[HSF] SVR via left thoracotomy

Tea Acuff tacuff at swbell.net
Mon Oct 16 18:42:08 EDT 2006 

If it is mild probably a SVR alone will improve it. I do a suture annulaplasty from the v side if more severe, but this is probably easier with a cross clamp.
Tea


----- Original Message ----
From: ebender001 at charter.net
To: OpenHeart-L at lists.hsforum.com
Sent: Monday, October 16, 2006 11:34:50 AM
Subject: Re: [HSF] SVR via left thoracotomy


Hal,
Thanks for your comments.  No MR on echo.  Except for the apical aneurysm, this is a normal heart.  The mitral annulus is not calcified.  Therefore, if there were a mild amount of MR on TEE, I think I would do an edge-to-edge repair. Excuse me while I gird myself for the predictable slings and arrows to come from the forum.  Just to add to the drama, the patient is the mother-in-law of one of our orthopods, and she used to be Alfred Blalock's scrub nurse at Vanderbilt.  (Drum roll please).

Ed Bender, MD



---- hgrmd at aol.com wrote: 
> Ed,
>   I echo Ani's concerns regarding the approach to the LV aneurysm.  If you haven't already done a TEE, I'd do one before approaching this patient via left thoracotomy.  Out of the approximately 20 SVR cases I've done, none have not needed a mitral repair. Virtually all of them have at least moderate MR due to remodeling.  In fact, I recall that the last one I did only had mild MR at induction, so I decided that this would finally be one where I could finesse the valve.  However, upon trying to come off CPB, there was now severe MR.  I suspect the LV repair somehow pushed the tip of the posterior papillary muscle towards the annulus.  Anyway, I went back on bypass and installed an MC3 ring.  I came back off CPB, there was no MR, but now there was severe TR!.  I went back on bypass, and with the heart warm and beating, installed an MC3 ring.  The patient finally came off with an IABP.  I recall she was intubated several days.  However, I saw her in the office just last
 week,!
  an
>  d she was Class I and back to work.  The echo showed no MR or TR with an EF of 35%.
>   I can anticipate that your defense of the LV approach will be that, if needed, you can do the mitral repair via the LV.  I think that a DeVega repair via the LV is crap.  In no way could that be expected to be an adequate repair for asymmetric annular dilatation, which is what you would expect in these types of hearts.  A full rigid ring is now widely recognized as the standard for these types of repairs.
>   BTW, I'm now in Leiden, Netherlands for a valve repair meeting.  I'll keep everyone posted to the highlights.
> Hal 
>  
>  
> -----Original Message-----
> From: anianyanwu at hotmail.com
> To: OpenHeart-L at lists.hsforum.com
> Sent: Sun, 15 Oct 2006 10:15 PM
> Subject: Re: [HSF] SVR via left thoracotomy
> 
> 
> Dear Ed
> 
> Why exactly do you want to do this procedure through a left thoracotomy as 
> opposed to a median sternotomy - do you assess the risk of repeat sternotomy as 
> particularly prohibitive in this case or is there an anatomical or other reason 
> for favouring thoracotomy? I presume she has no mitral or aortic regurgitation 
> as either might favor a sternotomy.
> 
> Ani
> 
>   ----- Original Message ----- 
>   From: Edward Bender<mailto:ebender001 at charter.net> 
>   To: OpenHeart-L<mailto:OpenHeart-L at hsforum.com> 
>   Sent: Friday, October 13, 2006 7:55 PM
>   Subject: [HSF] SVR via left thoracotomy
> 
> 
>   I was asked to see an 83 year old female with class 3-4 CHF,  
>   orthopnea, moderate pulmonary hypertension.  CABG 8 years ago (LIMA  
>   to LAD, SVG to RCA).  Postop anterior MI.  Taken to cath lab on post- 
>   op day one and was found to have occluded LIMA at point of insertion  
>   to LAD and no distal perfusion.  Nothing was done at that time except  
>   medical therapy.  Since her symptoms of heart failure have progressed  
>   dramatically over the past 4-6 months, she underwent cath showing a  
>   large LV apical aneurysm, the mid and basal parts of the heart have a  
>   regional ejection fraction of 80% (mostly ejecting into the LV  
>   aneurysm), cardiac index of 1.6.  Interestingly, her LIMA graft is  
>   widely patent, filling a large LAD that wraps around the apex, with a  
>   95% proximal LAD stenosis.  The right graft looks great.  I think she  
>   would greatly benefit from resection of her aneurysm.  She is thin  
>   and frail, and I would like to do this without a sternotomy.  I would  
>   be interested in experiences of the members with a left thoracotomy,  
>   warm, beating technique or any other approaches.  Although she is  
>   quite small, I am confident that she can be cannulated peripherally  
>   without difficulty (I usually use a 17Fr biomedicus arterial and the  
>   small heartport venous).  Any pitfalls, bad experiences, good  
>   experiences?
> 
>   Thanks,
> 
>   Ed Bender, MD
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