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Posts Tagged ‘heart surgery’

Note:  I owe Dr. Vasquez a much more detailed article – which I am currently writing – but after our intellectually stimulating talk the other day, my mind headed off in it’s own direction..

Had a great sit down lunch and a fascinating talk with Dr. Vasquez.  As per usual – our discussion was lively, (a bit more lively than usual) which really got my gears turning.  Dr. Vasquez is a talented surgeon – but he could be even better with just a little ‘help’.  No – I am not trying to sell him a nurse practitioner – instead I am trying to sell Mexicali, and a comprehensive cardiac surgery program to the communities on both sides of the border..  Mexicali really could be the ‘land of opportunity’ for medical care – if motivated people and corporations got involved.

During lunch, Dr. Vasquez was explaining that there is no real ‘heart hospital’ or cardiac surgery program, per se in Mexicali – he just operates where ever his patients prefer.  In the past that has included Mexicali General, Issstecali (the public hospitals) as well as the tiny but more upscale private facilities such as Hospital Alamater, and Hospital de la Familia..

Not such a big deal if you are a plastic surgeon doing a nip/tuck here and there, or some outpatient procedures – okay even for general surgeons – hernia repairs and such – but less than ideal for a cardiac surgeon – who is less of a ‘lone wolf’ due to the nature and scale of cardiac surgery procedures..

Cardiac surgery differs from other specialties in its reliance on a cohesive, well-trained and experienced group – not one surgeon – but a whole team of people to look out for the patients; Before, During & After surgery..  That team approach [which includes perfusionists, cardiac anesthesiologists (more specialized than regular anesthesia), operating room personnel, cardiology interventionalists and specialty training cardiac surgery intensive care nurses]  is not easily transported from facility to facility.

just a couple members of the cardiac surgery team

That’s just the people involved; it doesn’t even touch on all the specialty equipment; such as the bypass pump itself, echocardiogram equipment, Impella/ IABP (intra-aortic balloon pump), ECMO or other equipment for the critically ill – or even just the infrastructure needed to support a heart team – like a pharmacy division that knows that ‘right now’ in the cardiac OR means five minutes ago, or a blood bank with an adequate stock of platelets, FFP and a wide range of other blood products..

We haven’t even gotten into such things such as a hydrid operating rooms and 24/7 caths labs – all the things you need for urgent/ emergent cases, endovascular interventions – things a city the size of Mexicali should really have..

But all of those things take money – and commitment, and I’m just not sure that the city of Mexicali is ready to commit to supporting Dr. Vasquez (and the 20 – something cases he’s done this year..) It also takes vision..

This is where a company/ corporation could come in and really change things – not just for Dr. Vasquez – and Mexicali – but for California..

It came to me again while I was in the operating room with Dr. Vasquez – watching him do what he does best – which is sometimes when I do what I do best.. (I have some of my best ideas in the operating room – where I tend to be a bit quieter.. More thinking, less talking)..

Dr. Vasquez, doing what he does best..

As I am watching Dr. Vasquez – I starting thinking about all the different cardiac surgery programs I’ve been to: visited, worked in – trained in.. About half of these programs were small – several were tiny, single surgeon programs a lot like his.. (You only need one great surgeon.. It’s all the other niceties that make or break a program..)

All of the American programs had the advantages of all the equipment / specialty trained staff that money could buy***

[I know what you are thinking – “well – but isn’t it all of these ‘niceties’ that make everything cost so darn much?”  No – actually it’s not – which is how the Cardioinfantils, and Santa Fe de Bogotas can still make a profit offering world-class services at Colombian prices…]

The cost of American programs are inflated due to the cost of defensive medicine practices (and lawyers), and the costs of medications/ equipment in the United States****

the possibilities are endless – when I spend quality time in the operating room (thinking!)

Well – there is plenty of money in Calexico, California** and not a hospital in sight – just a one room ‘urgent care center’.  The closest facility is in El Centro, California – and while it boasts a daVinci robot, and a (part-time?) heart surgeon (based out of La Mesa, California – 100 + miles away)– patients usually end up being transferred to San Diego for surgery.

Of course, in addition to all of the distance – there is also all of the expense..  So what’s a hard-working, blue-collar guy from Calexico with severe CAD going to do?  It seems the easiest and most logical thing – would be to walk/ drive/ head across the street to Mexicali.. (If only Kaiser Permanente or Blue Cross California would step up and spearhead this project – we could have the best of both worlds – for residents of both cities.. 

