Let's do some echo:

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abolt18 said:
You are not wrong. We pushed pretty hard. We discussed the previous anesthetic and the measures required to care for her. She described herself outright as a "difficult patient" which was more than true. We pushed the arterial line and went round and round without success. It was basically "only if I'm doing really really badly."

This whole case stressed me out. I was dissatisfied with the progression of the events. Hard to provide the best care you can when the patient is not onboard. I appreciate the criticisms though, as I'm open to feedback so I can make it a better experience the next time.
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What was the 10mg of propofol for? A “just to see” push of anything in that pt sounds..... odd.
 
If she wants (needs?) anesthesia for this routine, office based procedure then she gets what you decide is safe or nothing at all. Talk to your gyne colleague. Tell them this is the only way you can get her through any kind of anesthetic alive.

The patient being cutesy and saying she’s difficult tells you she has no insight into the severity of her disease process. There is no meaningful shared decision making with a patient like this. We don’t do mask GAs in patients with full stomachs because they don’t like the idea of having a breathing tube and they’re self admittedly “difficult.”

Either patient agrees to your plan (which involves an a-line) or anesthesia isn’t involved, full stop.
 
Beeftenderloin said:
If she wants (needs?) anesthesia for this routine, office based procedure then she gets what you decide is safe or nothing at all. Talk to your gyne colleague. Tell them this is the only way you can get her through any kind of anesthetic alive.

The patient being cutesy and saying she’s difficult tells you she has no insight into the severity of her disease process. There is no meaningful shared decision making with a patient like this. We don’t do mask GAs in patients with full stomachs because they don’t like the idea of having a breathing tube and they’re self admittedly “difficult.”

Either patient agrees to your plan (which involves an a-line) or anesthesia isn’t involved, full stop.
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Yeah I appreciate this. I had never run into so much resistance from a patient before, especially one so close to death every day of their life. I was very taken off-guard. Knowing how bad her disease process is, I assumed she'd just jump onboard. Lack of insight is a gentle way of putting it. Belligerent is another. I should have stuck to my guns.

Gyn was 100% supportive of us and said "you do whatever you need to do."
 
Guess I should have made a separate thread to discuss this. I'll just say I appreciate people's input. This case didn't sit well with me and I've asked myself what I could have/should have done better.

Now we can return to the regularly scheduled programming of @vector2 and @sevoflurane sharing cool images.
 
abolt18 said:
Here for a very minor procedure that is usually done in GYN clinic without any anesthetic.
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abolt18 said:
One challenge was management of the patient's expectations. Plan was for the art line. She refused. So it turned into "art line and ultrasound available at bedside and if things go sideways it's going in."
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abolt18 said:
She described herself outright as a "difficult patient" which was more than true.
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Difficult, unreasonable patients are tough but sometimes the simplest and best answer is just no. Write "Extensive discussion of risks and benefits of anesthesia with the patient. Ultimately she declined to consent." on the chart and move to the next case.
 
pgg said:
Difficult, unreasonable patients are tough but sometimes the simplest and best answer is just no. Write "Extensive discussion of risks and benefits of anesthesia with the patient. Ultimately she declined to consent." on the chart and move to the next case.
Click to expand...
In today's busy environment, we forget that physicians get to consent as well.
 
Using a new device today.
Worth a mention:

Watchmen flx is superior to previous gen watchman device. More malleable for difficult appendages.

0CF81D32-C81F-41FD-ABD5-96386B0B50A1.jpeg
 
Nice mitral shoulder pre compression

CF15173C-23FA-42A9-AC02-78C5CACC8313.jpeg


Not ideal
 
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Pretty sure the 2.5 is going to be phased out.
 
*watchaman not watchmen... lol i watched that movie last night.
 
Nah.... scale is turned way down like 30 cm/s. No VC/device leak at 0,45,90 and 135. Clean fluoro. Mitral shoulder tucked in as beat as possible. Probably would have been a real challange with a watchman 2.5.
 
3D CF scale was also turned down. Reassuring. 🤘🏽
 
Do any of you actually believe the watchman is beneficial to the patient???
 
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dchz said:
Do any of you actually believe the watchman is beneficial to the patient???
Click to expand...

Ummm... yeah. What’s so bad about taking someone off of anticoagulants? 75 y/o with history of falls? Should have seen my 4th watchman patient yesterday. Kind of like this but worse.

A31AA564-74DA-4DBB-AE51-3428D3B5DDC6.jpeg
 
Watchman is vastly superior than say a Lariat procedure IMO.
 
