Interventional cardiology vs cardiac surgery

[DarkProtonics]

Can an interventional cardiologist correct almost all of Tetralogy of Fallot, leaving the overriding aorta to the cardiac surgeon? I suppose the interventional cardiologist would do this:

• Occlude the VSD using an Amplatzer® Muscular VSD Occluder, under ICE guidance. This will correct the right-to-left shunt, and deoxygenated blood will no longer go to systemic circulation, resulting in arterial oxygen content increasing, and elimination, for the most part, of the hypoxia and cyanosis.
• Correct the pulmonary valve stenosis by ICE-guided percutaneous valve replacement. This will increase the blood flow to the lungs, which is now possible due to the occlusion of the VSD. The grim prospect of secondary PAH is now averted. As well as the fact that the RVH should no longer progress, because the pulmonary valve is widened, resulting in less resistance to pump against.
• Use ICE-guided ethanol septal ablation to correct the RVH, increasing right ventricular compliance, which should also improve pulmonary arterial blood flow.

What would be the advantages and disadvantages compared to the Sano shunt, or performing cardiac surgery for the entire tetralogy? Faster operating and recovery time?

When do they use CABG, instead of angioplasty?

Why does cardiac surgery require a five year general surgery residency? Couldn't it just be one year of a surgical internship, and then 5 years of cardiac surgery residency?

Does anyone here use the nifty ultrasonic surgical instruments developed by Harmonic? They cauterize when they cut, reducing unecessary bleeding.

Can most cardiac surgeries be performed thoracoscopically?

What are the advantages and disadvantages of interventional cardiology vs cardiac surgery? Skill level and intellectual challenge, rewards, lifestyle, demand, salary.

Is interventional cardiology slowly reducing cardiac surgery to last-resort status?

Thanks!

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[jarodmc]

I can only speak to your question regarding TOF. Percutaneous VSD closure may be more difficult simply because this is a malalignment VSD rather than a muscular VSD. Additionally, percutaneous treatment of pulmonic stenosis is highly unlikely to be successful simply because the cause of the obstruction is more complex than just a small valve. The outflow tract itself is markedly decreased in size due to abnormal anterior displacement of the infundibular septum. The valve is small, but so is the annulus, the pulmonary trunk, and the rest of the RVOT. A common way of correcting this is to remove some of the muscle in the outflow tract that is obstructing flow, and in some cases to completely remove the pulmonic valve itself. This creates a functionally completely incompetent pulmonic valve that usually must be replaced later in life, but it avoids the problem of putting in a prosthetic valve that cannot grow with the child. Therefore, there is really no current percutaneous method of addressing the significant outflow obstruction present in TOF. Hope that helps somewhat.

 

[ESU_MD]

nobody in their right mind would allow the *****s in the cath lab to do these things to a kid. although it does seem feasible by your explanation, itt doesnt make sense to do inferior procedures to a person with a whole lifespan in front of them.

cath lab stuff is for the most part salvage procedures for people who are not surgical candidates.

surgery is tried and true- it offers the best long term results with only minimal risk in major centers (for peds cardiac surgery, there may only be ~10 places in the country- if that)

 

[DarkProtonics]

I can only speak to your question regarding TOF. Percutaneous VSD closure may be more difficult simply because this is a malalignment VSD rather than a muscular VSD. Additionally, percutaneous treatment of pulmonic stenosis is highly unlikely to be successful simply because the cause of the obstruction is more complex than just a small valve. The outflow tract itself is markedly decreased in size due to abnormal anterior displacement of the infundibular septum. The valve is small, but so is the annulus, the pulmonary trunk, and the rest of the RVOT. A common way of correcting this is to remove some of the muscle in the outflow tract that is obstructing flow, and in some cases to completely remove the pulmonic valve itself. This creates a functionally completely incompetent pulmonic valve that usually must be replaced later in life, but it avoids the problem of putting in a prosthetic valve that cannot grow with the child. Therefore, there is really no current percutaneous method of addressing the significant outflow obstruction present in TOF. Hope that helps somewhat.

That was really interesting!

Couldn't you use ethanol septal ablation to cause that excess muscle obstructing the RVOT to infarct, instead of doing a myectomy?

