[HSF] redo double valve
Tea Acuff
tacuff at swbell.net
Sun Oct 8 18:38:42 EDT 2006
I suspect that shoe horning a slightly bigger valve in the aortic position is a mistake. When I was doing pedi I did a (small) nine year old who had several resections for aortic and subaortic stenosis. The pedi surgeon mentioned transplant to the mom ( a doctor friend of mine), who then talked with me. I did a konno which really opened up the whole outflow tract and put in a 21 mechanical. I have lost contact but he did not have recurrent subvalvular problems for the several years. Fix the LVOT and I would expect a better intermediate solution. If you plan a double valve you can also do a Moungian incision onto the mitral and enlarge the mitral annulus, repairing the left atrial defect, mitral annulus, out flow tract and aortic wall with room for a larger aortic annulus and aortic wall and sinus, using a long patch of tube graft. Try it on a couple of pig hearts first. The anatomy is a little disorienting from normal approaches. Or come to the Dallas Valve Meeting at the
end of this month to try it in a wet lab.
Tea
----- Original Message ----
From: prasannasimha <prasannasimha at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Sunday, October 8, 2006 12:48:54 AM
Subject: Re: [HSF] redo double valve
Ani,
It would be difficult to judge the operation in retrospect but If the
mitral valve was repairable I would have repaired it and done an AVR
with a mechanical prosthesis with the full understanding that this child
would probably require a redo later.I still strongly believe that an AVR
+ MV repair has a better long term outcome compared to a primary DVR
even if you include the inevitable re MVR that will have to be done later.
I have done a few rheumatic aortic repairs in young children (usually
those who are 5-10 years old )so that we can tide over the growth period
to allow an AVR later. (I have also done 3 triple valve repairs in young
children (5-6 years of age) - two are doing well and have entered their
teens and one died after 2 years when he got fungal endocarditis after
IV fluid therapy for a bout diarrhea)
After saying that, I do not implant 19 mm valves often and with a non
everting mattress or simple suture technique I can implant at least a 21
mm valve in cases where I would have put a 19 mm valve. (This child was
supposed to have a BSA of 2.0 m2 and I would definitely not place a 19
mm valve in him. Why a 19 mm valve was placed after attempted root
enlargement is worrisome. Assuming that a Manouguian increase the
annulus by 2-3 sizes then was the original annulus 16 mm - unusual for
rheumatic AR and would also imply a narrow LVOT.
In young rheumatics Ross is not a good option and worse still with
concomitant mitral valve disease. Homografts also calcify rapidly at his
age .So a mechanical DVR would be the only "real world" option for him.
I am still considering subcoronary homografts / inclusion cylinder
homografts for young patients who will have to go to the "Hinterland"
where anticoagulation monitoring is really impracticable but the main
problem is getting homografts. The Deac procedure seems to be an
attractive option in nonrepairable mitrals going to the Hinterland.
Since I do a lot of rheumatic repairs I now usually am referred
repairable valves and there may be some "preselection bias" and I now
rarely replace a valve which I have preoperatively deemed repairable.
In this case we would have to do a redo DVR. I am sure that there will
be pannus / thin layer of clot that is causing the problem. This pannus
is usually "subvalvar" and can cause obstruction even if the leaflets
appear to have a normal excursion..
My personal way of approaching this case now a days is as follows.
I check if the pleurae were open in the previous surgery. Like Hal I do
keep a femoral arterial cannula routinely though I do not usually keep a
femoral venous cannula routinely but only selectively. During induction
a couple of units of blood is drawn from the neck line and I usually RAP
the arterial line to allow the heart to become less turgid while doing
the sternotomy. I then dissect the heart of the sternum with an
intention of intentionally entering the pleural space and cannulate the
RA through the intact pericardium. This is easy to do and then I dissect
enough aorta to cross clamp and deliver cardioplegia. I do not go on
bypass now but inform the perfusionist to go on either when I/
Anesthesiologist tells him or he notices hemodynamic instability. I
then dissect and open the left pleural space to allow defibrillation and
deairing if I do not have external patch defibrillator's- that happens
often !!)
I now minimally dissect the aorta further to find a place for aortotomy
and the LA will be approached through intact adherent pericardium behind
the phrenic and above the pulmonary vein entrance. I use continuous
retrograde with intermittent antegrade and usually cool to 25 deg C
This allows minimal dissection, less bleeding and less painful
dissection which is unnecessary. One interesting thing is if you use
balloon cannulae for the RA you can incise onto the RA appendage stuck
to the aorta and this is very easy to close over rather than peeling of
the appendage etc etc.
If the pleural tubes had been previously placed, I will still open the
pleura - usually there are a few stringy adhesions that can be divided
and the same thing continues. If there are dense adhesions then grin
and bear it and dissect the right sided structures to cannulate and
approach the mitral valve either via the original incision or trans RA.
I still think this patient can get at least a 21 aortic and a 27 mitral.
If not then consideration for a Manouguian double valve with enlargement
of the aortomitral continuity may be considered though I still feel it
may be less likely.
If you want to put a larger mitral prosthesis , eccentric placement of a
mitral valve can also be done- anteriorly non everting and posterior
everting mattress sutures allows one size larger mitral prosthesis too.
With a minimal dissection technique, I usually do not have to transfuse
any blood and the surgery is quicker and faster. There is no point in
freeing the LV if you are not going to put any grafts to it.
If the mitral valve appears pretty deep you can take a large towel and
displace it behind the PV via the left pleura though I do that very rarely.
If there is LV distention prior to adequate dissection I push a 16 G
Abbocath through the RV via the septum into the LV and vent it.
One attractive option that I have not yet done would be to transect the
aorta and reach the mitral via the dome and do both through a upper
limited hemisternotomy with minimal dissection. I do not have access to
CO2 gas and external defibrillator patches so I have not done it.
Prasanna
Ani Anyanwu wrote:
> It would be interesting also to hear the thoughts from Prasanna, NFA and others who deal with lot of rheumatic disease on the choice of operation she had 12 years ago and the implications for the present management. T
>
> I presume from the description the gradients definitely arise from the valves and not the ventricle?
>
> Ani
>
>
> ----- Original Message -----
> From: James S Gammie<mailto:gammie at comcast.net>
> To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
> Sent: Saturday, October 07, 2006 10:30 PM
> Subject: [HSF] redo double valve
>
>
> Interested in the forum's opinion on this case:
>
> 24 yo female s/p AVR/MVR with mechanical valves at age 12 (12 years ago) for
> rheumatic disease.
>
> Presents with progressive dyspnea, now with minimal exertion. Did well
> after initial operation.
>
> Old operative note not available, cardiology letter states that a 19 St Jude
> valve placed in aortic position along
> with an "enlargement" procedure, and a 27 in mitral position. Early postop
> a gradient of 38 noted across aortic valve (not stated if mean or peak). St
> jude medical has record of 19 HP insertion in aortic position, no record of
> mitral.
>
> Patient is about 5 ft 6 inches 200 pounds, and was that size at age 12.
>
> Fluoroscopy shows all leaflets moving normally. Also confirmed on TEE and
> MSCT. Normal ejection performance.
>
> Gradient across aortic valve = 100 peak, 55 mean. No subvalvular
> obstruction.
>
> Gradient across mitral valve (mean) = 12. Measurement of ID of mitral valve
> on MSCT suggests it may actually be a size 25 valve.
>
> Would be delighted to have any advice from forum on managment. Am
> particularly puzzled with mitral gradient in the presence of normally
> functioning reasonably sized valve.
>
> Thanks
>
> jim gammie
>
>
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