Newtwo said:
Is there anything we do thats definitely beneficial?
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Absolutely! CABG in triple vessel dz and TAVR definitely showed mortality benefit compared to pci or no intervention with crossmatched controls. As far as I'm aware all the RCTs for watchman didn't show any mortality benefit.

Furthermore what's the number needed to treat for a watchman? What % of watchman procedures have to result in CPB to make it not worth it?

sevoflurane said:
Ummm... yeah. What’s so bad about taking someone off of anticoagulants? 75 y/o with history of falls? Should have seen my 4th watchman patient yesterday. Kind of like this but worse.

View attachment 333343
Click to expand...

Assuming you're serious, what evidence do you have that shows putting a watchman in someone like her and then stopping anti coags is better than just stopping anti coags without a watchman?
 
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dchz said:
Absolutely! CABG in triple vessel dz and TAVR definitely showed mortality benefit compared to pci or no intervention with crossmatched controls. As far as I'm aware all the RCTs for watchman didn't show any mortality benefit.

Furthermore what's the number needed to treat for a watchman? What % of watchman procedures have to result in CPB to make it not worth it?



Assuming you're serious, what evidence do you have that shows putting a watchman in someone like her and then stopping anti coags is better than just stopping anti coags without a watchman?
Click to expand...

🤦🏽‍♂️

So.... take everyone off of anticoagulants?
 
sevoflurane said:
🤦🏽‍♂️

So.... take everyone off of anticoagulants?
Click to expand...
lol ofc not. not everyone. raccoon eyes also never killed anyone, but watchman has.

-The PREVAIL study didn't really show non-inferiority to warfarin with primary end point. A lot of data massaging in this study.
-You have to under go anticoag anyways (clopidegrel and ASA) after watchman implant during which period you're just as likely to fall and bleed.
-the procedural risk at an experience operator is passable. But how many patients are actually getting watchmans under experienced operators? our practice saw 3/5 watchman procedures go on CPB to fix procedural complications in 1 month.
-There has never been any study with mortality benefit with the watchman procedure.

I totally agree with you it's better than the Lariat procedure. There is certainly an economic incentive to put it in patients. But i'm not sure it actually helps the patient overall because it's never shown any mortality benefit and questionable stroke benefit...
 
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Hork Bajir said:
@sevoflurane @vector2 how are you guys posting your echo clips on here? I have some good cases to share but can’t figure out how to post them
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We use a web browser to log into essentially a virtual PACS. Once I’m playing the clip I use www.gifcap.dev to capture a gif, and then I host it on Imgur.com
 
dchz said:
lol ofc not. not everyone. raccoon eyes also never killed anyone, but watchman has.

-The PREVAIL study didn't really show non-inferiority to warfarin with primary end point. A lot of data massaging in this study.
-You have to under go anticoag anyways (clopidegrel and ASA) after watchman implant during which period you're just as likely to fall and bleed.
-the procedural risk at an experience operator is passable. But how many patients are actually getting watchmans under experienced operators? our practice saw 3/5 watchman procedures go on CPB to fix procedural complications in 1 month.
-There has never been any study with mortality benefit with the watchman procedure.

I totally agree with you it's better than the Lariat procedure. There is certainly an economic incentive to put it in patients. But i'm not sure it actually helps the patient overall because it's never shown any mortality benefit and questionable stroke benefit...
Click to expand...

-You sure PREVAIL and PROTECT didn't show an improved survival? Morbidity is certainly reduced. I'll have to look at those again.
-Of course you have to be on anticoagulation after you place it- but then you are OFF blood thinners. No labs, no pills no appointments. Sounds pretty nice to me and I am sure it sounds good to patients as well. Think of it as a service line for those who qualify and prefer to be off thinners.
-History of GIB, Strokes/SAB, falls, or even traumas in people with active lifestyles. Just had a FP doc have a massive ICB 2 weeks after he was started on blood thinners for afib- scary.
- It certainly makes things easier in the heart room or trauma bay when you don't have blood thinners on board.
-I am glad there is an alternative for patients to choose how they want to live their lives.
-Sounds like your structural cards needs some help. That is A LOT of complications for that procedure. How many does he/she do a year? There is clear evidence that those who have a lot of reps have excellent operative outcomes. 100 a year sounds about right. We did 4 yesterday and they were super quick in very sick patients all of which had a history of significant morbidity due to anticoagulants. Procedure time just over 20 minutes on our third one. This cardiologist crosses the septum at least 30x a week. Never any drama.

