@Angus Avagadro , Echoing
@bigdan , props to you for doing the best thing you can for your family. I was recently in a similar situation with my father and i'm not sure I would be as cool headed you to ask for consensus from experts, kudos. I will present my perspective on the matter:
Before med school I did data entry research for liver transplants for months. I also sat in on the weekly liver transplant listing meetings numerous times. I've personally provided anesthesia for 30+ liver transplants and many many more CABGs. I have also sat in on the weekly cardiology conferences during fellowship and I've seen a lot of caths. These experiences give me just enough knowledge to be dangerous, but not enough to see the entire picture. E.g. I have never followed up on my liver transplant pts after more than 2 weeks post op nor have I followed up on my CABG pts for more than 2 weeks post op. I may not know what I don't know so take my perspective with a grain of salt.
Liver transplant surgery and immediate recovery: it should not be a big deal given the
right surgeon and anesthesiologist. The skill level of liver transplant surgeons vary greatly, even within the same group. The #1 thing you can do to lower mortality for your family member is trying to find the best surgeon possible. You don't want the surgeon that screams at you about the CVP when the pt has 3+ TR, all the while taking 20 mins to control one bleeding vein. You want the guy that is a cool cat that can sew the anastomosis when there is bomb going off. The CAD with no symptoms and normal heart is not a major road block in execution of the anesthestic. I would encourage you to get a place with good dedicated intensivists. That's really easily said than done. I'm not sure i've been at an institution where I would feel entirely comfortable with the intensivists on staff. Going to an institution that does >100 liver transplants per year also helps a lot, the experience of ICU staff also matters a lot in post op recovery.
Transplant listing: I was pretty naive before med school, but i don't remember one time a doctor did not fight for their patient during a transplant listing. You're right, their incentives are not 100% aligned, they are incentivized to protect their numbers. However, I cannot remember one time where the patient's doctor didn't do everything in their power to get their patients the best shot at long time quality of life. I also wonder if may be we are missing some crucial information here. Is the patient being considered compliant? was there some other history being left out? If they come back with this consensus, there must be more to the picture than mod CAD. You might be right, may be this is brand new transplant program. But I would try to read in between the lines and etc. Sometimes they see it as risk mitigation - if a noncompliant patient is compliant enough to get through CABG and cardiac rehab, he is much lower risk to this limited resource of a liver.
Couple of other things to consider:
-Several metroplexes can be gamed to double list in two different UNOS regions. I'm not sure if this is still true, but back in the day Dallas was one region while Ft Worth was a different UNOS region. Meaning a patient living in the metroplex could be listed in two regions at the same time. The NE also has several UNOS regions that can provide similar situations.
-I would not burn any bridges. I would
HIGHLY recommend NOT going on TV to denounce a liver transplant program. Not only does this separate your concentration into a lot unproductive efforts. It will taint your loved one's ability to get listed elsewhere.
-Being there for your loved one also provides a great amount of comfort and support. Take the time to explain how the process goes. Given them some insight to what's going on behind the scenes, how the surgery and recovery process goes, etc. Just taking the time to explain the minutia with your loved one can mean a world to them.
- Balloon angioplasty suggested by
@bigdan is a great alternative/compromise to CABG. Highly worth a try.