April 26, 2017, 7:53 pm
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1 Philippine Peso = 0.07374 UAE Dirham
1 Philippine Peso = 2.49799 Albanian Lek
1 Philippine Peso = 0.03594 Neth Antilles Guilder
1 Philippine Peso = 0.30869 Argentine Peso
1 Philippine Peso = 0.02653 Australian Dollar
1 Philippine Peso = 0.03594 Aruba Florin
1 Philippine Peso = 0.04016 Barbados Dollar
1 Philippine Peso = 1.66265 Bangladesh Taka
1 Philippine Peso = 0.0362 Bulgarian Lev
1 Philippine Peso = 0.00756 Bahraini Dinar
1 Philippine Peso = 34.12309 Burundi Franc
1 Philippine Peso = 0.02008 Bermuda Dollar
1 Philippine Peso = 0.02795 Brunei Dollar
1 Philippine Peso = 0.13795 Bolivian Boliviano
1 Philippine Peso = 0.06279 Brazilian Real
1 Philippine Peso = 0.02008 Bahamian Dollar
1 Philippine Peso = 1.29719 Bhutan Ngultrum
1 Philippine Peso = 0.20691 Botswana Pula
1 Philippine Peso = 402.00804 Belarus Ruble
1 Philippine Peso = 0.04012 Belize Dollar
1 Philippine Peso = 0.02712 Canadian Dollar
1 Philippine Peso = 0.01999 Swiss Franc
1 Philippine Peso = 13.14779 Chilean Peso
1 Philippine Peso = 0.13823 Chinese Yuan
1 Philippine Peso = 57.61044 Colombian Peso
1 Philippine Peso = 11.0492 Costa Rica Colon
1 Philippine Peso = 0.02008 Cuban Peso
1 Philippine Peso = 2.03795 Cape Verde Escudo
1 Philippine Peso = 0.4955 Czech Koruna
1 Philippine Peso = 3.5743 Djibouti Franc
1 Philippine Peso = 0.13744 Danish Krone
1 Philippine Peso = 0.94578 Dominican Peso
1 Philippine Peso = 2.18602 Algerian Dinar
1 Philippine Peso = 0.28902 Estonian Kroon
1 Philippine Peso = 0.36285 Egyptian Pound
1 Philippine Peso = 0.45783 Ethiopian Birr
1 Philippine Peso = 0.01847 Euro
1 Philippine Peso = 0.04172 Fiji Dollar
1 Philippine Peso = 0.01569 Falkland Islands Pound
1 Philippine Peso = 0.0157 British Pound
1 Philippine Peso = 0.08205 Ghanaian Cedi
1 Philippine Peso = 0.88052 Gambian Dalasi
1 Philippine Peso = 185.36145 Guinea Franc
1 Philippine Peso = 0.14727 Guatemala Quetzal
1 Philippine Peso = 4.10221 Guyana Dollar
1 Philippine Peso = 0.15618 Hong Kong Dollar
1 Philippine Peso = 0.46867 Honduras Lempira
1 Philippine Peso = 0.13713 Croatian Kuna
1 Philippine Peso = 1.33153 Haiti Gourde
1 Philippine Peso = 5.74598 Hungarian Forint
1 Philippine Peso = 267.38956 Indonesian Rupiah
1 Philippine Peso = 0.07311 Israeli Shekel
1 Philippine Peso = 1.29488 Indian Rupee
1 Philippine Peso = 23.71486 Iraqi Dinar
1 Philippine Peso = 651.34539 Iran Rial
1 Philippine Peso = 2.16064 Iceland Krona
1 Philippine Peso = 2.5751 Jamaican Dollar
1 Philippine Peso = 0.01423 Jordanian Dinar
1 Philippine Peso = 2.20343 Japanese Yen
1 Philippine Peso = 2.06888 Kenyan Shilling
1 Philippine Peso = 1.34789 Kyrgyzstan Som
1 Philippine Peso = 80.12048 Cambodia Riel
1 Philippine Peso = 9.2747 Comoros Franc
1 Philippine Peso = 18.07229 North Korean Won
1 Philippine Peso = 22.75743 Korean Won
1 Philippine Peso = 0.0061 Kuwaiti Dinar
1 Philippine Peso = 0.01647 Cayman Islands Dollar
1 Philippine Peso = 6.25622 Kazakhstan Tenge
1 Philippine Peso = 164.67872 Lao Kip
1 Philippine Peso = 30.25502 Lebanese Pound
1 Philippine Peso = 3.05723 Sri Lanka Rupee
1 Philippine Peso = 1.80723 Liberian Dollar
1 Philippine Peso = 0.26094 Lesotho Loti
1 Philippine Peso = 0.06122 Lithuanian Lita