Not trying to argue here, but there are some patients that can really benefit from it. You make it sound like a sham, which it isn't.
 
sevoflurane said:
-Of course you have to be on anticoagulation after you place it- but then you are OFF blood thinners. No labs, no pills no appointments. Sounds pretty nice to me and I am sure it sounds good to patients as well. Think of it as a service line for those who qualify and prefer to be off thinners.
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I've done plenty with experienced people around 20 mins each. They are ok except for the radiation to my face when doing it. but we cover a lot of the heart stuff all across town. The experience level.... varies.

In regards of willy nilly choosing to be off blood thinners and just get a watchman that's not really what the data support though. It failed to demonstrate non-inferior to anticoagulation in PREVAIL, right? may be i'm not understanding medical evidence.
 
I don't know the data for Watchman per se, but what I do know is that structural heart and its associated data/EBM are totally industry driven, and we deploy all kinds of super expensive devices in pts who are barely getting a morbidity benefit let alone a mortality benefit.
 
Some of us are years out from actual Evidence Based Medicine and Statistics course from med school. But only weeks out from a fancy steak bought by the reps while looking at studies with N of 5.

So here is some recap:
- If you test enough for random variables correlations, just by sheer statics and chances alone, you're going to find something that correlates. That's not enough in the current standard of medical evidence.
- If you want that correlation to mean something, you need to have enough numbers of people to properly power for the size of the effect.
- Smaller the benefit -> more N needed to be appropriately powered. Bigger the benefit -> smaller N required to show benefit.
- Mortality benefit in properly powered prospective randomized control trials is the most confounder-immune evidence we can have in medicine.
- Do enough of those kind of RCTs and have a meta-analysis, it's pretty much true.
- Meta analysis evidence should be the ultimate litmus test to see if you want the procedure/device done to you.

Things they didn't teach us in medical school:
- All of the above starts to mean less if $$$$$ is involved.
- Industry does not need good evidence to make money.
- Industry gains money when you don't see their subtle slight of hand tricks with the data or faux studies.
- Some devices are on the magnitude of $30-$40k each (watchman is cheaper? i've never gotten an answer out of a rep, they always quote me out of pocket cost rather than device price). Imagine doing 4 of those in a day. Then imagine the incentive to keep that cashflow coming in.

- The watchman device failed twice at FDA approval. Finally approved with less than stellar data
- several electrophysiologists i've spoken to share the same sentiment that they're not sure the device is actually beneficial to the patient, therefore they choose not to perform the procedure.
 
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dchz said:
Some of us are years out from actual Evidence Based Medicine and Statistics course from med school. But only weeks out from a fancy steak bought by the reps while looking at studies with N of 5.

So here is some recap:
- If you test enough for random variables correlations, just by sheer statics and chances alone, you're going to find something that correlates. That's not enough in the current standard of medical evidence.
- If you want that correlation to mean something, you need to have enough numbers of people to properly power for the size of the effect.
- Smaller the benefit -> more N needed to be appropriately powered. Bigger the benefit -> smaller N required to show benefit.
- Mortality benefit in properly powered prospective randomized control trials is the most confounder-immune evidence we can have in medicine.
- Do enough of those kind of RCTs and have a meta-analysis, it's pretty much true.
- Meta analysis evidence should be the ultimate litmus test to see if you want the procedure/device done to you.

Things they didn't teach us in medical school:
- All of the above starts to mean less if $$$$$ is involved.
- Industry does not need good evidence to make money.
- Industry gains money when you don't see their subtle slight of hand tricks with the data or faux studies.
- Some devices are on the magnitude of $30-$40k each (watchman is cheaper? i've never gotten an answer out of a rep, they always quote me out of pocket cost rather than device price). Imagine doing 4 of those in a day. Then imagine the incentive to keep that cashflow coming in.

- The watchman device failed twice at FDA approval. Finally approved with less than stellar data
- several electrophysiologists i've spoken to share the same sentiment that they're not sure the device is actually beneficial to the patient, therefore they choose not to perform the procedure.
Click to expand...
Regarding that last part. I practice in a place with well regarded and very skilled EPs and we don’t do Watchmans and I get a sense it’s for that reason.
 
N of 5? lol.

Does Left Atrial Appendage Closure Reduce Mortality? A Vital Status Analysis of the Randomized PROTECT AF and PREVAIL Clinical Trials - PMC

Compared with warfarin, left atrial appendage closure (LAAC) reduced mortality in an analysis of the PROTECTAF and PREVAIL trials. However, these data were limited by patient drop-out.We sought to estimatethe mortality benefit with LAACusing updated ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

NNT to prevent one death is 16 according to the above.

