CONTACTS
SUBJECTS
Background Heart Bypass Surgery Quadruple (4) Coronary Artery Bypass
0703 -
0703 - ..
0704 - Summary/Objective
0705 -
070501 - Follow up ref SDS 12 0000. ref SDS 11 0000.
070502 -
070503 -
070504 - [On 100928 0706 received VA's report on surgery today, prepared
070505 - by Neil. ref SDS 23 C58I
070507 - ..
070508 - [On 140213 0830 meeting at VA consider performing CT and
070509 - related tests to evaluate regression of atherosclerosis
070510 - lesions based on labs showing elevated LDL-C, but also high
070511 - HDL and low triglycerides (TG), which could signal
070512 - discordance, i.e., low LDL-P, ref SDS 30 JZ4O, which is the
070513 - healthiest condition for CVD patients, shown by research on
070514 - 131125 0005. ref SDS 29 FI3G
070516 - ..
070517 - [On 151019 0930 Radiology report on CCTA test performed on
070518 - 151019, indicates calcification in original bypassed
070519 - arteries has increased since CABG +4 surgery on 091022,
070520 - ref SDS 31 J14N; seems conflicting with this research on
070521 - 131125, theorizing atherosclerosis plaques regress rapidly
070522 - with elevated HDL and EPCs. ref SDS 29 RA7K
070524 - ..
070525 - [On 181102 1928 study in Denmark found 8-10 year survivors
070526 - after CABG surgery have an increased mortality of between
070527 - 60 and 80 per cent when compared with the general
070528 - population. This may be due to the fact that the disease
070529 - is progressive and that the atherosclerosis or hardening of
070530 - the arteries increases, or that the implanted material
070531 - begins to fail. ref SDS 35 144J
070533 - ..
070534 - [On 190527 0857 letter asks Doctor Simpson's take on this
070535 - article on Denmark study finding significantly increased
070536 - mortality 8-10 years after heart bypass, in relation to
070537 - CABG x4 in this case 10 years ago on 091022, and 2-CCTA
070538 - studies which reported bypassed blood vessels contain
070539 - significant plaque. ref SDS 37 NE56
070541 - ..
070542 - [On 190101 0730 case study report for hike on 191210, felt
070543 - pressure in chest, similar to feeling hiking up 1st hill at
070544 - Lafayette Reservoir that was reported to doctor Lee at the
070545 - VA on 090908, and which led to having CABG x4 today on
070546 - 091022. Chest pain on 191210, resolves within a mile and
070547 - did not recur, despite hiking uphills of 1 mile and over 15
070548 - mile hike. ref SDS 36 YTWS
070550 - ..
070551 - [On 191228 1416 letter to Doctor Simpson in Cardiology at
070552 - VAMCSF notifies chest pain on hills hiking 20 miles,
070553 - similar to report to Doctor Lee on 090908, leading to CABG
070554 - x4 on 091022. ref SDS 38 B64Y Seems like bypass saphenous
070555 - graft failed under elevated load wearing elastic bandage on
070556 - left knee. ref SDS 38 B665 Pause hiking until hear from
070557 - the doctor. ref SDS 38 B668
070559 - ..
070560 - [On 200103 0700 treadmill stress test found no evidence of
070561 - blocked blood vessels, including coronary artery bypass
070562 - grafts. ref SDS 39 TS6L
070564 - ..
070565 - [On 200124 0705 cardiac catheterization IVUS angiogram
070566 - found no evidence blocked coronary artery bypass grafts;
070567 - found 1 branch vessel with 80-90% blockage; doctor
070568 - described best condition every seen 10 years after CABG;
070569 - told patient to keep doing whatever he is doing.
070570 - ref SDS 40 ME8G
070571 -
070572 -
070573 -
070574 -
070575 -
070577 - ..
0706 -
0707 -
0708 - Background
0709 -
070901 - On 081207 record hiking with Millie mostly at Lafayette Reservoir,
070902 - averaged 6 miles per day 4 - 6 days a week. ref SDS 4 X64F This was
070903 - level of walking resulted in HDL 30, very high risk for CVD/CAD.
070905 - ..
070906 - On 090916 VA performed stress test, which indicated possible heart
070907 - and circulation problems - CVD/CAD.
070909 - ..
070910 - On 091002 met with Doctor Egan, Cardiologist at the VA. The doctor
070911 - advised that 10 of 11 test points in the stress test showed positive
070912 - for circulation problems, i.e., CVD/CAD, and so the doctor ordered
070913 - angiogram. ref SDS 6 1W5I
070915 - ..
070916 - On 091006 0843 Karen called and scheduled angiogram test on 091020 at
070917 - the VA in San Francisco. ref SDS 7 1W5I Received a letter from Karen
070918 - on 091006 at 1045 confirming schedule for the test which requires
070919 - arriving at the VA on 091019 to do prep for the test on 091020.
070920 - ref SDS 7 GK8L
070922 - ..
070923 - On 091007 0021 sent a letter notifying the medical team that Doctor
070924 - Egan's treatment plan is being implemented, and asked a question about
070925 - the cause of pain based on level of effort. ref SDS 8 4Z75
070927 - ..
