:17 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: <89c4ed2d1003040446n5aa9bbdapf4cd8f1b075653bb@mail.gmail.com> Message-ID: Thank you,Prasanna. > Release the aorta, Release the aorta from where? I think you meant I should separate the proximal aortic wall from RV outflow muscle as we do for the root implantation method. Correct? By the way, Have you had aortitis syndrom in your Indian patient population? Or cases with the tissue problem like this with other causes? Such as Bachet? Tohru From toruasai at belle.shiga-med.ac.jp Fri Mar 5 14:21:46 2010 From: toruasai at belle.shiga-med.ac.jp (Tohru Asai) Date: Fri Mar 5 00:22:36 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: Message-ID: Dear Giuseppe, What is Cormatrix for? > have you any exeperience/opinions on Cormatrix? Our pediatric surgeon > is using it liberally with very good results. > > Giuseppe P.S. I appreciated you like my DVD. Sorry for late reply. I would answer you for GEA questions later. Grazie Tohru From toruasai at belle.shiga-med.ac.jp Fri Mar 5 14:31:03 2010 From: toruasai at belle.shiga-med.ac.jp (Tohru Asai) Date: Fri Mar 5 00:31:25 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: Message-ID: Dear Don, Just I am old fashioned, still doing exactly the same way that I learned at NYU 20 years ago. Have not had any problem with the technique for most of cases. But number of mechanical prosthesis is strikingly decreased as biologic valve increased (which I implant as you describe as such mattress sutures placed from the ventricular side, through the annulus tissue and then the prosthesis). Please tell me the reference which describes your story if you can find. Thank you in advance. I am also interested in the method to implant prosthetic valve by each HSF member. Tohru > Tohru, > I am interested in your decision to use everting mattress sutures for > aortic valve replacement. > There was a paper, years ago, testing the strength of various valve > replacement suturing techniques > and mattress sutures placed from the ventricular side , through the > annulus tissue and then the prosthesis proved to be the strongest . > They sewed the valves in animals and measured how much force was > required to rip them out. > How many other members use everting sutures or AVR > Don From donross at bigpond.com Fri Mar 5 17:16:08 2010 From: donross at bigpond.com (Donald Ross) Date: Fri Mar 5 01:19:27 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: References: Message-ID: Tohru, I am sorry I can't oblige with the reference. It could be thirty year old and even beyond the scope of our professor. I remember it because the everting technique was used by one of my bosses and since I thought it illogical, the paper was welcome. I think prosthetic valves which have a leaflet descending below the plane of the annulus can have a problem with buttresses on the inflow side.( I always used simple sutures for Bjok and Med Hall valves ) Perhaps this is the reason why everting sutures were popular. Don On 05/03/2010, at 4:31 PM, Tohru Asai wrote: > Dear Don, > Just I am old fashioned, still doing exactly the same way that I > learned at > NYU 20 years ago. Have not had any problem with the technique for > most of > cases. But number of mechanical prosthesis is strikingly decreased as > biologic valve increased (which I implant as you describe as such > mattress > sutures placed from the ventricular side, through the annulus > tissue and > then the prosthesis). > > Please tell me the reference which describes your story if you can > find. > Thank you in advance. > > I am also interested in the method to implant prosthetic valve by > each HSF > member. > Tohru > >> Tohru, >> I am interested in your decision to use everting mattress sutures for >> aortic valve replacement. >> There was a paper, years ago, testing the strength of various valve >> replacement suturing techniques >> and mattress sutures placed from the ventricular side , through the >> annulus tissue and then the prosthesis proved to be the strongest . >> They sewed the valves in animals and measured how much force was >> required to rip them out. >> How many other members use everting sutures or 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 and > disclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- From prasannasimha at gmail.com Fri Mar 5 12:58:15 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Fri Mar 5 02:52:59 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: References: <002101cabbea$26819b90$3fd9e818@toshibauser> Message-ID: <89c4ed2d1003042328n599fed41ne4a4f79582d0ebdb@mail.gmail.com> We do get aortoarteritis (though more often for peripheral occlusion and occasionally for aortic valve replacement. Incidentaly I now always place mysutures from LV annuluys to sewing rim type of mattress sutures.Seems to hold well and also decreased pannus formation. I avoid pledgets as far as possible. Prasanna On 3/5/10, Tohru Asai wrote: > Dear Gustavo, > Great help. Many thanks. These are great photos.Now I can be confidently > take a good bit of suture. > Tohru > >> Here are two photos of the heart conduction system from the left side. >> The lateral wall of the left ventricle is open and we can see the left >> aspect >> of the septum, the aortic valve and the anterior mitral valve. >> In one photo an asterisk is at the level of the membranous septum. >> LAB AND LPB are the anterior and posterior branches of the left bundle of >> His >> (no midle branch in these two sepcimens). >> The right coronary cusp is far from the conduction tissues. The non >> coronary >> sinus is near the left bundle, which is protected by the right fibrous >> trigone. >> Hope this help. >> gustavo. > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 Rwmfglycar at aol.com Fri Mar 5 03:09:49 2010 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Fri Mar 5 03:10:32 2010 Subject: [HSF] redo redo AVR for aortitis Message-ID: <8cde5.229562be.38c2164d@aol.com> Very good Gustavo and so important to remind us that classical anatomy remains a vital obligatory part of the knowledge we need to function. (Ya, ya, ya here the preacher goes again). However we do need also to remember that previous surgery and the postoperative healing/scarring that accompanies it can distort the previously normal anatomy. That is why I advocate horizontal sutures from outside in the special circumstance we are discussing. Bob In a message dated 3/5/2010 12:31:59 A.M. South Africa Standard Time, gabuin@intramed.net writes: Here are two photos of the heart conduction system from the left side. The lateral wall of the left ventricle is open and we can see the left aspect of the septum, the aortic valve and the anterior mitral valve. In one photo an asterisk is at the level of the membranous septum. LAB AND LPB are the anterior and posterior branches of the left bundle of His (no midle branch in these two sepcimens). The right coronary cusp is far from the conduction tissues. The non coronary sinus is near the left bundle, which is protected by the right fibrous trigone. Hope this help. gustavo. ----- Original Message ----- From: "Tohru Asai" To: Sent: Thursday, March 04, 2010 7:07 AM Subject: Re: [HSF] redo redo AVR for aortitis > Michael, Prasanna, Tomas, Don and Bob > Thanks for prompt comments. > > The patient is small Japanese woman (146 cm, 50 kg) known to have Aortitis > syndrome (Takayasu's disease) involving total occlusion of the right common > carotid artery prior to the first AVR for AR and CHF. The first Surgery was > performed with Carbomedicus Tophat 21 or 23 mm by the other surgeon. > Perivalvular leak, mainly from the RCC annulus area, became rapidly > increased in 4 months, when I was referred for the urgent second operation. > > The prosthesis was a third dehiscence but the annular tissue looked OK. I > thought it was a simply technical problem and replaced with SJM 23 mm > prosthesis. No obvious calcification present or no sign of endocarditis. > My AVR method: I always go very proximal aortotomy, about 5 to 10 mm above > the RCA orifice and very meticulously and completely clean up the annulus if > calcium is present ( not in this case). And I choose very large size of > prosthesis sometime even cutting down ST junction. Everting mattress sutures > with spaghettie (pledget-ike thing) is used for mechanical prosthesis > (mostly SJM) and total 12 or more sutures are used usually.I put the suture > quite deep to get a part of aortic tissue, In my small series of 400 cases > in past 8 years, I have not experienced paravalvular leak more than mild > except for this case. > > After my second AVR, The echo report demonstrated a trivial AR ( not > structural). Since then, it took 7 years. She has been on 7.5 mg of > Predonisolone PO. No obvious episode of IE, Now she presented with SOB and > enlarged CTR, severe AR especially from RCC annulus area ( it was mild AR in > last year echo),estimated PASP 41, moderate MR, mild TR. LAD 49 mm, Aortic > annulus and ascending is not enlarged too much, although some calcification > is seen in the ascending aorta. WBC 10,000, CRP0.7 to 1.2 > > How would you handle this problem? How would you reinforce the RCC annulus, > if it is too fragile, where the conduction tissue running nearby? Mattress > suture from outside of aorta in this area? > > Tohru > > >> How many sutures were placed? >> Exactly what type were they? We know the valve is intraannular, but: >> simple?, figure of eight?, horizontal mattress?, everting?, inverting?, >> pledgets?. >> How deep were the sutures? i.e. how much tissue did they encircle? >> Was calcium completely excised the first time?, the second time? >> Were both ops for paravalvular leak? >> If so, is the leak now in the same site as the first time? >> In the absence of endocarditis paravalvar leaks can be attributed to >> 1)Technique, technique, technique, 2) tissue quality, 3) host healing (in >> order of importance). >> If this is a recurrent leak at the same site as it occurred before then I >> found using a strip of bovine pericardium through which all the sutures are >> passed before they pass through the tissue (there are several ways to do >> this) would produce a permanent fix. > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 Fri Mar 5 03:25:56 2010 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Fri Mar 5 03:27:03 2010 Subject: [HSF] redo redo AVR for aortitis Message-ID: <8d0cc.32e29e7a.38c21a14@aol.com> There was a paper on suture pullout strength. Are you sure it was not done on the mitral annulus? I don't have the reference but my memory tells me the senior author (not the first author) was Quentin Stiles and I think his son may have been one of the coauthors. Again , I am relying on an all too fallible memory, but I don't recall that everting mattress was the strongest. It was a fashion in NY in the 70's. I used it for a while but I never liked it because it forced tissues into unnatural and unanatomical positions. What I have just said is, of course, stupid if this is a technique that guarantees absence of perivalvar leaks. Since we were measuring intraoperative gradients and outputs in every case we knew that the valves we were using were leaving our patients with a degree of obstruction, and we were getting the least out of the available tissue orifice because this technique forces an intraannular replacement. At that time our solution was liberal root enlargement. Later using pledgetted mattresses from the ventricular side which allows supraannular placement along the bases of the sinuses (but not at the interleaflet triangles), allowed better use of the tissue orifice relative to the available flow orifice of the device. The orifice that the valve provides for a given mounting size is design dependent and newer designs of both tissue and mechanical valves have improved the internal -mounting orfice ratio. I will discuss the relationship of suture technique to prevention of paravalvar leaks in another post. For now I hope we can agree that the load on the suture line is definable and that the more sutures that are used, the narrower the gaps will be and and the lighter the load on any one suture and the tissue it embraces. Bob In a message dated 3/5/2010 6:27:55 A.M. South Africa Standard Time, tacuff@swbell.net writes: I do what you describe: subannular, supraannular, then sewing ring. Especially if one uses a valve that sits supraannular the line of force is linear on the suture. If one uses a smaller intraannular valve everting should do the same. However once or twice whether one counts patients or valves out of 400 speaks for itself. Tea Sent from my iPhone On Mar 4, 2010, at 10:08 PM, Donald Ross wrote: Tohru, I am interested in your decision to use everting mattress sutures for aortic valve replacement. There was a paper, years ago, testing the strength of various valve replacement suturing techniques and mattress sutures placed from the ventricular side , through the annulus tissue and then the prosthesis proved to be the strongest . They sewed the valves in animals and measured how much force was required to rip them out. How many other members use everting sutures or AVR Don On 05/03/2010, at 3:42 AM, Rwmfglycar@aol.com wrote: Dear Tohru, It seems you have a good technique for avoiding perivalvar leak.12 mattress sutures for the size patient you have should be good. In this case tissue quality is the factor. But note that the recurrence is where it was the first time. I have seen this before. Your idea of bringing the sutures through from outside is excellent. You need to get about 3mm of aorta exposed proximal to the RCA orifice to be able to pass the sutures horizontally though the bolster strip and though the base of the sinus into the sewing ring, avoiding the conducting tissue. I don't have to tell you .that this is "tiger" country and it may be impossible to expose properly without removing the whole valve. A soft coronary perfusion catheter in the right coronary will be a help. Once the dissection is done probably 4 or 5 horizontal mattress sutures passed through the bolster strip will produce a cure. My bias in these cases was to avoid removing the valve and just be patient about getting optimal exposure. We probably can declare that tissue quality is dominant in the etiology of the recurrent leak. Your previous suture technique for the rest of the annulus has worked. When the tissue is at fault you need more of it with each bite for the sutures to hold. Perhaps your sutures at the second operation were a little tentative because of your knowledge of the conducting system close by. Nevertheless it worked for 2/3 of the diseased annulus. Why disturb the part that has worked already? This area will demand placing the needles at a different angle on the needle driver for each mattress suture and passage through strip/tissue and ring will be separate actions.Be sure that each suture emerges on the inside well below the coronary orifice. What I am describing worked for me. I do not have large numbers but as surgeon of last resort in my department I would get these cases. Best of luck Bob In a message dated 3/4/2010 12:09:21 P.M. South Africa Standard Time, toruasai@belle.shiga-med.ac.jp writes: Michael, Prasanna, Tomas, Don and Bob Thanks for prompt comments. The patient is small Japanese woman (146 cm, 50 kg) known to have Aortitis syndrome (Takayasu's disease) involving total occlusion of the right common carotid artery prior to the first AVR for AR and CHF. The first Surgery was performed with Carbomedicus Tophat 21 or 23 mm by the other surgeon. Perivalvular leak, mainly from the RCC annulus area, became rapidly increased in 4 months, when I was referred for the urgent second operation. The prosthesis was a third dehiscence but the annular tissue looked OK. I thought it was a simply technical problem and replaced with SJM 23 mm prosthesis. No obvious calcification present or no sign of endocarditis. My AVR method: I always go very proximal aortotomy, about 5 to 10 mm above the RCA orifice and very meticulously and completely clean up the annulus if calcium is present ( not in this case). And I choose very large size of prosthesis sometime even cutting down ST junction. Everting mattress sutures with spaghettie (pledget-ike thing) is used for mechanical prosthesis (mostly SJM) and total 12 or more sutures are used usually.I put the suture quite deep to get a part of aortic tissue, In my small series of 400 cases in past 8 years, I have not experienced paravalvular leak more than mild except for this case. After my second AVR, The echo report demonstrated a trivial AR ( not structural). Since then, it took 7 years. She has been on 7.5 mg of Predonisolone PO. No obvious episode of IE, Now she presented with SOB and enlarged CTR, severe AR especially from RCC annulus area ( it was mild AR in last year echo),estimated PASP 41, moderate MR, mild TR. LAD 49 mm, Aortic annulus and ascending is not enlarged too much, although some calcification is seen in the ascending aorta. WBC 10,000, CRP0.7 to 1.2 How would you handle this problem? How would you reinforce the RCC annulus, if it is too fragile, where the conduction tissue running nearby? Mattress suture from outside of aorta in this area? Tohru How many sutures were placed? Exactly what type were they? We know the valve is intraannular, but: simple?, figure of eight?, horizontal mattress?, everting?, inverting?, pledgets?. How deep were the sutures? i.e. how much tissue did they encircle? Was calcium completely excised the first time?, the second time? Were both ops for paravalvular leak? If so, is the leak now in the same site as the first time? In the absence of endocarditis paravalvar leaks can be attributed to 1)Technique, technique, technique, 2) tissue quality, 3) host healing (in order of importance). If this is a recurrent leak at the same site as it occurred before then I found using a strip of bovine pericardium through which all the sutures are passed before they pass through the tissue (there are several ways to do this) would produce a permanent fix. _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/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 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 ----------------------------------------- From gabuin at intramed.net Fri Mar 5 08:46:05 2010 From: gabuin at intramed.net (gustavo abuin) Date: Fri Mar 5 06:47:04 2010 Subject: [HSF] redo redo AVR for aortitis References: <8cde5.229562be.38c2164d@aol.com> Message-ID: <003501cabc59$72ba3e80$3fd9e818@toshibauser> Agree Bob. Anatomy is only one tool. Another tip is that the the His bundle in human hearts are located predominantly from the right side of the septum (80% of the cases). So, this natural protection against cardiac surgeons needles seems work very well!!! The horizontal sutures are a good tool too. gustavo,. ----- Original Message ----- From: To: Sent: Friday, March 05, 2010 5:09 AM Subject: Re: [HSF] redo redo AVR for aortitis > Very good Gustavo and so important to remind us that classical anatomy > remains a vital obligatory part of the knowledge we need to function. (Ya, > ya, > ya here the preacher goes again). However we do need also to remember that > previous surgery and the postoperative healing/scarring that accompanies > it > can distort the previously normal anatomy. That is why I advocate > horizontal sutures from outside in the special circumstance we are > discussing. > > Bob > > In a message dated 3/5/2010 12:31:59 A.M. South Africa Standard Time, > gabuin@intramed.net writes: > > Here are two photos of the heart conduction system from the left side. > The lateral wall of the left ventricle is open and we can see the left > aspect of the septum, the aortic valve and the anterior mitral valve. > In one photo an asterisk is at the level of the membranous septum. > LAB AND LPB are the anterior and posterior branches of the left bundle of > His (no midle branch in these two sepcimens). > The right coronary cusp is far from the conduction tissues. The non > coronary sinus is near the left bundle, which is protected by the right > fibrous > trigone. > Hope this help. > gustavo. > > ----- Original Message ----- > From: "Tohru Asai" > To: > Sent: Thursday, March 04, 2010 7:07 AM > Subject: Re: [HSF] redo redo AVR for aortitis > > >> Michael, Prasanna, Tomas, Don and Bob >> Thanks for prompt comments. >> >> The patient is small Japanese woman (146 cm, 50 kg) known to have > Aortitis >> syndrome (Takayasu's disease) involving total occlusion of the right > common >> carotid artery prior to the first AVR for AR and CHF. The first Surgery > was >> performed with Carbomedicus Tophat 21 or 23 mm by the other surgeon. >> Perivalvular leak, mainly from the RCC annulus area, became rapidly >> increased in 4 months, when I was referred for the urgent second > operation. >> >> The prosthesis was a third dehiscence but the annular tissue looked OK. >> I >> thought it was a simply technical problem and replaced with SJM 23 mm >> prosthesis. No obvious calcification present or no sign of endocarditis. >> My AVR method: I always go very proximal aortotomy, about 5 to 10 mm > above >> the RCA orifice and very meticulously and completely clean up the > annulus if >> calcium is present ( not in this case). And I choose very