1 Philippine Peso = 0.01246 Latvian Lat
1 Philippine Peso = 0.02828 Libyan Dinar
1 Philippine Peso = 0.19886 Moroccan Dirham
1 Philippine Peso = 0.38584 Moldovan Leu
1 Philippine Peso = 1.13153 Macedonian Denar
1 Philippine Peso = 27.04819 Myanmar Kyat
1 Philippine Peso = 48.27309 Mongolian Tugrik
1 Philippine Peso = 0.16089 Macau Pataca
1 Philippine Peso = 7.14859 Mauritania Ougulya
1 Philippine Peso = 0.6994 Mauritius Rupee
1 Philippine Peso = 0.30622 Maldives Rufiyaa
1 Philippine Peso = 14.41345 Malawi Kwacha
1 Philippine Peso = 0.37604 Mexican Peso
1 Philippine Peso = 0.08831 Malaysian Ringgit
1 Philippine Peso = 0.261 Namibian Dollar
1 Philippine Peso = 6.3253 Nigerian Naira
1 Philippine Peso = 0.59056 Nicaragua Cordoba
1 Philippine Peso = 0.17162 Norwegian Krone
1 Philippine Peso = 2.07129 Nepalese Rupee
1 Philippine Peso = 0.02861 New Zealand Dollar
1 Philippine Peso = 0.00772 Omani Rial
1 Philippine Peso = 0.02008 Panama Balboa
1 Philippine Peso = 0.065 Peruvian Nuevo Sol
1 Philippine Peso = 0.06586 Papua New Guinea Kina
1 Philippine Peso = 1 Philippine Peso
1 Philippine Peso = 2.10141 Pakistani Rupee
1 Philippine Peso = 0.07841 Polish Zloty
1 Philippine Peso = 110.69879 Paraguayan Guarani
1 Philippine Peso = 0.07311 Qatar Rial
1 Philippine Peso = 0.08354 Romanian New Leu
1 Philippine Peso = 1.11942 Russian Rouble
1 Philippine Peso = 16.43896 Rwanda Franc
1 Philippine Peso = 0.07529 Saudi Arabian Riyal
1 Philippine Peso = 0.15744 Solomon Islands Dollar
1 Philippine Peso = 0.27046 Seychelles Rupee
1 Philippine Peso = 0.13372 Sudanese Pound
1 Philippine Peso = 0.17781 Swedish Krona
1 Philippine Peso = 0.02796 Singapore Dollar
1 Philippine Peso = 0.01569 St Helena Pound
1 Philippine Peso = 0.4459 Slovak Koruna
1 Philippine Peso = 149.5984 Sierra Leone Leone
1 Philippine Peso = 10.98394 Somali Shilling
1 Philippine Peso = 452.80121 Sao Tome Dobra
1 Philippine Peso = 0.17514 El Salvador Colon
1 Philippine Peso = 10.34096 Syrian Pound
1 Philippine Peso = 0.26104 Swaziland Lilageni
1 Philippine Peso = 0.68916 Thai Baht
1 Philippine Peso = 0.05006 Tunisian Dinar
1 Philippine Peso = 0.04645 Tongan paʻanga
1 Philippine Peso = 0.07169 Turkish Lira
1 Philippine Peso = 0.13453 Trinidad Tobago Dollar
1 Philippine Peso = 0.60745 Taiwan Dollar
1 Philippine Peso = 44.77912 Tanzanian Shilling
1 Philippine Peso = 0.53434 Ukraine Hryvnia
1 Philippine Peso = 72.53012 Ugandan Shilling
1 Philippine Peso = 0.02008 United States Dollar
1 Philippine Peso = 0.57068 Uruguayan New Peso
1 Philippine Peso = 74.29719 Uzbekistan Sum
1 Philippine Peso = 0.2003 Venezuelan Bolivar
1 Philippine Peso = 456.10443 Vietnam Dong
1 Philippine Peso = 2.17892 Vanuatu Vatu
1 Philippine Peso = 0.0517 Samoa Tala
1 Philippine Peso = 12.11064 CFA Franc (BEAC)
1 Philippine Peso = 0.05422 East Caribbean Dollar
1 Philippine Peso = 12.18876 CFA Franc (BCEAO)
1 Philippine Peso = 2.19137 Pacific Franc
1 Philippine Peso = 5.01908 Yemen Riyal
1 Philippine Peso = 0.26099 South African Rand
1 Philippine Peso = 104.20683 Zambian Kwacha
1 Philippine Peso = 7.26707 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.

***

Visit philipSchua.com Email: scalpelpen@gmail.com
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