070928 - On 091007 0818 received letter from Karen at VA in San Francisco
070929 - responding to the letter this morning asking the medical team for
070930 - cause of chest pain that correlates to level of effort. Doctor Egan
070931 - has not had time to respond. Karen attributes pain to possible
070932 - angina, but does not explain what causes pain. ref SDS 9 A68H
070934 - ..
070935 - 091019 1300 meeting at VA in Cardiology for blood test to prepare for
070936 - angiogram test tomorrow, ref SDS 10 X59F, per Karen's letter on 091007
070937 - 0818. ref SDS 9 A68H
070939 - ..
070940 - 091020 0700 meeting at VA in San Francisco for angiogram test delayed,
070941 - ref SDS 11 01F9, explained in the record on 091019 1300. ref SDS 10 VH6Q
070943 - ..
070944 - 091021 0716 Meeting at VA to complete angiogram test orientation
070945 - meeting, ref SDS 12 01F9, and perform test.
070947 - ..
070948 - On 091022 0700 Doctor Tseng, Neal, Joe, Casey, Paula, and others
070949 - performed the surgery. ref SDS 0 01F9
070950 -
070951 -
070953 - ..
0710 -
0711 -
0712 - Progress
0713 -
071301 - Doctor Sarah Gebauer and Jusin arrived about 0645 in the ICU and tried
071302 - to set some IVs for heart bypass surgery required by the angiogram
071303 - test yesterday on 091021 0716, ref SDS 12 7L43; and as shown in
071304 - Sarah's work plan later yesterday evening on 091021 0716. ref SDS 12
071305 - PL81
071307 - ..
071308 - This morning, there were further difficulties getting blood to flow
071309 - through catheters, as encountered yesterday in ICU, reported on 091021
071310 - 0716. ref SDS 12 737P Sarah decided to complete the work in the OR
071311 - using a sonogram to find veins and arteries with sufficient blood flow
071312 - in the left and right arms for placing IV catheters required for
071313 - heart surgery.
071314 -
071315 - [...below on 091022 0700 later in the morning, Sarah and Justin
071316 - had further difficulties setting IVs using sonogram technology
071317 - to locate veins and arteries. Doctor Brezinski provided
071318 - assistance and training to complete IV catheters required for
071319 - CABG surgery, ref SDS 0 LN71, though he too had problems
071320 - performing the work. ref SDS 0 LN9T
071322 - ..
071323 - [On 091101 0910 Joy placed a catheter in the right arm above
071324 - the wrist; used hot towel with a tournaquet to do this on the
071325 - first attempt. ref SDS 16 EX3P
071327 - ..
071328 - [On 110429 1230 case study on similar problems at VA in
071329 - Martinez, getting adequate blood flow through IV catheter,
071330 - related to dehydration from heavy exercise and low water
071331 - intake hours before medical care; solved by getting another
071332 - nurse to complete work. ref SDS 25 SR8M
071334 - ..
071335 - [On 091219 0600 4 days after Heller Myotomy surgery planning
071336 - discharge or following day; therefore standard protocol to
071337 - replace IV catheter not followed to avoid expense and
071338 - inconvenience to patient. ref SDS 19 0L46
071340 - ..
071341 - [On 091228 1049 notified Doctor Egan in Cardiology at VA in
071342 - Martinez, and also Doctor Sandhu in Primary Care of successful
071343 - heart surgery on 091022. ref SDS 20 JN9X
071345 - ..
071346 - About 0700, Doctor Brzezinski, Chief of Anesthesia, arrived in ICU.
071347 -
071348 - Marek Brzezinski, MD, PhD
071349 -
071350 - http://profiles.ucsf.edu/marek.brzezinski
071351 -
071352 - Title Professor
071353 - School UCSF School of Medicine
071354 - Department Anesthesia
071355 - Address 4150 Clement St
071356 - San Francisco CA 94121
071357 - Phone 415-221-4810x4454
071358 - Email Marek.Brzezinski@ucsf.edu
071359 -
071361 - ..
071362 - Office Location & Contact
071363 -
071364 - http://health.usnews.com/doctors/marek-brzezinski-432418
071365 -
071366 - 4150 Clement St
071367 - Anesthesiology Services (129)
071368 - Va Medical Center
071369 - San Francisco, CA 94121
071370 - (415) 750-2069
071372 - ..
071373 - Justin, Sarah, and Doctor Brzezinski wheeled the gurney from ICU into
071374 - the OR. The OR was busy when we arrived, so the team wheeled the
071375 - gurney down the hall to an administrative area, where they continued
071376 - working on anesthesia IV chatheters to prepare for surgery.
071378 - ..
071379 - In the OR holding area, Doctor Brzezinski gave instructions for Sarah
071380 - and Justin to place IVs in both arms.
071381 -
071382 -
071383 -
0714 -
SUBJECTS
Default Null Subject Account for Blank Record
0803 -
080401 - ..
080402 - Preventive Management Achalasia Investigate Avoid Cardiac Arrest
080403 - Achalasia Avoid Cardiac Arrest During Heart Surgery Proactive Planning
080404 - VA Computer Records Proactive Case Mangement Improve Patient Outcomes
080405 -
080406 - Asked Doctor Brzezinski to explain precautions the team will take to
080407 - accomodate achalasia, discussed previously with Doctor Tseng during
080408 - the meeting yesterday on 091021 0716 at 1429? ref SDS 12 R78O
080410 - ..