Maybe we can make a VSD occluder that can expand as the VSD grows?

Maybe you could use ethanol septal ablation to widen the RVOT?

That other poster seems to think that interventional cardiologists are useless; what would HE rather have done if he had a STEMI, an angioplasty, or a CABG?

 

[Winged Scapula]

That other poster seems to think that interventional cardiologists are useless; what would HE rather have done if he had a STEMI, an angioplasty, or a CABG?

While "useless" may be overstating the case, I know exactly what ESUMD would say because its the same thing the rest of us with 3v or Left Main would say:

"we want the CABG now while we're in relatively good shape, rather than a stent which will fail and result in our needing a CABG in a few years anyway".

There's good, recent evidence that for the above conditions (3v, left main disease) CABG is superior to stents. The American public will continue to *think* they prefer stents, just as you do, because they've been brainwashed to think that faster and easier is better. No one says CABGs are a barrel full of monkeys but the risks are low and the benefits high, immediate and long term. Can't say the same for stents.

Once Medicare and the other insurers realize they are paying for stents and redo stents and then finally bypass on patients, they will start to ask why and either insist that stents be equivalent to CABG or they will refuse to pay for stents at all.

ESU...its your turn now! 😉

 

[DarkProtonics]

While "useless" may be overstating the case, I know exactly what ESUMD would say because its the same thing the rest of us with 3v or Left Main would say:

"we want the CABG now while we're in relatively good shape, rather than a stent which will fail and result in our needing a CABG in a few years anyway".

There's good, recent evidence that for the above conditions (3v, left main disease) CABG is superior to stents. The American public will continue to *think* they prefer stents, just as you do, because they've been brainwashed to think that faster and easier is better. No one says CABGs are a barrel full of monkeys but the risks are low and the benefits high, immediate and long term. Can't say the same for stents.

Once Medicare and the other insurers realize they are paying for stents and redo stents and then finally bypass on patients, they will start to ask why and either insist that stents be equivalent to CABG or they will refuse to pay for stents at all.

ESU...its your turn now! 😉

Well, the quality of stenting is improving.

 

[Winged Scapula]

Well, the quality of stenting is improving.

Not according to the latest study FUNDED by a STENT MAKER:

http://online.wsj.com/article/SB122030992836488545.html?mod=rss_Health

or here: http://content.nejm.org/cgi/content/short/358/4/331

I expect stents to get better but until you can prove to me that they are superior to the time proven CABG, I'll take the surgery thanks.

 

[jarodmc]

DarkProtonics, your question is interesting, but I cannot see that being a viable approach to the problem of RVOT obstruction in TOF. Too often congenital heart syndromes are characterized as being a collection of various anomalies, hence TOF being characterized as four separate defects. In reality, it is one specific aberration in embryological development that leads to four related defects. The muscular outflow obstruction is one that is due both to hypertrophy as well as to simple improper placement due to the underlying problem in normal development. Relief of the obstruction requires repair of the outflow tract and relief of the valvular obstruction caused by an abnormally small valve. Ethanol ablation would be unlikely to address a reconstruction that typically requires significant surgical skill. There is no small degree of elegance that goes into reconstructing the RVOT of a tet baby to try to achieve some semblance of normal physiology. Ablation assumes that hypertrophy is the only problem and that removal of muscle fixes the issue, and this is simply not the case. As far as the VSD goes, even if there were percutaneous devices properly suited to address a malalignment VSD, the fact that the remainder of a tet repair requires surgery would argue for simply placing a septal patch at the time of surgery, since this is the well established standard of care. There is no evidence that any percutaneous VSD closure device is superior to surgical repair. The fact is, TOF is a surgical disease, and it is difficult to view such a complex structural and physiologic disorder as anything but that. It must be treated as a complete entity, rather than be broken down into parts. This in general is true of many congenital problems.
As far as interventional cardiology goes, I think both ESU and WS make important points. IC has made useful strides in the treatment of coronary disease, but they often times tend to push methodologies with little evidence of improvement over the pre-exisiting standard of care. Many would argue that this is still the case for drug eluting stents vs. bare metal stents. Additionally, it is well-established that diabetics do better with CABG than with PCI, and more and more research is showing that this is also true not only in non-diabetics with left main and 3vd, but probably also in two vessel disease. This is not to say that IC's are useless, and indeed they remain the first line of defense in acute STEMI. Many, however, have probably pushed their trade beyond the point where it can safely go based upon the preponderance of evidence at this time. I've seen more than one left main stent thrombose, and these are stents that probably shouldn't even be placed at all unless the patient is an abhorrent surgical candidate. I think as more long-term data comes out showing the frequency of complications, re-stenting, need for bypass, and even death in stent patients, the superiority of CABG in terms of long-term revascularization patency will become more evident. Even the advantage of the avoidance of a sternotomy scar will have trouble competing with hard end points like these.

