June 26, 2017, 8:00 pm
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1 Philippine Peso = 0.07443 UAE Dirham
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1 Philippine Peso = 0.32436 Argentine Peso
1 Philippine Peso = 0.02723 Australian Dollar
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1 Philippine Peso = 0.02027 Bermuda Dollar
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1 Philippine Peso = 0.13904 Bolivian Boliviano
1 Philippine Peso = 0.06579 Brazilian Real
1 Philippine Peso = 0.02027 Bahamian Dollar
1 Philippine Peso = 1.30624 Bhutan Ngultrum
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1 Philippine Peso = 0.02733 Canadian Dollar
1 Philippine Peso = 0.01952 Swiss Franc
1 Philippine Peso = 13.57175 Chilean Peso
1 Philippine Peso = 0.13799 Chinese Yuan
1 Philippine Peso = 58.59343 Colombian Peso
1 Philippine Peso = 11.43535 Costa Rica Colon
1 Philippine Peso = 0.02027 Cuban Peso
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1 Philippine Peso = 0.47231 Czech Koruna
1 Philippine Peso = 3.59951 Djibouti Franc
1 Philippine Peso = 0.13357 Danish Krone
1 Philippine Peso = 0.95278 Dominican Peso
1 Philippine Peso = 2.19181 Algerian Dinar
1 Philippine Peso = 0.28109 Estonian Kroon
1 Philippine Peso = 0.36583 Egyptian Pound
1 Philippine Peso = 0.46433 Ethiopian Birr
1 Philippine Peso = 0.01797 Euro
1 Philippine Peso = 0.04244 Fiji Dollar
1 Philippine Peso = 0.01573 Falkland Islands Pound
1 Philippine Peso = 0.01572 British Pound
1 Philippine Peso = 0.08685 Ghanaian Cedi
1 Philippine Peso = 0.91021 Gambian Dalasi
1 Philippine Peso = 182.75233 Guinea Franc
1 Philippine Peso = 0.1491 Guatemala Quetzal
1 Philippine Peso = 4.14512 Guyana Dollar
1 Philippine Peso = 0.15784 Hong Kong Dollar
1 Philippine Peso = 0.47422 Honduras Lempira
1 Philippine Peso = 0.13229 Croatian Kuna
1 Philippine Peso = 1.24625 Haiti Gourde
1 Philippine Peso = 5.54195 Hungarian Forint
1 Philippine Peso = 269.57844 Indonesian Rupiah
1 Philippine Peso = 0.07211 Israeli Shekel
1 Philippine Peso = 1.30521 Indian Rupee
1 Philippine Peso = 23.93595 Iraqi Dinar
1 Philippine Peso = 657.62059 Iran Rial
1 Philippine Peso = 1.9771 Iceland Krona
1 Philippine Peso = 2.6139 Jamaican Dollar
1 Philippine Peso = 0.01433 Jordanian Dinar
1 Philippine Peso = 2.23666 Japanese Yen
1 Philippine Peso = 2.0906 Kenyan Shilling
1 Philippine Peso = 1.38113 Kyrgyzstan Som
1 Philippine Peso = 81.57681 Cambodia Riel
1 Philippine Peso = 9.12404 Comoros Franc
1 Philippine Peso = 18.24078 North Korean Won
1 Philippine Peso = 22.6366 Korean Won
1 Philippine Peso = 0.00614 Kuwaiti Dinar
1 Philippine Peso = 0.01662 Cayman Islands Dollar
1 Philippine Peso = 6.364 Kazakhstan Tenge
1 Philippine Peso = 166.08836 Lao Kip
1 Philippine Peso = 30.51277 Lebanese Pound
1 Philippine Peso = 3.08877 Sri Lanka Rupee
1 Philippine Peso = 1.84435 Liberian Dollar
1 Philippine Peso = 0.25922 Lesotho Loti
1 Philippine Peso = 0.06179 Lithuanian Lita
1 Philippine Peso = 0.01258 Latvian Lat
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1 Philippine Peso = 0.19642 Moroccan Dirham