 A fully staffed, well-funded, well-designed, cohesive heart program in ONE medium- sized Mexicali facility – without the exorbitant costs of an American program (from defensive medicine practices, and outlandish American salaries.)  Not only that – but as a side benefit, there are NO drug shortages here..

How many ‘cross-border’ cases would it take to bring a profit to the investors?  I don’t know – but I’m sure once word got out – people would come from all over Southern California and Arizona – as well as Mexicali, other parts of Baja, and even places in Sonora like San Luis – which is closer to Mexicali than Hermasillo..  Then Dr. Vasquez could continue to do what he does so well – operate – but on a larger scale, without worrying about resources, or having to bring a suitcase full of equipment to the OR.

The Mexican – American International Cardiac Health Initiative?

But then – this article isn’t really about the ‘Mexican- American cross-border cardiac health initiative’

It is about a young, kind cardiac surgeon – with a vision of his own.

That vision brought Dr. Vasquez from his home in Guadalajara (the second largest city in Mexico) to one of my favorite places, Mexicali after graduating from the Universidad Autonomica in Guadalajara, and completing much of his training in Mexico (D.F.).  After finishing his training – Dr. Vasquez was more than ready to take on the world – and Mexicali as it’s first full-time cardiac surgeon.

Mexicali’s finest: Dr. Vasquez, (cardiac surgeon) Dr. Campa(anesthesia) and Dr. Ochoa (thoracic surgeon

Since arriving here almost two years ago – that’s exactly what he’s done.. Little by little, and case by case – he has begun building his practice; doing a wide range of cardiovascular procedures including coronary bypass surgery (CABG), valve replacement procedures, repair of the great vessels (aneurysm/ dissections), congenital repairs, and pulmonary thrombolectomies..

Dr. Vasquez, Mexicali’s cardiac surgeon

Dr. Cuauhtemoc Vasquez Jimenez, MD

Cardiac Surgeon

Calle B No. 248 entre Obregon y Reforma

Col. Centro, Mexicali, B. C.

Email: drcvasquez@hotmail.com

Tele: (686) 553 – 4714 (appointments)

Notes:

*The Imperial Valley paper reports that Calexico makes 3 million dollars a day off of Mexicali residents who cross the border to shop.

***In all the programs I visited  – there are a couple of things that we (in the United States do well..  Heart surgery is one of those things..)

**** Yes – they charge us more in Calexico for the same exact equipment made in India and sold everywhere else in the world..

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As readers know, I recently gave a CME presentation on The Syntax Trial   and discussed the new Revascularization guidelines that were released last month.  I’ve posted the slides for anyone who wants to use them.  (It would be nice if you mentioned where you got them – but feel free to use them.)

Now – new criticisms of these revised guidelines are already emerging.  But before tackling these new criticisms, we should review the old controversies surrounding the previous guidelines.

In a interesting article (by one of my favorite summarists) Reed Miller over at The Heart.org reviews the issues behind the old (2009) guidelines..  It’s a good article that talks about many of the issues behind the 2012 revisions. I’ve re-posted the article below.

PCI appropriateness criteria draw criticism

(originally posted February 8th, 2012 at the Heart.org)

Kansas City, MO – The interminable controversy about appropriate use and overuse of PCI is being stirred up again [1].

Dr Steven P Marso (St Luke’s Mid-America Heart Institute, Kansas City, MO) and five other cardiologists have published a paper online February 8, 2012 in the Journal of the American College of Cardiology: Cardiovascular Interventions criticizing both the 2009 coronary revascularization appropriate-use criteria (AUC) and how those criteria have been applied to the study of contemporary practice patterns.

As reported by heartwire, the AUC were created by a technical committee representing six professional societies. Last summer, Marso’s colleague in Kansas City, Dr Paul Chan (St Luke’s Mid-America Heart Institute), led a study of PCI cases in the National Cardiovascular Data Registry (NCDR) that showed that only 50.4% of nonacute cases in the registry during the yearlong study period would be classified as appropriate under the AUC and that 11.6% of nonacute cases were classified as inappropriate.

“We are duty bound to evaluate appropriate use of PCI and other medical procedures,” Marso told heartwire. “The problem is that we are no closer to being able to identify overuse based upon these appropriate-use criteria than before they were created. The reason is that there are too many assumptions and too much variability that go into that 11.6% inappropriate rate.”

