May 26, 2017, 9:54 am
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1 Philippine Peso = 0.07381 UAE Dirham
1 Philippine Peso = 2.39851 Albanian Lek
1 Philippine Peso = 0.03597 Neth Antilles Guilder
1 Philippine Peso = 0.32504 Argentine Peso
1 Philippine Peso = 0.02683 Australian Dollar
1 Philippine Peso = 0.03597 Aruba Florin
1 Philippine Peso = 0.04019 Barbados Dollar
1 Philippine Peso = 1.61957 Bangladesh Taka
1 Philippine Peso = 0.03496 Bulgarian Lev
1 Philippine Peso = 0.00756 Bahraini Dinar
1 Philippine Peso = 34.20217 Burundi Franc
1 Philippine Peso = 0.0201 Bermuda Dollar
1 Philippine Peso = 0.02784 Brunei Dollar
1 Philippine Peso = 0.13867 Bolivian Boliviano
1 Philippine Peso = 0.06563 Brazilian Real
1 Philippine Peso = 0.0201 Bahamian Dollar
1 Philippine Peso = 1.30125 Bhutan Ngultrum
1 Philippine Peso = 0.20751 Botswana Pula
1 Philippine Peso = 402.33121 Belarus Ruble
1 Philippine Peso = 0.04015 Belize Dollar
1 Philippine Peso = 0.0271 Canadian Dollar
1 Philippine Peso = 0.01953 Swiss Franc
1 Philippine Peso = 13.47267 Chilean Peso
1 Philippine Peso = 0.13847 Chinese Yuan
1 Philippine Peso = 58.35812 Colombian Peso
1 Philippine Peso = 11.51125 Costa Rica Colon
1 Philippine Peso = 0.0201 Cuban Peso
1 Philippine Peso = 1.96925 Cape Verde Escudo
1 Philippine Peso = 0.47339 Czech Koruna
1 Philippine Peso = 3.57074 Djibouti Franc
1 Philippine Peso = 0.13296 Danish Krone
1 Philippine Peso = 0.94574 Dominican Peso
1 Philippine Peso = 2.17205 Algerian Dinar
1 Philippine Peso = 0.27938 Estonian Kroon
1 Philippine Peso = 0.36314 Egyptian Pound
1 Philippine Peso = 0.46021 Ethiopian Birr
1 Philippine Peso = 0.01786 Euro
1 Philippine Peso = 0.0421 Fiji Dollar
1 Philippine Peso = 0.01545 Falkland Islands Pound
1 Philippine Peso = 0.01546 British Pound
1 Philippine Peso = 0.08669 Ghanaian Cedi
1 Philippine Peso = 0.90334 Gambian Dalasi
1 Philippine Peso = 181.20981 Guinea Franc
1 Philippine Peso = 0.14748 Guatemala Quetzal
1 Philippine Peso = 4.11013 Guyana Dollar
1 Philippine Peso = 0.15644 Hong Kong Dollar
1 Philippine Peso = 0.47082 Honduras Lempira
1 Philippine Peso = 0.13208 Croatian Kuna
1 Philippine Peso = 1.33903 Haiti Gourde
1 Philippine Peso = 5.50744 Hungarian Forint
1 Philippine Peso = 267.16239 Indonesian Rupiah
1 Philippine Peso = 0.0719 Israeli Shekel
1 Philippine Peso = 1.29803 Indian Rupee
1 Philippine Peso = 23.73392 Iraqi Dinar
1 Philippine Peso = 651.98958 Iran Rial
1 Philippine Peso = 2.0008 Iceland Krona
1 Philippine Peso = 2.60008 Jamaican Dollar
1 Philippine Peso = 0.01424 Jordanian Dinar
1 Philippine Peso = 2.23286 Japanese Yen
1 Philippine Peso = 2.07094 Kenyan Shilling
1 Philippine Peso = 1.36441 Kyrgyzstan Som
1 Philippine Peso = 81.2902 Cambodia Riel
1 Philippine Peso = 9.04341 Comoros Franc
1 Philippine Peso = 18.08682 North Korean Won
1 Philippine Peso = 22.44775 Korean Won
1 Philippine Peso = 0.00609 Kuwaiti Dinar
1 Philippine Peso = 0.01648 Cayman Islands Dollar
1 Philippine Peso = 6.24598 Kazakhstan Tenge
1 Philippine Peso = 164.32878 Lao Kip
1 Philippine Peso = 30.27532 Lebanese Pound
1 Philippine Peso = 3.06873 Sri Lanka Rupee
1 Philippine Peso = 1.84887 Liberian Dollar