1 Philippine Peso = 0.36735 Moldovan Leu
1 Philippine Peso = 1.09972 Macedonian Denar
1 Philippine Peso = 27.52331 Myanmar Kyat
1 Philippine Peso = 48.27726 Mongolian Tugrik
1 Philippine Peso = 0.16258 Macau Pataca
1 Philippine Peso = 7.25578 Mauritania Ougulya
1 Philippine Peso = 0.70024 Mauritius Rupee
1 Philippine Peso = 0.31394 Maldives Rufiyaa
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1 Philippine Peso = 0.37863 Mexican Peso
1 Philippine Peso = 0.08672 Malaysian Ringgit
1 Philippine Peso = 0.2604 Namibian Dollar
1 Philippine Peso = 6.52615 Nigerian Naira
1 Philippine Peso = 0.59972 Nicaragua Cordoba
1 Philippine Peso = 0.17055 Norwegian Krone
1 Philippine Peso = 2.08654 Nepalese Rupee
1 Philippine Peso = 0.02835 New Zealand Dollar
1 Philippine Peso = 0.00779 Omani Rial
1 Philippine Peso = 0.02027 Panama Balboa
1 Philippine Peso = 0.06622 Peruvian Nuevo Sol
1 Philippine Peso = 0.06654 Papua New Guinea Kina
1 Philippine Peso = 1 Philippine Peso
1 Philippine Peso = 2.11897 Pakistani Rupee
1 Philippine Peso = 0.0753 Polish Zloty
1 Philippine Peso = 112.82935 Paraguayan Guarani
1 Philippine Peso = 0.0738 Qatar Rial
1 Philippine Peso = 0.08196 Romanian New Leu
1 Philippine Peso = 1.14766 Russian Rouble
1 Philippine Peso = 16.61897 Rwanda Franc
1 Philippine Peso = 0.076 Saudi Arabian Riyal
1 Philippine Peso = 0.16004 Solomon Islands Dollar
1 Philippine Peso = 0.26836 Seychelles Rupee
1 Philippine Peso = 0.13498 Sudanese Pound
1 Philippine Peso = 0.17451 Swedish Krona
1 Philippine Peso = 0.02797 Singapore Dollar
1 Philippine Peso = 0.01573 St Helena Pound
1 Philippine Peso = 0.45006 Slovak Koruna
1 Philippine Peso = 152.00649 Sierra Leone Leone
1 Philippine Peso = 11.08634 Somali Shilling
1 Philippine Peso = 435.85326 Sao Tome Dobra
1 Philippine Peso = 0.17678 El Salvador Colon
1 Philippine Peso = 10.43737 Syrian Pound
1 Philippine Peso = 0.26014 Swaziland Lilageni
1 Philippine Peso = 0.6897 Thai Baht
1 Philippine Peso = 0.04917 Tunisian Dinar
1 Philippine Peso = 0.04647 Tongan paʻanga
1 Philippine Peso = 0.0711 Turkish Lira
1 Philippine Peso = 0.13537 Trinidad Tobago Dollar
1 Philippine Peso = 0.61011 Taiwan Dollar
1 Philippine Peso = 45.17633 Tanzanian Shilling
1 Philippine Peso = 0.53223 Ukraine Hryvnia
1 Philippine Peso = 72.78071 Ugandan Shilling
1 Philippine Peso = 0.02027 United States Dollar
1 Philippine Peso = 0.57377 Uruguayan New Peso
1 Philippine Peso = 77.82732 Uzbekistan Sum
1 Philippine Peso = 0.20216 Venezuelan Bolivar
1 Philippine Peso = 459.54601 Vietnam Dong
1 Philippine Peso = 2.18241 Vanuatu Vatu
1 Philippine Peso = 0.05201 Samoa Tala
1 Philippine Peso = 11.77483 CFA Franc (BEAC)
1 Philippine Peso = 0.05472 East Caribbean Dollar
1 Philippine Peso = 11.82205 CFA Franc (BCEAO)
1 Philippine Peso = 2.13174 Pacific Franc
1 Philippine Peso = 5.06546 Yemen Riyal
1 Philippine Peso = 0.25921 South African Rand
1 Philippine Peso = 105.17835 Zambian Kwacha
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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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