080411 - Doctor Brzezinski was not familiar with achalasia. He seemed to
080412 - indicate his review of the medical chart did not reveal this problem.
080413 - The doctor asked if achalasia has been reported to the VA?
080414 -
080415 - [On 100928 0706 received CD with VA medical records on
080416 - heart surgery, showing incorrectly patient was "educated"
080417 - which means notified to be prepared for post-op conditions.
080418 - ref SDS 18 4Q4N
080420 - ..
080421 - [On 100928 0706 medical chart review shows no consideration
080422 - in Neil's preop check list, ref DRP 1 L44F, to avoid
080423 - aspiration from achalasia. ref SDS 25 L44F
080425 - ..
080426 - Briefly explained achalasia causes vomitting and breathing problems,
080427 - when laying flat for surgery. The VA has been working the achalasia
080428 - problem in this case beginning with barrium swallow test on 050714,
080429 - ref SDS 1 2I9J, and later examination in GI Clinic on 051202 1430.
080430 - ref SDS 2 5B5K, noted in discussion with Doctor Tseng and the CT team
080431 - yesterday on 091021 0716 at 1429. ref SDS 12 LJ7Y At that time, the
080432 - surgery team planned for special configuration to prevent aspiration
080433 - problems from escalating out of control during surgery today.
080434 - ref SDS 12 R78O
080436 - ..
080437 - Doctor Brzezinski indicated that his anesthesia team has
080438 - responsibility for patient safety during surgery. He concurred that
080439 - not eating since Monday helps control the vomitting problem,
080440 - recommended by Doctor Hoffman on 091019 1300. ref SDS 10 ZZ80 Doctor
080441 - Brzezinski further seemed to indicate that breathing problems, choking
080442 - and drowning present significant risks of fatality during long
080443 - procedures required for heart surgery.
080445 - ..
080446 - Discussed keeping the patient slightly tilted, so the head and neck
080447 - are above the stomach to prevent backflow into the esophagus,
080448 - previously reviewed with Doctor Tseng's team yesterday. ref SDS 12
080449 - KL5I The doctor seemed to say there will be a tube down my throat
080450 - that will suction backflow, so this should not be a problem. He will
080451 - also place a towel under my head so I am comfortable until anestheais
080452 - takes effect, and the team can place the suction tube down the throat.
080454 - ..
080455 - While Sarah and Justin continued work placing IVs, Doctor Brzezinski
080456 - walked across the aisle to a workstation. He used the VA comnputer
080457 - system to research VA Progress Notes for patient history on achalasia.
080459 - ..
080460 - After about 10 minutes, Doctor Brzezinski reported he could not find
080461 - anything on achalasia in the VA computer on this case. He asked for
080462 - dates of prior work. Difficulty today finding patient history in the
080463 - medical chart on the VA computer occurred yesterday during a meeting
080464 - with the surgery team to plan for CABG, reported on 091021 0716.
080465 - ref SDS 12 LJ7L
080467 - ..
080468 - Suggested checking VA records in Martinez, for Doctor Lee on 051202,
080469 - when achalasia was diagnosed. ref SDS 2 5B5K SDS records list
080470 - extensive follow up, beginning with endoscopy procedure on 051209
080471 - 1130. ref SDS 3 0001
080472 -
080473 - [On 091219 0600 report to Doctor Ratcliffe on benefits of VA
080474 - computer records supported through doctor patient partnership.
080475 - ref SDS 19 Z990
080477 - ..
080478 - Doctor Brzezinski found VA records on patient history of achalasia.
080479 -
080480 - [On 091030 0800 at 1406 meeting with Doctor Stewart proposes
080481 - resolving achalasia with Heller Myotomy surgery in December a
080482 - few months after heart surgery. ref SDS 15 KE3B
080483 -
080484 - [On 091030 0800 at 1440 meeting with medical team, including
080485 - Doctor Ratcliff concerned about maintaining nutrition to
080486 - recover from heart surgery while digestion is problematic due
080487 - to achalasia; proposed feeding tube for several months until
080488 - Heller Myotomy surgery. ref SDS 15 03GF
080490 - ..
080491 - [On 100911 0800 VA credited for improving speed of access
080492 - to computer records; discussed "Knowledge Management loop"
080493 - that redundancy and ignoring the record collapses
080494 - productivity and vitiates care because health care
080495 - professionals do not have command and control of the record
080496 - on patient history, ref SDS 22 OL50, citing case study of
080497 - work at VA today on 091021. ref SDS 12 FB5N
080499 - ..
080500 - [On 110429 1230 challenges persist getting medical records
080501 - in time to be effective for health care decisions.
080502 - ref SDS 25 NM9G
080504 - ..
080505 - [On 110727 1238 Melissa had difficulty using the VA
080506 - computer in the Martinez Primary Care Department to find
080507 - Doctor Egan's work plan in the Cardiology Department on
080508 - adding mercury to the lab. ref SDS 26 A25H
080510 - ..