For example, Marso et al argue that the AUC put too much emphasis on stress testing without precise definitions to guide the interpretation of those tests. “The vast majority of AUC scenarios require knowledge of preprocedural stress-test findings . . . [but] the NCDR does not require interpreting physicians to determine this risk. Therefore, this data-collection burden falls onto the data abstractors, who are required to assign a risk category based on vague guidelines,” they say. “Essentially, they are required to interpret the interpretation.”

Chan told heartwire that the appropriateness criteria were never intended to be perfect, but they are the best effort to sort out which procedures are supported by evidence and which are not. They will evolve over several iterations, including the recent update, which provides more detail on patients with unstable angina. However, Chan does not expect any major changes from the 2009 version to be made soon.

Chan also pointed out that the purpose of the AUCs is to explain the existing evidence base, not pass judgment on each procedure, so nobody should interpret “inappropriate” in the AUCs to mean “fraudulent.”

“Ultimately, my main concern is that we don’t lose sight of the forest for the trees. Our profession of cardiology has taken an amazing leadership role in defining quality and appropriateness of care—in a way that no subspecialty has done to date. In so doing, we have moved the quality yardstick forward,” Chan said. “[But] we need to be humble as physicians to recognize that sometimes we may actually be doing procedures that have little evidence to support their use . . . and that not only are we not providing benefit but perhaps subjecting patients to unnecessary procedure risks and costs.”

Who decides which side is “right” and which side is “wrong?”

Marso et al are especially concerned with the AUC’s treatment of patients with one- or two-vessel disease, no proximal left anterior descending artery involvement or prior coronary artery bypass graft, class I or II symptoms, low-risk noninvasive findings, and on no or minimal medications. The AUC state that PCI in this scenario, labeled scenario 12b, is “inappropriate.” This scenario accounted for nearly 40% of the inappropriate nonacute procedures categorized by Chan et al as inappropriate, making it the most common type of procedure in this category.

Prior to the release of the 2009 AUCs, Chan et al surveyed 85 cardiologists—including 44 interventionalists and 41 noninterventional cardiologists—on the appropriateness of 68 coronary revascularization indications also addressed by the AUCs. That group classified scenario 12b as “uncertain.” Instead of assuming that the cardiologists in the survey need to be educated about the appropriateness of this procedure, Marso et al suggest it’s the technical panel that could learn something from the cardiologists in the survey. “These are 80 clinical cardiologists who answered questions about what they thought was appropriate, driven by medical decision-making, and they concluded that the technical panel just plain got it wrong,” Marso told heartwire.

In response to this specific point, Chan told heartwire, “The decision of the AUC technical panel to make this scenario inappropriate was based on the lack of available clinical evidence to support PCI in patients who have only mild to moderate symptoms with intermediate stress tests without a trial of medical therapy. This is, indeed, consistent with the COURAGE trial, wherein medical therapy was found to be comparable to PCI for patients with even greater symptoms and more severe ischemia.

“Although the COURAGE quality-of-life substudy did find that patients who underwent PCI, compared with medical therapy, had modestly improved angina relief during the first year, this benefit was likely concentrated in those COURAGE patients who had far greater symptoms than [Canadian Cardiovascular Society (CCS)] class I or II—eg, CCS class II or IV,” Chan said. “Dr Marso’s assertion that this indication should be uncertain, however, is not supported by any evidence to date.”

Who decides who gets to decide?

Marso et al also object to the composition of the technical panel, which included only four interventionalists out of 16 total members. The panel was put together according to the so-called Rand method to prevent conflicts of interest. Marso objects to the technical panel’s insinuation that “interventional cardiologists are inherently biased due a financial bias or an intellectual bias, that their ideas are preconceived, and that they are unwilling to evaluate data in an objective manner.” He points out that the FDA, which certainly has a vested interest in rooting out both financial and intellectual bias from its advisory panels, does not limit whole categories of experts from serving on these panels. Instead, it evaluates the background and potential conflicts of interest of each individual.