1 Philippine Peso = 0.26588 Lesotho Loti
1 Philippine Peso = 0.06127 Lithuanian Lita
1 Philippine Peso = 0.01247 Latvian Lat
1 Philippine Peso = 0.02803 Libyan Dinar
1 Philippine Peso = 0.19542 Moroccan Dirham
1 Philippine Peso = 0.36586 Moldovan Leu
1 Philippine Peso = 1.09586 Macedonian Denar
1 Philippine Peso = 27.49196 Myanmar Kyat
1 Philippine Peso = 48.43248 Mongolian Tugrik
1 Philippine Peso = 0.16115 Macau Pataca
1 Philippine Peso = 7.19453 Mauritania Ougulya
1 Philippine Peso = 0.69695 Mauritius Rupee
1 Philippine Peso = 0.3115 Maldives Rufiyaa
1 Philippine Peso = 14.4168 Malawi Kwacha
1 Philippine Peso = 0.37541 Mexican Peso
1 Philippine Peso = 0.08626 Malaysian Ringgit
1 Philippine Peso = 0.26598 Namibian Dollar
1 Philippine Peso = 6.33039 Nigerian Naira
1 Philippine Peso = 0.59385 Nicaragua Cordoba
1 Philippine Peso = 0.16751 Norwegian Krone
1 Philippine Peso = 2.07195 Nepalese Rupee
1 Philippine Peso = 0.02866 New Zealand Dollar
1 Philippine Peso = 0.00773 Omani Rial
1 Philippine Peso = 0.0201 Panama Balboa
1 Philippine Peso = 0.06572 Peruvian Nuevo Sol
1 Philippine Peso = 0.06587 Papua New Guinea Kina
1 Philippine Peso = 1 Philippine Peso
1 Philippine Peso = 2.10309 Pakistani Rupee
1 Philippine Peso = 0.07495 Polish Zloty
1 Philippine Peso = 111.9996 Paraguayan Guarani
1 Philippine Peso = 0.07317 Qatar Rial
1 Philippine Peso = 0.0813 Romanian New Leu
1 Philippine Peso = 1.13651 Russian Rouble
1 Philippine Peso = 16.46403 Rwanda Franc
1 Philippine Peso = 0.07535 Saudi Arabian Riyal
1 Philippine Peso = 0.15881 Solomon Islands Dollar
1 Philippine Peso = 0.26967 Seychelles Rupee
1 Philippine Peso = 0.13384 Sudanese Pound
1 Philippine Peso = 0.17452 Swedish Krona
1 Philippine Peso = 0.02785 Singapore Dollar
1 Philippine Peso = 0.01546 St Helena Pound
1 Philippine Peso = 0.44626 Slovak Koruna
1 Philippine Peso = 149.31673 Sierra Leone Leone
1 Philippine Peso = 11.03296 Somali Shilling
1 Philippine Peso = 437.5784 Sao Tome Dobra
1 Philippine Peso = 0.17528 El Salvador Colon
1 Philippine Peso = 10.34928 Syrian Pound
1 Philippine Peso = 0.26605 Swaziland Lilageni
1 Philippine Peso = 0.69031 Thai Baht
1 Philippine Peso = 0.04822 Tunisian Dinar
1 Philippine Peso = 0.04643 Tongan paʻanga
1 Philippine Peso = 0.0716 Turkish Lira
1 Philippine Peso = 0.13463 Trinidad Tobago Dollar
1 Philippine Peso = 0.60344 Taiwan Dollar
1 Philippine Peso = 44.81511 Tanzanian Shilling
1 Philippine Peso = 0.52904 Ukraine Hryvnia
1 Philippine Peso = 72.62862 Ugandan Shilling
1 Philippine Peso = 0.0201 United States Dollar
1 Philippine Peso = 0.56692 Uruguayan New Peso
1 Philippine Peso = 76.36656 Uzbekistan Sum
1 Philippine Peso = 0.20045 Venezuelan Bolivar
1 Philippine Peso = 454.6624 Vietnam Dong
1 Philippine Peso = 2.15394 Vanuatu Vatu
1 Philippine Peso = 0.05199 Samoa Tala
1 Philippine Peso = 11.70539 CFA Franc (BEAC)
1 Philippine Peso = 0.05426 East Caribbean Dollar
1 Philippine Peso = 11.75181 CFA Franc (BCEAO)
1 Philippine Peso = 2.11917 Pacific Franc
1 Philippine Peso = 5.02271 Yemen Riyal
1 Philippine Peso = 0.2661 South African Rand
1 Philippine Peso = 104.2906 Zambian Kwacha
1 Philippine Peso = 7.27291 Zimbabwe dollar