 

[DarkProtonics]

DarkProtonics, your question is interesting, but I cannot see that being a viable approach to the problem of RVOT obstruction in TOF. Too often congenital heart syndromes are characterized as being a collection of various anomalies, hence TOF being characterized as four separate defects. In reality, it is one specific aberration in embryological development that leads to four related defects. The muscular outflow obstruction is one that is due both to hypertrophy as well as to simple improper placement due to the underlying problem in normal development. Relief of the obstruction requires repair of the outflow tract and relief of the valvular obstruction caused by an abnormally small valve. Ethanol ablation would be unlikely to address a reconstruction that typically requires significant surgical skill. There is no small degree of elegance that goes into reconstructing the RVOT of a tet baby to try to achieve some semblance of normal physiology. Ablation assumes that hypertrophy is the only problem and that removal of muscle fixes the issue, and this is simply not the case. As far as the VSD goes, even if there were percutaneous devices properly suited to address a malalignment VSD, the fact that the remainder of a tet repair requires surgery would argue for simply placing a septal patch at the time of surgery, since this is the well established standard of care. There is no evidence that any percutaneous VSD closure device is superior to surgical repair. The fact is, TOF is a surgical disease, and it is difficult to view such a complex structural and physiologic disorder as anything but that. It must be treated as a complete entity, rather than be broken down into parts. This in general is true of many congenital problems.
As far as interventional cardiology goes, I think both ESU and WS make important points. IC has made useful strides in the treatment of coronary disease, but they often times tend to push methodologies with little evidence of improvement over the pre-exisiting standard of care. Many would argue that this is still the case for drug eluting stents vs. bare metal stents. Additionally, it is well-established that diabetics do better with CABG than with PCI, and more and more research is showing that this is also true not only in non-diabetics with left main and 3vd, but probably also in two vessel disease. This is not to say that IC's are useless, and indeed they remain the first line of defense in acute STEMI. Many, however, have probably pushed their trade beyond the point where it can safely go based upon the preponderance of evidence at this time. I've seen more than one left main stent thrombose, and these are stents that probably shouldn't even be placed at all unless the patient is an abhorrent surgical candidate. I think as more long-term data comes out showing the frequency of complications, re-stenting, need for bypass, and even death in stent patients, the superiority of CABG in terms of long-term revascularization patency will become more evident. Even the advantage of the avoidance of a sternotomy scar will have trouble competing with hard end points like these.

Well, it was a theory...thanks for informing me about the holes in it.

Should I still try to become an IC? Or is IC just a passing fad? I've got at least 17 years before I become an IC; maybe by then it'll have drastically improved and give results comparable to CABG.

What about repairing a thrombosed stent by using an irrigating balloon catheter to infuse tPA directly to the thrombus? It is strongly my opinion that surgery should be the last resort, after everything else has failed.

Why is a CABG superior to an angioplasty w/ a PTFE-coated sirolimus-eluting stent?

 

[twood]

LIMA to LAD is a direct artery to artery anastomosis. "self" tissue will have higher patency because there is no opportunity for inflammatory reaction and subsequent thrombosis.

You're forgetting that you have to have CT surgeons to cover cath lab errors (the whole "why are you allowed to do a procedure when you can't fix the complications" debate)

 

[Winged Scapula]

All stents and grafts, whether central or peripheral vascular have higher failure and occlusion rates than native tissue. It doesn't matter if its LIMA to LAD, Brachio-Cephalic or Fem-Pop.

