Court Case: TEE, Surgeons and Defamation

[vector2]

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And this one. Please tell me they replaced that valve. Mine would/should, I can see the VC is at least 7mm on my phone.

This guy was actually coming for an MVR/CABGx2/maze-pvi/clip. Rheumatic with preop mva 1.5 (3d planimetry) and lowish gradient but apparently higher gradients on exertion. He also had a functionally bicuspid AV with moderate AS. No comment about his AI which clearly would've confounded his mitral inflow gradients and PHT. Original plan was to leave the AV alone and TAVR him later since he was already getting a lot of surgery.

We ended up doing AVR + the rest given how bad the AI was. Luckily these surgeons haul ass so the clamp time was 2 hrs for everything

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[PpfSuxTube]

Similarly I have had patients show up to surgery after medical management of functional MR. Torrential preop MR to trace/mild. This always prompts discussion on what to do.

I hate that.

I dont get too involved in the discussion tho. I drive the pressure and tell them the grade of current MR and any structural lesions. I dont get too involved in 'changing the plan' conversations. Not my job to be a sacrifical lamb for any post op complications.

 

[vector2]

Similarly I have had patients show up to surgery after medical management of functional MR. Torrential preop MR to trace/mild. This always prompts discussion on what to do.

Repair/replacement hasn't been shown to improve survival in secondary MR even when they show up with severe regurgitation. Def cancel. Send 'em for a clip if GDMT (which is highly effective nowadays) starts failing them down the road.

 

[Beeftenderloin]

I hate that.

I dont get too involved in the discussion tho. I drive the pressure and tell them the grade of current MR and any structural lesions. I dont get too involved in 'changing the plan' conversations. Not my job to be a sacrifical lamb for any post op complications.

If it’s recommended by guidelines, I’ll list my findings and say that. Sure, you can’t make the surgeon operate, but the whole point of being APTE boarded is to prove you are qualified to direct surgical decision making, not just report findings. People who don’t feel comfortable doing that probably shouldn’t be holding the probe. Ive been fortunate to work with mostly great surgeons who know the guidelines and do what’s indicated without much convincing. And If the patient gets an appropriately indicated procedure and has a complication, that’s unfortunately a known possibility in cardiac surgery world, not the fault of the diagnostician.

 

[sevoflurane]

Repair/replacement hasn't been shown to improve survival in secondary MR even when they show up with severe regurgitation. Def cancel. Send 'em for a clip if GDMT (which is highly effective nowadays) starts failing them down the road.

that is the exact scenario i am referring to.
you place a clip on mild, previously severe functional mr, you are going to double their gradient maybe more if use more than one clip… not sure I would want that.

 

[sevoflurane]

whenever this happens even if moderate MR, cards/ct surg/cardiac anesthesia all discuss the patient and do provocative maneuvers. We then asses and re-evaluate and proceed or not.

 

[vector2]

I hate that.

I dont get too involved in the discussion tho. I drive the pressure and tell them the grade of current MR and any structural lesions. I dont get too involved in 'changing the plan' conversations. Not my job to be a sacrifical lamb for any post op complications.

I understand where you're coming from, but I disagree. And not just cause you should be able to join in the conversation about operative decisions (in a tactful, collegial way) due to your knowledge of echo and the guidelines, but also because you are arguably the most qualified person in that room to decide whether the patient, given their physiology, can or cannot tolerate the morbidity/clamp time/pump time of the additional procedures being discussed. CT surgeons are knowledgeable about the structural problems, but most are simply not capable of integrating the full picture of the patient's history, medical problems, anesthesia interactions, dynamic echo findings, and invasive hemodynamics the way the cardiac anesthesiologist can.