Dr John Spertus, the director of outcomes research at Saint Luke’s Mid America Heart Institute and senior author of the AUC writing group, does not agree that the AUC technical committee needs more interventionalists. “The benefits of revascularization should be very transparent. Clinicians caring for patients should all be on the same page with the same perspectives of revascularization of patients. That isn’t information that is uniquely known to the interventional community,” he said. “While they have extensive expertise and knowledge around the technical aspects of doing the procedure, whether it should be done or not is something that all clinicians caring for patients with coronary disease should know, appreciate, and be able to communicate to their patients.”

The missing voice: The patient

In an accompanying editorial [2], Dr James Blankenship (Geisinger Medical Center, Danville, PA) argues that the AUC “will never fully define the best treatment decision for a particular patient . . . because occasionally, patients will have exceptional circumstances that dictate treatment different from that recommended by AUC and guidelines; and different patients experience a given level of symptoms differently.

“Determinations of appropriateness by the AUC based on angina class fail to take patients’ perceptions and preferences into account. This is a fundamental flaw, because patients’ perceptions and preferences are a critical component of decision making,” Blankenship argues. However, he acknowledges that “factoring in patient preferences raises a host of new problems. Patients’ preferences are routinely based on incorrect perceptions and nonobjective factors; [they] routinely overestimate the benefits of PCI, underestimate its risks, and underestimate the efficacy of medical therapy [and] tend to discount the sometimes-superior benefits of one treatment (eg, CABG for very complex triple-vessel disease), because those benefits accrue later, and instead prefer the more immediate but lesser benefits of another treatment (eg, PCI) because they accrue sooner (temporal discounting).”

More data on the way

Chan said that a prospective study of 7000 to 8000 patients measuring the change in quality of life from baseline to six months among patients who have undergone PCI will soon be complete. Results of this study, intended to validate the ratings of the AUC, will probably be available this summer, he said.

“We anticipate that we will find that patients with inappropriate AUC ratings will have little to no improvement in quality of life at six months, appropriate AUC ratings will have substantial improvements in quality of life, and uncertain AUC ratings will have modest improvements in quality of life,” Chan said. “Once we have these results, we will be able to say with confidence whether indications such as 12b should be kept as inappropriate or changed to uncertain.”

Spertus said that the AUC will be updated when there are methodological or technical deficiencies in the current approach or if important new evidence on PCI is published. One of the goals of the AUC is to identify gaps in the scientific knowledge that need further study.

Marso reports no personal conflicts of interest during the previous 24 months.

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Below is a re-post from Heartwire.com on the use of multi-vessel PCI (stenting) for patients presenting with an acute myocardial infarction (heart attack).  As you can see for the headlines – two research studies suggest “Don’t do it.”  The studies suggest that only the culprit (or vessel causing chest pain/ heart attack) should be treated during the event.  Of course, these studies ignore the other, BIGGER question of whether we should be doing multi-vessel PCI (staged or not) AT ALL.  There is quite a bit of research (presented in other posts) to suggest that the strategy should be stenting the culprit vessel (to treat the immediate ischemia) followed by surgery, not more stents.  But since interventional cardiologists were conducting the study, not surgeons – this isn’t addressed at all.

Of course, I am speaking from my own position as someone who has worked in both cardiology and cardiothoracic surgery – which carries it’s own bias.  But, I do know the long-term data, which clearly favors surgery for multi-vessel disease.

Multivessel PCI during STEMI associated with higher short- and long-

term mortality

August 5, 2011            |            Michael O’Riordan

Groningen, the Netherlands and Tel Aviv, Israel – Two new studies published this week confirm clinical recommendations that a deferred angioplasty strategy of nonculprit lesions should remain the standard interventional approach in patients with ST-segment elevation MI (STEMI) undergoing primary PCI [1,2].

In the first study, an analysis of the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS AMI) study, investigators, led by Dr Ron Kornowski (Tel Aviv University, Israel), observed significantly higher one-year mortality and stent-thrombosis rates among patients undergoing multivessel PCI compared with individuals undergoing staged PCI.

In the second study, a meta-analysis that included 18 studies and more than 40 000 patients, the investigators report that multivessel PCI was associated with the highest rates of death in short- and long-term follow-up when compared with culprit-lesion PCI and staged PCI.

Dr Pieter Vlaar (University Medical Center, Groningen, the Netherlands), the lead researcher of the meta-analysis, told heartwire that the results support current guidelines discouraging multivessel primary PCI for STEMI patients. That said, the guidelines are not based on large randomized controlled clinical trials, and this had led to some confusion and variability across different centers. Even at their institution, Vlaar said clinicians differ in their opinions about whether nonculprit lesions should be treated during the initial intervention. However, these new data suggest that when significant nonculprit lesions are suitable for PCI, “they should be treated only during staged interventions.”