080511 - With Doctor Brzezinski researching the achalasia problem for scope of
080512 - anesthesia measures during the operation, Sarah and Justin continued
080513 - work setting IV catheters. Sarah was frustrated because the sonogram
080514 - showed clearly where blood flowed. The team could see what looked
080515 - like veins, and the veins felt like there was a strong pulse.
080516 - However, nothing worked. Sarah made 2 tries on the right arm. Justin
080517 - tried twice on the left arm. Everything failed and arms hurt.
080519 - ..
080520 - After completing review of achalasia issue, Doctor Brzezinski assisted
080521 - Sarah and Justin. He provided pointers on good practice and tips on
080522 - setting IV catheters. The doctor cited a paper he has written on
080523 - performing IVs, which will be published next month.
080525 - ..
080526 - Requested a copy of the paper.
080528 - ..
080529 - Doctor Brzezinski indicated he would submit a copy to the patient.
080530 -
080531 - [On 091219 0600 Doctor Brzezinski visited briefly months
080532 - after heart surgery, and while recovering from another
080533 - surgery to treat achalasia, ref SDS 19 0O59, apologized
080534 - forgetting to submit his paper, and cited Internet release;
080535 - nothing in that release seems to present ideas on better IV
080536 - work. ref SDS 19 KA6I
080538 - ..
080539 - The doctor also had problems setting IV catheters. After more
080540 - attempts, IVs were successfully placed in the top of the left hand,
080541 - the inner wrist on the right arm, and bicept in the right arm.
080542 - Another catheter was placed in the inner elbow of the left arm. This
080543 - will greatly complicate working after surgery today.
080544 -
080545 - [On 091101 0910 Joy placed a catheter in the right arm above
080546 - the wrist; used hot towel with a tournaquet to do this on the
080547 - first attempt. ref SDS 16 EX3P
080549 - ..
080550 - [On 110429 1230 case study on similar problems at VA in
080551 - Martinez, getting adequate blood flow through IV catheter,
080552 - related to dehydration from heavy exercise and low water
080553 - intake hours before medical care; solved by getting another
080554 - nurse to complete work. ref SDS 25 SR8M
080556 - ..
080557 - Doctor Brzezinski seemed to say several more IVs would be needed
080558 - during the operation.
080560 - ..
080561 - The doctor further advised that this case will require a cardio
080562 - pulmonary heart bypass pump listed in Sarah's review of the work plan
080563 - on 091021 0716, ref SDS 12 PL9U, and to solve the achalasia vomitting
080564 - and breathing problems during heart surgery today. He feels research
080565 - on the VA computer, guided by the SDS record through doctor/patient
080566 - partnership, revealed high risk condition, discussed above,
080567 - ref SDS 0 JF9K, so that measures can be used to prevent complications
080568 - that could otherwise cause death during surgery, as planned by Doctor
080569 - Tseng, during the meeting with the CT team yesterday, reported, 091021
080570 - 0716, ref SDS 12 R78O
080572 - ..
080573 - [On 091023 0445 woke up in panic with tubes in the throat that
080574 - seemed to restrict breathing and prevented talking, so could
080575 - not explain to the nurse feeling extreme duress. ref SDS 14 01F9
080577 - ..
080578 - [On 091219 0600 report to Doctor Ratcliffe on benefits of VA
080579 - computer records supported through doctor patient partnership.
080580 - ref SDS 19 FX3M
080582 - ..
080583 - [On 100928 0706 received CD with VA medical records on
080584 - heart surgery, showing incorrectly patient was "educated"
080585 - which means notified to be prepared for post-op
080586 - conditions that cause anxiety and fear, in this case
080587 - having a tube inserted into the throat needed to prevent
080588 - complications from achalasia during heart surgry.
080589 - ref SDS 23 4Q4N
080591 - ..
080592 - [On 100928 0706 review of Medical Chart pre-procedure
080593 - Anesthesia planning report makes no mention of planning to
080594 - avoid complications due to achalasia performing heart surgery,
080595 - ref SDS 23 WP4F
080597 - ..
080598 - [On 100928 0706 review of Medical Chart pre-procedure shows
080599 - Doctor Brzezinski amended Anesthesia work plan filed on 091021,
080600 - the next day on 091022 0926, ref SDS 23 EK6G, after meeting in
080601 - OR with patient, per above. ref SDS 0 JF9K
080603 - ..
080604 - [On 100928 0706 review of Medical Chart post-procedure
080605 - Operation Report cites complications due to achalasia
080606 - performing heart surgery, ref SDS 23 633I, and discloses
080607 - cardioplmonry bypass was applied. ref SDS 23 MP5K
080608 -
080609 -
080611 - ..
0807 -
0808 -
0809 - 0731
0810 -
081001 - CABG x4 - Coronary Artery Bypass Graft - Quadruple Heart Surgery
081002 - Quadruple Bypass Surgery resolve Coronrary Artery Restrictions
081003 -
081004 - Finally wheeled into OR, after anesthesia team completed initial prep,
081005 - per above, ref SDS 0 01F9, including plans to manage complications
081006 - from achalasia, per above, ref SDS 0 JF9K, and implementing work plans
081007 - developed with attending physician, Doctor Elaine Tseng, and the CT
081008 - surgery team yesterday, on 091021 0716 at 1429. ref SDS 12 FB5N
081010 - ..
