Posted in cardiac surgery, Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology journal club, tagged beating heart surgery, Beware of beating heart CABG : It is minimally invasive and minimally effective !, cabg, cardiac surgery, cardio pulmonary bypass, cardiology journal club, jacc, LAD, lima graft, midcab, minimally invasive cardia surgery, nejm, obcab, off pump cabg, on pump cabg, RCA, rooby, rooby cabg study, svg graft on November 6, 2009|
Leave a Comment »
The NEJM’s breaks the hidden truths about cardiopulmonary bypass in a beating heart. The irony in medical science is , trend setting land mark articles usually arrive very late . . . to disappoint all those patients who got the wrong treatment ! Off pump by pass is definitely one among them . . .
The major reason for off pump CABG’s s poor showing is
- The surgeon’s conflict in defining what is successful CABG .The success of CABG is in relief of symptoms & providing good bypass graft with long term patency .It is not in less thoracic trauma or in a quick hospital discharge !
- The second major reason is denial of the fact that off pump CABG is indeed inferior and hence no course correction was attempted ! ( And now that it has become a hard evidence we expect some changes . It required almost 10 years for our cardiology community to recognise this .)
- Lesion access and difficulty in mobilizing LIMA .Many times the the point of anastomoses is preselected by the accessibility and technical issues rather than lesion guided approach .This often happens than we imagine , and this could be a very bad advertisement for off pump CABG
Click on the link to NEJM abstract ROOBY study
Read Full Post »
Posted in cardiac surgery, tagged acc.aha, ambrose, bari 2, bari satudy, cabg, cabg vs PCI, cass study, diagonal, double vessel disease, ellis, LAD, lcx, lima graft, mid lad, midcab, obtuse marginal, om 1, om 2, opcab, pci, posterior descending artery, proximal lad, ptca, RCA, single vessel disease, svg graft, syntax score, triple vessel disease, venous graft on May 9, 2009|
1 Comment »
Can we advice CABG for single vessel disease ?
Yes, CABG may be indicated in
- Critical , proximal , complex LAD disease with or without ostium involvement.
- Many of the bifurcation lesions with large and significant side branch
- Small caliber LAD with diffuse disease .
When these occur in diabetic subjects , the indication for CABG is more certain .
* Present generation cardiologists would feel every lesion is stentable and should not be referred to the surgeon .But it should be emphasized here, technical feasibility alone , does not imply PCI is superior and ideal in all coronary interventions.
Can we do a CABG in single vessel disease with normal LAD ?
CABG is very rarely indicated for isolated RCA or LCX disease. It should be consciously avoided in this patient population.
This is because the at risk myocardium supplied by these vessels are far less than that of LAD. PCI is preferred in these vessels .(Ofcourse , after considering medical management ) .
CABG is , too traumatic a surgery , to offer in this low risk coronary lesions.
CABG can still be done in following situations for non LAD single vessel disease.
- Left dominant circulation with complex lesions in LCX /OMs.
- It is common to see diffuse , long segment and severe disease of RCA with normal LAD /LCX system .PCI is not feasible in this subset.
- Failed PCI
- Recurrent instent restenosis.
- Bail out CABG after a acute complication during PCI
One should remember , inability to do a PCI does not mean , the patient should land in surgeon’s table .We should recall , from our memory medical management is an effective and established form of treatment in single vessel disease ( Mainly for non LAD , and some cases of LAD also !)
Read Full Post »