[HSF] redo double valve
Nasser F. Abou'Seada
nfaabouseada at gmail.com
Mon Oct 16 12:30:02 EDT 2006
Ani: .... I'm glad that you agree with me this time ..! ..:-) ..... free
thinking boosting abstract one and anecdotal experience !
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: Monday, October 16, 2006 8:05 AM
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] redo double valve
>
> Certainly if one is already in a chest and the reop is going well, it adds
very little to
> rereplace the mitral valve too. With the aortic out it should be a
straightforward
> replacement. Obviously if the reop has gone bad then one does a minimalist
> procedure.
>
> Given our lack of knowledge on the cause of pannus, if I were the patient
I would
> certainly want the valve rereplaced - as NFA says how are we to know it is
not an
> intrinsic problem with the valve that triggers the pannus. The philosophy
I have been
> taught about reops is to do everything that can be done so that it does
not become a
> wasted reop opportunity (I.e. use the opportunity to correct all
correctibles so as to
> prevent patient from being reoperated again for a problem that could have
been
> sorted this time). For the same reason I would have a very low threshold
for repairing
> the tricuspid valve in this patient too.
>
> Another mentor taught me that "wishful thinking will never take a problem
away - if
> you take the easy way out to smooth out a jagged edge, thinking you have
cured a
> problem it will likely still come back to haunt you so always do your best
to eliminate
> the problem entirely first time around". Scrapping pannus I would see as
akin to
> placing few sutures round a paravalvar leak rather than replacing the
valve - it will
> work sometimes but othertimes it doesn't and we would have wasted the reop
> opportunity. Obviously as Prasanna says there is a role for this procedure
in some
> patients and some circumstances but where possible surely a valve with a
gradient
> due to pannus should be rereplaced.
>
> PS - in several of the responses to the initial post it was suggested he
needed a
> double valve replacement, so I still think that is the usual practice in
this scenario.
>
> Ani
> ----- Original Message -----
> From: Nasser F. Abou'Seada<mailto:nfaabouseada at gmail.com>
> To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
> Sent: Monday, October 16, 2006 4:18 AM
> Subject: RE: [HSF] redo double valve
>
>
> 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> [mailto:openheart-l-
> > bounces at lists.hsforum.com<mailto: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<mailto: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<mailto:gammie at comcast.net>>
> > To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-
> L at lists.hsforum.com<mailto: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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