Dark Protonics...you should follow whichever path interests you and its WAY too early to know that. Many of us changed paths multiple times once we got to medical school and actually worked in a certain field (ie, surgery was the last thing I was going to do).

IC will undoubtedly be very different 17 years from now, just as CTS will be. But what will be true is that there are surgeons and there are non-surgeons. If you want to be a surgeon and do procedures, do a surgical residency which will allow you to do the interventions AND fix them should they go wrong. If you prefer IM, then do IC.

Keep your mind open as there are lots of interesting things in the medical world and you are much too young to focus yourself in one area.

 

[DarkProtonics]

LIMA to LAD is a direct artery to artery anastomosis. "self" tissue will have higher patency because there is no opportunity for inflammatory reaction and subsequent thrombosis.

You're forgetting that you have to have CT surgeons to cover cath lab errors (the whole "why are you allowed to do a procedure when you can't fix the complications" debate)

Of course. I'd always consult a C/Th surgeon about whether angioplasty or CABG is more appropriate for my patient, and keep the on-call C/Th surgeon's pager on speed-dial while in the cath lab. I don't for a second think ICs can fix everything; alot, but not everything.

Maybe we could make a stent that's totally immunologically inert, or make one of out thin slivers of bone.

 

[DarkProtonics]

All stents and grafts, whether central or peripheral vascular have higher failure and occlusion rates than native tissue. It doesn't matter if its LIMA to LAD, Brachio-Cephalic or Fem-Pop.

Dark Protonics...you should follow whichever path interests you and its WAY too early to know that. Many of us changed paths multiple times once we got to medical school and actually worked in a certain field (ie, surgery was the last thing I was going to do).

IC will undoubtedly be very different 17 years from now, just as CTS will be. But what will be true is that there are surgeons and there are non-surgeons. If you want to be a surgeon and do procedures, do a surgical residency which will allow you to do the interventions AND fix them should they go wrong. If you prefer IM, then do IC.

Keep your mind open as there are lots of interesting things in the medical world and you are much too young to focus yourself in one area.

I know! A few months ago, I wanted to be an electrophysiologist, before that, a critical care neurologist, and before that, a hematologist/oncologist.

I don't want to be a C/Th surgeon because, currently, I'm freaked about leaving a sponge inside the pt. But that may change. And the tools and operations are so cool! Do they still perform the Blalock-Thomas-Taussig shunt procedure; I watched a really cool movie about that, Something the Lord Made.

I wanted to shadow a C/Th surgeon, but he doesn't allow visitors in the OR...they allow med and nursing students, why not pre-meds? But his nurse complimented me on my writing of the letter of request.

 

[Winged Scapula]

I know! A few months ago, I wanted to be an electrophysiologist, before that, a critical care neurologist, and before that, a hematologist/oncologist.

Ahhh...see. A few months from now you might want to do something totally different.

I don't want to be a C/Th surgeon because, currently, I'm freaked about leaving a sponge inside the pt.

There are risks in everything you do. Frankly, leaving a sponge inside a patient is fixable; there are a lot of other things worth worrying about which are much more morbid. But with training and experience comes skill and confidence (hopefully).

But that may change. And the tools and operations are so cool! Do they still perform the Blalock-Thomas-Taussig shunt procedure; I watched a really cool movie about that, Something the Lord Made.

Great movie. Yes, the BT Shunt is still performed although somewhat modified from the original by using synthetic graft.

I wanted to shadow a C/Th surgeon, but he doesn't allow visitors in the OR...they allow med and nursing students, why not pre-meds? But his nurse complimented me on my writing of the letter of request.

Most likely hospital policy. They will make up something like, "you don't have malpractice" but neither does the circulator or other people in the room. Its basically because they don't want the responsibility if you pass out and crack your skull open or are psychologically traumatized. The OR staff cannot be taking the time to take care of a pre-med who might (it happens frequently) pass out, ask too many questions, etc. If the CTS (you don't need to type C/Th surgeon here) was forceful enough he could probably get you in, but I wouldn't press it.

 

[teddybear]

I know! A few months ago, I wanted to be an electrophysiologist, before that, a critical care neurologist, and before that, a hematologist/oncologist.