Both studies, as well as an accompanying editorial [3], are published in the August 9, 2011 issue of the Journal of the American College of Cardiology.

HORIZONS-AMI and the meta-analysisIn the meta-analysis, Vlaar and colleagues included data from four prospective and 14 retrospective studies involving 40 280 patients with multivessel disease undergoing primary PCI for STEMI. Three treatment strategies were compared:

  • PCI of the culprit vessel only.
  • Multivessel PCI, defined as PCI of the culprit vessel as well as one or more nonculprit vessel lesions.
  • Staged PCI, defined as PCI confined to the culprit vessel only, with one or more nonculprit lesions treated in staged interventions.

Compared with the staged-PCI strategy, PCI of the culprit lesion only and multivessel PCI were associated with a significant three- and fivefold increased risk of in-hospital/30-day mortality, respectively. In addition, 30-day mortality was significantly lower in patients treated with culprit PCI compared with multivessel PCI (odds ratio 0.66; 95% CI 0.48-0.89). Regarding long-term mortality, multivessel PCI was associated with a 60% increased risk of long-term mortality compared with culprit PCI, as well as a significantly greater risk compared with staged PCI.

In the HORIZONS-AMI study, the investigators compared primary PCI of the culprit and nonculprit lesions with patients who underwent PCI of the culprit lesions only and those who underwent staged PCI of the nonculprit lesion at a later date. Of the 3602 patients enrolled in the trial, 668 underwent PCI of the culprit and nonculprit lesions for multivessel disease, of whom 275 underwent a single PCI strategy and 393 underwent staged PCI.

At one year, patients who underwent single PCI had a mortality rate of 9.2% compared with 2.3% in patients who underwent staged PCI. In addition, single PCI was associated with significantly higher rates of cardiac mortality compared with staged PCI (6.2% vs 2.0%, respectively) and higher rates of definite/probable stent thrombosis (5.7% vs 2.3%, respectively).

In their paper, Kornowski and colleagues, including senior investigator Dr Gregg Stone (Columbia University, New York), state that a “deferred angioplasty strategy of nonculprit lesions should remain the standard approach in patients with STEMI undergoing primary PCI, as multivessel PCI may be associated with a greater hazard of mortality and stent thrombosis.”

Some unanswered questionsCommenting on the findings for heartwire, Dr David Kandzari (Piedmont Heart Institute, Atlanta, GA) said, “Both papers provide welcome information to clinicians,” especially since there are few randomized trials to provide sufficient information to guide treatment decisions. Most of the clinical recommendations are based on some clinical evidence, including cohort and retrospective studies, but they are largely the opinion of interventional experts.

In the US, the American College of Cardiology/American Heart Association guidelines state definitively that PCI “should not be performed in a noninfarct artery at the time of primary PCI in patients without hemodynamic compromise.” The class-III (harm)/level-of-evidence B recommendation differs slightly from the European Society of Cardiology/European Association for Cardiothoracic Surgery guidelines, which are slightly more lenient. The European guidelines state that with the exception of cardiogenic shock, PCI for STEMI should be limited to the culprit lesion (class IIa, level of evidence B).

To heartwire, Kandzari explained that treating other lesions in patients with cardiogenic shock remains a “bit of a gray area” in the US. Although the guidelines explicitly state not to perform PCI of the nonculprit lesions, some clinicians will treat other stenoses in cardiogenic-shock patients in an attempt to provide as much flow as possible. That said, there is a discrepancy between the number of clinicians performing multivessel PCI and rates of cardiogenic shock. Dr John Bittl (Ocala Heart Institute, FL), who wrote an editorial accompanying the published studies, observed a similar discrepancy. For example, in HORIZONS-AMI, 18.5% of patients underwent multivessel PCI, but only 1.5% had cardiogenic shock. In the New York State registry, 12.5% of patients were treated with multivessel PCI, but only 4.4% met the definition of hemodynamic compromise.

