[HSF] redo double valve
Nasser F. Abou'Seada
nfaabouseada at gmail.com
Mon Oct 16 05:18:29 EDT 2006
I have seen some cases with pannus ..... ..... some associated with mitral
prosthesis but mainly associated with Aortic Mechanical Prostheses ......
have replaced them all ....... the idea behind that is that "I" -the
surgeon- have been already there .... would take an extra 25-30 minutes at
most to replace a valve that has been working for some years .... with a
defect somewhere resulting in pannus formation .... why take chances ????
.... why not give the patient the best chance for a brand new prosthesis
especially that the surgeon is already there opening the aorta standing in
front of the valve ???? with a scalpel in his hand, nurse holding needle
holder, valve ready to be opened in a fraction of a second ..... same
setting of cardioplegia anyway .... no new cardioplegia time ... !!!! .....
..... Finance ??? .... not a fraction of the cost of the bypass,
consumables, Operating theatre time and operation already incurred .... !!
.... in fact sparing another future operation that would certainly have to
be performed to remove a future pannus from the same valve, should it have
been left in place ...... "same location same predisposing factors .... same
everything!!!".
No RCT ..... just anecdotal practice .... surgically biased !!!
NFA
> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
> bounces at lists.hsforum.com] On Behalf Of Ani Anyanwu
> Sent: Sunday, October 15, 2006 10:27 PM
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] redo double valve
>
> Dear Dr Gammie
>
> Did you open the left atrium widely and insert the scope or did you put
the videoscope
> through a stab incision? Sounds rather slick and maybe something we could
do like in
> endocarditis cases and reops where we just need to visually inspect the
valve.
>
> BTW is there a chance this pannus could recur? One of my old bosses once
told me
> that the treatment for pannus round a mechanical valve was always to
change the
> prosthesis and if it is merely scraped away it would recur. I do not know
if his view
> was based on any evidence or just anecdote and would be keen to learn from
the
> experience of senior members in this regards.
>
> Ani Anyanwu
>
>
> ----- 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: Thursday, October 12, 2006 10:32 PM
> Subject: Re: [HSF] redo double valve
>
>
> Wanted to thank my friends on the HSF for sage advice on my patient with
> prior double mechanical valve replacements.
>
> Operated on her today: straightforward redo sternotomy; previous
surgeon
> used a large patch (?dacron) on the aortotomy; it was
> heavily calcified, so i excised it. You guys were on the money re
pannus:
> there was a ring-like band of pannus just below the aortic valve;
> removed old valved, completetely debrided annulus, and extended
aortotomy
> down through annulus and beyond about 1 cm, stopping just
> before roof of left atrium (is this a nicks or manouguian, i am not
sure..);
> used a bullet-shaped dacron patch to reconstruct and was able
> to insert a 21 HP St Jude valve. Before doing so got a good look at the
> mitral through the lvot: there was a ring of pannus here, as well;
> was able to peel that off with a rongeur quite nicely; videoscope then
> confirmed no obstruction of valve on either side.
> Post op tee gradient across mitral down to 4, doing great in icu.
> Thanks for help
> jsg
>
>
>
>
> 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.
>
>
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