large size of >> prosthesis sometime even cutting down ST junction. Everting mattress > sutures >> with spaghettie (pledget-ike thing) is used for mechanical prosthesis >> (mostly SJM) and total 12 or more sutures are used usually.I put the > suture >> quite deep to get a part of aortic tissue, In my small series of 400 > cases >> in past 8 years, I have not experienced paravalvular leak more than mild >> except for this case. >> >> After my second AVR, The echo report demonstrated a trivial AR ( not >> structural). Since then, it took 7 years. She has been on 7.5 mg of >> Predonisolone PO. No obvious episode of IE, Now she presented with SOB > and >> enlarged CTR, severe AR especially from RCC annulus area ( it was mild > AR in >> last year echo),estimated PASP 41, moderate MR, mild TR. LAD 49 mm, > Aortic >> annulus and ascending is not enlarged too much, although some > calcification >> is seen in the ascending aorta. WBC 10,000, CRP0.7 to 1.2 >> >> How would you handle this problem? How would you reinforce the RCC > annulus, >> if it is too fragile, where the conduction tissue running nearby? > Mattress >> suture from outside of aorta in this area? >> >> Tohru >> >> >>> How many sutures were placed? >>> Exactly what type were they? We know the valve is intraannular, but: >>> simple?, figure of eight?, horizontal mattress?, everting?, inverting?, >>> pledgets?. >>> How deep were the sutures? i.e. how much tissue did they encircle? >>> Was calcium completely excised the first time?, the second time? >>> Were both ops for paravalvular leak? >>> If so, is the leak now in the same site as the first time? >>> In the absence of endocarditis paravalvar leaks can be attributed to >>> 1)Technique, technique, technique, 2) tissue quality, 3) host healing > (in >>> order of importance). >>> If this is a recurrent leak at the same site as it occurred before then > I >>> found using a strip of bovine pericardium through which all the sutures > are >>> passed before they pass through the tissue (there are several ways to >>> do >>> this) would produce a permanent fix. >> >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/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 prasannasimha at gmail.com Fri Mar 5 20:02:26 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Fri Mar 5 10:02:22 2010 Subject: [HSF] Skeletonized IMA again Message-ID: <89c4ed2d1003050632n18629c9dha524ee7bfb2529a5@mail.gmail.com> How do members (Like our moderator Mark Levinson) skeletonize IMA's when doing it through a transabdominal approach or through a hemisternotomy ? Prasanna -- Prasanna Simha M From tacuff at swbell.net Fri Mar 5 07:16:55 2010 From: tacuff at swbell.net (Tea Acuff) Date: Fri Mar 5 10:18:26 2010 Subject: [HSF] redo redo AVR for aortitis Message-ID: <112932.51040.qm@web81604.mail.mud.yahoo.com> Why do use one technique for mechanical an another for tissue valves? They both have sewing rings. I presume that takesyour denominator (400) down considerably also. Tea Sent from my iPhone On Mar 4, 2010, at 11:31 PM, Tohru Asai wrote: Dear Don, Just I am old fashioned, still doing exactly the same way that I learned at NYU 20 years ago. Have not had any problem with the technique for most of cases. But number of mechanical prosthesis is strikingly decreased as biologic valve increased (which I implant as you describe as such mattress sutures placed from the ventricular side, through the annulus tissue and then the prosthesis). Please tell me the reference which describes your story if you can find. Thank you in advance. I am also interested in the method to implant prosthetic valve by each HSF member. Tohru Tohru, I am interested in your decision to use everting mattress sutures for aortic valve replacement. There was a paper, years ago, testing the strength of various valve replacement suturing techniques and mattress sutures placed from the ventricular side , through the annulus tissue and then the prosthesis proved to be the strongest . They sewed the valves in animals and measured how much force was required to rip them out. How many other members use everting sutures or 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 and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From flege19 at gmail.com Fri Mar 5 07:42:45 2010 From: flege19 at gmail.com (Flege John) Date: Fri Mar 5 10:36:22 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: References: <5df55.3e00a131.38c13cf7@aol.com> Message-ID: Don, It seems to me that mattress or horizontal sutures placed from the ventricular side would invert the annulus and evert the sewing cuff. I think that vertical sutures without pledgets provide the most approximation between the aortic annulus and the sewing ring. John On Mar 4, 2010, at 11:08 PM, Donald Ross wrote: > Tohru, > I am interested in your decision to use everting mattress sutures for aortic valve replacement. > There was a paper, years ago, testing the strength of various valve replacement suturing techniques > and mattress sutures placed from the ventricular side , through the annulus tissue and then the prosthesis proved to be the strongest . They sewed the valves in animals and measured how much force was required to rip them out. > How many other members use everting sutures or AVR > Don > > On 05/03/2010, at 3:42 AM, Rwmfglycar@aol.com wrote: > >> Dear Tohru, >> It seems you have a good technique for avoiding perivalvar leak.12 mattress >> sutures for the size patient you have should be good. In this case tissue >> quality is the factor. But note that the recurrence is where it was the >> first time. I have seen this before. Your idea of bringing the sutures through >> from outside is excellent. You need to get about 3mm of aorta exposed >> proximal to the RCA orifice to be able to pass the sutures horizontally though >> the bolster strip and though the base of the sinus into the sewing ring, >> avoiding the conducting tissue. I don't have to tell you .that this is >> "tiger" country and it may be impossible to expose properly without removing >> the whole valve. A soft coronary perfusion catheter in the right coronary >> will be a help. Once the dissection is done probably 4 or 5 horizontal >> mattress sutures passed through the bolster strip will produce a cure. My bias in >> these cases was to avoid removing the valve and just be patient about >> getting optimal exposure. We probably can declare that tissue quality is >> dominant in the etiology of the recurrent leak. Your previous suture technique >> for the rest of the annulus has worked. When the tissue is at fault you need >> more of it with each bite for the sutures to hold. Perhaps your sutures >> at the second operation were a little tentative because of your knowledge of >> the conducting system close by. Nevertheless it worked for 2/3 of the >> diseased annulus. Why disturb the part that has worked already? >> This area will demand placing the needles at a different angle on the >> needle driver for each mattress suture and passage through strip/tissue and >> ring will be separate actions.Be sure that each suture emerges on the inside >> well below the coronary orifice. >> What I am describing worked for me. I do not have large numbers but as >> surgeon of last resort in my department I would get these cases. >> Best of luck >> Bob >> >> >> >> In a message dated 3/4/2010 12:09:21 P.M. South Africa Standard Time, >> toruasai@belle.shiga-med.ac.jp writes: >> >> Michael, Prasanna, Tomas, Don and Bob >> Thanks for prompt comments. >> >> The patient is small Japanese woman (146 cm, 50 kg) known to have Aortitis >> syndrome (Takayasu's disease) involving total occlusion of the right common >> carotid artery prior to the first AVR for AR and CHF. The first Surgery >> was >> performed with Carbomedicus Tophat 21 or 23 mm by the other surgeon. >> Perivalvular leak, mainly from the RCC annulus area, became rapidly >> increased in 4 months, when I was referred for the urgent second operation. >> >> The prosthesis was a third dehiscence but the annular tissue looked OK. I >> thought it was a simply technical problem and replaced with SJM 23 mm >> prosthesis. No obvious calcification present or no sign of endocarditis. >> My AVR method: I always go very proximal aortotomy, about 5 to 10 mm above >> the RCA orifice and very meticulously and completely clean up the annulus >> if >> calcium is present ( not in this case). And I choose very large size of >> prosthesis sometime even cutting down ST junction. Everting mattress >> sutures >> with spaghettie (pledget-ike thing) is used for mechanical prosthesis >> (mostly SJM) and total 12 or more sutures are used usually.I put the suture >> quite deep to get a part of aortic tissue, In my small series of 400 cases >> in past 8 years, I have not experienced paravalvular leak more than mild >> except for this case. >> >> After my second AVR, The echo report demonstrated a trivial AR ( not >> structural). Since then, it took 7 years. She has been on 7.5 mg of >> Predonisolone PO. No obvious episode of IE, Now she presented with SOB and >> enlarged CTR, severe AR especially from RCC annulus area ( it was mild AR >> in >> last year echo),estimated PASP 41, moderate MR, mild TR. LAD 49 mm, Aortic >> annulus and ascending is not enlarged too much, although some calcification >> is seen in the ascending aorta. WBC 10,000, CRP0.7 to 1.2 >> >> How would you handle this problem? How would you reinforce the RCC annulus, >> if it is too fragile, where the conduction tissue running nearby? Mattress >> suture from outside of aorta in this area? >> >> Tohru >> >> >>> How many sutures were placed? >>> Exactly what type were they? We know the valve is intraannular, but: >>> simple?, figure of eight?, horizontal mattress?, everting?, inverting?, >>> pledgets?. >>> How deep were the sutures? i.e. how much tissue did they encircle? >>> Was calcium completely excised the first time?, the second time? >>> Were both ops for paravalvular leak? >>> If so, is the leak now in the same site as the first time? >>> In the absence of endocarditis paravalvar leaks can be attributed to >>> 1)Technique, technique, technique, 2) tissue quality, 3) host healing >> (in >>> order of importance). >>> If this is a recurrent leak at the same site as it occurred before then I >>> found using a strip of bovine pericardium through which all the sutures >> are >>> passed before they pass through the tissue (there are several ways to do >>> this) would produce a permanent fix. >> >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/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 anddisclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- From jrodriguezcampos at yahoo.com Fri Mar 5 08:32:05 2010 From: jrodriguezcampos at yahoo.com (Jorge Rodriguez Campos) Date: Fri Mar 5 11:33:33 2010 Subject: [HSF] Skeletonized IMA again In-Reply-To: <89c4ed2d1003050632n18629c9dha524ee7bfb2529a5@mail.gmail.com> References: <89c4ed2d1003050632n18629c9dha524ee7bfb2529a5@mail.gmail.com> Message-ID: <777166.56334.qm@web51404.mail.re2.yahoo.com> In transabdominal access I use gastroepiploic, in hemiesternotomy inferior until third intercostal space, the main one taken care of is not to traction that zone hinge of the third space not to bring about tear in the mammary one,(it has minimun resistance to traction ) we raised the separator placed at distal level near the xifoides and upwards dissected the mammary one from the xifoides, after dissecting it in his part inferior, when arriving at the third space and to be free the mammary one, just we separated, soon dissects upwards a space, (3 cm) of such way to isolate it of the zone of esternal fixation. - Dr. Jorge F. Rodriguez Campos ________________________________ De: Prasanna Simha M Para: OpenHeart-L Enviado: vie, marzo 5, 2010 12:32:26 PM Asunto: [HSF] Skeletonized IMA again How do members (Like our moderator Mark Levinson) skeletonize IMA's when doing it through a transabdominal approach or through a hemisternotomy ? Prasanna -- 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 ----------------------------------------- ____________________________________________________________________________________ ?Obt?n la mejor experiencia en la web! Descarga gratis el nuevo Internet Explorer 8. http://downloads.yahoo.com/ieak8/?l=e1 From jrodriguezcampos at yahoo.com Fri Mar 5 10:20:25 2010 From: jrodriguezcampos at yahoo.com (Jorge Rodriguez Campos) Date: Fri Mar 5 13:20:53 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: References: Message-ID: <288241.43281.qm@web51401.mail.re2.yahoo.com> Dear Tohru: Respect your questions number 3 , " . About choice of a prosthesis, as you know the sewing ring of mechanical prosthesis is a flat circle and rigid. On the other hand, stented bioprosthesis has more natural 3 dimentional annular shape, and not as stiff as mechanical valve. And stentless bioprosthesis can be applied with more flexibility of its annular character. Probably homograft is more ideal in this regard. Do you think or know the difference with regard to incidence of dehesience in this kind of setting?" Yes I think the stentless bioprosthesis is better in this case becouse there are not rigid, and traction is lower.- Any way I usually non-everting sutures and position supra-annular for all AVR about 12 years ago.- Dr. Jorge F. Rodriguez Campos ________________________________ De: Tohru Asai Para: OpenHeart-L@lists.hsforum.com Enviado: vie, marzo 5, 2010 3:08:39 AM Asunto: Re: [HSF] redo redo AVR for aortitis Dear Bob, Thank you for very informative and educational advices. A few more questions I would like to ask. 1. Everting mattress suturing method may be harmful to this kind of tissue quality related (or suspected) cases? If it is so, maybe supraannular implantation with horizontal mattress or simple interrupted suture technique is better than the everting method? Because I was wondering that the everting method bring the annular tissue more stress, and maybe causing a little tissue cutting compared to other two methods. Should I have avoided the everting method? I learned the everting horizontal mattress for mechanical and non-everting supra-annular for bioprosthesis about 20 years ago for regular cases in my training. Do you do that in the same way? Or simple interruption is more natural, non-stressful to annular tissue? 2. Aortitis Syndrome (Takayasu's disease) may be uncommon in western countries. ( In fact, Dr. Takayasu was Dean of my graduating medical school of Kanazawa University about 100 years ago. He was a ophthalmologist.)So let's change the situation. If tissue factors are suspected with other diseases such as Bachet disease, when you have a patient with dehesiece of prosthetic valve, how would you handle the problem differently? 3. About choice of a prosthesis, as you know the sewing ring of mechanical prosthesis is a flat circle and rigid. On the other hand, stented bioprosthesis has more natural 3 dimentional annular shape, and not as stiff as mechanical valve. And stentless bioprosthesis can be applied with more flexibility of its annular character. Probably homograft is more ideal in this regard. Do you think or know the difference with regard to incidence of dehesience in this kind of setting? Thank you again in advance. Tohru > Dear Tohru, > It seems you have a good technique for avoiding perivalvar leak.12 mattress > sutures for the size patient you have should be good. In this case tissue > quality is the factor. But note that the recurrence is where it was the > first time. I have seen this before. Your idea of bringing the sutures > through > from outside is excellent. You need to get about 3mm of aorta exposed > proximal to the RCA orifice to be able to pass the sutures horizontally though > the bolster strip and though the base of the sinus into the sewing ring, > avoiding the conducting tissue. I don't have to tell you .that this is > "tiger" country and it may be impossible to expose properly without removing > the whole valve. A soft coronary perfusion catheter in the right coronary > will be a help. Once the dissection is done probably 4 or 5 horizontal > mattress sutures passed through the bolster strip will produce a cure. My > bias in > these cases was to avoid removing the valve and just be patient about > getting optimal exposure. We probably can declare that tissue quality is > dominant in the etiology of the recurrent leak. Your previous suture > technique > for the rest of the annulus has worked. When the tissue is at fault you need > more of it with each bite for the sutures to hold. Perhaps your sutures > at the second operation were a little tentative because of your knowledge of > the conducting system close by. Nevertheless it worked for 2/3 of the > diseased annulus. Why disturb the part that has worked already? > This area will demand placing the needles at a different angle on the > needle driver for each mattress suture and passage through strip/tissue and > ring will be separate actions.Be sure that each suture emerges on the inside > well below the coronary orifice. > What I am describing worked for me. I do not have large numbers but as > surgeon of last resort in my department I would get these cases. > Best of luck > Bob _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and disclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- ____________________________________________________________________________________ ?Obt?n la mejor experiencia en la web! Descarga gratis el nuevo Internet Explorer 8. http://downloads.yahoo.com/ieak8/?l=e1 From donross at bigpond.com Sat Mar 6 08:05:20 2010 From: donross at bigpond.com (Donald Ross) Date: Fri Mar 5 16:08:47 2010 Subject: [HSF] redo redo AVR for aortitis In-Reply-To: References: <5df55.3e00a131.38c13cf7@aol.com> Message-ID: <739B4074-083D-4CBE-89AB-292288B27B38@bigpond.com> John, Perhaps there is some eversion but not nearly so much when the suture is started on the outflow side of the annulus. I think 20-30 simple sutures give the best approximation between valve and annulus but I guess I gave that technique up for the convenience and speed of 12-15 plegeted mattress sutures. Don On 05/03/2010, at 11:42 PM, Flege John wrote: > Don, It seems to me that mattress or horizontal sutures placed from > the ventricular side would invert the annulus and evert the sewing > cuff. I think that vertical sutures without pledgets provide the > most approximation between the aortic annulus and the sewing ring. > John > > On Mar 4, 2010, at 11:08 PM, Donald Ross wrote: > >> Tohru, >> I am interested in your decision to use everting mattress sutures >> for aortic valve replacement. >> There was a paper, years ago, testing the strength of various >> valve replacement suturing techniques >> and mattress sutures placed from the ventricular side , through >> the annulus tissue and then the prosthesis proved to be the >> strongest . They sewed the valves in animals and measured how much >> force was required to rip them out. >> How many other members use everting sutures or AVR >> Don >> >> On 05/03/2010, at 3:42 AM, Rwmfglycar@aol.com wrote: >> >>> Dear Tohru, >>> It seems you have a good technique for avoiding perivalvar leak.12 >>> mattress >>> sutures for the size patient you have should be good. In this case >>> tissue >>> quality is the factor. But note that the recurrence is where it >>> was the >>> first time. I have seen this before. Your idea of bringing the >>> sutures through >>> from outside is excellent. You need to get about 3mm of aorta >>> exposed >>> proximal to the RCA orifice to be able to pass the sutures >>> horizontally though >>> the bolster strip and though the base of the sinus into the >>> sewing ring, >>> avoiding the conducting tissue. I don't have to tell you .that >>> this is >>> "tiger" country and it may be impossible to expose properly >>> without removing >>> the whole valve. A soft coronary perfusion catheter in the right >>> coronary >>> will be a help. Once the dissection is done probably 4 or 5 >>> horizontal >>> mattress sutures passed through the bolster strip will produce a >>> cure. My bias in >>> these cases was to avoid removing the valve and just be patient >>> about >>> getting optimal exposure. We probably can declare that tissue >>> quality is >>> dominant in the etiology of the recurrent leak. Your previous >>> suture technique >>> for the rest of the annulus has worked. When the tissue is at >>> fault you need >>> more of it with each bite for the sutures to hold. Perhaps your >>> sutures >>> at the second operation were a little tentative because of your >>> knowledge of >>> the conducting system close by. Nevertheless it worked for 2/3 of >>> the >>> diseased annulus. Why disturb the part that has worked already? >>> This area will demand placing the needles at a different angle on >>> the >>> needle driver for each mattress suture and passage through strip/ >>> tissue and >>> ring will be separate actions.Be sure that each suture emerges on >>> the inside >>> well below the coronary orifice. >>> What I am describing worked for me. I do not have large numbers >>> but as >>> surgeon of last resort in my department I would get these cases. >>> Best of luck >>> Bob >>> >>> >>> >>> In a message dated 3/4/2010 12:09:21 P.M. South Africa Standard >>> Time, >>> toruasai@belle.shiga-med.ac.jp