I don't want to be a C/Th surgeon because, currently, I'm freaked about leaving a sponge inside the pt. But that may change. And the tools and operations are so cool! Do they still perform the Blalock-Thomas-Taussig shunt procedure; I watched a really cool movie about that, Something the Lord Made.

I wanted to shadow a C/Th surgeon, but he doesn't allow visitors in the OR...they allow med and nursing students, why not pre-meds? But his nurse complimented me on my writing of the letter of request.

Do you mind if I ask how you know all this terminology? Just curious.

 

[DarkProtonics]

Ahhh...see. A few months from now you might want to do something totally different.



There are risks in everything you do. Frankly, leaving a sponge inside a patient is fixable; there are a lot of other things worth worrying about which are much more morbid. But with training and experience comes skill and confidence (hopefully).



Great movie. Yes, the BT Shunt is still performed although somewhat modified from the original by using synthetic graft.



Most likely hospital policy. They will make up something like, "you don't have malpractice" but neither does the circulator or other people in the room. Its basically because they don't want the responsibility if you pass out and crack your skull open or are psychologically traumatized. The OR staff cannot be taking the time to take care of a pre-med who might (it happens frequently) pass out, ask too many questions, etc. If the CTS (you don't need to type C/Th surgeon here) was forceful enough he could probably get you in, but I wouldn't press it.

I didn't force it; his nurse who called me was very nice, complimented me on my good writing skills for a 17 yr old, and basically said I wouldn't want to shadow him, b/c I wouldn't learn much, b/c he "hides away" b/w surgeries.

 

[DarkProtonics]

Do you mind if I ask how you know all this terminology? Just curious.

My Mom was an RN, and two of her friends are Drs. I also enjoy reading through her textbooks every once in a while, as well as being addicted to "Discovery Health" channel and "House"; I also had to be in hospitals a lot when I was younger. All of those combined made me want to be a Dr.

 

[teddybear]

My Mom was an RN, and two of her friends are Drs. I also enjoy reading through her textbooks every once in a while, as well as being addicted to "Discovery Health" channel and "House"; I also had to be in hospitals a lot when I was younger. All of those combined made me want to be a Dr.

sweet

 

[DarkProtonics]

sweet

Really? I'm sure you have better reasons to be a doctor than being interested in technology and puzzle-solving.

Do any of you guys know how I could start shadowing physicians...I'm trying to work something out w/ my FP.

 

[dynx]

Well, the quality of stenting is improving.

You've stumbled on the reasoning that will keep the CABG from ebing fully utilized like it should. People (cardiologists) that think like this are the reason nobody should hope for the CABG's return to its rightful place. The limitations of studies in this regard is that they take a long time...and stent makers can keep tweeking thier stents to add this and that and claim...."oh! that last study did make stents look inferior but now we have a stent coated in butter and goat urine and Im sure than in just 5 years when the new study comes out we'll see that its just as good"...flash forward five years all the while using the butter and goat urine stents and the study comes out showing that they too are inferior. BUT WAIT! now we have a stent coated in margarin and goat urine...and we're sure that if we just wait for the study to come out that this stent will be just as good......and on....and on...and on.

 

[teddybear]

Really? I'm sure you have better reasons to be a doctor than being interested in technology and puzzle-solving.

Do any of you guys know how I could start shadowing physicians...I'm trying to work something out w/ my FP.

I have better reasons than you do. I was just being nice and not letting you know what I really thought of your asinine response.

 

[DarkProtonics]

I have better reasons than you do. I was just being nice and not letting you know what I really thought of your asinine response.

Then it wasn't so nice...

 

[Winged Scapula]

Please refrain from insulting other users when disagreeing with their posts.

 

[DarkProtonics]

Please refrain from insulting other users when disagreeing with their posts.

Is that directed to me, or teddybear?

I also really have a desire to help people in illness, for I've had severe illnesses --born 16 weeks premature, almost died 9 mos. later from a kidney abscess which was a result from UTI complications--, my aunt died from cancer, and my cousin has AML and Down's. I want to do my part to treat those w/ illnesses, esp. complicated ones.

 

[Winged Scapula]

Is that directed to me, or teddybear?

The bear...whom, despite the name change, knows better.

 

[DarkProtonics]

The bear...whom, despite the name change, knows better.