Kandzari said he would like to know the reasons that the clinicians performed multivessel PCI in these STEMI patients, noting that in some instances it is difficult to determine what the culprit lesion is in acute MI. Some centers might not perform left and right coronary angiography before revascularizing the patient, and without assessment of the entire coronary anatomy, it is possible, although rare, to treat the wrong lesion. Some patients might not show any improvement following culprit PCI and as a result will undergo treatment of other lesions, he said.

In his editorial, Bittl made similar statements, noting that “no single approach is applicable to the myriad presentations of STEMI.” He also noted that multivessel PCI might be necessary in the cases where patients do not show improvement following primary PCI of the culprit lesion. He added that patients with severe multivessel disease might require follow-up angiography and that fractional flow reserve (FFR) can be considered during the acute phase, but the “results should be used whenever possible to support a decision for staged PCI.”

To heartwire, Vlaar said the benefit of staging patients is that angiograms can be discussed with a joint heart team and additional noninvasive ischemia tests and FFR can be performed before deciding to perform additional revascularizations.

Kandzari told heartwire that there still remain some questions regarding staged PCI in STEMI patients. For example, Kandzari said the optimal time for the second PCI is unknown. In the US, revascularization is driven by reimbursement issues, with physicians not compensated for staged PCI performed within 30 days of PCI for acute MI, so most clinicians are reluctant to treat other vessels even when the patient is in the hospital.

“Financial issues aside, we still don’t know if it’s better to treat the nonculprit lesions when the patient is still in the hospital, two weeks after the primary PCI, or four weeks after primary PCI,” said Kandzari.

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A new article was recently published on medical tourism and heart surgery in Cali, Colombia.  Of course, this article is promoting a book (alas! not mine) on medical tourism too but I thought readers might find it interesting..

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The newest study (meta-analysis) on the use of clopidogrel for ACS (acute coronary syndrome) gives dramatically different results that previously published studies, and years of clinical experience.  This study, (abstract lifted from cardiosource and re-posted below) attributes adverse events and increased mortality in the patients receiving clopidogrel to underlying cardiac status.  In this patient population – that could certainly be true.

However, when a meta-analysis comes up with results that our dramatically different from the previous studies it’s using for its composite – then it’s time to take a closer look at the data they used to compile their conclusions..

Without further access to the rest of the study (abstract published ahead of article publication), we will just have to wait..

But in the meantime, I’d still recommend judicious/ cautious clopidogrel use prior to the operating room.  Ten years of clinical reports and multiple studies showing increased bleeding/ bleeding complications/ MACE can’t be undone by one statistical analysis.. (At least until methodology is examined.)

Also the phrasing of the study is pretty precarious – I’ve italicized some of the results – where the authors skirt around the results to try and prove the hypothesis that they want.. Re-operation is increased in patients receiving clopidogrel BUT.. it’s increased in all patients receiving clopidogrel, not just ACS patients..  [That’s kind of a thready conclusion, in my humble opinion..]

Readers, what do you think?

Abstract:  Safety of Clopidogrel Being Continued Until the Time of Coronary Artery Bypass Grafting in Patients With Acute Coronary Syndrome: A Meta-Analysis of 34 Studies

        Authors:   Nijjer SS, Watson G, Athanasiou T, Malik IS

        Citation:

        Safety of Clopidogrel Being Continued Until the Time of Coronary Artery Bypass Grafting in Patients With Acute Coronary Syndrome: A Meta-Analysis of 34 Studies
        June 2, 2011
        Nijjer SS, Watson G, Athanasiou T, Malik IS.
Eur Heart J 2011;May 24:[Epub ahead of print].
 
Study Question:
      What is the risk of mortality, reoperation, perioperative myocardial infarction (MI), and stroke in the acute coronary syndrome (ACS) population undergoing coronary artery bypass grafting (CABG) while on clopidogrel?

        Methods:

Thirty-four studies with 22,584 patients undergoing CABG were assessed. Patients with recent clopidogrel exposure (CL) were compared with those without recent clopidogrel (NC). Uni- and multivariate meta-regression was performed for the main outcomes of mortality, reoperation, postoperative MI, and stroke using the logarithm of the odds ratio (OR) as the dependent variable. Interaction analysis was performed creating interaction terms between the variable ACS status and the following variables: year of study, the use of on-pump surgery, patient urgency status, and use of concomitant antiplatelet agents, including aspirin and glycoprotein IIb/IIIa antagonists.