Beating heart surgery

OFF Pump Coronary Artery Bypass surgery is the most popular minimally invasive heart bypass operation today, one that is done on a beating heart. Conventionally, coronary bypass is done on an arrested heart (chemically-induced cardiac arrest to allow for a quiet field) with the patient connected to a heart-lung machine (pump) that temporarily takes over the oxygenation (lung function) and circulation (heart function) of the patient while the surgery is going on.

Is OPCAB better?

If at all possible, OPCAB, or beating heart surgery, is preferred. Doing the coronary bypass on a beating (non-arrested) heart precludes the use of the heart lung machine. This pump has the potential of destroying some blood cells, of wasting some essential clotting factors in the blood, and of forming blood clots or air bubbles that could cause stroke, albeit very rare. So, not using the heart-lung machine is a definite advantage, much less invasive and stressful for the patient. As a result, OPCAB patients recover a lot faster, go home much sooner, usually after 3-4 days after surgery. However, OPCAB is not for everyone.

How is the heart stilled?

With the patient connected to the pump, the heart is arrested by lowering the body temperature (thru blood cooling using a special cooler machine connected to the pump) down to about 28-30 degrees centigrade, and by giving the patient a high dose of potassium chloride which stops the heart beat in a relaxed (flabby) muscular state. This allows the cardiac surgeon to make tiny (2 mm-4 mm) anastomoses (suturing together two arteries or a vein and an artery of the heart, like sewing a sleeve to the shirt, an end-to-side or T-connection) using a magnifying surgical loop (special eyeglasses for an enlarged view), on a non-beating heart.

What are the sizes of the arteries?

The coronary arteries (which feed the muscles of the heart) and the internal mammary arteries (which are harvested as grafts from the undersurface of the breast bone, one from the left and one from the right side) are usually about 2 to 3 millimeters in diameter, about the size of a round toothpick or the lead in pencils. The vein grafts that are harvested from the leg are on the average about 4 to 5 mm in diameter.

To connect vessels this small, we arrest the heart and use a magnifying loop as mentioned above for precise suturing. This is a delicate and a most essential part of the bypass surgery, and requires extreme attention to details, in order for the “pipe connection” to allow maximum blood flow, with the least resistance or impedance. Any buckling, purse-stringing, or twisting of the anastomosis will cause blood clots in the area of the T-joint which eventually blocks off, leading to failure of the surgery. This could spell a disaster, a heart attack. This particular “plumbing job” must be “perfect.”

What suture materials are used?

The sutures we use for the anastomoses have a diameter smaller than human hair. They are technically known as 6-0, 7-0, or, 8-0, which is the smallest of the three. They are prophylene (plastic-like, but with greater tensile strength) sutures, commercially called Prolene, which are non-absorbable, unlike silk, which disintegrate with time. Prolene sutures stay intact forever.

How are blockages diagnosed?

The stenoses (narrowing) or occlusion (total blockage) of the coronary arteries are diagnosed with the aid of coronary angiogram (also referred to as cardiac catherterization), where a spaghetti-sized catheter is inserted into the femoral (groin) artery under local anesthesia and its tip directed to the opening of the left and right main coronary arteries. Dye is injected into the coronary arteries and the whole procedure is recorded in a video movie. This will show the dye in motion, the diameter and integrity of the lumen (inner channel) of the arteries and whether there are blockages or none.

Why not do this test on everyone?

While cardiac catheterization is a safe procedure done daily in various heart centers around the world, it has potential complications like transient irregular heart rhythm, blood clots, arterial leak, disruption in the wall of the artery, bleeding at the puncture site in the groin. While these are rare, there is a golden rule in medicine that says tests, in general, must only be done if there is an clinical indication (justification). If a person has no symptoms or strong family history of heart disease, cardiac catheterization is not recommended. Just about the only exceptions could be an employer required executive check-up, or airline mandated test for commercial pilots. Besides, this is an expensive procedure and insurance companies do not consider this to be a reimbursable prophylactic test.

How is OPCAB done?

With the patient under general anesthesia, the chest is split in the middle, from the base of the neck down to about the tail of the sternum (breastbone), same as in the conventional technique. With OPCAB, the patient is not connected to a heart lung machine. There is a special instrument (cardiac stabilizer) that minimizes the heart action in the area of the artery to be bypassed. The rest of the heart continues to beat. This stabilizer restricts the contraction of the heart in the target area, allowing the cardiac surgeon to do his suturing, aided by a surgical loop for magnified (3-4 times) view. With beating heart surgery, the patient does not feel so zapped, rundown and tired compared to the standard procedure where heart lung machine and cardiac arrest are used.

Does every heart surgeon do OPCAB?

No. Only those who had additional training on this particular technique perform beating heart surgery. It is a more tedious procedure and more difficult for the surgeon but much easier on the patient. Putting sutures on tiny arteries while the heart is beating is just like “shooting a tiny moving target.” A surgeon has to “retrain” his mind and hands, and gets used to this cutting edge-technology to be able to do OPCAB. 

This writer had to undergo such hands-on OPCAB surgical training at the Boston University Hospital in Massachussetts, under Dr. R. Cohn, the inventor of the Genzyme Cardiac Stabilizer. My team and I did our first OPCAB on a 68-year-old American from California, a retiree in Cebu, on June 8, 1999, the first quadruple OPCAB bypass performed in the Philippines, at the Cebu Doctors University Hospital. Even in the United States, only a little more than 60% of the surgeons perform OPCAB procedures.

Is the conventional bypass obsolete?

Most definitely not. There are still a large number of patients who could be better served with the conventional on-pump heart bypass. As I stated earlier, OPCAB is not for everyone. But the trend shows more and more coronary bypass procedures are being done on beating hearts today. It stands to reason that OPCAB is here to stay.

***

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