Surgical Consultation No. 1

[skeptic49]

On Monday, January 5, I met with a cardio-thoracic surgeon at Penn Presbyterian Hospital, a branch of the Penn Medicine health care system in Philadelphia. Unfortunately, my husband and I were forced to wait over two hours past our appointment time before we finally got a chance to talk to the doctor himself. While the consultation was valuable in terms of adding to the information we need to make decisions about my surgery, we both felt that this particular surgeon would not be the best choice for me, and we were disappointed in the way we were treated at the facility. Unlike my meeting with another surgeon back in 2009 at a different branch of Penn Medicine, this doctor was at least personable, honest and sincere. He was also willing to listen to our concerns are to try to accommodate my wishes in terms of how I view the procedure I need. In particular, while he initially indicated that his conservative approach would be to not address my 4.6 cm aortic aneurysm at the time of AVR, he agreed to replace it after I indicated that I wanted it addressed. At first he told me "I don't think it will give you any problems." Perhaps not, but who wants to have open heart surgery and not see the surgeon correct an aneurysm that could potentially dissect in the future or require another operation? This captures the difference between the approach of this surgeon and the approach that I need. I don't want a conservative approach. I want a surgeon with a proactive approach willing to fix as much as possible as long as he is in there. So Wednesday we meet with another surgeon at a different facility. Hopefully, the experience will be better and the surgeon will prove to be more in line with my needs and expectations.

 

[epstns]

I know what you mean. I was lucky enough to find two surgeons at two area medical centers who shared my view of my treatment plan. I'm sure, though, that in a major metro area like Philadelphia, you will be able to find a surgeon who meets your needs as well as your desires.

Hang in there.

 

[cldlhd]

I waited over 4 hrs to meet with my surgeon at Penn but apparently there was an emergency surgery so there was a valid reason. My measurements are 4.8 for the root and 4.7cm for the ascending and the surgeon wants to replace both with a graft. Its my only cause for surgery as the valve has np stenosis and only minor leakage.

 

[river-wear]

Wow, sorry to hear that Jim. I'm pretty amazed that every surgeon wouldn't address the aneurysm along with the AVR. That seems a little crazy; 4.6cm is above the normal range. I hope your next consultation is a better fit for you.

 

[Bushman]

I had a similar experience at my 1st consultation with the surgeon who was supposed to do my surgery. I had a bad vibe from him and didn't like the way he approached my situation. I subsequently spoke with the chief of surgery and he agreed that there were a few strange comments and answers from this particular surgeon and had no issues sending my file to a different surgeon(2 surgeons in fact). I am having another set of tests done Jan 12th and another consult Jan 21st.

If something doesn't feel right or you get a bad vibe or the experience isn't acceptable, don't settle for the 1st doctor they assign to you. I think it is easier to have a second opinion that a second surgery.

Best of luck to you

 

[skeptic49]

The procedure I need and want is on YouTube...of course, it's Dr. Roselli at the Cleveland Clinic, but you would think that somebody in a big hospital town like Philadelphia would be up to speed on this.

 

[cldlhd]

I skimmed thru the video as I'm not sure I want to see too much of it this close to my surgery. Is the main difference the mini sternotomy compared to the full?

 

[river-wear]

How many surgeons in Philadelphia did you talk to? I think we're all familiar with the idea that each surgeon has their own preferred way of doing things. I'm sure some of them take the mini approach.

Press on until you find someone you trust, but I don't understand why the size of the incision is your first order of concern.

 

[Paleowoman]

Just bear in mind that mini doesn't always end up as mini - what about my incision which was minimally invasive sternotomy, it's more than three quarters the length of my sternum, no idea why the surgeon had to do it so long, but once they get in there things don't always go the text book way.

 

[cldlhd]

I googled the difference between a mini or full sternotomy and read a NCBI study that said many planned mini sternotomies end up being full and end up having more pump time than a planned full. I tried uploading it here but either my skills are lacking or there's something wrong with the site.