081011 - Purpose of surgery today, is to relieve severe CVD/CAD symptoms that
081012 - occurred due to low HDL 30, despite patient hiking 3 - 8 miles per
081013 - day, 4 - 6 days per week the past 4 years, shown by case study on
081014 - 081207 0700. ref SDS 4 X64F This level of effort was not enough to
081015 - raise HDL > 60, considered a theraputic condition that regresses
081016 - plaque in blood vessels.
081018 - ..
081019 - [On 100928 0706 review Medical Chart Progress Notes
081020 - reporting 4 bypass grafts performed for CABG surgery.
081021 - ref SDS 23 HT9G
081023 - ..
081024 - [On 131121 0930 Karen advised that Doctor Tseng promoted to
081025 - Chief of Surgery. ref SDS 28 NQ31, and cited in letter to
081026 - Karen the next day on 131125 0005. ref SDS 29 UK3O
081028 - ..
081029 - [On 131125 0005 research found HDL > 60 together with
081030 - elevated EPCs regress cholesterol plaque buildup in blood
081031 - vessels, through reverse cholesterol transport, which is
081032 - the healthiest condition for CVD patients. ref SDS 29 HG7N
081034 - ..
081035 - [On 140213 0830 meeting at VA consider performing CT and
081036 - related tests to evaluate regression of atherosclerosis
081037 - lesions based on labs showing elevated LDL-C, but also high
081038 - HDL and low triglycerides (TG), which could signal
081039 - discordance, i.e., low LDL-P, ref SDS 30 JZ4O, which is the
081040 - healthiest condition for CVD patients, shown by research on
081041 - 131125 0005. ref SDS 29 FI3G
081043 - ..
081044 - [On 190101 0730 case study report for hike on 191210, felt
081045 - pressure in chest, similar to feeling hiking up 1st hill at
081046 - Lafayette Reservoir that was reported to doctor Lee at the
081047 - VA on 090908, and which led to having CABG x4 today on
081048 - 091022. Chest pain on 191210, resolves within a mile and
081049 - did not recur, despite hiking uphills of 1 mile and over 15
081050 - mile hike. ref SDS 36 YTWS
081052 - ..
081053 - [On 191228 1416 letter to Doctor Simpson in Cardiology at
081054 - VAMCSF notifies chest pain on hills hiking 20 miles,
081055 - similar to report to Doctor Lee on 090908, leading to CABG
081056 - x4 on 091022. ref SDS 38 B64Y Seems like bypass saphenous
081057 - graft failed under elevated load wearing elastic bandage on
081058 - left knee. ref SDS 38 B665 Pause hiking until hear from
081059 - the doctor. ref SDS 38 B668
081061 - ..
081062 - [On 200103 0700 treadmill stress test found no evidence of
081063 - blocked blood vessels, including coronary artery bypass
081064 - grafts. ref SDS 39 TS6L
081066 - ..
081067 - [On 200124 0705 cardiac catheterization IVUS angiogram
081068 - found no evidence blocked coronary artery bypass grafts;
081069 - found 1 branch vessel with 80-90% blockage; doctor
081070 - described best condition every seen 10 years after CABG;
081071 - told patient to keep doing whatever he is doing.
081072 - ref SDS 40 ME8G
081074 - ..
081075 - Doctor Brzezinski placed a Cordis catheter in the right neck, which
081076 - included an inner catheter that sets probes deep into the chest around
081077 - the heart for monitoring the work. The main catheter delivers
081078 - medication to maintain heart function during the procedure.
081079 -
081080 - [On 091030 0810 CT test to evaluate achalasia and fluid on the
081081 - lungs indicates possible DVT at the location where the Cordis
081082 - catheter was placed for heart surgery; sonogram test confirmed
081083 - DVT, which delays discharge and requires warfarin treatment.
081084 - ref SDS 15 1N6L
081086 - ..
081087 - [On 100405 2302 letter from Candi reporting she reviewed the
081088 - record on Eddie's memorial services, ref SDS 21 295S; and,
081089 - seems to have followed several links to discover heart surgery.
081090 - today. ref SDS 21 4R6N
081092 - ..
081093 - Doctor Tseng called and reported she was leaving Moffit Field, about
081094 - 50 miles south of San Francisco. She is expected to arrive by 1100 to
081095 - do the operation, after all of the preparation. This aligns with work
081096 - plan presented by the doctor yesterday on 091021 0716. ref SDS 12 3V4N
081098 - ..
081099 - Recognized Paula, KC, and Neal from the meeting yesterday afternoon,
081100 - reported on 091021 0716. ref SDS 12 P34P
081101 -
081102 - [On 091119 1000 Neil approved ending Amiodarone on 091122, 30
081103 - days after surgery on 091022. ref SDS 17 LC5F
081104 -
081105 - [On 110406 1230 treadmill stress test performed; initial
081106 - indications are 100% performance, with one node showing
081107 - possible slight irregularity. ref SDS 24 OF8F
081108 -
081109 -
081111 - ..
0812 -
0813 -
0814 - 0930
0815 -
081501 - Doctor Tseng Attending Quadruple Bypass Heart Surgery
081502 -
081503 - Asleep for remainder of operation.
081505 - ..
