[HSF] RV failure management strategies

Ani Anyanwu anianyanwu at hotmail.com
Mon Dec 4 08:32:24 EST 2006 

Dear Roberto

I am not sure that the two examples (TEE and flow measures) are analogous - for the former it is the standard of care and there is plenty of evidence and anecdote that routine TEE in valve cases is beneficial. 

In contrast there is no evidence that measuring flows of bypass grafts has any bearing on (clinical) outcome. While flow measure may demonstrate a technically inadequate operation, there is no evidence that correction of these inadequacies (which some would argue are inherent to CABG surgery as up to 10% of grafts are occluded within a month of surgery), there is no evidence that correction of these inadequacies leads to better outcomes. This is an easy RCT to do - can you not randomize patients to flow measure or no flow measure then examine one year (clinical and angiographic) outcomes?

Ani
  ----- Original Message ----- 
  From: Dr. Roberto Battellini<mailto:battr at medizin.uni-leipzig.de> 
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
  Sent: Monday, December 04, 2006 4:01 AM
  Subject: AW: [HSF] RV failure management strategies


  Hal,

  I agree, many times an AVR is done under preop MI I and after going out of
  pump, the AI is grade II.
  For example last week I assisted a resident doing an AVR, and after going
  off pump the MI was grade II. I put a Cosgrove ring and was not enough and
  hat to reimplant 8 cordae with Mohr´s loops, as the cordae were elongated .
  (Bad preop diagnosis I told to the Echo-people.)
  It was cumbersome with a 25 Epic valve in situ...
  TEE is to valves as Flowmeasures are to cabg.
  Roberto

  -----Ursprüngliche Nachricht-----
  Von: openheart-l-bounces at lists.hsforum.com<mailto:openheart-l-bounces at lists.hsforum.com>
  [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von prasannasimha
  Gesendet: Samstag, 2. Dezember 2006 14:44
  An: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
  Betreff: Re: [HSF] RV failure management strategies

  Leaving an incomplete correction can lead anyway to disaster.
  One thing that I do not like to leave is Afib it can make a mess of both 
  perioperative and postoperative management.
  I have shifted to using a Goretex strip TV plasty after various 
  discussions in the forum. I really have not had a bad experience with a 
  De Vega in rheumatics probably related to their thicker annulus but I 
  felt that if literature says it fails putting a strip hardly takes extra 
  time and eliminates guitar stringing which is the basic mechanism of 
  failure. It doesn't take much time either. I cannot use a preformed ring 
  for obvious reasons.One thing is that I have not had problems per se 
  with the Goretex /Pericardial strip annuloplasty.
  I have had many of these rotten cases and have pulled out these but some 
  cases are lost. I presume others too would have a similar experience.
  Prasanna

  Hgrmd at aol.com<mailto:Hgrmd at aol.com> wrote:
  > 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
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