        Results:

Although mortality is increased in CL versus NC (OR, 1.6; 95% confidence interval [CI], 1.30-1.96; p < 0.00001), it is influenced by the ACS status and case urgency in these mainly nonrandomized studies. In ACS patients, there is no significant difference in mortality (OR, 1.44; 95% CI, 0.97-2.1; p = 0.07) or in postoperative MI (OR, 0.57; 95% CI, 0.31-1.07; p = 0.08) and stroke rates (OR, 1.23; 95% CI, 0.66-2.29; p = 0.52). Combined major adverse cardiovascular events (MACE) (stroke, MI, and death) were not different in the two groups (OR, 1.10; 95% CI, 0.87-1.41; p = 0.43). Reoperation rates are elevated on clopidogrelbut have reduced over time, and were specifically not different in ACS patients (OR, 1.5; 95% CI, 0.88-2.54; p = 0.13).

        Conclusions:

The authors concluded that ACS patients requiring urgent CABG proceed with surgery without delay for a clopidogrel-free period.

        Perspective:

This meta-analysis suggests that continuing dual antiplatelet therapy until the day of CABG reduces the risk of recurrent ischemic events in ACS patients and reduces MI postoperatively. While mortality and reoperation rates are increased after recent clopidogrel exposure, event rates were still low and overall MACE rates did not appear to be significantly increased in the clopidogrel group. These data demonstrate the need for a randomized clinical trial assessing different discontinuation times prior to CABG to definitively answer the question. Meanwhile, the evidence appears to suggest that many ACS patients can undergo CABG safely with recent clopidogrel exposure in expert hands.

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As a former resident of Canada, and well as someone with several family members living in Canada – I would like to welcome my Canadian readers to the site. Since publishing my first book on medical tourism, I was told by multiple people, “Canadians will never be interested,” but as someone familiar with the Canadian healthcare system, I knew this not to be true.

There is a huge amount of national pride and Canadian identity tied up in their healthcare system – but this pride fails to address many of the problems endemic to the system itself.  All health care systems have problems, everywhere. It’s the nature of trying to address the needs of a growing, dynamic entity like a population of nation – a population that in many countries is sicker, and older with more chronic diseases than ever before.  It is inevitable that there will be shortfalls in some areas, and nothing for citizens to be ashamed of.

The most important thing is for the people to have access to care, where ever that care comes from, in a timely fashion.   For many years, it meant that Canadians slipped across the border to the United States for heart surgery, cancer treatments or other medical problems of a more urgent nature. But now, the USA’s health care system is spiralling out of control – making it imperitive that Canadians find another destination for those times when they just can’t (or don’t want to) wait.

In many cases, patients (from the USA) can go to Colombia, or other countries for medical tourism using their current insurance.  I’d like for my Canadian readers, insurance writers and medical tourism professionals now to chime in and let me know how it works for my friends to the North.

If insurance doesn’t currently pay for medical tourism – then push!! the insurance companies to do so. (It’s in their best interest for cost savings – so you might be surprised to hear what they have to say.) Insurance companies here in the USA were some of the earliest adoptors of medical tourism, first thru targeted pilot programs – and now with whole divisions set up to help patients go abroad for care.

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Dr. Francisco Holguin, and his charming wife, Ximena Reyes

Spent a charming afternoon with Dr. Francisco Holguin Rueda and his wife, Ximena Reyes (RN) on a sunny afternoon here in Bogota.   Now that I had a chance to sit down with Dr. Holguin, we talked about Medical City, what it was, and what he expected it to bring to the Cartagena area.  We are planning another sit down later next week – to talk more in-depth, so I can bring it to all of your here.

Medical City is Dr. Holguin’s latest creation – to bring large-scale, centralized medical care to Cartagena that is designed to attract, and serve the needs of medical tourists from around the globe.  Cartagena’s convenient and strategic location makes it an ideal destination for medical tourists from North , Central and South America, and well as the entire Caribbean.. By creating a medical center, just outside Cartagena (10 km) from the airport, in an upscale neighborhood, that is already home to many Americans and other ex-pats – patients can receive a wide range of medical and surgical services all in one place, without having to navigate Cartagena city traffic, or transverse the city from one specialist to another.

All the major surgical specialties will be represented with specialized centers; cardiac surgery, orthopedic surgery, plastic surgery, and of course, Dr. Holguin’s specialty, Bariatric surgery.  I am looking forward to our next meeting, so I can bring you more information.  Check back next week.

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