081506 - Quadruple bypass heart surgery resolved 2 major and a 3rd possible
081507 - coronrary artery blockages discovered during angiogram test yesterday
081508 - on 091021 0716. ref SDS 12 7L43, and following stress test ordered by
081509 - Doctor Lee on 090908 1130. ref SDS 5 H27N Surgery today was
081510 - recommended by Doctor Shunk following angiogram test, again yesterday.
081511 - ref SDS 12 7L61 CABG 4x may reflect a 4th blockage discovered with
081512 - sonogram radiology, reported on 091021 0716, ref SDS 12 TD60, and
081513 - implemented planning by the Cardiothoracic (CT) surgery team during
081514 - the meeting in the ICU, also, on 091021 0716 at 1429. ref SDS 12 FB5N
081516 - ..
081517 - [On 100928 0706 review Progress Notes reporting 4 bypass
081518 - grafts performed for CABG surgery. ref SDS 23 HT9G
081520 - ..
081521 - The operation was apparently completed about 1800, so it was a long
081522 - day with multiple complications, shown by Neals' excellent report in
081523 - the VA's medical chart. ref DRP 1 S89M
081525 - ..
081526 - Paula made an incision on the inner side of the right leg to harvest
081527 - vein tissue for performing quadruple heart bypass surgery.
081529 - ..
081530 - After surgical opening was closed, an inventory discovered needle
081531 - count was one short. Doctor Tseng ordered an xray study to verify
081532 - harmful needle was not inside the patient. In addition to reporting
081533 - what was found, the Radiology department affirmatively reported a
081534 - finding that anything even suspicious of a needle was not found (see
081535 - report in the record, shown in the record on 100928 0706. ref SDS 23
081536 - 0W4O
081538 - ..
081539 - [On 100928 0706 received VA's report on surgery today, prepared
081540 - by Neil. ref SDS 23 C58I
081542 - ..
081543 - [On 100928 0706 VA Progress Notes for pre-op surgery review
081544 - reports Special Tests Yes: Carotid Ultrasound, age > 60, TIA,
081545 - CVA, prior vascular surgery. ref DRP 1 I26M
081547 - ..
081548 - [On 130122 1330 visited Doctor Tseng briefly and thanked her
081549 - for excellent work performing CABG 4x surgery, reflecting
081550 - patient history showing good recovery; Doctor Tseng indicates
081551 - peripheral neuropathy parathesia not expected due to surgery 3
081552 - years later. ref SDS 27 LM8K
081554 - ..
081555 - Planned to watch World Series game this evening at 1900, between the
081556 - Yankees and Angels, but did not wake up until the next day about 0640.
081557 -
081558 - [On 091023 0445 woke up in panic with tubes in the throat that
081559 - seemed to restrict breathing and prevented talking, so could
081560 - not explain to the nurse extreme duress. ref SDS 14 01F9
081562 - ..
081563 - [On 091030 0800 medical team, including Doctor Ratcliff
081564 - concerned about how to maintain nutrition for the patient to
081565 - recover from heart surgery while digestion remains problematic
081566 - due to achalasia; proposes feeding tube for several months
081567 - until Heller Myotomy surgery. ref SDS 15 03GF
081569 - ..
081570 - [On 091219 0600 at 1104 visited with Doctor Ratcliffe and the
081571 - Cardiothoracic (CT) surgery team; was pleased to commend Doctor
081572 - Tseng and the VA for outstanding care. ref SDS 19 0M6S;
081573 - discussed doing clinical trial to improve patient outcomes with
081574 - stronger case management through better communication that
081575 - reduces mistakes. ref SDS 19 Z990
081577 - ..
081578 - Need VA's records on doctor's notes to report other work performed
081579 - for heart surgery today, e.g., who made the chest incision; what
081580 - findings were made, particulars of the work to address findings?
081581 -
081582 - [On 091208 1300 ordered VA's records on the operation
081583 - today, and for the period in the hospital. ref SDS 18 EK6I
081585 - ..
081586 - [On 100928 0706 received VA's report on surgery today, prepared
081587 - by Neil. ref SDS 23 C58I
081589 - ..
081590 - [On 100928 0706 review Medical Chart Progress Notes
081591 - reporting 4 bypass grafts performed for CABG surgery.
081592 - ref SDS 23 HT9G
081594 - ..
081595 - [On 140213 0830 meeting at VA consider performing CT and
081596 - related tests to evaluate regression of atherosclerosis
081597 - lesions based on labs showing elevated LDL-C, but also high
081598 - HDL and low triglycerides (TG), which could signal
081599 - discordance, i.e., low LDL-P, ref SDS 30 JZ4O, which is the
081600 - healthiest condition for CVD patients, shown by research on
081601 - 131125 0005. ref SDS 29 FI3G
081603 - ..
081604 - [On 151019 0930 Radiology report on CCTA test performed on
081605 - 151019, indicates calcification in original bypassed
081606 - arteries has increased since CABG +4 surgery on 091022,
081607 - ref SDS 31 J14N; seems conflicting with this research on
081608 - 131125, theorizing atherosclerosis plaques regress rapidly
081609 - with elevated HDL and EPCs. ref SDS 29 RA7K
081610 -
081611 -
081612 -
081614 - ..
