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August 18, 2018

You have probably heard about EBM (Evidence Based Medicine), and those of you who are not doctors probably presume that a lot of what we do is based on Evidence.....

NOT SURE!  There is a lot more of the other EBM - Eminence Based Medicine, that gets used.

How do we as cardiothoracic surgeons deal with evidence? 

Lets take a simple example - use of multiple arterial grafts in Coronary Artery Bypass Graft (CABG) surgery. Bypass surgery started off as a method of providing an additional channel of blood from the aorta to the blocked coronary artery - obviously beyond the blockage in the artery. Interestingly, an early pioneer in the use of arterial bypasses using the Left Internal Mammary Artery (LIMA), Dr Kolessov showed success of this approach in the old Soviet Union - Leningrad (now St Petersburg), in the late 1960s. His work did not get much airplay or credence because it was from behind the Iron Curtain.  The Cleveland Clinic promoted the use of Saphenous Vein Grafts around the same t...

August 12, 2018

If one was given the choice between a small hole in the groin, compared to a great big crack down the middle of the chest, there is no contest. I remember the early descriptions of successes in percutaneous coronary artery intervention - with stents in the early 1990s: I was training in cardiothoracic surgery and my learned superiors dismissed the notion out of hand. The common refrain - "Can you imagine showing a metal spring or coil into an artery?" We all had come to appreciate the endothelium or lining of blood vessels, especially small ones - they were so prone to spasm and injury. Coronary artery surgery was this delicate balance of skillful suturing of bypass grafts onto coronary arteries beyond major blockages, care being taken not to injure, interfere with or incapacitate the underlying artery. After all, the aim was to provide a durable and robust alternative blood flow to the blocked artery. 

As expected, early successes of stenting coronary artery were plagued by re-stenosis...

August 11, 2018

The late Dr Louis Cohen was a delightful man, and an incredibly caring cardiologist with a passion for squash, who was very well known at the University of Chicago for his dedication to his patients.  A large, luxuriant and very prominent white beard graced his face. As a fortunate collaborator of his, I was the beneficiary of many entertaining stories and some interesting, high profile Chicago faculty members as patients. His refrain about the sternum - "every one of these white hair in my beard is a reminder of a sternal wound problem in one of my patients".  It was a gross exaggeration, but you get the idea. This wonderful access incision, the sternotomy has been plagued over the years with a bad reputation. Some of the negatives -

1. A big bone-breaking incision

2. Issues with pain and limitation afterwards

3. Problems with slow healing and wound infections.

4. Restrictions in terms of activity.

5. Sternal dehiscence and/or infections of the sternum & under...

August 8, 2018

Yes, why not? Every other bone that is broken in the body is internally fixed with plates and screws.  

I am sure the medical members of the audience will remember mention of flail chest or painful rib fractures. In the "old days", the standard treatment for both was conservative with some shaking of the head and trying to control the pain.

Both of these can be addressed very effectively with plating of the ribs. Dr Sylvana Marasco, from the Alfred Hospital, Melbourne is a very innovative surgeon who was a trainee when I first was in practice in Melbourne. She conducted a randomized study which showed the benefit of fixing multiple ribs in patients with flail chest. I have personal experience with this approach with excellent results, over the years.  Incidentally, this is still not standard of care, yet...

One could extend this practice to painful rib fractures also. This approach definitely saves the patients from  unnecessary opioid use and use of other painkillers.

What about when...

August 1, 2018

Lets continue...

The median or midline sternotomy was first studied and shown to be effective in goats in 1897. It was another 50 years before Dr Ormand Julian at Rush Presbyterian Medical Center popularized it. The sternotomy is the most commonly performed bone-breaking procedure or osteotomy in world today.  At that stage, bone was lashed together with heavy suture or twine - and the technique was called cerclage.

As I mentioned in the previous blog, wire closure is not effective in eliminating micro-movement and is associated with inadequate bony approximation on biomechanical studies.  Persistent movement between the bony fragments predisposes to delayed healing, inadequate healing, pain or infection. Some of these are intertwined. Sternal wound infections are a big deal - and a major cause of morbidity and mortality after heart surgery.  Frequently, the bony fragments of the sternum are involved in the infection. This may result in loss of bone and structural integrity of the c...

July 31, 2018

Lets start with the sternum. This dagger shaped breast bone is the most commonly fractured bone in the body - because of heart surgery. We as cardiac surgeons break and fix more bone than most other bone handling surgeons including orthopods.

The sternum is a cancellous bone which means it is thin and has a hollow interior with marrow in it. It is also spongy or trabecular bone. It is very porous and contains red bone marrow, where blood cells are made. It is weaker and easier to fracture than cortical bone, which makes up the shafts of long bones. Little wonder that this bone that we typically break in a controlled fashion as we enter the chest and then bring together at the end of the heart operation - is prone to complications in terms of healing, pain, infection, etc.

Historically, this has been closed with wire cerclage - getting the 2 halves of the sternum together and lashing them together with stainless steel wire. However, this may be not sound bio-mechanically because the...

May 21, 2017

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Jaishankar Raman, MBBS MMed, FRACS, PhD

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