30% reduction in all cause mortality


This is probably more accurate though. ^

People hated TAVRs when it first came out. Regardless of cost, it’s a fantastic procedure for the right patient. Similarly normalization of PVW reversal immediately after a mitral clip is a great indicator that you did something good for the patient. Haters gonna hate.

As for watchman, the champion AF trial is going to tell us a lot.

Currently, I have zero hiccups for this device as second line therapy for those who have suffered strokes.

Beyond that, it is a place for the cardiac anesthesiologist to make a presence in the cath lab. I personally have been evolving my practice to be an integral part of that team as I feel like there is a lot of stuff coming down the pipeline that will further distance me from these toxic midlevels.
 
As for expensive rep dinners.... I could care less. I only go if my cards and ct surgeon really want me there. My time is way more valuable than going to these dinners. Only dinners that are worth it to me are those group interview dinners.
 
@sevoflurane Not sure if you're trying to pull a fast one on me. I'm gonna give you the benefit of the doubt.

sevoflurane said:

Does Left Atrial Appendage Closure Reduce Mortality? A Vital Status Analysis of the Randomized PROTECT AF and PREVAIL Clinical Trials - PMC

Compared with warfarin, left atrial appendage closure (LAAC) reduced mortality in an analysis of the PROTECTAF and PREVAIL trials. However, these data were limited by patient drop-out.We sought to estimatethe mortality benefit with LAACusing updated ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

NNT to prevent one death is 16 according to the above.

30% reduction in all cause mortality


This is probably more accurate though. ^
Click to expand...
It's actually not "accurate" at all. It's data massaging pure and simple.

- If you test enough for random variables correlations, just by sheer statics and chances alone, you're going to find something that correlates. That's not enough in the current standard of medical evidence.
- Mortality benefit in properly powered prospective randomized control trials is the most confounder-immune evidence we can have in medicine.

The paper you quoted is just re-slicing the pie to make it look good for Boston Scientific.

From the actual paper you quoted:
"Limitations of our analysis include the fact it was retrospective and not pre-specified during the clinical trials. Also, even with updated vital status information for 76 subjects, a substantial proportion (13.6%) still did not complete full 5-year follow-up."

Again, if you test enough for random variables correlations, just by sheer statics and chances alone, you're going to find something that correlates.

This is pure data massaging for the benefit of the industry.
 
Yeah not a great study which is why I quoted the second paper as being more accurate. But what OTHER studies are there so we can say yeah... watchman sucks. Puhhhlease show me.

Watchman is NOT inferior. Can you agree to that? If so, can you agree that in patients who have had hemorrhagic stroke MAY benefit and won’t have a negative outcome?

As I said earlier, some patients may elect for this procedure to avoid anticoagulants, lab work, dr. appointments, etc. Can you agree to THAT benefit?

Do you think we are just doing this for money? Is that your primary end point? If so, let me open your eyes to something: Medicine is a business always has been always will be. Business usually breeds innovation.

There is a ton of ongoing studies in structural heart happening now. I think we are all heading that way whether you like it or not.

Let’s revisit this in a few years shall we and avoid jumping to premature conclusions.
 
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The watchmans we put in, are for wrecks. Never had a hgb better than 80 in years. Regular admits for gi bleeds. Idk what happens them after but thats what we see
 
sevoflurane said:
N of 5? lol.

Does Left Atrial Appendage Closure Reduce Mortality? A Vital Status Analysis of the Randomized PROTECT AF and PREVAIL Clinical Trials - PMC

Compared with warfarin, left atrial appendage closure (LAAC) reduced mortality in an analysis of the PROTECTAF and PREVAIL trials. However, these data were limited by patient drop-out.We sought to estimatethe mortality benefit with LAACusing updated ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

NNT to prevent one death is 16 according to the above.

30% reduction in all cause mortality


This is probably more accurate though. ^

People hated TAVRs when it first came out. Regardless of cost, it’s a fantastic procedure for the right patient. Similarly normalization of PVW reversal immediately after a mitral clip is a great indicator that you did something good for the patient. Haters gonna hate.

As for watchman, the champion AF trial is going to tell us a lot.

Currently, I have zero hiccups for this device as second line therapy for those who have suffered strokes.

Beyond that, it is a place for the cardiac anesthesiologist to make a presence in the cath lab. I personally have been evolving my practice to be an integral part of that team as I feel like there is a lot of stuff coming down the pipeline that will further distance me from these toxic midlevels.
Click to expand...
As before, I agree with that last part
 
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