I see. And what is your opinion on me? Should I be a physician?

 

[ESU_MD]

great thread. i was actually DOING heart surgery so i couldnt chime in as much.

Stent technology is evolving indeed, should be interesting to see where it goes. The idea thing would be for ONE person to be able to do both stents and cabg that way they can offer either to the patient with less bias. (although I can see how at 7pm fri nite I would rather stent than operate...)

There is certainly a trend towards bypass based on my opinion. I am seeing more isolated LAD cases. This week alone we did 2 lima-lad cases. This case is nice, can be done offpump in less than 90 minutes skin to skin, with the pt extubated the same day. no lifelong plavix or worrying about thrombosis etc.. this particular case is perfect for minimally invasive techniques and in fact they are already being done, but not ready for prime time yet.

its all about the LIMA. it is the best conduit in the body. I still take more time than usual to harvest it since if it gets screwed up, you just decreased the pts survival significantly, unlike the vein which if you put a hole in it, you just fix it.

the BT shunt is perfomed not too infrequently in major pediatric centers. in fact one of the members of the original BT surgery team is still alive and well.

btw..dark protonics I am impressed by your knowledge for a 17yr old. I think you should focus on video games and members of the opposite sex at your age instead of worrying about cath labs. you will have plenty of time to think about these things after medical school!! life is too short to get too wrapped up in your career.

 

[Winged Scapula]

I see. And what is your opinion on me? Should I be a physician?

I dunno, you seem bright and interested enough. Other than that, I have no personal opinion about your qualifications as I am loathe to invoke Burnett's Law.

 

[DarkProtonics]

I dunno, you seem bright and interested enough. Other than that, I have no personal opinion about your qualifications as I am loathe to invoke Burnett's Law.

That's what I like to hear.

Btw, I suspect it's possible for erythrocytosis to cause ventricular hypertrophy --what do you listen for on the phonocardiogram?-- as well as PVD, b/c my own latest lab work, and symptoms, are concerning me about this. Am I correct in making that assumption?

 

[Winged Scapula]

Sounds like a question for a cardiologist.

Frankly, although I know what the terms "phono", "cardio" and "gram" mean, I am not familiar with a phonocardiogram.

Besides, you know we can't give you medical advice here.

 

[DarkProtonics]

great thread. i was actually DOING heart surgery so i couldnt chime in as much.

Stent technology is evolving indeed, should be interesting to see where it goes. The idea thing would be for ONE person to be able to do both stents and cabg that way they can offer either to the patient with less bias. (although I can see how at 7pm fri nite I would rather stent than operate...)

There is certainly a trend towards bypass based on my opinion. I am seeing more isolated LAD cases. This week alone we did 2 lima-lad cases. This case is nice, can be done offpump in less than 90 minutes skin to skin, with the pt extubated the same day. no lifelong plavix or worrying about thrombosis etc.. this particular case is perfect for minimally invasive techniques and in fact they are already being done, but not ready for prime time yet.

its all about the LIMA. it is the best conduit in the body. I still take more time than usual to harvest it since if it gets screwed up, you just decreased the pts survival significantly, unlike the vein which if you put a hole in it, you just fix it.

the BT shunt is perfomed not too infrequently in major pediatric centers. in fact one of the members of the original BT surgery team is still alive and well.

btw..dark protonics I am impressed by your knowledge for a 17yr old. I think you should focus on video games and members of the opposite sex at your age instead of worrying about cath labs. you will have plenty of time to think about these things after medical school!! life is too short to get too wrapped up in your career.

I've got a good number of opposite-sex friends at Cerritos...too bad we're all interested in a Career In Medicine...I want to be a cardiologist, my girl-friend wants to be a psychiatrist, and my other girl-friend wants to be a nurse. I do play some PC games --Sim City, Age of Empires, ER; Code Red, etc.--, as well as read webcomics, write short stories, draw, etc.

Instead of doing a graft, couldn't the C/Th team just anastomize an unblocked coronary vessel to the blocked one, like a detour? Or is that too risky?

I'd put my stent pts on clopidogrel+asa+atorvastatin, to prevent both types of coronary blockages, the thromboembolus type, and the atheroma type.