writes: >>> >>> Michael, Prasanna, Tomas, Don and Bob >>> Thanks for prompt comments. >>> >>> The patient is small Japanese woman (146 cm, 50 kg) known to have >>> Aortitis >>> syndrome (Takayasu's disease) involving total occlusion of the >>> right common >>> carotid artery prior to the first AVR for AR and CHF. The first >>> Surgery >>> was >>> performed with Carbomedicus Tophat 21 or 23 mm by the other >>> surgeon. >>> Perivalvular leak, mainly from the RCC annulus area, became rapidly >>> increased in 4 months, when I was referred for the urgent second >>> operation. >>> >>> The prosthesis was a third dehiscence but the annular tissue >>> looked OK. I >>> thought it was a simply technical problem and replaced with SJM >>> 23 mm >>> prosthesis. No obvious calcification present or no sign of >>> endocarditis. >>> My AVR method: I always go very proximal aortotomy, about 5 to 10 >>> mm above >>> the RCA orifice and very meticulously and completely clean up the >>> annulus >>> if >>> calcium is present ( not in this case). And I choose very large >>> size of >>> prosthesis sometime even cutting down ST junction. Everting >>> mattress >>> sutures >>> with spaghettie (pledget-ike thing) is used for mechanical >>> prosthesis >>> (mostly SJM) and total 12 or more sutures are used usually.I put >>> the suture >>> quite deep to get a part of aortic tissue, In my small series of >>> 400 cases >>> in past 8 years, I have not experienced paravalvular leak more >>> than mild >>> except for this case. >>> >>> After my second AVR, The echo report demonstrated a trivial AR >>> ( not >>> structural). Since then, it took 7 years. She has been on 7.5 mg of >>> Predonisolone PO. No obvious episode of IE, Now she presented >>> with SOB and >>> enlarged CTR, severe AR especially from RCC annulus area ( it was >>> mild AR >>> in >>> last year echo),estimated PASP 41, moderate MR, mild TR. LAD 49 >>> mm, Aortic >>> annulus and ascending is not enlarged too much, although some >>> calcification >>> is seen in the ascending aorta. WBC 10,000, CRP0.7 to 1.2 >>> >>> How would you handle this problem? How would you reinforce the >>> RCC annulus, >>> if it is too fragile, where the conduction tissue running nearby? >>> Mattress >>> suture from outside of aorta in this area? >>> >>> Tohru >>> >>> >>>> How many sutures were placed? >>>> Exactly what type were they? We know the valve is intraannular, >>>> but: >>>> simple?, figure of eight?, horizontal mattress?, everting?, >>>> inverting?, >>>> pledgets?. >>>> How deep were the sutures? i.e. how much tissue did they encircle? >>>> Was calcium completely excised the first time?, the second time? >>>> Were both ops for paravalvular leak? >>>> If so, is the leak now in the same site as the first time? >>>> In the absence of endocarditis paravalvar leaks can be >>>> attributed to >>>> 1)Technique, technique, technique, 2) tissue quality, 3) host >>>> healing >>> (in >>>> order of importance). >>>> If this is a recurrent leak at the same site as it occurred >>>> before then I >>>> found using a strip of bovine pericardium through which all the >>>> sutures >>> are >>>> passed before they pass through the tissue (there are several >>>> ways to do >>>> this) would produce a permanent fix. >>> >>> >>> _______________________________________________ >>> OpenHeart-L mailing list >>> >>> Send postings to: >>> OpenHeart-L@lists.hsforum.com >>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>> http://mmp.cjp.com/mailman/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 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 > ----------------------------------------- From Rwmfglycar at aol.com Fri Mar 5 18:16:09 2010 From: Rwmfglycar at aol.com (Rwmfglycar@aol.com) Date: Fri Mar 5 18:17:18 2010 Subject: [HSF] redo redo AVR for aortitis Message-ID: <2beb1.77396cdb.38c2eab9@aol.com> In a message dated 3/5/2010 7:10:37 A.M. South Africa Standard Time, toruasai@belle.shiga-med.ac.jp writes: I hope the bold print that I am writing thisin will appear in the Email Bob, Thank you for very informative and educational advices. A few more questions I would like to ask. 1. Everting mattress suturing method may be harmful to this kind of tissue quality related (or suspected) cases? If it is so, maybe supraannular implantation with horizontal mattress or simple interrupted suture technique is better than the everting method? Because I was wondering that the everting method bring the annular tissue more stress, and maybe causing a little tissue cutting compared to other two methods. Should I have avoided the everting method? In another post I discussed some of these questions. If you read it you will see that my major objection to the everting method is that it always produces an intraannular insertion which tends to result in the choice of smaller valves. I don't think that a method you have used for many cases succesfully is by itself the cause of the failure. It is possible that you placed your usual number of sutures instead of using more than usual because you were stitching to diseased tissue. Since landmarks were obliterated by previous surgery, you might have taken shallower than usual bites because of concern about conducting tissue. butbut. Goven concern aboutthe conductingtissueI learned the everting horizontal mattress for mechanical and non-everting supra-annular for bioprosthesis about 20 years ago for regular cases in my training. Do you do that in the same way? Or simple interruption is more natural, non-stressful to annular tissue? A word about the "aortic annulus". Robert Anderson contends that the aortic annulus does not exist. He and I wrote a sort of opinion piece on this subject which I thought should have been published by now but we are still waiting. Anyway let me say that the coronal shaped line of leaflet attachment that remains after valve excision is what surgeons describe as the annulus. The three muscular shelves at the base of each sinus are what we are talking about when we describe supra and intra-annular insertions and the infelicitous terms "everting" and "inverting". These, however, constitute less than 2/3 of the "annular" circumference. The rest of the leaflet attachment lines are flush with the fibrous aortic wall and form the sides of the three interleaflet triangles. The attachment of the inserted prosthesis MUST be intraannular at these three sites. I believe 90% of surgeons who have been following the curve of the three sinus bases with their stitches will follow straight lines across the base of the interleaflet triangles. This makes a nonsense of some commercial illustrations of an artificial valve designed to be "supraannular" sitting on top of a completely circumferential shelf. This is not to say that something is not gained by placing 2/3 of the sewing ring on the aortic side of the muscle shelves. What has this discussion to do with dehiscence of sutures leading to perivalvar leak? Here is where I present an opinion that you will not find in any article or textbook but which I think is relevant to our question. When I was patching VSD's through a right ventricular incision I noticed that where the aortic leaflets met the septal muscle there was a thickening of the leaflet fibrous tissue. I never sutured a patch to the leaflet of course but at least at the lowest point of the leaflet, one stitch would go through that thickening and it was always firm. I came to the conclusion that the tissue at the meeting of muscle and leaflet was identifiable as the attachment site and stronger than muscle. It could be thought of as the equivalent of an annulus. If simple sutures encircle this leaflet attachment site and at the interleaflet triangles develop a fold in the fibrous wall of the sinus (a vertical mattress) or as I did often switch from the simple to a horizontal mattress passed through the wall of the sinus, the sewing ring will effectively be anchored to fibrous tissue. John and Don have clearly come to this method. You will tie double the amount of knots but you will not need pledgets to stop the sutures from tearing through muscle. Some of you may be thinking "where is this fibrous base of the leaflet after I have excised a calcific valve?". If you remove calcium by sharp dissection on the calcium, you will in fact still have a fibrous leaflet base most of the time. Paul Urbanski in Germany is on his second hundred of calcific aortic stenosis cases in which he removes the calcium leaving the leaflet free edge and the base intact and sutures tanned pericardial inserts to these sites to reconstruct a competent tissue valve. 2. Aortitis Syndrome (Takayasu's disease) may be uncommon in western countries. ( In fact, Dr. Takayasu was Dean of my graduating medical school of Kanazawa University about 100 years ago. He was a ophthalmologist.)So let's change the situation. If tissue factors are suspected with other diseases such as Bachet disease, when you have a patient with dehesiece of prosthetic valve, how would you handle the problem differently? Use a combination of strips of bovine pericardium to reinforce the tissue, and many more sutures than usual to lessen the load on each suture. 3. About choice of a prosthesis, as you know the sewing ring of mechanical prosthesis is a flat circle and rigid. On the other hand, stented bioprosthesis has more natural 3 dimentional annular shape, and not as stiff as mechanical valve. And stentless bioprosthesis can be applied with more flexibility of its annular character. Probably homograft is more ideal in this regard. Do you think or know the difference with regard to incidence of dehesience in this kind of setting? Surgeons have distorted the scalloped attachment line of the aortic valve since the beginning of aortic valve replacement. Not all the sewing rings on mechanical valves are stiff; some are relatively soft and pliable. Most socalled stentless valves have a straight cylindrical bottom end designed to be sutured along a straight circular path at the bottom end of the valve followed by a scalloped second layer further downstream. It is quite possible to get a hematoma between the xenograft or homograft tissue and the host aortic wall, unless a large number of sutures are meticulously placed. Perhaps because there are two suture lines perivalvar leaks are rare. But so are they rare when either mechanical or bioprosthetic valves are placed with sufficient numbers of sutures encompassing the strongest available tissue. I believe the device is less important than the insertion technique. This failure that you have seen is better handled by a modification of the insertion technique for the special circumstances of the case. Bob Thank you again in advance. Tohru > Dear Tohru, > It seems you have a good technique for avoiding perivalvar leak.12 mattress > sutures for the size patient you have should be good. In this case tissue > quality is the factor. But note that the recurrence is where it was the > first time. I have seen this before. Your idea of bringing the sutures > through > from outside is excellent. You need to get about 3mm of aorta exposed > proximal to the RCA orifice to be able to pass the sutures horizontally though > the bolster strip and though the base of the sinus into the sewing ring, > avoiding the conducting tissue. I don't have to tell you .that this is > "tiger" country and it may be impossible to expose properly without removing > the whole valve. A soft coronary perfusion catheter in the right coronary > will be a help. Once the dissection is done probably 4 or 5 horizontal > mattress sutures passed through the bolster strip will produce a cure. My > bias in > these cases was to avoid removing the valve and just be patient about > getting optimal exposure. We probably can declare that tissue quality is > dominant in the etiology of the recurrent leak. Your previous suture > technique > for the rest of the annulus has worked. When the tissue is at fault you need > more of it with each bite for the sutures to hold. Perhaps your sutures > at the second operation were a little tentative because of your knowledge of > the conducting system close by. Nevertheless it worked for 2/3 of the > diseased annulus. Why disturb the part that has worked already? > This area will demand placing the needles at a different angle on the > needle driver for each mattress suture and passage through strip/tissue and > ring will be separate actions.Be sure that each suture emerges on the inside > well below the coronary orifice. > What I am describing worked for me. I do not have large numbers but as > surgeon of last resort in my department I would get these cases. > Best of luck > Bob _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/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 Fri Mar 5 18:10:56 2010 From: tacuff at swbell.net (Tea Acuff) Date: Fri Mar 5 21:11:27 2010 Subject: [HSF] redo redo AVR for aortitis Message-ID: <158903.37123.qm@web81604.mail.mud.yahoo.com> He said "in"verted which I had to reread to note. Tea Sent from my iPhone On Mar 5, 2010, at 3:05 PM, Donald Ross wrote: John, Perhaps there is some eversion but not nearly so much when the suture is started on the outflow side of the annulus. I think 20-30 simple sutures give the best approximation between valve and annulus but I guess I gave that technique up for the convenience and speed of 12-15 plegeted mattress sutures. Don On 05/03/2010, at 11:42 PM, Flege John wrote: Don, It seems to me that mattress or horizontal sutures placed from the ventricular side would invert the annulus and evert the sewing cuff. I think that vertical sutures without pledgets provide the most approximation between the aortic annulus and the sewing ring. John On Mar 4, 2010, at 11:08 PM, Donald Ross wrote: Tohru, I am interested in your decision to use everting mattress sutures for aortic valve replacement. There was a paper, years ago, testing the strength of various valve replacement suturing techniques and mattress sutures placed from the ventricular side , through the annulus tissue and then the prosthesis proved to be the strongest . They sewed the valves in animals and measured how much force was required to rip them out. How many other members use everting sutures or AVR Don On 05/03/2010, at 3:42 AM, Rwmfglycar@aol.com wrote: Dear Tohru, It seems you have a good technique for avoiding perivalvar leak.12 mattress sutures for the size patient you have should be good. In this case tissue quality is the factor. But note that the recurrence is where it was the first time. I have seen this before. Your idea of bringing the sutures through from outside is excellent. You need to get about 3mm of aorta exposed proximal to the RCA orifice to be able to pass the sutures horizontally though the bolster strip and though the base of the sinus into the sewing ring, avoiding the conducting tissue. I don't have to tell you .that this is "tiger" country and it may be impossible to expose properly without removing the whole valve. A soft coronary perfusion catheter in the right coronary will be a help. Once the dissection is done probably 4 or 5 horizontal mattress sutures passed through the bolster strip will produce a cure. My bias in these cases was to avoid removing the valve and just be patient about getting optimal exposure. We probably can declare that tissue quality is dominant in the etiology of the recurrent leak. Your previous suture technique for the rest of the annulus has worked. When the tissue is at fault you need more of it with each bite for the sutures to hold. Perhaps your sutures at the second operation were a little tentative because of your knowledge of the conducting system close by. Nevertheless it worked for 2/3 of the diseased annulus. Why disturb the part that has worked already? This area will demand placing the needles at a different angle on the needle driver for each mattress suture and passage through strip/tissue and ring will be separate actions.Be sure that each suture emerges on the inside well below the coronary orifice. What I am describing worked for me. I do not have large numbers but as surgeon of last resort in my department I would get these cases. Best of luck Bob In a message dated 3/4/2010 12:09:21 P.M. South Africa Standard Time, toruasai@belle.shiga-med.ac.jp writes: Michael, Prasanna, Tomas, Don and Bob Thanks for prompt comments. The patient is small Japanese woman (146 cm, 50 kg) known to have Aortitis syndrome (Takayasu's disease) involving total occlusion of the right common carotid artery prior to the first AVR for AR and CHF. The first Surgery was performed with Carbomedicus Tophat 21 or 23 mm by the other surgeon. Perivalvular leak, mainly from the RCC annulus area, became rapidly increased in 4 months, when I was referred for the urgent second operation. The prosthesis was a third dehiscence but the annular tissue looked OK. I thought it was a simply technical problem and replaced with SJM 23 mm prosthesis. No obvious calcification present or no sign of endocarditis. My AVR method: I always go very proximal aortotomy, about 5 to 10 mm above the RCA orifice and very meticulously and completely clean up the annulus if calcium is present ( not in this case). And I choose very large size of prosthesis sometime even cutting down ST junction. Everting mattress sutures with spaghettie (pledget-ike thing) is used for mechanical prosthesis (mostly SJM) and total 12 or more sutures are used usually.I put the suture quite deep to get a part of aortic tissue, In my small series of 400 cases in past 8 years, I have not experienced paravalvular leak more than mild except for this case. After my second AVR, The echo report demonstrated a trivial AR ( not structural). Since then, it took 7 years. She has been on 7.5 mg of Predonisolone PO. No obvious episode of IE, Now she presented with SOB and enlarged CTR, severe AR especially from RCC annulus area ( it was mild AR in last year echo),estimated PASP 41, moderate MR, mild TR. LAD 49 mm, Aortic annulus and ascending is not enlarged too much, although some calcification is seen in the ascending aorta. WBC 10,000, CRP0.7 to 1.2 How would you handle this problem? How would you reinforce the RCC annulus, if it is too fragile, where the conduction tissue running nearby? Mattress suture from outside of aorta in this area? Tohru How many sutures were placed? Exactly what type were they? We know the valve is intraannular, but: simple?, figure of eight?, horizontal mattress?, everting?, inverting?, pledgets?. How deep were the sutures? i.e. how much tissue did they encircle? Was calcium completely excised the first time?, the second time? Were both ops for paravalvular leak? If so, is the leak now in the same site as the first time? In the absence of endocarditis paravalvar leaks can be attributed to 1)Technique, technique, technique, 2) tissue quality, 3) host healing (in order of importance). If this is a recurrent leak at the same site as it occurred before then I found using a strip of bovine pericardium through which all the sutures are passed before they pass through the tissue (there are several ways to do this) would produce a permanent fix. _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: http://mmp.cjp.com/mailman/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 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 ----------------------------------------- _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, 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 ----------------------------------------- From prasannasimha at gmail.com Sat Mar 6 21:30:44 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sat Mar 6 11:29:44 2010 Subject: [HSF] shent introducer ? Message-ID: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com> http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html What is that device that you used to push in Don's "Shent" Is it made of ordinary steel wire ? Prasanna -- Prasanna Simha M From anianyanwu at hotmail.com Sat Mar 6 18:15:47 2010 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Sat Mar 6 13:16:15 2010 Subject: [HSF] shent introducer ? In-Reply-To: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com> References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com> Message-ID: Amazing the exposure one can get from the subxiphoid approach - Mark Levinson has really pushed the frontier on minimally invasive CABG here as sparing sternotomy AND thoracotomy can potentially be a real benefit, as then in terms of trauma not much difference from an upper GI operation and very little limitation on post operative physical activity once pain settles (assuming the sternal retraction is not disruptive or destructive in any way). One comment though is that not very factual as stated on the website that conventional CABG incision is 12 inches long. Surely incisions have not been that long in decades? Ani > Date: Sat, 6 Mar 2010 21:30:44 +0530 > From: prasannasimha@gmail.com > To: OpenHeart-L@lists.hsforum.com > CC: mmlevinson@mac.com > Subject: [HSF] shent introducer ? > > http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html > What is that device that you used to push in Don's "Shent" Is it made of > ordinary steel wire ? > Prasanna > > -- > 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 > ----------------------------------------- _________________________________________________________________ Tell us your greatest, weirdest and funniest Hotmail stories http://clk.atdmt.com/UKM/go/195013117/direct/01/ From prasannasimha at gmail.com Sun Mar 7 07:47:13 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sat Mar 6 21:17:46 2010 Subject: [HSF] shent introducer ? In-Reply-To: References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com> Message-ID: <89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com> People do get 1 foot long incisions !! I have seen people doing it regularly. I have done transxiphoid pericardiectomies for children with pyopericardium and was surprised at the amount of exposure that it affords. The sternal sparing is a definite advantage but I am not so sure if an upper abdominal incision is less painful. The upper abdominal incision is considered more painful than a sternotomy or a lower abdominal incision though various blocks and pain control measures can obviate that. Prasanna On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu wrote: > > Amazing the exposure one can get from the subxiphoid approach - Mark > Levinson has really pushed the frontier on minimally invasive CABG here as > sparing sternotomy AND thoracotomy can potentially be a real benefit, as > then in terms of trauma not much difference from an upper GI operation and > very little limitation on post operative physical activity once pain settles > (assuming the sternal retraction is not disruptive or destructive in any > way). > > > > One comment though is that not very factual as stated on the website that > conventional CABG incision is 12 inches long. Surely incisions have not been > that long in decades? > > > > Ani > > > > > > Date: Sat, 6 Mar 2010 21:30:44 +0530 > > From: prasannasimha@gmail.com > > To: OpenHeart-L@lists.hsforum.com > > CC: mmlevinson@mac.com > > Subject: [HSF] shent introducer ? > > > > http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html > > What is that device that you used to push in Don's "Shent" Is it made of > > ordinary steel wire ? > > Prasanna > > > > -- > > 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 > > ----------------------------------------- > > _________________________________________________________________ > Tell us your greatest, weirdest and funniest Hotmail stories > > http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________ > OpenHeart-Lmailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 Sat Mar 6 21:55:31 2010 From: msfirst at gmail.com (Michael Firstenberg) Date: Sat Mar 6 22:25:41 2010 Subject: [HSF] shent introducer ? In-Reply-To: <89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com> References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com> <89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com> Message-ID: <8CABA34C-69B3-4594-8760-0D058D345C71@gmail.com> oh here we going again - my incision is smaller than yours. Granted children are different (or are they????? since they will heal anything) Many patients within a month or so, particularly men with chest hair, the incision (if closed properly) is barely noticeable. However, the scapular pain and the pain from broken ribs and torn ligaments/cartilage lasts longer........ -michael On Mar 6, 2010, at 9:17 PM, Prasanna Simha M wrote: > People do get 1 foot long incisions !! I have seen people doing it > regularly. > I have done transxiphoid pericardiectomies for children with pyopericardium > and was surprised at the amount of exposure that it affords. > The sternal sparing is a definite advantage but I am not so sure if an upper > abdominal incision is less painful. The upper abdominal incision is > considered more painful than a sternotomy or a lower abdominal incision > though various blocks and pain control measures can obviate that. > Prasanna > > On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu wrote: > >> >> Amazing the exposure one can get from the subxiphoid approach - Mark >> Levinson has really pushed the frontier on minimally invasive CABG here as >> sparing sternotomy AND thoracotomy can potentially be a real benefit, as >> then in terms of trauma not much difference from an upper GI operation and >> very little limitation on post operative physical activity once pain settles >> (assuming the sternal retraction is not disruptive or destructive in any >> way). >> >> >> >> One comment though is that not very factual as stated on the website that >> conventional CABG incision is 12 inches long. Surely incisions have not been >> that long in decades? >> >> >> >> Ani >> >> >> >> >>> Date: Sat, 6 Mar 2010 21:30:44 +0530 >>> From: prasannasimha@gmail.com >>> To: OpenHeart-L@lists.hsforum.com >>> CC: mmlevinson@mac.com >>> Subject: [HSF] shent introducer ? >>> >>> http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html >>> What is that device that you used to push in Don's "Shent" Is it made of >>> ordinary steel wire ? >>> Prasanna >>> >>> -- >>> 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 >>> ----------------------------------------- >> >> _________________________________________________________________ >> Tell us your greatest, weirdest and funniest Hotmail stories >> >> http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________ >> OpenHeart-Lmailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/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 prasannasimha at gmail.com Sun Mar 7 09:11:08 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sat Mar 6 22:41:27 2010 Subject: [HSF] shent introducer ? In-Reply-To: <8CABA34C-69B3-4594-8760-0D058D345C71@gmail.com> References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com> <89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com> <8CABA34C-69B3-4594-8760-0D058D345C71@gmail.com> Message-ID: <89c4ed2d1003061941l282eb3dbue474a238018860e@mail.gmail.com> Michael, it is not a my incision is bigger than yours or whatever. People like it or not like to have smaller incisions. Reduce incision size , reduce stretch and secondary injury etc etc are realities which we need to attend to or strive to do However this should not be at the cost of safety and outcomes. I heard these same arguments when Lap procedures were advocated but they have found a definitive place.There are anatomical constraints with the chest compared to the abdomen but if I could avoid getting the sternum cracked open why not ? Also there will be people pushing the boundaries of science and investigation and we need to have them or else we will not improve. You say men with chest hair - it is unnoticable etc but check out your patients with these scars and see where they button up their shirts and dresses to. Ask the lady whether she likes having a scar cutting up across her blouse line -she will subtely wear a closed neck dress and so on and so forth. I bet they (at least most of them) don't parade that scar like a masochistic trophy. Also if you are taking down bilateral IMA's why not spare the sternum if you can if it is a reproducible technique ? You seem to be anti anything but full incision surgery. I am not so sure why but I can tell you that if you do hemisternotomies without lateral cuts, they actually interlock rigidly and have less pain and get out home earlier (and home for many of us in other parts of the world is usually 200 -500 kms away and sometimes even 3000 kms away and not to an SNF/nursing home or whatever). If we can significantly reduce morbidity why not ? Having said all that I still am curious how the "shent" introducer was made. It looked elegant. Prasanna On Sun, Mar 7, 2010 at 8:25 AM, Michael Firstenberg wrote: > oh here we going again - my incision is smaller than yours. > Granted children are different (or are they????? since they will heal > anything) > > Many patients within a month or so, particularly men with chest hair, the > incision (if closed properly) is barely noticeable. However, the scapular > pain and the pain from broken ribs and torn ligaments/cartilage lasts > longer........ > > -michael > > > > > On Mar 6, 2010, at 9:17 PM, Prasanna Simha M wrote: > > > People do get 1 foot long incisions !! I have seen people doing it > > regularly. > > I have done transxiphoid pericardiectomies for children with > pyopericardium > > and was surprised at the amount of exposure that it affords. > > The sternal sparing is a definite advantage but I am not so sure if an > upper > > abdominal incision is less painful. The upper abdominal incision is > > considered more painful than a sternotomy or a lower abdominal incision > > though various blocks and pain control measures can obviate that. > > Prasanna > > > > On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu > wrote: > > > >> > >> Amazing the exposure one can get from the subxiphoid approach - Mark > >> Levinson has really pushed the frontier on minimally invasive CABG here > as > >> sparing sternotomy AND thoracotomy can potentially be a real benefit, as > >> then in terms of trauma not much difference from an upper GI operation > and > >> very little limitation on post operative physical activity once pain > settles > >> (assuming the sternal retraction is not disruptive or destructive in any > >> way). > >> > >> > >> > >> One comment though is that not very factual as stated on the website > that > >> conventional CABG incision is 12 inches long. Surely incisions have not > been > >> that long in decades? > >> > >> > >> > >> Ani > >> > >> > >> > >> > >>> Date: Sat, 6 Mar 2010 21:30:44 +0530 > >>> From: prasannasimha@gmail.com > >>> To: OpenHeart-L@lists.hsforum.com > >>> CC: mmlevinson@mac.com > >>> Subject: [HSF] shent introducer ? > >>> > >>> http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html > >>> What is that device that you used to push in Don's "Shent" Is it made > of > >>> ordinary steel wire ? > >>> Prasanna > >>> > >>> -- > >>> 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 > >>> ----------------------------------------- > >> > >> _________________________________________________________________ > >> Tell us your greatest, weirdest and funniest Hotmail stories > >> > >> > http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________ > >> OpenHeart-L< > http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________%0AOpenHeart-L>mailing > list > >> > >> Send postings to: > >> OpenHeart-L@lists.hsforum.com > >> > >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: > >> http://mmp.cjp.com/mailman/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 > ----------------------------------------- > -- Prasanna Simha M From msfirst at gmail.com Sat Mar 6 22:50:23 2010 From: msfirst at gmail.com (Michael Firstenberg) Date: Sat Mar 6 22:50:55 2010 Subject: [HSF] shent introducer ? In-Reply-To: <89c4ed2d1003061941l282eb3dbue474a238018860e@mail.gmail.com> References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com> <89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com> <8CABA34C-69B3-4594-8760-0D058D345C71@gmail.com> <89c4ed2d1003061941l282eb3dbue474a238018860e@mail.gmail.com> Message-ID: I am not anti-everything. I just like to argue (debate?) - in part because sometimes some of the stuff that comes across here is written in a way that suggests than anyone that does "x" is a great surgeon and anyone who does "negative x" or less than "x" should be put out to pasture. I just like discussing some of the cons to the approaches that people take........ -michael On Mar 6, 2010, at 10:41 PM, Prasanna Simha M wrote: > Michael, it is not a my incision is bigger than yours or whatever. People > like it or not like to have smaller incisions. Reduce incision size , reduce > stretch and secondary injury etc etc are realities which we need to attend > to or strive to do However this should not be at the cost of safety and > outcomes. I heard these same arguments when Lap procedures were advocated > but they have found a definitive place.There are anatomical constraints with > the chest compared to the abdomen but if I could avoid getting the sternum > cracked open why not ? Also there will be people pushing the boundaries of > science and investigation and we need to have them or else we will not > improve. You say men with chest hair - it is unnoticable etc but check out > your patients with these scars and see where they button up their shirts and > dresses to. Ask the lady whether she likes having a scar cutting up across > her blouse line -she will subtely wear a closed neck dress and so on and so > forth. I bet they (at least most of them) don't parade that scar like a > masochistic trophy. > Also if you are taking down bilateral IMA's why not spare the sternum if you > can if it is a reproducible technique ? > You seem to be anti anything but full incision surgery. I am not so sure why > but I can tell you that if you do hemisternotomies without lateral cuts, > they actually interlock rigidly and have less pain and get out home earlier > (and home for many of us in other parts of the world is usually 200 -500 kms > away and sometimes even 3000 kms away and not to an SNF/nursing home or > whatever). If we can significantly reduce morbidity why not ? > Having said all that I still am curious how the "shent" introducer was > made. It looked elegant. > Prasanna > > On Sun, Mar 7, 2010 at 8:25 AM, Michael Firstenberg wrote: > >> oh here we going again - my incision is smaller than yours. >> Granted children are different (or are they????? since they will heal >> anything) >> >> Many patients within a month or so, particularly men with chest hair, the >> incision (if closed properly) is barely noticeable. However, the scapular >> pain and the pain from broken ribs and torn ligaments/cartilage lasts >> longer........ >> >> -michael >> >> >> >> >> On Mar 6, 2010, at 9:17 PM, Prasanna Simha M wrote: >> >>> People do get 1 foot long incisions !! I have seen people doing it >>> regularly. >>> I have done transxiphoid pericardiectomies for children with >> pyopericardium >>> and was surprised at the amount of exposure that it affords. >>> The sternal sparing is a definite advantage but I am not so sure if an >> upper >>> abdominal incision is less painful. The upper abdominal incision is >>> considered more painful than a sternotomy or a lower abdominal incision >>> though various blocks and pain control measures can obviate that. >>> Prasanna >>> >>> On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu >> wrote: >>> >>>> >>>> Amazing the exposure one can get from the subxiphoid approach - Mark >>>> Levinson has really pushed the frontier on minimally invasive CABG here >> as >>>> sparing sternotomy AND thoracotomy can potentially be a real benefit, as >>>> then in terms of trauma not much difference from an upper GI operation >> and >>>> very little limitation on post operative physical activity once pain >> settles >>>> (assuming the sternal retraction is not disruptive or destructive in any >>>> way). >>>> >>>> >>>> >>>> One comment though is that not very factual as stated on the website >> that >>>> conventional CABG incision is 12 inches long. Surely incisions have not >> been >>>> that long in decades? >>>> >>>> >>>> >>>> Ani >>>> >>>> >>>> >>>> >>>>> Date: Sat, 6 Mar 2010 21:30:44 +0530 >>>>> From: prasannasimha@gmail.com >>>>> To: OpenHeart-L@lists.hsforum.com >>>>> CC: mmlevinson@mac.com >>>>> Subject: [HSF] shent introducer ? >>>>> >>>>> http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html >>>>> What is that device that you used to push in Don's "Shent" Is it made >> of >>>>> ordinary steel wire ? >>>>> Prasanna >>>>> >>>>> -- >>>>> 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 >>>>> ----------------------------------------- >>>> >>>> _________________________________________________________________ >>>> Tell us your greatest, weirdest and funniest Hotmail stories >>>> >>>> >> http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________ >>>> OpenHeart-L< >> http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________%0AOpenHeart-L>mailing >> list >>>> >>>> Send postings to: >>>> OpenHeart-L@lists.hsforum.com >>>> >>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>> http://mmp.cjp.com/mailman/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 >> ----------------------------------------- >> > > > > -- > 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 prasannasimha at gmail.com Sun Mar 7 09:24:48 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sat Mar 6 22:55:07 2010 Subject: [HSF] shent introducer ? In-Reply-To: References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com> <89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com> <8CABA34C-69B3-4594-8760-0D058D345C71@gmail.com> <89c4ed2d1003061941l282eb3dbue474a238018860e@mail.gmail.com> Message-ID: <89c4ed2d1003061954i5b7e1510nd4ae609617696dbd@mail.gmail.com> Really !! ;) I thought the comment made was expression of appreciation on developing a new technique and pushing frontiers. I bet we did not think of doing it !! Of course one has to be an extremely confident surgoen with a full open technique before even thinking of embarking on such a venture. Prasanna On Sun, Mar 7, 2010 at 9:20 AM, Michael Firstenberg wrote: > I am not anti-everything. > I just like to argue (debate?) - in part because sometimes some of the > stuff that comes across here is written in a way that suggests than anyone > that does "x" is a great surgeon and anyone who does "negative x" or less > than "x" should be put out to pasture. > > I just like discussing some of the cons to the approaches that people > take........ > > > > -michael > > > On Mar 6, 2010, at 10:41 PM, Prasanna Simha M wrote: > > > Michael, it is not a my incision is bigger than yours or whatever. People > > like it or not like to have smaller incisions. Reduce incision size , > reduce > > stretch and secondary injury etc etc are realities which we need to > attend > > to or strive to do However this should not be at the cost of safety and > > outcomes. I heard these same arguments when Lap procedures were advocated > > but they have found a definitive place.There are anatomical constraints > with > > the chest compared to the abdomen but if I could avoid getting the > sternum > > cracked open why not ? Also there will be people pushing the boundaries > of > > science and investigation and we need to have them or else we will not > > improve. You say men with chest hair - it is unnoticable etc but check > out > > your patients with these scars and see where they button up their shirts > and > > dresses to. Ask the lady whether she likes having a scar cutting up > across > > her blouse line -she will subtely wear a closed neck dress and so on and > so > > forth. I bet they (at least most of them) don't parade that scar like a > > masochistic trophy. > > Also if you are taking down bilateral IMA's why not spare the sternum if > you > > can if it is a reproducible technique ? > > You seem to be anti anything but full incision surgery. I am not so sure > why > > but I can tell you that if you do hemisternotomies without lateral cuts, > > they actually interlock rigidly and have less pain and get out home > earlier > > (and home for many of us in other parts of the world is usually 200 -500 > kms > > away and sometimes even 3000 kms away and not to an SNF/nursing home or > > whatever). If we can significantly reduce morbidity why not ? > > Having said all that I still am curious how the "shent" introducer was > > made. It looked elegant. > > Prasanna > > > > On Sun, Mar 7, 2010 at 8:25 AM, Michael Firstenberg >wrote: > > > >> oh here we going again - my incision is smaller than yours. > >> Granted children are different (or are they????? since they will heal > >> anything) > >> > >> Many patients within a month or so, particularly men with chest hair, > the > >> incision (if closed properly) is barely noticeable. However, the > scapular > >> pain and the pain from broken ribs and torn ligaments/cartilage lasts > >> longer........ > >> > >> -michael > >> > >> > >> > >> > >> On Mar 6, 2010, at 9:17 PM, Prasanna Simha M wrote: > >> > >>> People do get 1 foot long incisions !! I have seen people doing it > >>> regularly. > >>> I have done transxiphoid pericardiectomies for children with > >> pyopericardium > >>> and was surprised at the amount of exposure that it affords. > >>> The sternal sparing is a definite advantage but I am not so sure if an > >> upper > >>> abdominal incision is less painful. The upper abdominal incision is > >>> considered more painful than a sternotomy or a lower abdominal incision > >>> though various blocks and pain control measures can obviate that. > >>> Prasanna > >>> > >>> On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu > >> wrote: > >>> > >>>> > >>>> Amazing the exposure one can get from the subxiphoid approach - Mark > >>>> Levinson has really pushed the frontier on minimally invasive CABG > here > >> as > >>>> sparing sternotomy AND thoracotomy can potentially be a real benefit, > as > >>>> then in terms of trauma not much difference from an upper GI operation > >> and > >>>> very little limitation on post operative physical activity once pain > >> settles > >>>> (assuming the sternal retraction is not disruptive or destructive in > any > >>>> way). > >>>> > >>>> > >>>> > >>>> One comment though is that not very factual as stated on the website > >> that > >>>> conventional CABG incision is 12 inches long. Surely incisions have > not > >> been > >>>> that long in decades? > >>>> > >>>> > >>>> > >>>> Ani > >>>> > >>>> > >>>> > >>>> > >>>>> Date: Sat, 6 Mar 2010 21:30:44 +0530 > >>>>> From: prasannasimha@gmail.com > >>>>> To: OpenHeart-L@lists.hsforum.com > >>>>> CC: mmlevinson@mac.com > >>>>> Subject: [HSF] shent introducer ? > >>>>> > >>>>> http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html > >>>>> What is that device that you used to push in Don's "Shent" Is it made > >> of > >>>>> ordinary steel wire ? > >>>>> Prasanna > >>>>> > >>>>> -- > >>>>> 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 > >>>>> ----------------------------------------- > >>>> > >>>> _________________________________________________________________ > >>>> Tell us your greatest, weirdest and funniest Hotmail stories > >>>> > >>>> > >> > http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________ > >>>> OpenHeart-L< > >> > http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________%0AOpenHeart-L > >mailing > >> list > >>>> > >>>> Send postings to: > >>>> OpenHeart-L@lists.hsforum.com > >>>> > >>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: > >>>> http://mmp.cjp.com/mailman/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 > >> ----------------------------------------- > >> > > > > > > > > -- > > 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 > ----------------------------------------- > -- Prasanna Simha M From msfirst at gmail.com Sat Mar 6 23:11:14 2010 From: msfirst at gmail.com (Michael Firstenberg) Date: Sat Mar 6 23:19:16 2010 Subject: [HSF] shent introducer ? In-Reply-To: <89c4ed2d1003061954i5b7e1510nd4ae609617696dbd@mail.gmail.com> References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com> <89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com> <8CABA34C-69B3-4594-8760-0D058D345C71@gmail.com> <89c4ed2d1003061941l282eb3dbue474a238018860e@mail.gmail.com> <89c4ed2d1003061954i5b7e1510nd4ae609617696dbd@mail.gmail.com> Message-ID: <132F2D9B-A9B9-40BF-927F-E6AB26C2FCD4@gmail.com> Prasanna Surgeons like you and hal and many of the others who frequently comment are in my mind master surgeons. Not just as indiviuduals but also those who have command if the entire orchestra that is the operating room. Unless everyone us on board and in harmony then sometime pushing the envelope when others don't want it pushed regardless of the skills judgement and wisdom of the surgeon can lead to disaster. I have seen it. -michael/iPhone On Mar 6, 2010, at 10:54 PM, Prasanna Simha M wrote: > Really !! ;) I thought the comment made was expression of > appreciation on > developing a new technique and pushing frontiers. I bet we did not > think of > doing it !! Of course one has to be an extremely confident surgoen > with a > full open technique before even thinking of embarking on such a > venture. > Prasanna > > On Sun, Mar 7, 2010 at 9:20 AM, Michael Firstenberg > wrote: > >> I am not anti-everything. >> I just like to argue (debate?) - in part because sometimes some of >> the >> stuff that comes across here is written in a way that suggests than >> anyone >> that does "x" is a great surgeon and anyone who does "negative x" >> or less >> than "x" should be put out to pasture. >> >> I just like discussing some of the cons to the approaches that people >> take........ >> >> >> >> -michael >> >> >> On Mar 6, 2010, at 10:41 PM, Prasanna Simha M wrote: >> >>> Michael, it is not a my incision is bigger than yours or whatever. >>> People >>> like it or not like to have smaller incisions. Reduce incision >>> size , >> reduce >>> stretch and secondary injury etc etc are realities which we need to >> attend >>> to or strive to do However this should not be at the cost of >>> safety and >>> outcomes. I heard these same arguments when Lap procedures were >>> advocated >>> but they have found a definitive place.There are anatomical >>> constraints >> with >>> the chest compared to the abdomen but if I could avoid getting the >> sternum >>> cracked open why not ? Also there will be people pushing the >>> boundaries >> of >>> science and investigation and we need to have them or else we will >>> not >>> improve. You say men with chest hair - it is unnoticable etc but >>> check >> out >>> your patients with these scars and see where they button up their >>> shirts >> and >>> dresses to. Ask the lady whether she likes having a scar cutting up >> across >>> her blouse line -she will subtely wear a closed neck dress and so >>> on and >> so >>> forth. I bet they (at least most of them) don't parade that scar >>> like a >>> masochistic trophy. >>> Also if you are taking down bilateral IMA's why not spare the >>> sternum if >> you >>> can if it is a reproducible technique ? >>> You seem to be anti anything but full incision surgery. I am not >>> so sure >> why >>> but I can tell you that if you do hemisternotomies without >>> lateral cuts, >>> they actually interlock rigidly and have less pain and get out home >> earlier >>> (and home for many of us in other parts of the world is usually >>> 200 -500 >> kms >>> away and sometimes even 3000 kms away and not to an SNF/nursing >>> home or >>> whatever). If we can significantly reduce morbidity why not ? >>> Having said all that I still am curious how the "shent" >>> introducer was >>> made. It looked elegant. >>> Prasanna >>> >>> On Sun, Mar 7, 2010 at 8:25 AM, Michael Firstenberg >> wrote: >>> >>>> oh here we going again - my incision is smaller than yours. >>>> Granted children are different (or are they????? since they will >>>> heal >>>> anything) >>>> >>>> Many patients within a month or so, particularly men with chest >>>> hair, >> the >>>> incision (if closed properly) is barely noticeable. However, the >> scapular >>>> pain and the pain from broken ribs and torn ligaments/cartilage >>>> lasts >>>> longer........ >>>> >>>> -michael >>>> >>>> >>>> >>>> >>>> On Mar 6, 2010, at 9:17 PM, Prasanna Simha M wrote: >>>> >>>>> People do get 1 foot long incisions !! I have seen people doing it >>>>> regularly. >>>>> I have done transxiphoid pericardiectomies for children with >>>> pyopericardium >>>>> and was surprised at the amount of exposure that it affords. >>>>> The sternal sparing is a definite advantage but I am not so sure >>>>> if an >>>> upper >>>>> abdominal incision is less painful. The upper abdominal >>>>> incision is >>>>> considered more painful than a sternotomy or a lower abdominal >>>>> incision >>>>> though various blocks and pain control measures can obviate that. >>>>> Prasanna >>>>> >>>>> On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu >>>> > >>>> wrote: >>>>> >>>>>> >>>>>> Amazing the exposure one can get from the subxiphoid approach - >>>>>> Mark >>>>>> Levinson has really pushed the frontier on minimally invasive >>>>>> CABG >> here >>>> as >>>>>> sparing sternotomy AND thoracotomy can potentially be a real >>>>>> benefit, >> as >>>>>> then in terms of trauma not much difference from an upper GI >>>>>> operation >>>> and >>>>>> very little limitation on post operative physical activity once >>>>>> pain >>>> settles >>>>>> (assuming the sternal retraction is not disruptive or >>>>>> destructive in >> any >>>>>> way). >>>>>> >>>>>> >>>>>> >>>>>> One comment though is that not very factual as stated on the >>>>>> website >>>> that >>>>>> conventional CABG incision is 12 inches long. Surely incisions >>>>>> have >> not >>>> been >>>>>> that long in decades? >>>>>> >>>>>> >>>>>> >>>>>> Ani >>>>>> >>>>>> >>>>>> >>>>>> >>>>>>> Date: Sat, 6 Mar 2010 21:30:44 +0530 >>>>>>> From: prasannasimha@gmail.com >>>>>>> To: OpenHeart-L@lists.hsforum.com >>>>>>> CC: mmlevinson@mac.com >>>>>>> Subject: [HSF] shent introducer ? >>>>>>> >>>>>>> http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html >>>>>>> What is that device that you used to push in Don's "Shent" Is >>>>>>> it made >>>> of >>>>>>> ordinary steel wire ? >>>>>>> Prasanna >>>>>>> >>>>>>> -- >>>>>>> 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 >>>>>>> ----------------------------------------- >>>>>> >>>>>> _________________________________________________________________ >>>>>> Tell us your greatest, weirdest and funniest Hotmail stories >>>>>> >>>>>> >>>> >> http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________ >>>>>> OpenHeart-L< >>>> >> http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________%0AOpenHeart-L >>> mailing >>>> list >>>>>> >>>>>> Send postings to: >>>>>> OpenHeart-L@lists.hsforum.com >>>>>> >>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>>> http://mmp.cjp.com/mailman/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 >>>> ----------------------------------------- >>>> >>> >>> >>> >>> -- >>> 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 >> ----------------------------------------- >> > > > > -- > 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 prasannasimha at gmail.com Sun Mar 7 09:22:55 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sat Mar 6 23:24:12 2010 Subject: [HSF] shent introducer ? In-Reply-To: References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com> Message-ID: <89c4ed2d1003061952q1a6503a9m2eb9ba967ed6a68c@mail.gmail.com> Dr Valavanur Subramaniam had described using a chevron type incision (which is associated with lesser pain and detechement of the recti actually spreads out the chest and is supposed to give a better exposure. Has anyone tried out that ? Prasanna On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu wrote: > > Amazing the exposure one can get from the subxiphoid approach - Mark > Levinson has really pushed the frontier on minimally invasive CABG here as > sparing sternotomy AND thoracotomy can potentially be a real benefit, as > then in terms of trauma not much difference from an upper GI operation and > very little limitation on post operative physical activity once pain settles > (assuming the sternal retraction is not disruptive or destructive in any > way). > > > > One comment though is that not very factual as stated on the website that > conventional CABG incision is 12 inches long. Surely incisions have not been > that long in decades? > > > > Ani > > > > > > Date: Sat, 6 Mar 2010 21:30:44 +0530 > > From: prasannasimha@gmail.com > > To: OpenHeart-L@lists.hsforum.com > > CC: mmlevinson@mac.com > > Subject: [HSF] shent introducer ? > > > > http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html > > What is that device that you used to push in Don's "Shent" Is it made of > > ordinary steel wire ? > > Prasanna > > > > -- > > 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 > > ----------------------------------------- > > _________________________________________________________________ > Tell us your greatest, weirdest and funniest Hotmail stories > > http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________ > OpenHeart-Lmailing list > > Send postings to: > OpenHeart-L@lists.hsforum.com > > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > http://mmp.cjp.com/mailman/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 Mar 7 09:57:17 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sun Mar 7 00:20:51 2010 Subject: [HSF] shent introducer ? In-Reply-To: <132F2D9B-A9B9-40BF-927F-E6AB26C2FCD4@gmail.com> References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com> <89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com> <8CABA34C-69B3-4594-8760-0D058D345C71@gmail.com> <89c4ed2d1003061941l282eb3dbue474a238018860e@mail.gmail.com> <89c4ed2d1003061954i5b7e1510nd4ae609617696dbd@mail.gmail.com> <132F2D9B-A9B9-40BF-927F-E6AB26C2FCD4@gmail.com> Message-ID: <89c4ed2d1003062027s322f4d9fqd564213f8c8dcbb0@mail.gmail.com> Of course it does and part of the planning is to enthuse and get people on board or carry them along with you !! Sometimes evolution of a technique in steps is better than a sudden paradigm shift. I have seen it first hand and let me tell you change is not something acceptable to many.It is a human trait as much as exploration is a human quaklity (Yikes I am talking like Tea ;) ) Even rocks are split by the constant weathering of a stream. Prasanna On Sun, Mar 7, 2010 at 9:41 AM, Michael Firstenberg wrote: > Prasanna > Surgeons like you and hal and many of the others who frequently comment are > in my mind master surgeons. Not just as indiviuduals but also those who have > command if the entire orchestra that is the operating room. Unless everyone > us on board and in harmony then sometime pushing the envelope when others > don't want it pushed regardless of the skills judgement and wisdom of the > surgeon can lead to disaster. > > I have seen it. > > -michael/iPhone > > > On Mar 6, 2010, at 10:54 PM, Prasanna Simha M > wrote: > > Really !! ;) I thought the comment made was expression of appreciation on >> developing a new technique and pushing frontiers. I bet we did not think >> of >> doing it !! Of course one has to be an extremely confident surgoen with a >> full open technique before even thinking of embarking on such a venture. >> Prasanna >> >> On Sun, Mar 7, 2010 at 9:20 AM, Michael Firstenberg > >wrote: >> >> I am not anti-everything. >>> I just like to argue (debate?) - in part because sometimes some of the >>> stuff that comes across here is written in a way that suggests than >>> anyone >>> that does "x" is a great surgeon and anyone who does "negative x" or less >>> than "x" should be put out to pasture. >>> >>> I just like discussing some of the cons to the approaches that people >>> take........ >>> >>> >>> >>> -michael >>> >>> >>> On Mar 6, 2010, at 10:41 PM, Prasanna Simha M wrote: >>> >>> Michael, it is not a my incision is bigger than yours or whatever. >>>> People >>>> like it or not like to have smaller incisions. Reduce incision size , >>>> >>> reduce >>> >>>> stretch and secondary injury etc etc are realities which we need to >>>> >>> attend >>> >>>> to or strive to do However this should not be at the cost of safety and >>>> outcomes. I heard these same arguments when Lap procedures were >>>> advocated >>>> but they have found a definitive place.There are anatomical constraints >>>> >>> with >>> >>>> the chest compared to the abdomen but if I could avoid getting the >>>> >>> sternum >>> >>>> cracked open why not ? Also there will be people pushing the boundaries >>>> >>> of >>> >>>> science and investigation and we need to have them or else we will not >>>> improve. You say men with chest hair - it is unnoticable etc but check >>>> >>> out >>> >>>> your patients with these scars and see where they button up their shirts >>>> >>> and >>> >>>> dresses to. Ask the lady whether she likes having a scar cutting up >>>> >>> across >>> >>>> her blouse line -she will subtely wear a closed neck dress and so on and >>>> >>> so >>> >>>> forth. I bet they (at least most of them) don't parade that scar like a >>>> masochistic trophy. >>>> Also if you are taking down bilateral IMA's why not spare the sternum if >>>> >>> you >>> >>>> can if it is a reproducible technique ? >>>> You seem to be anti anything but full incision surgery. I am not so sure >>>> >>> why >>> >>>> but I can tell you that if you do hemisternotomies without lateral >>>> cuts, >>>> they actually interlock rigidly and have less pain and get out home >>>> >>> earlier >>> >>>> (and home for many of us in other parts of the world is usually 200 -500 >>>> >>> kms >>> >>>> away and sometimes even 3000 kms away and not to an SNF/nursing home or >>>> whatever). If we can significantly reduce morbidity why not ? >>>> Having said all that I still am curious how the "shent" introducer was >>>> made. It looked elegant. >>>> Prasanna >>>> >>>> On Sun, Mar 7, 2010 at 8:25 AM, Michael Firstenberg >>> wrote: >>>> >>>> oh here we going again - my incision is smaller than yours. >>>>> Granted children are different (or are they????? since they will heal >>>>> anything) >>>>> >>>>> Many patients within a month or so, particularly men with chest hair, >>>>> >>>> the >>> >>>> incision (if closed properly) is barely noticeable. However, the >>>>> >>>> scapular >>> >>>> pain and the pain from broken ribs and torn ligaments/cartilage lasts >>>>> longer........ >>>>> >>>>> -michael >>>>> >>>>> >>>>> >>>>> >>>>> On Mar 6, 2010, at 9:17 PM, Prasanna Simha M wrote: >>>>> >>>>> People do get 1 foot long incisions !! I have seen people doing it >>>>>> regularly. >>>>>> I have done transxiphoid pericardiectomies for children with >>>>>> >>>>> pyopericardium >>>>> >>>>>> and was surprised at the amount of exposure that it affords. >>>>>> The sternal sparing is a definite advantage but I am not so sure if an >>>>>> >>>>> upper >>>>> >>>>>> abdominal incision is less painful. The upper abdominal incision is >>>>>> considered more painful than a sternotomy or a lower abdominal >>>>>> incision >>>>>> though various blocks and pain control measures can obviate that. >>>>>> Prasanna >>>>>> >>>>>> On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu >>>>>> >>>>> wrote: >>>>> >>>>>> >>>>>> >>>>>>> Amazing the exposure one can get from the subxiphoid approach - Mark >>>>>>> Levinson has really pushed the frontier on minimally invasive CABG >>>>>>> >>>>>> here >>> >>>> as >>>>> >>>>>> sparing sternotomy AND thoracotomy can potentially be a real benefit, >>>>>>> >>>>>> as >>> >>>> then in terms of trauma not much difference from an upper GI operation >>>>>>> >>>>>> and >>>>> >>>>>> very little limitation on post operative physical activity once pain >>>>>>> >>>>>> settles >>>>> >>>>>> (assuming the sternal retraction is not disruptive or destructive in >>>>>>> >>>>>> any >>> >>>> way). >>>>>>> >>>>>>> >>>>>>> >>>>>>> One comment though is that not very factual as stated on the website >>>>>>> >>>>>> that >>>>> >>>>>> conventional CABG incision is 12 inches long. Surely incisions have >>>>>>> >>>>>> not >>> >>>> been >>>>> >>>>>> that long in decades? >>>>>>> >>>>>>> >>>>>>> >>>>>>> Ani >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>> Date: Sat, 6 Mar 2010 21:30:44 +0530 >>>>>>>> From: prasannasimha@gmail.com >>>>>>>> To: OpenHeart-L@lists.hsforum.com >>>>>>>> CC: mmlevinson@mac.com >>>>>>>> Subject: [HSF] shent introducer ? >>>>>>>> >>>>>>>> http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html >>>>>>>> What is that device that you used to push in Don's "Shent" Is it >>>>>>>> made >>>>>>>> >>>>>>> of >>>>> >>>>>> ordinary steel wire ? >>>>>>>> Prasanna >>>>>>>> >>>>>>>> -- >>>>>>>> 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 >>>>>>>> ----------------------------------------- >>>>>>>> >>>>>>> >>>>>>> _________________________________________________________________ >>>>>>> Tell us your greatest, weirdest and funniest Hotmail stories >>>>>>> >>>>>>> >>>>>>> >>>>> >>> http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________ >>> >>>> OpenHeart-L< >>>>>>> >>>>>> >>>>> >>> http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________%0AOpenHeart-L >>> >>>> mailing >>>> >>>>> list >>>>> >>>>>> >>>>>>> Send postings to: >>>>>>> OpenHeart-L@lists.hsforum.com >>>>>>> >>>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>>>> http://mmp.cjp.com/mailman/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 >>>>> ----------------------------------------- >>>>> >>>>> >>>> >>>> >>>> -- >>>> 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 >>> ----------------------------------------- >>> >>> >> >> >> -- >> 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 > anddisclaimers posted at: > > http://www.hsforum.com/listdisclaim > ----------------------------------------- > -- Prasanna Simha M From grescigno at mac.com Sun Mar 7 09:51:29 2010 From: grescigno at mac.com (Giuseppe Rescigno) Date: Sun Mar 7 03:57:25 2010 Subject: [HSF] shent introducer ? In-Reply-To: <89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com> References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com> <89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com> Message-ID: Prasanna, I am very favorable to minimally invasive, mini incisions, cosmetic results etc. However, this is not always source of better outcome. I have a recent example of a quite young woman (around 50 yo) I operated on 1 month ago of double ITA. She is diabetic and a little bit overweight (not very much indeed). I did a limited skin incision (not extreme but sufficient to be hidden by a "large" bra. ITA harvesting was of course longer as well as the entire operation (performed on pump for exposure difficulty). She had excellent recovery, however I noticed some skin suffering at the upper extremity before discharge. She went home and came back one week after with one third of the incision completely open. After debridement, the tissue loss required a double advancement flap to close the soft tissues. Luckily there was no infection. Now she is slowly healing but the cosmetic result will not be very good. I anticipate your criticisms saying that spreading was very careful (I worked with the tips of the fingers). Discussing with the lady she told me that her look was not so important to afford such a complication. I guess that many of our patients prefer to go home in good fit and as soon as possible instead of caring about cosmesis. Giuseppe Il giorno 07/mar/10, alle