Dick vs. Bill

Bill Clinton gets chest pain, hits the hospital, gets a few stents and, voilà, is back at work. A veritable poster child for stents. No doubt JNJ stock climbed on the news.

On the flip side today: Dick Cheney gets chest pain, hits the hospital, and (I'll bet) he stays a while.

What do you mean, Dr. Wes? Can't cardiologist magically fix everything? Do a cath! Give him a stent! Cardiology is so slam bam thank you ma'am, isn't it? Heck, he's got an ICD! He's the bionic man!

Cardiology is easy until it isn't.

No doubt Mr. Cheney has had impecable cardiovacular care. But despite that care, after three bypasses, a history of atrial fibrillation, deep venous thrombosis, a cardiomyopathy that requires a defibrillator or two, and scores of medications to stabilize the angina - you've suddenly got a tough case. One thing's for sure, a re-do bypass is pretty much out of the question (he probably has limited vascular conduits left to borrow).

For the treating cardiologists hoping for an obvious target to angioplasty, I wouldn't be surprised the "target" vessel will not be so obvious to determine after his angiogram today. Look for a nuclear scan tomorrow to figure which wall of his heart is affected (yes, Congress, he'll get one of those all-too-often ordered i-m-a-g-i-n-g studies!). Then look for either a risky angioplasty atempt to improve his symptoms or a (more appropriate) "tuning" of his medication regimen that will take time.

Bill vs. Dick: it's not about Democrats vs. Republicans. Rather, it's about the multifasceted care required of the same disease in two different patients that demonstrates nicely how health care for the individual will never be adequately managed through cookbook means.

-Wes

Photo Gallery: The Heart

Click image to enlarge

The above is a retouched photograph of an 82 year old patient's chest x-ray with a pacemaker and pneumonia that hails from the photo gallery from National Geographic.

You can download "wallpaper" sized images from their collection at the link above to adorn your computer monitor's background or the wall of your office or lab.

-Wes

The Sights and Sounds of Open Heart Surgery

Here's some nice footage of open heart bypass surgery.

(Warning: the heart contains blood.)

In medical school, I was always impressed that the sounds and smells of the operating room never accompanied pictures I'd see in text books. For the unititiated, these can take one by surprise. Although the smell of electrocautery cannot be captured in this video, the sound of the bone saw as it cuts through the sternum is recorded... loudly.

-Wes

How to Pay for Your $350,000 Bypass Operation

... just screw your fellow man:

Authorities say John Parsons, 57, of Oak Park stole the identity of a mentally disabled friend to pay for heart bypass surgery at Northwestern Memorial Hospital in Chicago in 2007. Parsons allegedly racked up about $350,000 in medical expenses billed to the friend's Medicaid account.

This behavior might help you with the ultimate governmental double-dip: (1) as you tap the government for your health bill and (2) for housing in the slammer after you're caught. But hey, since they can't take back the bypasses, at least you'll be chest pain free!

Sick, just sick.

-Wes

PS: Judith Graham has a nice piece on what to do if you suspect medical identity theft in her blog, Triage.

Bioengineered Blood Vessels

The New York Times reports on a correspondence published today in the New England Journal of Medicine which describes the development of bioengineered blood vessels made from a patient's own skin cells.

This might have huge implications for patients with severe peripheral vascular disease or those with poor vein harvesting sites for coronary bypass surgery.

Very cool.

-Wes

Image credit: The New York Times.

So You Want to Keep Being a Millionaire?...

Regis wisely decides to have his bypass.

-Wes

Video Slideshow of Heart Bypass Surgery

A fairly well-done (but perhaps graphic for some) video slideshow of coronary bypass surgery was reported by the New York Times and demonstrates some aspects of "beating heart" bypass including the harvesting of the left internal mammary artery and use of Guidant's (now Boston Scientific's) Acrobat Mechanical Off-Pump System that is used to lift and stabilize the heart for sewing of the grafts.

-Wes

Combined Carotid and Coronary Bypass - Safe?

"Dad needs a bypass."

"Are you kidding?"

"No, really, all of the major blood vessels to his heart are critically blocked and the doctors think it's best to proceed with bypass soon."

"So what's the hang up?"

"It seems they found he has a 95% narrowing of his carotid artery on the right, too. They're worried he might have a stroke if the put him of the heart bypass machine."

There aren't too many more complicated issues for recommending a patient with severe coronary disease for bypass when there's a critical narrowing of a carotid artery. It is incredibly harrowing to fight the battle of coronary artery revascularization, only to lose the war when a patient wakes with an expressive aphasia (inability to speak) or the ability to move one side of their body after suffering a major stroke during bypass. This is not minor issue.

So today's article in Neurology with gushing claims from the lay press tries to shed a bit of light on the issue, claiming a 40% increased risk of stroke exists if a carotid endarterectomy is performed in conjunction with a heart bypass procedure, rather than as separate procedures.

But caution must be exercised when interpreting these researchers' findings. There is a clue to the problems with this trial: why was such a "cardiovascularly-related" article found in the journal Neurology? Could it be that the data are suffering from a homonymous hemianopsia?

In evaluating this work, the reader and lay press would be well-advised to review the methodology of this study. It used retrospective chart review of computer-coded data, albeit in large numbers of charts, in an attempt to glean a flicker of data with which to draw a glimmer of a trend - NOT a conclusion. To attempt to make any sweeping treatment recommendations (e.g. there is a higher risk of stroke with combined bypass and endarterecy) without knowing the severity of carotid narrowing, or even if stroke victims had both carotid arteries narrowed as opposed to one, quickly demonstrates the flaws in such a retrospective analysis. Teasing out the validity of data requires "retrospective" analysis that can be subject to bias as well - many of which cannot be anticipated by the reviewer - like coding bias - wich may have been performed to improve reimbursement by the hospital. Another bias might be changes in operators or surgical technique that occurred over the time period studied. Can the authors prove this did NOT happen with their retrospective evaluation? Of course not.

But the most damning of the findings of the study were the admission of the investigators themselves:

"The limitations to the use of administrative data sets include both inaccuracies and inadequacies of available data. Diagnostic coding errors are common, though improving over time. We have tried to eliminate as many miscoded cases as possible by narrowing the data set."

Translation: "We know the data are poor and we fixed them a bit to clean them up and erased some data, but don't worry about that."

What can be said is that there were alot of computer-generated codes flying through a microprocessor and a statistics package that suggested a trend in increased risk might exist. To say much more with this study is meaningless.

A better source is the data from the 2004 ACC/AHA Guidelines for Coronary Artery Bypass Surgery:

Hemodynamically significant carotid stenoses are thought to be responsible for up to 30% of early postoperative strokes. The trend for coronary surgery to be performed in an increasingly elderly population and the increasing prevalence of carotid disease in this same group of patients underscore the importance of this issue. Perioperative stroke risk is thought to be <2% when carotid stenoses are <50%, 10% when stenoses are 50% to 80%, and 11% to 19% in patients with stenoses >80%. Patients with untreated, bilateral, high-grade stenoses and/or occlusions have a 20% chance of stroke. Carotid endarterectomy for patients with high-grade stenosis is generally done preceding or coincident with coronary bypass surgery and, with proper teamwork in high-volume centers, is associated with a low risk for both short- and long-term neurological sequelae. Carotid endarterectomy performed in this fashion carries a low mortality (3.5%) and reduces early postoperative stroke risk to <4%, with a concomitant 5-year freedom from stroke of 88% to 96%.

'nough said.

-Wes