081615 - CABG Successful Last 8 - 15 Years - CABG x4 Reduced Survival
081616 -
081617 - Research on CABG surgical procedures says...
081618 -
081619 - https://en.wikipedia.org/wiki/Coronary_artery_bypass_surgery
081620 -
081621 - 1. Prognosis following CABG depends on a variety of factors, and
081622 - successful grafts typically last 8-15 years.[citation needed]
081623 - In general, CABG improves the chances of survival of patients
081624 - who are at high risk (generally triple or higher bypass),
081625 - though statistically after about five years the difference in
081626 - survival rate between those who have had surgery and those
081627 - treated by drug therapy diminishes. Age at the time of CABG is
081628 - critical to the prognosis, younger patients with no
081629 - complicating diseases doing better, while older patients can
081630 - usually be expected to suffer further blockage of the coronary
081631 - arteries.
081632 -
081633 - [On 181102 1928 study in Denmark found 8-10 year survivors
081634 - after CABG surgery have an increased mortality of between
081635 - 60 and 80 per cent when compared with the general
081636 - population. This may be due to the fact that the disease
081637 - is progressive and that the atherosclerosis or hardening of
081638 - the arteries increases, or that the implanted material
081639 - begins to fail. ref SDS 35 144J
081641 - ..
081642 - [On 190527 0857 letter asks Doctor Simpson's take on this
081643 - article on Denmark study finding significantly increased
081644 - mortality 8-10 years after heart bypass, in relation to
081645 - CABG x4 in this case 10 years ago on 091022, and 2-CCTA
081646 - studies which reported bypassed blood vessels contain
081647 - significant plaque. ref SDS 37 NE56
081649 - ..
081650 - [On 200103 0700 treadmill stress test found no evidence of
081651 - blocked blood vessels, including coronary artery bypass
081652 - grafts. ref SDS 39 TS6L
081654 - ..
081655 - [On 200124 0705 cardiac catheterization IVUS angiogram
081656 - found no evidence blocked coronary artery bypass grafts;
081657 - found 1 branch vessel with 80-90% blockage; doctor
081658 - described best condition every seen 10 years after CABG;
081659 - told patient to keep doing whatever he is doing.
081660 - ref SDS 40 ME8G
081662 - ..
081663 - 2. A coronary artery may be unsuitable for bypass grafting if it
081664 - is small (< 1 mm or < 1.5 mm), heavily calcified, or located
081665 - within the heart muscle rather than on the surface. A single
081666 - obstruction of the left main coronary artery is associated
081667 - with a higher risk for a cardiac death and usually receives a
081668 - double bypass.
081670 - ..
081671 - 3. The surgeon reviews the coronary angiogram prior to surgery
081672 - and identifies the number of obstructions, the percent
081673 - obstruction of each, and the suitability of the arteries
081674 - beyond the obstruction(s) as targets. The presumed number of
081675 - bypass grafts needed as well as the location for graft
081676 - attachment is determined in a preliminary fashion prior to
081677 - surgery, but the final decision as to number and location is
081678 - made at surgery via direct examination of the heart.
081680 - ..
081681 - 4. Grafts can become diseased and may partially or completely
081682 - occlude - that is, lose their patency - in the months to years
081683 - after bypass surgery is performed. A graft is considered
081684 - patent if there is normal flow through the graft: flow begins
081685 - to diminish with around a 70 percent stenosis in the graft.
081686 -
081687 - [On 151019 0930 CCTA study was performed at the VA Medical
081688 - Center in San Francisco, for the purpose of testing
081689 - response to treatment hiking 10K miles in prior 4 years
081690 - that raised HDL 30 to HDL 70, and where favorable response
081691 - could support reducing line of care with statin medication
081692 - and hiking in order to reduce debilitating side effects;
081693 - CCTA test found "All the bypass grafts are patent," with no
081694 - affirmative findings of blockages of any kind 6 years after
081695 - CABG +4 due to severe atherosclerosis caused by HDL 30;
081696 - this left a question whether there could be blockages of up
081697 - to 70% anywhere in the active circulatory system,
081698 - consistent with the finding of "patent." ref SDS 32 JW8O
081700 - ..
081701 - [On 160104 0855 Doctor Jha, attending physician for this
081702 - CCTA imaging study, advised that standard of practice for
081703 - radiology reporting is to present any and all blockages of
081704 - any kind observable in CCTA scan imaging; so, in this case,
081705 - since none are reported, the CCTA test on 151019, can
081706 - correctely be interpretted to mean there are no blockages,
081707 - plaques, stenosis of any kind evident from the scan file
081708 - record. ref SDS 34 054G
081710 - ..
081711 - [On 200103 0700 treadmill stress test found no evidence of
081712 - blocked blood vessels, including coronary artery bypass
081713 - grafts. ref SDS 39 TS6L
081715 - ..
081716 - [On 200124 0705 cardiac catheterization IVUS angiogram
081717 - found no evidence blocked coronary artery bypass grafts;
081718 - found 1 branch vessel with 80-90% blockage; doctor
081719 - described best condition every seen 10 years after CABG;
081720 - told patient to keep doing whatever he is doing.
081721 - ref SDS 40 ME8G
081722 -
081724 - ..
081725 - Another article...