ore 03:17, Prasanna Simha M ha scritto: > People do get 1 foot long incisions !! I have seen people doing it > regularly. > I have done transxiphoid pericardiectomies for children with > pyopericardium > and was surprised at the amount of exposure that it affords. > The sternal sparing is a definite advantage but I am not so sure if > an upper > abdominal incision is less painful. The upper abdominal incision is > considered more painful than a sternotomy or a lower abdominal > incision > though various blocks and pain control measures can obviate that. > Prasanna > > On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu > wrote: > >> >> Amazing the exposure one can get from the subxiphoid approach - Mark >> Levinson has really pushed the frontier on minimally invasive CABG >> here as >> sparing sternotomy AND thoracotomy can potentially be a real >> benefit, as >> then in terms of trauma not much difference from an upper GI >> operation and >> very little limitation on post operative physical activity once >> pain settles >> (assuming the sternal retraction is not disruptive or destructive >> in any >> way). >> >> >> >> One comment though is that not very factual as stated on the >> website that >> conventional CABG incision is 12 inches long. Surely incisions >> have not been >> that long in decades? >> >> >> >> Ani >> >> >> >> >>> Date: Sat, 6 Mar 2010 21:30:44 +0530 >>> From: prasannasimha@gmail.com >>> To: OpenHeart-L@lists.hsforum.com >>> CC: mmlevinson@mac.com >>> Subject: [HSF] shent introducer ? >>> >>> http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html >>> What is that device that you used to push in Don's "Shent" Is it >>> made of >>> ordinary steel wire ? >>> Prasanna >>> >>> -- >>> 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 >>> ----------------------------------------- >> >> _________________________________________________________________ >> Tell us your greatest, weirdest and funniest Hotmail stories >> >> http://clk.atdmt.com/UKM/go/195013117/direct/01/ >> _______________________________________________ >> OpenHeart-L> _______________________________________________%0AOpenHeart- >> L>mailing list >> >> Send postings to: >> OpenHeart-L@lists.hsforum.com >> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >> http://mmp.cjp.com/mailman/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 prasannasimha at gmail.com Sun Mar 7 16:36:48 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sun Mar 7 06:07:06 2010 Subject: [HSF] shent introducer ? In-Reply-To: References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com> <89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com> Message-ID: <89c4ed2d1003070306j62d06abax5ab8de208b9aa9af@mail.gmail.com> Yes of course they will want that too but don't just blame the technical failure to a small incision . Read bilateral ITA , diabetic which would have predisposed her to wound infection wether it was full or limited incision.We may equally argue that using Marc Levinsons sternal sparing echnique for arguments sake) maybe the sternum andskin would not have given away at all !! Did you use a partial or full sternotomy ?Was the mammary harvest skeletonized ? How was the perioperative glycemic control of this patient ? What was the preop gHbA1C levels ? Did she smoke before and after surgery ? Incidentally while you may say you did minimaly invasive it may be argued that avoiding CPB may be another minimaly "invasive" approach.Viewpoints vary. Prasanna On Sun, Mar 7, 2010 at 2:21 PM, Giuseppe Rescigno wrote: > Prasanna, > > I am very favorable to minimally invasive, mini incisions, cosmetic results > etc. However, this is not always source of better outcome. I have a recent > example of a quite young woman (around 50 yo) I operated on 1 month ago of > double ITA. She is diabetic and a little bit overweight (not very much > indeed). I did a limited skin incision (not extreme but sufficient to be > hidden by a "large" bra. ITA harvesting was of course longer as well as the > entire operation (performed on pump for exposure difficulty). She had > excellent recovery, however I noticed some skin suffering at the upper > extremity before discharge. She went home and came back one week after with > one third of the incision completely open. After debridement, the tissue > loss required a double advancement flap to close the soft tissues. Luckily > there was no infection. Now she is slowly healing but the cosmetic result > will not be very good. I anticipate your criticisms saying that spreading > was very careful (I worked with the tips of the fingers). Discussing with > the lady she told me that her look was not so important to afford such a > complication. I guess that many of our patients prefer to go home in good > fit and as soon as possible instead of caring about cosmesis. > > Giuseppe > > > Il giorno 07/mar/10, alle ore 03:17, Prasanna Simha M ha scritto: > > People do get 1 foot long incisions !! I have seen people doing it >> regularly. >> I have done transxiphoid pericardiectomies for children with >> pyopericardium >> and was surprised at the amount of exposure that it affords. >> The sternal sparing is a definite advantage but I am not so sure if an >> upper >> abdominal incision is less painful. The upper abdominal incision is >> considered more painful than a sternotomy or a lower abdominal incision >> though various blocks and pain control measures can obviate that. >> Prasanna >> >> On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu >> wrote: >> >> >>> Amazing the exposure one can get from the subxiphoid approach - Mark >>> Levinson has really pushed the frontier on minimally invasive CABG here >>> as >>> sparing sternotomy AND thoracotomy can potentially be a real benefit, as >>> then in terms of trauma not much difference from an upper GI operation >>> and >>> very little limitation on post operative physical activity once pain >>> settles >>> (assuming the sternal retraction is not disruptive or destructive in any >>> way). >>> >>> >>> >>> One comment though is that not very factual as stated on the website that >>> conventional CABG incision is 12 inches long. Surely incisions have not >>> been >>> that long in decades? >>> >>> >>> >>> Ani >>> >>> >>> >>> >>> Date: Sat, 6 Mar 2010 21:30:44 +0530 >>>> From: prasannasimha@gmail.com >>>> To: OpenHeart-L@lists.hsforum.com >>>> CC: mmlevinson@mac.com >>>> Subject: [HSF] shent introducer ? >>>> >>>> http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html >>>> What is that device that you used to push in Don's "Shent" Is it made of >>>> ordinary steel wire ? >>>> Prasanna >>>> >>>> -- >>>> 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 >>>> ----------------------------------------- >>>> >>> >>> _________________________________________________________________ >>> Tell us your greatest, weirdest and funniest Hotmail stories >>> >>> >>> http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________ >>> OpenHeart-L< >>> http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________%0AOpenHeart-L>mailing >>> list >>> >>> >>> Send postings to: >>> OpenHeart-L@lists.hsforum.com >>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>> http://mmp.cjp.com/mailman/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 > anddisclaimers posted at: > > http://www.hsforum.com/listdisclaim > ----------------------------------------- > -- Prasanna Simha M From grescigno at mac.com Sun Mar 7 12:43:54 2010 From: grescigno at mac.com (Giuseppe Rescigno) Date: Sun Mar 7 06:49:44 2010 Subject: [HSF] shent introducer ? In-Reply-To: <89c4ed2d1003070306j62d06abax5ab8de208b9aa9af@mail.gmail.com> References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com> <89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com> <89c4ed2d1003070306j62d06abax5ab8de208b9aa9af@mail.gmail.com> Message-ID: Prasanna, of course there were other risk factors. OPCAB was quite impossible as heart tilting was contrasted by small incision. She was a smoker in the past. Blood glucose was well controlled. OT: yeasterday evening I celebrated, as every year, the birthday of my daughter Greta (17!!!) at the usual indian restaurant in Milan and it was really good. I had Tandoori Chicken with rice and Naan. I love indian cuisine! Giuseppe Il giorno 07/mar/10, alle ore 12:06, Prasanna Simha M ha scritto: > Yes of course they will want that too but don't just blame the > technical > failure to a small incision . Read bilateral ITA , diabetic which > would > have predisposed her to wound infection wether it was full or limited > incision.We may equally argue that using Marc Levinsons sternal > sparing > echnique for arguments sake) maybe the sternum andskin would not > have given > away at all !! > Did you use a partial or full sternotomy ?Was the mammary harvest > skeletonized ? How was the perioperative glycemic control of this > patient ? > What was the preop gHbA1C levels ? Did she smoke before and after > surgery ? > Incidentally while you may say you did minimaly invasive it may be > argued > that avoiding CPB may be another minimaly "invasive" > approach.Viewpoints > vary. > Prasanna > > On Sun, Mar 7, 2010 at 2:21 PM, Giuseppe Rescigno > wrote: > >> Prasanna, >> >> I am very favorable to minimally invasive, mini incisions, >> cosmetic results >> etc. However, this is not always source of better outcome. I have >> a recent >> example of a quite young woman (around 50 yo) I operated on 1 >> month ago of >> double ITA. She is diabetic and a little bit overweight (not very >> much >> indeed). I did a limited skin incision (not extreme but sufficient >> to be >> hidden by a "large" bra. ITA harvesting was of course longer as >> well as the >> entire operation (performed on pump for exposure difficulty). She had >> excellent recovery, however I noticed some skin suffering at the >> upper >> extremity before discharge. She went home and came back one week >> after with >> one third of the incision completely open. After debridement, the >> tissue >> loss required a double advancement flap to close the soft tissues. >> Luckily >> there was no infection. Now she is slowly healing but the cosmetic >> result >> will not be very good. I anticipate your criticisms saying that >> spreading >> was very careful (I worked with the tips of the fingers). >> Discussing with >> the lady she told me that her look was not so important to afford >> such a >> complication. I guess that many of our patients prefer to go home >> in good >> fit and as soon as possible instead of caring about cosmesis. >> >> Giuseppe >> >> >> Il giorno 07/mar/10, alle ore 03:17, Prasanna Simha M ha scritto: >> >> People do get 1 foot long incisions !! I have seen people doing it >>> regularly. >>> I have done transxiphoid pericardiectomies for children with >>> pyopericardium >>> and was surprised at the amount of exposure that it affords. >>> The sternal sparing is a definite advantage but I am not so sure >>> if an >>> upper >>> abdominal incision is less painful. The upper abdominal incision is >>> considered more painful than a sternotomy or a lower abdominal >>> incision >>> though various blocks and pain control measures can obviate that. >>> Prasanna >>> >>> On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu >>> >>> wrote: >>> >>> >>>> Amazing the exposure one can get from the subxiphoid approach - >>>> Mark >>>> Levinson has really pushed the frontier on minimally invasive >>>> CABG here >>>> as >>>> sparing sternotomy AND thoracotomy can potentially be a real >>>> benefit, as >>>> then in terms of trauma not much difference from an upper GI >>>> operation >>>> and >>>> very little limitation on post operative physical activity once >>>> pain >>>> settles >>>> (assuming the sternal retraction is not disruptive or >>>> destructive in any >>>> way). >>>> >>>> >>>> >>>> One comment though is that not very factual as stated on the >>>> website that >>>> conventional CABG incision is 12 inches long. Surely incisions >>>> have not >>>> been >>>> that long in decades? >>>> >>>> >>>> >>>> Ani >>>> >>>> >>>> >>>> >>>> Date: Sat, 6 Mar 2010 21:30:44 +0530 >>>>> From: prasannasimha@gmail.com >>>>> To: OpenHeart-L@lists.hsforum.com >>>>> CC: mmlevinson@mac.com >>>>> Subject: [HSF] shent introducer ? >>>>> >>>>> http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html >>>>> What is that device that you used to push in Don's "Shent" Is >>>>> it made of >>>>> ordinary steel wire ? >>>>> Prasanna >>>>> >>>>> -- >>>>> 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 >>>>> ----------------------------------------- >>>>> >>>> >>>> _________________________________________________________________ >>>> Tell us your greatest, weirdest and funniest Hotmail stories >>>> >>>> >>>> http://clk.atdmt.com/UKM/go/195013117/direct/01/ >>>> _______________________________________________ >>>> OpenHeart-L< >>>> http://clk.atdmt.com/UKM/go/195013117/direct/01/ >>>> _______________________________________________%0AOpenHeart- >>>> L>mailing >>>> list >>>> >>>> >>>> Send postings to: >>>> OpenHeart-L@lists.hsforum.com >>>> >>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>> http://mmp.cjp.com/mailman/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 >> anddisclaimers 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 prasannasimha at gmail.com Sun Mar 7 18:06:08 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sun Mar 7 07:43:39 2010 Subject: [HSF] shent introducer ? In-Reply-To: References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com> <89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com> <89c4ed2d1003070306j62d06abax5ab8de208b9aa9af@mail.gmail.com> Message-ID: <89c4ed2d1003070436p25be8013h538eb7fe86fa63c@mail.gmail.com> Tell her Happy Birthday on my behalf. One thing that I do for CABG's with bilateral IMA's is to always leave redivac in additional to regular drains in fatty people and you will be surprised at the amount of chicken broth that comes out. That often has positive cultures but (I hypothesize) that sucking out this rich culture medium prevents infection as otherwise it acts ads a good culture medium. Prasanna On Sun, Mar 7, 2010 at 5:13 PM, Giuseppe Rescigno wrote: > Prasanna, > > of course there were other risk factors. OPCAB was quite impossible as > heart tilting was contrasted by small incision. She was a smoker in the > past. Blood glucose was well controlled. > OT: yeasterday evening I celebrated, as every year, the birthday of my > daughter Greta (17!!!) at the usual indian restaurant in Milan and it was > really good. I had Tandoori Chicken with rice and Naan. I love indian > cuisine! > > Giuseppe > > > Il giorno 07/mar/10, alle ore 12:06, Prasanna Simha M ha scritto: > > > Yes of course they will want that too but don't just blame the technical >> failure to a small incision . Read bilateral ITA , diabetic which would >> have predisposed her to wound infection wether it was full or limited >> incision.We may equally argue that using Marc Levinsons sternal sparing >> echnique for arguments sake) maybe the sternum andskin would not have >> given >> away at all !! >> Did you use a partial or full sternotomy ?Was the mammary harvest >> skeletonized ? How was the perioperative glycemic control of this patient >> ? >> What was the preop gHbA1C levels ? Did she smoke before and after surgery >> ? >> Incidentally while you may say you did minimaly invasive it may be argued >> that avoiding CPB may be another minimaly "invasive" approach.Viewpoints >> vary. >> Prasanna >> >> On Sun, Mar 7, 2010 at 2:21 PM, Giuseppe Rescigno >> wrote: >> >> Prasanna, >>> >>> I am very favorable to minimally invasive, mini incisions, cosmetic >>> results >>> etc. However, this is not always source of better outcome. I have a >>> recent >>> example of a quite young woman (around 50 yo) I operated on 1 month ago >>> of >>> double ITA. She is diabetic and a little bit overweight (not very much >>> indeed). I did a limited skin incision (not extreme but sufficient to be >>> hidden by a "large" bra. ITA harvesting was of course longer as well as >>> the >>> entire operation (performed on pump for exposure difficulty). She had >>> excellent recovery, however I noticed some skin suffering at the upper >>> extremity before discharge. She went home and came back one week after >>> with >>> one third of the incision completely open. After debridement, the tissue >>> loss required a double advancement flap to close the soft tissues. >>> Luckily >>> there was no infection. Now she is slowly healing but the cosmetic result >>> will not be very good. I anticipate your criticisms saying that spreading >>> was very careful (I worked with the tips of the fingers). Discussing with >>> the lady she told me that her look was not so important to afford such a >>> complication. I guess that many of our patients prefer to go home in good >>> fit and as soon as possible instead of caring about cosmesis. >>> >>> Giuseppe >>> >>> >>> Il giorno 07/mar/10, alle ore 03:17, Prasanna Simha M ha scritto: >>> >>> People do get 1 foot long incisions !! I have seen people doing it >>> >>>> regularly. >>>> I have done transxiphoid pericardiectomies for children with >>>> pyopericardium >>>> and was surprised at the amount of exposure that it affords. >>>> The sternal sparing is a definite advantage but I am not so sure if an >>>> upper >>>> abdominal incision is less painful. The upper abdominal incision is >>>> considered more painful than a sternotomy or a lower abdominal incision >>>> though various blocks and pain control measures can obviate that. >>>> Prasanna >>>> >>>> On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu >>>> wrote: >>>> >>>> >>>> Amazing the exposure one can get from the subxiphoid approach - Mark >>>>> Levinson has really pushed the frontier on minimally invasive CABG here >>>>> as >>>>> sparing sternotomy AND thoracotomy can potentially be a real benefit, >>>>> as >>>>> then in terms of trauma not much difference from an upper GI operation >>>>> and >>>>> very little limitation on post operative physical activity once pain >>>>> settles >>>>> (assuming the sternal retraction is not disruptive or destructive in >>>>> any >>>>> way). >>>>> >>>>> >>>>> >>>>> One comment though is that not very factual as stated on the website >>>>> that >>>>> conventional CABG incision is 12 inches long. Surely incisions have not >>>>> been >>>>> that long in decades? >>>>> >>>>> >>>>> >>>>> Ani >>>>> >>>>> >>>>> >>>>> >>>>> Date: Sat, 6 Mar 2010 21:30:44 +0530 >>>>> >>>>>> From: prasannasimha@gmail.com >>>>>> To: OpenHeart-L@lists.hsforum.com >>>>>> CC: mmlevinson@mac.com >>>>>> Subject: [HSF] shent introducer ? >>>>>> >>>>>> http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html >>>>>> What is that device that you used to push in Don's "Shent" Is it made >>>>>> of >>>>>> ordinary steel wire ? >>>>>> Prasanna >>>>>> >>>>>> -- >>>>>> 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 >>>>>> ----------------------------------------- >>>>>> >>>>>> >>>>> _________________________________________________________________ >>>>> Tell us your greatest, weirdest and funniest Hotmail stories >>>>> >>>>> >>>>> >>>>> http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________ >>>>> OpenHeart-L< >>>>> >>>>> http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________%0AOpenHeart-L >>>>> >mailing >>>>> list >>>>> >>>>> >>>>> Send postings to: >>>>> OpenHeart-L@lists.hsforum.com >>>>> >>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>> http://mmp.cjp.com/mailman/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 >>> anddisclaimers 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 > anddisclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > -- Prasanna Simha M From robertobattellini at hotmail.com Sun Mar 7 14:42:00 2010 From: robertobattellini at hotmail.com (Roberto Battellini) Date: Sun Mar 7 08:42:49 2010 Subject: [HSF] =?iso-8859-1?q?Giuseppe=B4s_daughter_=28OT=29?