[HSF] RV failure management strategies

[Hgrmd at aol.com]

Dr. Rey,
  I politely but firmly disagree with your premise that doing the bare  
minimum is always the best philosophy in cardiac surgery.  Indeed,  sometimes it is 
true in patients who are extremely frail and old.  However,  most of the time 
this policy is a mistake.  The key is knowing how to do  many procedures 
swiftly and effectively.  If you think giving a lifetime of  amiodorone is better 
than a Cox-maze, you are mistaken. Amiodorone  pulmonary and hepatic toxicity 
and very real and very well described.   Besides, pharmacologic control of AF 
is notoriously ineffective.  It takes  me less than 15 minutes to do a left 
sided cryomaze with a long term success  rate of 92%.  Nearly all right side 
procedures (maze, tricuspid  valvuloplasty) are done off clamp during the 
terminal portions of the pump run  while the body is rewarming and the heart is 
recovering.  Without a doubt,  the DeVega has been shown to be inferior to a rigid 
or semirigid prosthetic ring  when doing valve repair.  Is it cheap and fast?  
Yes.  Would I  want one done to me or my family member?  No.  It generally 
takes me  20-25 minutes to install a simple mitral ring from the time I incise 
the left  atrium to the time I put in the last atriotomy stitch.  With today's  
techniques of myocardial preservation, that amount of time in 
inconsequential.  Numerous studies have shown that the DeVega repair in both the mitral and  
tricuspid position has a strong tendency to degrade with time.  Note the  
November '06 Annals paper by Tirone David's group on this subject.   Also note my 
discussion at the end of the paper.
  I can't tell you how many cases of severe MR in the presence of a  recent 
AVR that I've had referred to me over the years.  The initial  surgeon thinks 
and hopes that the "moderate" MR will disappear in the presence  of severe 
aortic stenosis.  Don't count on it.  My policy is fix it  once and fix it right.
Hal