I wouldn't be so arrogant in my skills as an IC not to consult a C/Th surgeon; I'd always review the angiograms together with him/her/it, and page him/her/it to the cath lab as soon as I'm paged in an emergency, like a STEMI. Then the pt would have the benefits of both skill sets.

 

[DarkProtonics]

Sounds like a question for a cardiologist.

Frankly, although I know what the terms "phono", "cardio" and "gram" mean, I am not familiar with a phonocardiogram.

Besides, you know we can't give you medical advice here.

Forgot, sorry. I'll ask my hematologist when I see him on Wednesday, and ask if he believes a referral to an invasive cardiologist or vascular medicine specialist is necessary. Do they do catheter angiograms for PVD?

A phonocardiogram is an auscultation of the heart...well, technically the recording of the sound waves.

 

[Winged Scapula]

Forgot, sorry. I'll ask my hematologist when I see him on Wednesday, and ask if he believes a referral to an invasive cardiologist or vascular medicine specialist is necessary. Do they do catheter angiograms for PVD?

Yes, commonly.

A phonocardiogram is an auscultation of the heart...well, technically the recording of the sound waves.

Well yes, I KNOW what it is. Only cardiologists care about phonocardiograms and even then its much ado about nothing, IMHO. Guess my sarcasm didn't come across. Let me try again...

I've got this thing that I put in my ears with a couple of tubes running down to a bell shaped thing to listen to the heart. It works pretty well.

 

[DarkProtonics]

Yes, commonly.



Well yes, I KNOW what it is. Only cardiologists care about phonocardiograms and even then its much ado about nothing, IMHO. Guess my sarcasm didn't come across. Let me try again...

I've got this thing that I put in my ears with a couple of tubes running down to a bell shaped thing to listen to the heart. It works pretty well.

Stethoscope, I know. I was funnier now. I'm using my Mom's, which is pink. Should I wear it w/ my black shirt and red tie and khakis to the hematologist's?

What do you listen for to detect ventricular hypertrophy? Or can that only be diagnosed by TTE?

 

[Winged Scapula]

Stethoscope, I know. I was funnier now. I'm using my Mom's, which is pink. Should I wear it w/ my black shirt and red tie and khakis to the hematologist's?

Only if you want to look like a tool.

What do you listen for to detect ventricular hypertrophy? Or can that only be diagnosed by TTE?

Again, questions for a cardiologist. Not because we don't want you asking them here, but you are asking general surgeons and surgery residents who are far out from their 3rd year medical school medicine rotation (when such things as this would be dealt with). There are many ways to diagnose ventricular hypertrophy - EKG, Echo, etc.

 

[teddybear]

Really? I'm sure you have better reasons to be a doctor than being interested in technology and puzzle-solving.

I just don't know what he means by this. I'm confused.

 

[DarkProtonics]

I just don't know what he means by this. I'm confused.

Don't worry about it.

 

[DarkProtonics]

Only if you want to look like a tool.

How? The fact that it's pink?

Again, questions for a cardiologist. Not because we don't want you asking them here, but you are asking general surgeons and surgery residents who are far out from their 3rd year medical school medicine rotation (when such things as this would be dealt with). There are many ways to diagnose ventricular hypertrophy - EKG, Echo, etc.

Then will ask the question on the cardiology forum

 

[teddybear]

Don't worry about it.

I don't think you are what you claim to be.

 

[DarkProtonics]

I don't think you are what you claim to be.

Really? Why?

 

[teddybear]

Really? Why?

I asked you how you know so much about these procedures being as how you're supposedly just a 17-year-old premed. I thought it was a reasonable question. Then you gave that sarcastic answer, and then said don't worry about it. Anyway let's drop it. I'm not going to junk up this forum with a silly juvenile argument.

 

[DarkProtonics]

I asked you how you know so much about these procedures being as how you're supposedly just a 17-year-old premed. I thought it was a reasonable question. Then you gave that sarcastic answer, and then said don't worry about it. Anyway let's drop it. I'm not going to junk up this forum with a silly juvenile argument.

That wasn't sarcastic; it was my real answer.

 

[teddybear]

That wasn't sarcastic; it was my real answer.

All apologies then. Still confused but it's not important.