= In-Reply-To: References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com>, , <89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com>, , <89c4ed2d1003070306j62d06abax5ab8de208b9aa9af@mail.gmail.com>, Message-ID: Giuseppe, take care, I read what is written... I will celebrate my son?s Mauro 21 years in July, (he is studying in Bristol) may be we can introduce each other... Roberto > From: grescigno@mac.com > Subject: Re: [HSF] shent introducer ? > Date: Sun, 7 Mar 2010 12:43:54 +0100 > To: OpenHeart-L@lists.hsforum.com > CC: > > Prasanna, > > of course there were other risk factors. OPCAB was quite impossible > as heart tilting was contrasted by small incision. She was a smoker > in the past. Blood glucose was well controlled. > OT: yeasterday evening I celebrated, as every year, the birthday of > my daughter Greta (17!!!) at the usual indian restaurant in Milan and > it was really good. I had Tandoori Chicken with rice and Naan. I love > indian cuisine! > > Giuseppe > > > Il giorno 07/mar/10, alle ore 12:06, Prasanna Simha M ha scritto: > > > Yes of course they will want that too but don't just blame the > > technical > > failure to a small incision . Read bilateral ITA , diabetic which > > would > > have predisposed her to wound infection wether it was full or limited > > incision.We may equally argue that using Marc Levinsons sternal > > sparing > > echnique for arguments sake) maybe the sternum andskin would not > > have given > > away at all !! > > Did you use a partial or full sternotomy ?Was the mammary harvest > > skeletonized ? How was the perioperative glycemic control of this > > patient ? > > What was the preop gHbA1C levels ? Did she smoke before and after > > surgery ? > > Incidentally while you may say you did minimaly invasive it may be > > argued > > that avoiding CPB may be another minimaly "invasive" > > approach.Viewpoints > > vary. > > Prasanna > > > > On Sun, Mar 7, 2010 at 2:21 PM, Giuseppe Rescigno > > wrote: > > > >> Prasanna, > >> > >> I am very favorable to minimally invasive, mini incisions, > >> cosmetic results > >> etc. However, this is not always source of better outcome. I have > >> a recent > >> example of a quite young woman (around 50 yo) I operated on 1 > >> month ago of > >> double ITA. She is diabetic and a little bit overweight (not very > >> much > >> indeed). I did a limited skin incision (not extreme but sufficient > >> to be > >> hidden by a "large" bra. ITA harvesting was of course longer as > >> well as the > >> entire operation (performed on pump for exposure difficulty). She had > >> excellent recovery, however I noticed some skin suffering at the > >> upper > >> extremity before discharge. She went home and came back one week > >> after with > >> one third of the incision completely open. After debridement, the > >> tissue > >> loss required a double advancement flap to close the soft tissues. > >> Luckily > >> there was no infection. Now she is slowly healing but the cosmetic > >> result > >> will not be very good. I anticipate your criticisms saying that > >> spreading > >> was very careful (I worked with the tips of the fingers). > >> Discussing with > >> the lady she told me that her look was not so important to afford > >> such a > >> complication. I guess that many of our patients prefer to go home > >> in good > >> fit and as soon as possible instead of caring about cosmesis. > >> > >> Giuseppe > >> > >> > >> Il giorno 07/mar/10, alle ore 03:17, Prasanna Simha M ha scritto: > >> > >> People do get 1 foot long incisions !! I have seen people doing it > >>> regularly. > >>> I have done transxiphoid pericardiectomies for children with > >>> pyopericardium > >>> and was surprised at the amount of exposure that it affords. > >>> The sternal sparing is a definite advantage but I am not so sure > >>> if an > >>> upper > >>> abdominal incision is less painful. The upper abdominal incision is > >>> considered more painful than a sternotomy or a lower abdominal > >>> incision > >>> though various blocks and pain control measures can obviate that. > >>> Prasanna > >>> > >>> On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu > >>> > >>> wrote: > >>> > >>> > >>>> Amazing the exposure one can get from the subxiphoid approach - > >>>> Mark > >>>> Levinson has really pushed the frontier on minimally invasive > >>>> CABG here > >>>> as > >>>> sparing sternotomy AND thoracotomy can potentially be a real > >>>> benefit, as > >>>> then in terms of trauma not much difference from an upper GI > >>>> operation > >>>> and > >>>> very little limitation on post operative physical activity once > >>>> pain > >>>> settles > >>>> (assuming the sternal retraction is not disruptive or > >>>> destructive in any > >>>> way). > >>>> > >>>> > >>>> > >>>> One comment though is that not very factual as stated on the > >>>> website that > >>>> conventional CABG incision is 12 inches long. Surely incisions > >>>> have not > >>>> been > >>>> that long in decades? > >>>> > >>>> > >>>> > >>>> Ani > >>>> > >>>> > >>>> > >>>> > >>>> Date: Sat, 6 Mar 2010 21:30:44 +0530 > >>>>> From: prasannasimha@gmail.com > >>>>> To: OpenHeart-L@lists.hsforum.com > >>>>> CC: mmlevinson@mac.com > >>>>> Subject: [HSF] shent introducer ? > >>>>> > >>>>> http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html > >>>>> What is that device that you used to push in Don's "Shent" Is > >>>>> it made of > >>>>> ordinary steel wire ? > >>>>> Prasanna > >>>>> > >>>>> -- > >>>>> 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 > >>>>> ----------------------------------------- > >>>>> > >>>> > >>>> _________________________________________________________________ > >>>> Tell us your greatest, weirdest and funniest Hotmail stories > >>>> > >>>> > >>>> http://clk.atdmt.com/UKM/go/195013117/direct/01/ > >>>> _______________________________________________ > >>>> OpenHeart-L< > >>>> http://clk.atdmt.com/UKM/go/195013117/direct/01/ > >>>> _______________________________________________%0AOpenHeart- > >>>> L>mailing > >>>> list > >>>> > >>>> > >>>> Send postings to: > >>>> OpenHeart-L@lists.hsforum.com > >>>> > >>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: > >>>> http://mmp.cjp.com/mailman/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 > >> anddisclaimers 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 Mar 7 11:39:56 2010 From: hgrmd at aol.com (hgrmd@aol.com) Date: Sun Mar 7 11:40:49 2010 Subject: [HSF] shent introducer ? In-Reply-To: References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com><89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com><8CABA34C-69B3-4594-8760-0D058D345C71@gmail.com><89c4ed2d1003061941l282eb3dbue474a238018860e@mail.gmail.com> Message-ID: <8CC8C2BF495E3B3-47AC-18F4E@webmail-m034.sysops.aol.com> Michael, I tend to agree with Prasanna. I've read your posts for a few years now, and you generally are down on anything other than traditional approaches. It's more of a stance that I would expect from someone my age, not yours. I think we can all agree that our specialty is in deep trouble. Innovation is crucial if we are to remain relevant. Granted, there will probably remain a few cases that require median sternotomy, arrested heart, etc., but do you really think the bulk of the cases will be done this way in 20 years? Maybe they will, but don't be surprised if they aren't. As for me, I'm trying to safely innovate as best I can. Last Friday, my first case was a 62 yo dialysis patient with medically unmanageable angina who had a widely patient LIMA to the LAD whose pedicle was redundant and perilously close to the sternum. He had a chronically occluded right, and a tight left main supplying a huge OM. Through a left thoracotomy, I did an off pump vein from the descending aorta to the OM. Though I know this is a well known technique, I guarantee you lots of surgeons would have either turned the case down or done a full sternotomy redo. I'm not patting myself on the back, but I can guarantee you that this procedure didn't even exist when I was training. Hal -----Original Message----- From: Michael Firstenberg To: OpenHeart-L@lists.hsforum.com Sent: Sat, Mar 6, 2010 10:50 pm Subject: Re: [HSF] shent introducer ? I am not anti-everything. just like to argue (debate?) - in part because sometimes some of the stuff hat comes across here is written in a way that suggests than anyone that does x" is a great surgeon and anyone who does "negative x" or less than "x" should e put out to pasture. I just like discussing some of the cons to the approaches that people ake........ -michael n Mar 6, 2010, at 10:41 PM, Prasanna Simha M wrote: > Michael, it is not a my incision is bigger than yours or whatever. People like it or not like to have smaller incisions. Reduce incision size , reduce stretch and secondary injury etc etc are realities which we need to attend to or strive to do However this should not be at the cost of safety and outcomes. I heard these same arguments when Lap procedures were advocated but they have found a definitive place.There are anatomical constraints with the chest compared to the abdomen but if I could avoid getting the sternum cracked open why not ? Also there will be people pushing the boundaries of science and investigation and we need to have them or else we will not improve. You say men with chest hair - it is unnoticable etc but check out your patients with these scars and see where they button up their shirts and dresses to. Ask the lady whether she likes having a scar cutting up across her blouse line -she will subtely wear a closed neck dress and so on and so forth. I bet they (at least most of them) don't parade that scar like a masochistic trophy. Also if you are taking down bilateral IMA's why not spare the sternum if you can if it is a reproducible technique ? You seem to be anti anything but full incision surgery. I am not so sure why but I can tell you that if you do hemisternotomies without lateral cuts, they actually interlock rigidly and have less pain and get out home earlier (and home for many of us in other parts of the world is usually 200 -500 kms away and sometimes even 3000 kms away and not to an SNF/nursing home or whatever). If we can significantly reduce morbidity why not ? Having said all that I still am curious how the "shent" introducer was made. It looked elegant. Prasanna On Sun, Mar 7, 2010 at 8:25 AM, Michael Firstenberg wrote: > oh here we going again - my incision is smaller than yours. > Granted children are different (or are they????? since they will heal > anything) > > Many patients within a month or so, particularly men with chest hair, the > incision (if closed properly) is barely noticeable. However, the scapular > pain and the pain from broken ribs and torn ligaments/cartilage lasts > longer........ > > -michael > > > > > On Mar 6, 2010, at 9:17 PM, Prasanna Simha M wrote: > >> People do get 1 foot long incisions !! I have seen people doing it >> regularly. >> I have done transxiphoid pericardiectomies for children with > pyopericardium >> and was surprised at the amount of exposure that it affords. >> The sternal sparing is a definite advantage but I am not so sure if an > upper >> abdominal incision is less painful. The upper abdominal incision is >> considered more painful than a sternotomy or a lower abdominal incision >> though various blocks and pain control measures can obviate that. >> Prasanna >> >> On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu > wrote: >> >>> >>> Amazing the exposure one can get from the subxiphoid approach - Mark >>> Levinson has really pushed the frontier on minimally invasive CABG here > as >>> sparing sternotomy AND thoracotomy can potentially be a real benefit, as >>> then in terms of trauma not much difference from an upper GI operation > and >>> very little limitation on post operative physical activity once pain > settles >>> (assuming the sternal retraction is not disruptive or destructive in any >>> way). >>> >>> >>> >>> One comment though is that not very factual as stated on the website > that >>> conventional CABG incision is 12 inches long. Surely incisions have not > been >>> that long in decades? >>> >>> >>> >>> Ani >>> >>> >>> >>> >>>> Date: Sat, 6 Mar 2010 21:30:44 +0530 >>>> From: prasannasimha@gmail.com >>>> To: OpenHeart-L@lists.hsforum.com >>>> CC: mmlevinson@mac.com >>>> Subject: [HSF] shent introducer ? >>>> >>>> http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html >>>> What is that device that you used to push in Don's "Shent" Is it made > of >>>> ordinary steel wire ? >>>> Prasanna >>>> >>>> -- >>>> 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 >>>> ----------------------------------------- >>> >>> _________________________________________________________________ >>> Tell us your greatest, weirdest and funniest Hotmail stories >>> >>> > http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________ >>> OpenHeart-L< > http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________%0AOpenHeart-L>mailing > list >>> >>> Send postings to: >>> OpenHeart-L@lists.hsforum.com >>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>> http://mmp.cjp.com/mailman/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 > ----------------------------------------- > -- 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 ----------------------------------------- _______________________________________________ penHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: ttp://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and isclaimers posted at: ttp://www.hsforum.com/listdisclaim ---------------------------------------- From hgrmd at aol.com Sun Mar 7 11:43:56 2010 From: hgrmd at aol.com (hgrmd@aol.com) Date: Sun Mar 7 11:45:12 2010 Subject: [HSF] shent introducer ? In-Reply-To: <132F2D9B-A9B9-40BF-927F-E6AB26C2FCD4@gmail.com> References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com><89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com><8CABA34C-69B3-4594-8760-0D058D345C71@gmail.com><89c4ed2d1003061941l282eb3dbue474a238018860e@mail.gmail.com><89c4ed2d1003061954i5b7e1510nd4ae609617696dbd@mail.gmail.com> <132F2D9B-A9B9-40BF-927F-E6AB26C2FCD4@gmail.com> Message-ID: <8CC8C2C834E7088-47AC-19047@webmail-m034.sysops.aol.com> Michael, I don't know if I would agree with you about me. Certainly, there are plenty of aspects of cardiac surgery (e.g., thoracoabdominal aneurysm) where I would refer the patient to a true master. We've all seen mishaps with minimally invasive approaches. I've also seen plenty with sternotomy. The way to innovate is to thoroughly do your homework (didactic, wet labs, proctoring, etc.) before trying a new approach. Hal -----Original Message----- From: Michael Firstenberg To: OpenHeart-L@lists.hsforum.com Sent: Sat, Mar 6, 2010 11:11 pm Subject: Re: [HSF] shent introducer ? Prasanna Surgeons like you and hal and many of the others who frequently comment are in my mind master surgeons. Not just as indiviuduals but also those who have command if the entire orchestra that is the operating room. Unless everyone us on board and in harmony then sometime pushing the envelope when others don't want it pushed regardless of the skills judgement and wisdom of the surgeon can lead to disaster. I have seen it. -michael/iPhone On Mar 6, 2010, at 10:54 PM, Prasanna Simha M wrote: > Really !! ;) I thought the comment made was expression of > appreciation on > developing a new technique and pushing frontiers. I bet we did not > think of > doing it !! Of course one has to be an extremely confident surgoen > with a > full open technique before even thinking of embarking on such a > venture. > Prasanna > > On Sun, Mar 7, 2010 at 9:20 AM, Michael Firstenberg > wrote: > >> I am not anti-everything. >> I just like to argue (debate?) - in part because sometimes some of >> the >> stuff that comes across here is written in a way that suggests than >> anyone >> that does "x" is a great surgeon and anyone who does "negative x" >> or less >> than "x" should be put out to pasture. >> >> I just like discussing some of the cons to the approaches that people >> take........ >> >> >> >> -michael >> >> >> On Mar 6, 2010, at 10:41 PM, Prasanna Simha M wrote: >> >>> Michael, it is not a my incision is bigger than yours or whatever. >>> People >>> like it or not like to have smaller incisions. Reduce incision >>> size , >> reduce >>> stretch and secondary injury etc etc are realities which we need to >> attend >>> to or strive to do However this should not be at the cost of >>> safety and >>> outcomes. I heard these same arguments when Lap procedures were >>> advocated >>> but they have found a definitive place.There are anatomical >>> constraints >> with >>> the chest compared to the abdomen but if I could avoid getting the >> sternum >>> cracked open why not ? Also there will be people pushing the >>> boundaries >> of >>> science and investigation and we need to have them or else we will >>> not >>> improve. You say men with chest hair - it is unnoticable etc but >>> check >> out >>> your patients with these scars and see where they button up their >>> shirts >> and >>> dresses to. Ask the lady whether she likes having a scar cutting up >> across >>> her blouse line -she will subtely wear a closed neck dress and so >>> on and >> so >>> forth. I bet they (at least most of them) don't parade that scar >>> like a >>> masochistic trophy. >>> Also if you are taking down bilateral IMA's why not spare the >>> sternum if >> you >>> can if it is a reproducible technique ? >>> You seem to be anti anything but full incision surgery. I am not >>> so sure >> why >>> but I can tell you that if you do hemisternotomies without >>> lateral cuts, >>> they actually interlock rigidly and have less pain and get out home >> earlier >>> (and home for many of us in other parts of the world is usually >>> 200 -500 >> kms >>> away and sometimes even 3000 kms away and not to an SNF/nursing >>> home or >>> whatever). If we can significantly reduce morbidity why not ? >>> Having said all that I still am curious how the "shent" >>> introducer was >>> made. It looked elegant. >>> Prasanna >>> >>> On Sun, Mar 7, 2010 at 8:25 AM, Michael Firstenberg >> wrote: >>> >>>> oh here we going again - my incision is smaller than yours. >>>> Granted children are different (or are they????? since they will >>>> heal >>>> anything) >>>> >>>> Many patients within a month or so, particularly men with chest >>>> hair, >> the >>>> incision (if closed properly) is barely noticeable. However, the >> scapular >>>> pain and the pain from broken ribs and torn ligaments/cartilage >>>> lasts >>>> longer........ >>>> >>>> -michael >>>> >>>> >>>> >>>> >>>> On Mar 6, 2010, at 9:17 PM, Prasanna Simha M wrote: >>>> >>>>> People do get 1 foot long incisions !! I have seen people doing it >>>>> regularly. >>>>> I have done transxiphoid pericardiectomies for children with >>>> pyopericardium >>>>> and was surprised at the amount of exposure that it affords. >>>>> The sternal sparing is a definite advantage but I am not so sure >>>>> if an >>>> upper >>>>> abdominal incision is less painful. The upper abdominal >>>>> incision is >>>>> considered more painful than a sternotomy or a lower abdominal >>>>> incision >>>>> though various blocks and pain control measures can obviate that. >>>>> Prasanna >>>>> >>>>> On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu >>>> > >>>> wrote: >>>>> >>>>>> >>>>>> Amazing the exposure one can get from the subxiphoid approach - >>>>>> Mark >>>>>> Levinson has really pushed the frontier on minimally invasive >>>>>> CABG >> here >>>> as >>>>>> sparing sternotomy AND thoracotomy can potentially be a real >>>>>> benefit, >> as >>>>>> then in terms of trauma not much difference from an upper GI >>>>>> operation >>>> and >>>>>> very little limitation on post operative physical activity once >>>>>> pain >>>> settles >>>>>> (assuming the sternal retraction is not disruptive or >>>>>> destructive in >> any >>>>>> way). >>>>>> >>>>>> >>>>>> >>>>>> One comment though is that not very factual as stated on the >>>>>> website >>>> that >>>>>> conventional CABG incision is 12 inches long. Surely incisions >>>>>> have >> not >>>> been >>>>>> that long in decades? >>>>>> >>>>>> >>>>>> >>>>>> Ani >>>>>> >>>>>> >>>>>> >>>>>> >>>>>>> Date: Sat, 6 Mar 2010 21:30:44 +0530 >>>>>>> From: prasannasimha@gmail.com >>>>>>> To: OpenHeart-L@lists.hsforum.com >>>>>>> CC: mmlevinson@mac.com >>>>>>> Subject: [HSF] shent introducer ? >>>>>>> >>>>>>> http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html >>>>>>> What is that device that you used to push in Don's "Shent" Is >>>>>>> it made >>>> of >>>>>>> ordinary steel wire ? >>>>>>> Prasanna >>>>>>> >>>>>>> -- >>>>>>> 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 >>>>>>> ----------------------------------------- >>>>>> >>>>>> _________________________________________________________________ >>>>>> Tell us your greatest, weirdest and funniest Hotmail stories >>>>>> >>>>>> >>>> >> http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________ >>>>>> OpenHeart-L< >>>> >> http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________%0AOpenHeart-L >>> mailing >>>> list >>>>>> >>>>>> Send postings to: >>>>>> OpenHeart-L@lists.hsforum.com >>>>>> >>>>>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>>>>> http://mmp.cjp.com/mailman/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 >>>> ----------------------------------------- >>>> >>> >>> >>> >>> -- >>> 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 >> ----------------------------------------- >> > > > > --> 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 anddisclaimers posted at: http://www.hsforum.com/listdisclaim ----------------------------------------- From prasannasimha at gmail.com Sun Mar 7 22:27:32 2010 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sun Mar 7 12:05:18 2010 Subject: [HSF] shent introducer ? In-Reply-To: <8CC8C2BF495E3B3-47AC-18F4E@webmail-m034.sysops.aol.com> References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com> <89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com> <8CABA34C-69B3-4594-8760-0D058D345C71@gmail.com> <89c4ed2d1003061941l282eb3dbue474a238018860e@mail.gmail.com> <8CC8C2BF495E3B3-47AC-18F4E@webmail-m034.sysops.aol.com> Message-ID: <89c4ed2d1003070857m5841d5ebj1db3f489f63a7a9@mail.gmail.com> Hal what did you do for the right ? Probably taking V.Subramaniam's cue a gastroepiploic to the right would have been an enticing thought if the artery was worth grafting along with your OM graft through a thoracotomy. I have seen him doing grafts through 2 seperate incisions when the redo risk was considered very high usually a left thoracotomy approach for the OM's/LAD and a right or transabdominal approach for the RCA/PDA and PLV's. Minimal dissection towards the target artery (the adhesions themselves act as a good stabilizer) seems to allow for such operations to be done more easily than traditional redos. How did you do your proximal to the descending thoracic aorta ? side clamp or did you use the subclavian artery as inflow ? Prasanna On Sun, Mar 7, 2010 at 10:09 PM, wrote: > > Michael, > I tend to agree with Prasanna. I've read your posts for a few years now, > and you generally are down on anything other than traditional approaches. > It's more of a stance that I would expect from someone my age, not yours. > I think we can all agree that our specialty is in deep trouble. Innovation > is crucial if we are to remain relevant. Granted, there will probably > remain a few cases that require median sternotomy, arrested heart, etc., but > do you really think the bulk of the cases will be done this way in 20 years? > Maybe they will, but don't be surprised if they aren't. > As for me, I'm trying to safely innovate as best I can. Last Friday, my > first case was a 62 yo dialysis patient with medically unmanageable angina > who had a widely patient LIMA to the LAD whose pedicle was redundant and > perilously close to the sternum. He had a chronically occluded right, and a > tight left main supplying a huge OM. Through a left thoracotomy, I did an > off pump vein from the descending aorta to the OM. Though I know this is a > well known technique, I guarantee you lots of surgeons would have either > turned the case down or done a full sternotomy redo. I'm not patting > myself on the back, but I can guarantee you that this procedure didn't even > exist when I was training. > > Hal > > > > > > > > > > > -----Original Message----- > From: Michael Firstenberg > To: OpenHeart-L@lists.hsforum.com > Sent: Sat, Mar 6, 2010 10:50 pm > Subject: Re: [HSF] shent introducer ? > > > I am not anti-everything. > just like to argue (debate?) - in part because sometimes some of the stuff > hat comes across here is written in a way that suggests than anyone that > does > x" is a great surgeon and anyone who does "negative x" or less than "x" > should > e put out to pasture. > I just like discussing some of the cons to the approaches that people > ake........ > > -michael > > n Mar 6, 2010, at 10:41 PM, Prasanna Simha M wrote: > > Michael, it is not a my incision is bigger than yours or whatever. People > like it or not like to have smaller incisions. Reduce incision size , > reduce > stretch and secondary injury etc etc are realities which we need to attend > to or strive to do However this should not be at the cost of safety and > outcomes. I heard these same arguments when Lap procedures were advocated > but they have found a definitive place.There are anatomical constraints > with > the chest compared to the abdomen but if I could avoid getting the > sternum > cracked open why not ? Also there will be people pushing the boundaries of > science and investigation and we need to have them or else we will not > improve. You say men with chest hair - it is unnoticable etc but check out > your patients with these scars and see where they button up their shirts > and > dresses to. Ask the lady whether she likes having a scar cutting up across > her blouse line -she will subtely wear a closed neck dress and so on and > so > forth. I bet they (at least most of them) don't parade that scar like a > masochistic trophy. > Also if you are taking down bilateral IMA's why not spare the sternum if > you > can if it is a reproducible technique ? > You seem to be anti anything but full incision surgery. I am not so sure > why > but I can tell you that if you do hemisternotomies without lateral cuts, > they actually interlock rigidly and have less pain and get out home > earlier > (and home for many of us in other parts of the world is usually 200 -500 > kms > away and sometimes even 3000 kms away and not to an SNF/nursing home or > whatever). If we can significantly reduce morbidity why not ? > Having said all that I still am curious how the "shent" introducer was > made. It looked elegant. > Prasanna > > On Sun, Mar 7, 2010 at 8:25 AM, Michael Firstenberg >wrote: > > > oh here we going again - my incision is smaller than yours. > > Granted children are different (or are they????? since they will heal > > anything) > > > > Many patients within a month or so, particularly men with chest hair, the > > incision (if closed properly) is barely noticeable. However, the > scapular > > pain and the pain from broken ribs and torn ligaments/cartilage lasts > > longer........ > > > > -michael > > > > > > > > > > On Mar 6, 2010, at 9:17 PM, Prasanna Simha M wrote: > > > >> People do get 1 foot long incisions !! I have seen people doing it > >> regularly. > >> I have done transxiphoid pericardiectomies for children with > > pyopericardium > >> and was surprised at the amount of exposure that it affords. > >> The sternal sparing is a definite advantage but I am not so sure if an > > upper > >> abdominal incision is less painful. The upper abdominal incision is > >> considered more painful than a sternotomy or a lower abdominal incision > >> though various blocks and pain control measures can obviate that. > >> Prasanna > >> > >> On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu > > wrote: > >> > >>> > >>> Amazing the exposure one can get from the subxiphoid approach - Mark > >>> Levinson has really pushed the frontier on minimally invasive CABG here > > as > >>> sparing sternotomy AND thoracotomy can potentially be a real benefit, > as > >>> then in terms of trauma not much difference from an upper GI operation > > and > >>> very little limitation on post operative physical activity once pain > > settles > >>> (assuming the sternal retraction is not disruptive or destructive in > any > >>> way). > >>> > >>> > >>> > >>> One comment though is that not very factual as stated on the website > > that > >>> conventional CABG incision is 12 inches long. Surely incisions have not > > been > >>> that long in decades? > >>> > >>> > >>> > >>> Ani > >>> > >>> > >>> > >>> > >>>> Date: Sat, 6 Mar 2010 21:30:44 +0530 > >>>> From: prasannasimha@gmail.com > >>>> To: OpenHeart-L@lists.hsforum.com > >>>> CC: mmlevinson@mac.com > >>>> Subject: [HSF] shent introducer ? > >>>> > >>>> http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html > >>>> What is that device that you used to push in Don's "Shent" Is it made > > of > >>>> ordinary steel wire ? > >>>> Prasanna > >>>> > >>>> -- > >>>> 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 > >>>> ----------------------------------------- > >>> > >>> _________________________________________________________________ > >>> Tell us your greatest, weirdest and funniest Hotmail stories > >>> > >>> > > > http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________ > >>> OpenHeart-L< > > > http://clk.atdmt.com/UKM/go/195013117/direct/01/_______________________________________________%0AOpenHeart-L > >mailing > > list > >>> > >>> Send postings to: > >>> OpenHeart-L@lists.hsforum.com > >>> > >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: > >>> http://mmp.cjp.com/mailman/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 > > ----------------------------------------- > > > > > > -- > 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 > ----------------------------------------- > _______________________________________________ > penHeart-L mailing list > Send postings to: > OpenHeart-L@lists.hsforum.com > To UNSUBSCRIBE, to CHANGE email address, or to view archives: > ttp://mmp.cjp.com/mailman/listinfo/openheart-l > All messages transmitted by the OpenHeart-L are subject to the policies and > isclaimers posted at: > ttp://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 From scott.silvestry at jefferson.edu Sun Mar 7 12:02:09 2010 From: scott.silvestry at jefferson.edu (Scott Silvestry) Date: Sun Mar 7 12:05:43 2010 Subject: [HSF] shent introducer ? In-Reply-To: <8CC8C2BF495E3B3-47AC-18F4E@webmail-m034.sysops.aol.com> References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com><89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com><8CABA34C-69B3-4594-8760-0D058D345C71@gmail.com><89c4ed2d1003061941l282eb3dbue474a238018860e@mail.gmail.com> <8CC8C2BF495E3B3-47AC-18F4E@webmail-m034.sysops.aol.com> Message-ID: <000001cabe17$ec8e8990$b28ca20a@tjumst.jefferson.edu> Hal: I like that operation as well BUT- that is a perfect case for Left main stenting, no? Of course I'll assume there was interval disease. I am sure you agree age does not always track with conservative nature. The most relevant quotes I use for various talks: Did you think you were going to do the same operation for the next 100 years? Bruce Lytle AATS 1998 or so IF you don't like change you're going to like irrelevance even less. General Eric Shinseki Scott Scott C. Silvestry, MD Associate Professor of Surgery Division of Cardiac Surgery Thomas Jefferson University Hospital 1025 Walnut Street 607 College Philadelphia, PA 19107 Phone (215)955-6996 Fax (215) 955-6010 Email: scott.silvestry@jefferson.edu The information contained in this email is confidential, privileged, or otherwise protected from disclosure. It is intended only for the use of the authorized individual as indicated in the e-mail. Any unauthorized disclosure, copying, distribution or taking of any action based on the contents of this material is strictly prohibited. Review by any individual other than the intended recipient does not waive or give up the physician-patient privilege. If you received this e-mail in error, please delete it immediately. -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of hgrmd@aol.com Sent: Sunday, March 07, 2010 11:40 AM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] shent introducer ? Michael, I tend to agree with Prasanna. I've read your posts for a few years now, and you generally are down on anything other than traditional approaches. It's more of a stance that I would expect from someone my age, not yours. I think we can all agree that our specialty is in deep trouble. Innovation is crucial if we are to remain relevant. Granted, there will probably remain a few cases that require median sternotomy, arrested heart, etc., but do you really think the bulk of the cases will be done this way in 20 years? Maybe they will, but don't be surprised if they aren't. As for me, I'm trying to safely innovate as best I can. Last Friday, my first case was a 62 yo dialysis patient with medically unmanageable angina who had a widely patient LIMA to the LAD whose pedicle was redundant and perilously close to the sternum. He had a chronically occluded right, and a tight left main supplying a huge OM. Through a left thoracotomy, I did an off pump vein from the descending aorta to the OM. Though I know this is a well known technique, I guarantee you lots of surgeons would have either turned the case down or done a full sternotomy redo. I'm not patting myself on the back, but I can guarantee you that this procedure didn't even exist when I was training. Hal -----Original Message----- From: Michael Firstenberg To: OpenHeart-L@lists.hsforum.com Sent: Sat, Mar 6, 2010 10:50 pm Subject: Re: [HSF] shent introducer ? I am not anti-everything. just like to argue (debate?) - in part because sometimes some of the stuff hat comes across here is written in a way that suggests than anyone that does x" is a great surgeon and anyone who does "negative x" or less than "x" should e put out to pasture. I just like discussing some of the cons to the approaches that people ake........ -michael n Mar 6, 2010, at 10:41 PM, Prasanna Simha M wrote: > Michael, it is not a my incision is bigger than yours or whatever. People like it or not like to have smaller incisions. Reduce incision size , reduce stretch and secondary injury etc etc are realities which we need to attend to or strive to do However this should not be at the cost of safety and outcomes. I heard these same arguments when Lap procedures were advocated but they have found a definitive place.There are anatomical constraints with the chest compared to the abdomen but if I could avoid getting the sternum cracked open why not ? Also there will be people pushing the boundaries of science and investigation and we need to have them or else we will not improve. You say men with chest hair - it is unnoticable etc but check out your patients with these scars and see where they button up their shirts and dresses to. Ask the lady whether she likes having a scar cutting up across her blouse line -she will subtely wear a closed neck dress and so on and so forth. I bet they (at least most of them) don't parade that scar like a masochistic trophy. Also if you are taking down bilateral IMA's why not spare the sternum if you can if it is a reproducible technique ? You seem to be anti anything but full incision surgery. I am not so sure why but I can tell you that if you do hemisternotomies without lateral cuts, they actually interlock rigidly and have less pain and get out home earlier (and home for many of us in other parts of the world is usually 200 -500 kms away and sometimes even 3000 kms away and not to an SNF/nursing home or whatever). If we can significantly reduce morbidity why not ? Having said all that I still am curious how the "shent" introducer was made. It looked elegant. Prasanna On Sun, Mar 7, 2010 at 8:25 AM, Michael Firstenberg wrote: > oh here we going again - my incision is smaller than yours. > Granted children are different (or are they????? since they will heal > anything) > > Many patients within a month or so, particularly men with chest hair, the > incision (if closed properly) is barely noticeable. However, the scapular > pain and the pain from broken ribs and torn ligaments/cartilage lasts > longer........ > > -michael > > > > > On Mar 6, 2010, at 9:17 PM, Prasanna Simha M wrote: > >> People do get 1 foot long incisions !! I have seen people doing it >> regularly. >> I have done transxiphoid pericardiectomies for children with > pyopericardium >> and was surprised at the amount of exposure that it affords. >> The sternal sparing is a definite advantage but I am not so sure if an > upper >> abdominal incision is less painful. The upper abdominal incision is >> considered more painful than a sternotomy or a lower abdominal incision >> though various blocks and pain control measures can obviate that. >> Prasanna >> >> On Sat, Mar 6, 2010 at 11:45 PM, Ani Anyanwu > wrote: >> >>> >>> Amazing the exposure one can get from the subxiphoid approach - Mark >>> Levinson has really pushed the frontier on minimally invasive CABG here > as >>> sparing sternotomy AND thoracotomy can potentially be a real benefit, as >>> then in terms of trauma not much difference from an upper GI operation > and >>> very little limitation on post operative physical activity once pain > settles >>> (assuming the sternal retraction is not disruptive or destructive in any >>> way). >>> >>> >>> >>> One comment though is that not very factual as stated on the website > that >>> conventional CABG incision is 12 inches long. Surely incisions have not > been >>> that long in decades? >>> >>> >>> >>> Ani >>> >>> >>> >>> >>>> Date: Sat, 6 Mar 2010 21:30:44 +0530 >>>> From: prasannasimha@gmail.com >>>> To: OpenHeart-L@lists.hsforum.com >>>> CC: mmlevinson@mac.com >>>> Subject: [HSF] shent introducer ? >>>> >>>> http://www.newoptionsinheartsurgery.com/subxiphoidphotos.html >>>> What is that device that you used to push in Don's "Shent" Is it made > of >>>> ordinary steel wire ? >>>> Prasanna >>>> >>>> -- >>>> 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 >>>> ----------------------------------------- >>> >>> _________________________________________________________________ >>> Tell us your greatest, weirdest and funniest Hotmail stories >>> >>> > http://clk.atdmt.com/UKM/go/195013117/direct/01/____________________________ ___________________ >>> OpenHeart-L< > http://clk.atdmt.com/UKM/go/195013117/direct/01/____________________________ ___________________%0AOpenHeart-L>mailing > list >>> >>> Send postings to: >>> OpenHeart-L@lists.hsforum.com >>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives: >>> http://mmp.cjp.com/mailman/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 > ----------------------------------------- > -- 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 ----------------------------------------- _______________________________________________ penHeart-L mailing list Send postings to: OpenHeart-L@lists.hsforum.com To UNSUBSCRIBE, to CHANGE email address, or to view archives: ttp://mmp.cjp.com/mailman/listinfo/openheart-l All messages transmitted by the OpenHeart-L are subject to the policies and isclaimers posted at: ttp://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 Mar 7 17:19:37 2010 From: hgrmd at aol.com (hgrmd@aol.com) Date: Sun Mar 7 12:17:28 2010 Subject: [HSF] shent introducer ? 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LS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLQ0K From hgrmd at aol.com Sun Mar 7 17:24:28 2010 From: hgrmd at aol.com (hgrmd@aol.com) Date: Sun Mar 7 12:21:18 2010 Subject: [HSF] shent introducer ? In-Reply-To: <000001cabe17$ec8e8990$b28ca20a@tjumst.jefferson.edu> References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com><89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com><8CABA34C-69B3-4594-8760-0D058D345C71@gmail.com><89c4ed2d1003061941l282eb3dbue474a238018860e@mail.gmail.com><8CC8C2BF495E3B3-47AC-18F4E@webmail-m034.sysops.aol.com><000001cabe17$ec8e8990$b28ca20a@tjumst.jefferson.edu> Message-ID: <1871974832-1267982447-cardhu_decombobulator_blackberry.rim.net-899819437-@bda730.bisx.prod.on.blackberry> U2NvdHQsDQogIFRoZSBQQ0kgYXBwcm9hY2ggd2FzIHR1cm5lZCBkb3duIGJ5IGFuIGV4cGVyaWVu Y2VkIGludGVydmVudGlvbmFsaXN0IGZvciB0ZWNobmljYWwgcmVhc29ucy4NCiAgR3JlYXQgcXVv dGVzLiAgSSBhbHJlYWR5IGtuZXcgTHl0bGUncyBxdW90ZS4gIFRoZSBvdGhlciBvbmUgaXMgYWxz byBhIGdlbS4NCg0KSGFsDQpTZW50IGZyb20gbXkgVmVyaXpvbiBXaXJlbGVzcyBCbGFja0JlcnJ5 DQoNCi0tLS0tT3JpZ2luYWwgTWVzc2FnZS0tLS0tDQpGcm9tOiAiU2NvdHQgU2lsdmVzdHJ5IiA8 c2NvdHQuc2lsdmVzdHJ5QGplZmZlcnNvbi5lZHU+DQpEYXRlOiBTdW4sIDcgTWFyIDIwMTAgMTI6 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In-Reply-To: <1106373576-1267982157-cardhu_decombobulator_blackberry.rim.net-434837584-@bda730.bisx.prod.on.blackberry> References: <89c4ed2d1003060800r788a1e63sadc7866c8abf81b6@mail.gmail.com> <89c4ed2d1003061817n2df1cb87s3942d2fc9e61b1da@mail.gmail.com> <8CABA34C-69B3-4594-8760-0D058D345C71@gmail.com> <89c4ed2d1003061941l282eb3dbue474a238018860e@mail.gmail.com> <8CC8C2BF495E3B3-47AC-18F4E@webmail-m034.sysops.aol.com> <89c4ed2d1003070857m5841d5ebj1db3f489f63a7a9@mail.gmail.com> <1106373576-1267982157-cardhu_decombobulator_blackberry.rim.net-434837584-@bda730.bisx.prod.on.blackberry> Message-ID: <89c4ed2d1003070921h207861c2n7fd47ffe1645cc03@mail.gmail.com> Of course. I was asking since you mentioned the right lesion but then there is no point grafting a vessel so small that it would occlude by the time you send him home !! Prsanna On Sun, Mar 7, 2010 at 10:49 PM, wrote: > Prasanna, > Didn't want to belabor the post by mentioning he had a chronic > thrombocytopenia (50k). The proximal was to the descending using a side > biter. A preop CT with contrast provided assurance that the aorta wasn't > too heavily diseased. I did it through a standard thoracotomy, so I was > loathe to add more incisions. Besides, the right wasn't much of a target. > As they say, "sometimes less is more". > > Hal > Sent from my Verizon Wireless BlackBerry > > -----Original Message----- > From: Prasanna Simha M > Date: Sun, 7 Mar 2010 22:27:32 > To: OpenHeart-L > Subject: Re: [HSF] shent introducer ? > > Hal what did you do for the right ? Probably taking V.Subramaniam's cue a > gastroepiploic to the right would have been an enticing thought if the > artery was worth grafting along with your OM graft through a thoracotomy. I > have seen him doing grafts through 2 seperate incisions when the redo risk > was considered very high usually a left thoracotomy approach for the > OM's/LAD and a right or transabdominal approach for the RCA/PDA and PLV's. > Minimal dissection towards the target artery (the adhesions themselves act > as a good stabilizer) seems to allow for such operations to be done more > easily than traditional redos. > How did you do your proximal to the descending thoracic aorta ? side clamp > or did you use the subclavian artery as inflow ? > Prasanna > > On Sun, Mar 7, 2010 at 10:09 PM, wrote: > > > > > Michael, > > I tend to agree with Prasanna. I've read your posts for a few years > now, > > and you generally are down on anything other than traditional approaches. > > It's more of a stance that I would expect from someone my age, not > yours. > > I think we can all agree that our specialty is in deep trouble. > Innovation > > is crucial if we are to remain relevant. Granted, there will probably > > remain a few cases that require median sternotomy, arrested heart, etc., > but > > do you really think the bulk of the cases will be done this way in 20 > years? > > Maybe they will, but don't be surprised if they aren't. > > As for me, I'm trying to safel