 

[cldlhd]

[No message]

 

[pellicle]

Minimally Invasive Aortic Valve Replacement

that worked for me, but for those who it didn't here are some salient points

although 14 of the 98 mini-sternotomies had to be converted to complete sternotomies intraoperatively due to technical problems. Such conversion doubled the operative time over that of the planned full sternotomies. In the group of patients whose operations were completed as mini-sternotomies, 4 died later of noncardiac causes. The aortic cross-clamp and perfusion times were significantly different across all groups (P < 0.001), with the intended full-sternotomy group having the shortest times.

In conclusion, the mini-aortic valve replacement is an excellent operation in selected patients, but its true advantages over conventional aortic valve replacement (other than a smaller scar) await evaluation by means of randomized clinical trial. The “extended mini-aortic valve replacement” operation, on the other hand, is a risky procedure that should be avoided by better preoperative evaluation of patients. In any event, the decision to extend a mini-sternotomy to a full sternotomy should be made early in the course of operation, before cardiopulmonary bypass is instituted.

the 4 died later from non cardiac causes indicates to me that the intended group are the frail ones.

 

[cldlhd]

that worked for me, but for those who it didn't here are some salient points



the 4 died later from non cardiac causes indicates to me that the intended group are the frail ones.

That makes sense but how later is later? I didn't do a thorough job reading the whole study as I was eating dinner and trying to watch Jeopardy but from what I gather the main advantage was considered cosmetic. I'll go over it again but I think for myself I'd rather the surgeon have full access.

 

[pellicle]

Hi

That makes sense but how later is later?

didn't see that mentioned ... or what the causes of deaths were ...

..but I think for myself I'd rather the surgeon have full access.

yeah, as previously discussed, when I do major surgery on my bike I prefer to pull all the farings off rather than try to screw around jamming my hand in here and my other hand in there and then get someone else to turn that ratchet .... just involves less swearing.

 

[AZ Don]

Looks like Penn Presbyterian is the top Cardiac hospital in Philly, but you still have other choices not too far away: http://health.usnews.com/best-hospitals/search?hospital_name=&specialty_id=IHQCARD&amp ;city=Philadelphia%2C+PA&distance=100

I feel that finding a surgeon for such an important procedure should be more involved than a simple referral that can have all types of biases unrelated to medical expertise. For a small fee you can look up top ranked Dr's at: http://www.castleconnolly.com/. How valid their ranking process is I can't say, but I assume it is better than random. Also, for free I have found Healthgrades to be useful as it allows patients to review their Dr's, and in my limited experience I have seen a strong correlation between Dr's with high Healthgrades reviews and those on the top Dr's list.

I've read that once an aneurysm reaches 4.7cm, it's virtually inevitable that it will progress. I believe that it contradicts the latest AHA guidelines not to address such an aneurysm (>4.5cm) during a valve replacement. I can't believe he told you "I don't think it will give you any problems". You were right to switch Dr's.

 

[cldlhd]

The surgeon I chose from Penn has been a Castle Connolly top doc for I think 13 years in a row but maybe I'm not remembering properly but I believe Skeptic had a less than satisfactory meeting with him.

 

[Paleowoman]

I googled the difference between a mini or full sternotomy and read a NCBI study that said many planned mini sternotomies end up being full and end up having more pump time than a planned full. I tried uploading it here but either my skills are lacking or there's something wrong with the site.

Surgical time with 'mini' sternotomies usually take longer too than full sternotomies because of the small access - incision normally around 2 inches. My total OHS AVR time was only 1 hour and 55 minutes with my time on the pump just 48 minutes. I don't think that could be done in that quick time with a "mini" and probably explains why my "mini" turned out to be a 3/4 sternotomy.

 

[cldlhd]

I guess less access is the reason it takes longer. I'm curious as to how they do the operation without circulatory arrest. That must take some skills, seems to me it would be like trying to throw a saddle on a baboon and going for s ride.