 

[dienekes88]

I've got this thing that I put in my ears with a couple of tubes running down to a bell shaped thing to listen to the heart. It works pretty well.

Whoa. You have one too?! 😱

Instead of doing a graft, couldn't the C/Th team just anastomize an unblocked coronary vessel to the blocked one, like a detour? Or is that too risky?

Do you mean detaching a coronary artery and attaching it to another one, e.g. detaching the left marginal and anastomosing it to the LAD? Coronary arteries are end-arteries, i.e. each coronary supplies a discrete section of myocardium, and there is only marginal development of collateral circulation.

If you meant grafting the other end of the vein/artery to a coronary artery, e.g. Right Marginal to LAD, then I believe you've got a problem of hemodynamics there (flow, wall tension, wall stress, etc.). On top of that, why would you do that when you've got an aorta just waiting to be the other end of your graft?

I wouldn't be so arrogant in my skills as an IC not to consult a C/Th surgeon; I'd always review the angiograms together with him/her/it, and page him/her/it to the cath lab as soon as I'm paged in an emergency, like a STEMI. Then the pt would have the benefits of both skill sets.

...or you could do fellowships in both interventional cardiology and cardiac surgery. I met a guy who did that. He was pretty intense in person. In fact, he didn't even talk to me... so I guess we didn't actually "meet."

 

[DarkProtonics]

Do you mean detaching a coronary artery and attaching it to another one, e.g. detaching the left marginal and anastomosing it to the LAD? Coronary arteries are end-arteries, i.e. each coronary supplies a discrete section of myocardium, and there is only marginal development of collateral circulation.

If you meant grafting the other end of the vein/artery to a coronary artery, e.g. Right Marginal to LAD, then I believe you've got a problem of hemodynamics there (flow, wall tension, wall stress, etc.). On top of that, why would you do that when you've got an aorta just waiting to be the other end of your graft?

I meant the first scenario...btw, if they're end-arteries, do they connect to capillaries and then to veins?

...or you could do fellowships in both interventional cardiology and cardiac surgery. I met a guy who did that. He was pretty intense in person. In fact, he didn't even talk to me... so I guess we didn't actually "meet."

He did both IM and GS residencies? That guy did PGME until PGY-14?!!?

 

[dienekes88]

I meant the first scenario...btw, if they're end-arteries, do they connect to capillaries and then to veins?

Yeah. There are a lot of veins: Great Cardiac Vein, Middle Cardiac Vein, Small Cardiac Vein, Anterior Cardiac Veins, Oblique Vein, etc.

He did both IM and GS residencies? That guy did PGME until PGY-14?!!?

Nah. He didn't have to do the IM residency. He just did the Interventional Cardiology fellowship after the Cardiothoracic Surgery fellowship. Dunno how...

 

[DarkProtonics]

Yeah. There are a lot of veins: Great Cardiac Vein, Middle Cardiac Vein, Small Cardiac Vein, Anterior Cardiac Veins, Oblique Vein, etc.



Nah. He didn't have to do the IM residency. He just did the Interventional Cardiology fellowship after the Cardiothoracic Surgery fellowship. Dunno how...

Ok, then.

Which do you believe is more of an intellectual challenge, cardiac surgery, or (interventional) cardiology?

 

[MossPoh]

I don't think the janitor could walk in and do either profession. You'll cross that bridge when you get there. You are thinking more than a decade into your future right now. Even doctors like to talk about trashy t.v. and sports once in a while. 😉 For all you know, you'll get into college and realize you want to design that miracle stent and ditch medical school.


This is a really bizarre thread.

 

[Blade28]

I don't want to be a C/Th surgeon because, currently, I'm freaked about leaving a sponge inside the pt.

As stated above, this should be the last reason you're dissuaded from going into surgery. This also doesn't happen as often as TV shows or the popular media would have you believe.

 

[DarkProtonics]

I don't think the janitor could walk in and do either profession. You'll cross that bridge when you get there. You are thinking more than a decade into your future right now. Even doctors like to talk about trashy t.v. and sports once in a while. 😉 For all you know, you'll get into college and realize you want to design that miracle stent and ditch medical school.


This is a really bizarre thread.

I know. But how is this bizarre?