081726 -
081727 - PMC
081728 - Outcomes of coronary artery bypass graft surgery
081729 - Date........................ December 2006
081730 -
081731 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1994021/
081733 - ..
081734 - The study revealed no significant difference in mortality 4
081735 - years after CABG in patients with one-, two- or three-vessel
081736 - disease, although a highly significant increase in survival
081737 - rate was observed in a subset of patients who underwent CABG
081738 - for left main coronary artery obstruction. The 4-year
081739 - mortality for CABG patients was 7% (n = 46), compared with 33%
081740 - for medical treatment (n = 44) (Hampton 1984).
081741 -
081742 - 10 years after CABG three quarters of vein conduits are
081743 - blocked or severely diseased
081745 - ..
081746 - Vein graft failure leads to reduced survival, recurrent
081747 - angina, late myocardial infarction, and the need for further
081748 - intervention (Eagle et al 1999), so that by 10?15 years after
081749 - the initial operation up to 40% of patients may require redo
081750 - CABG at increased risk and cost
081751 -
081752 -
081754 - ..
081755 - There is an impression that >3-vessel disease CABG is less frequently
081756 - recommended in 21st century, compared to prior practice. Mortality
081757 - seems to increase significantly, i.e., survival declines, for
081758 - patients having CABG with >3-vessel disease.
081760 - ..
081761 - In this case, cardiology recommended CABG, based on Doctor Shunk
081762 - diagnosing 2-vessel disease, and only possibly a 3rd, reported on for
081763 - cardiac catheritization for angiogram test, performed on 091021 0716.
081764 - ref SDS 12 AL9O If 4-vessel disease had been identified, would this
081765 - have resulted in not getting CABG surgery?
081766 -
081767 -
081769 - ..
081770 - Complications CABG Surgery
081771 -
081772 -
081773 - 1. Postperfusion syndrome (pumphead), a transient neurocognitive
081774 - impairment associated with cardiopulmonary bypass. Some
081775 - research shows the incidence is initially decreased by
081776 - off-pump coronary artery bypass, but with no difference beyond
081777 - three months after surgery. A neurocognitive decline over time
081778 - has been demonstrated in people with coronary artery disease
081779 - regardless of treatment (OPCAB, conventional CABG or medical
081780 - management). However, a 2009 research study suggests that
081781 - longer term (over 5 years) cognitive decline is not caused by
081782 - CABG but is rather a consequence of vascular disease.[5] Loss
081783 - of mental function is a complication of bypass surgery in
081784 - elderly people, and might influence procedure cost benefit
081785 - considerations.[15] Several factors may contribute to
081786 - immediate cognitive decline. The heart-lung blood circulation
081787 - system and the surgery itself release a variety of debris,
081788 - including bits of blood cells, tubing, and plaques. For
081789 - example, when surgeons clamp and connect the aorta to tubing,
081790 - resulting emboli block blood flow and cause mini strokes.
081791 - Other heart surgery factors related to mental damage may be
081792 - events of hypoxia, high or low body temperature, abnormal
081793 - blood pressure, irregular heart rhythms, and fever after
081794 - surgery
081796 - ..
081797 - 2. Myocardial infarction due to embolism, hypoperfusion, or graft
081798 - failure.
081800 - ..
081801 - 3. Late graft stenosis, particularly of saphenous vein grafts due
081802 - to atherosclerosis causing recurrent angina or myocardial
081803 - infarction.
081805 - ..
081806 - 4. Graft failure: grafts last 8-15 years, and then need to be
081807 - replaced.
081808 -
081809 - [On 151028 1000 Doctor Simpson comments in Progress Notes
081810 - that CCTA results on 151019 "... could be read as showing
081811 - some early changes in the [...saphenous vein grafts...]
081812 - SVGs. This is about what I had predicted." ref SDS 33 5Y6L
081814 - ..
081815 - [On 181102 1928 study in Denmark found 8-10 year survivors
081816 - after CABG surgery have an increased mortality of between
081817 - 60 and 80 per cent when compared with the general
081818 - population. This may be due to the fact that the disease
081819 - is progressive and that the atherosclerosis or hardening of
081820 - the arteries increases, or that the implanted material
081821 - begins to fail. ref SDS 35 144J
081823 - ..
081824 - [On 190527 0857 letter asks Doctor Simpson's take on this
081825 - article on Denmark study finding significantly increased
081826 - mortality 8-10 years after heart bypass, in relation to
081827 - CABG x4 in this case 10 years ago on 091022, and 2-CCTA
081828 - studies which reported bypassed blood vessels contain
081829 - significant plaque. ref SDS 37 NE56
081831 - ..
081832 - [On 200103 0700 treadmill stress test found no evidence of
081833 - blocked blood vessels, including coronary artery bypass
081834 - grafts. ref SDS 39 TS6L
081836 - ..
081837 - [On 200124 0705 cardiac catheterization IVUS angiogram
081838 - found no evidence blocked coronary artery bypass grafts;
081839 - found 1 branch vessel with 80-90% blockage; doctor
081840 - described best condition every seen 10 years after CABG;
081841 - told patient to keep doing whatever he is doing.
081842 - ref SDS 40 ME8G
081843 -
081844 -
081845 -
081846 -
081847 -
081848 -
081849 -
081850 -
081851 -
0819 -