[HSF] MVR in dilated LV

[Tea Acuff]

Agree. No transplant.
Tea


----- Original Message ----
From: Nasser F. Abou'Seada <nfaabouseada at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Monday, October 16, 2006 5:15:59 AM
Subject: RE: [HSF] MVR in dilated LV


> ESD is 5.96cm and EDD 7.49 cm. EF 40%
> FS 20.4%. Gradient across prosthesis 19mm, mean 8.8. RV syst pr are 47.6.

Transplant team ????? why Sir ??? .....  
These parameters are not largely deviate from common practice. 
Ideally I'd continue with antibiotics for enough time ... 8 weeks in case of
streptococcus PVE ..... yet in cases of haemodynamic deterioration   ????
severe MR ???? vs "???? NYHA class II" ... I'd go for urgent -not emergency-
operation to replace the valve under an umbrella of antibiotics.  

you need to plan your procedure "I'd start with preop GIK", plan your
incision "I'd go for re-sternotomy with oscillating saw, femoral cannulation
??" , plan your approach "I'd use SSI, TA LV venting, with no dissection of
the ventricles nor apex", Plan your good myocardial preservation, "I'd go
for continuous retrograde perfusion", replacing the prosthesis should be a
piece of cake. Inspecting the tricuspid valve on a beating heart is an
essential step to my mind, a tricuspid repair should be offered in any case
of doubt. The key element IMHO is excellent perfusion and perfect myocardial
salvage. trans LA venting of the LV to my mind plays a very crucial rule in
weaning off Bypass. 

The choice and execution of antibiotics policy is very important .... the
intricate help of an intensivist and a clinical microbiologist with interest
in PVE is very essential .. it depends on your local hospital flora and
isolated organisms ... 

Good luck with your case .... 
NFA

> From: nand kejriwal
> Dear members
> 
> I have been referred a 45 year old gentleman for opininon regarding Redo
> Redo MVR. He underwent mitral valve replacement in 1971 when apparently a
> stented homograft was used. The valve degenerated and in 1990 it was
> replaced with a 31 mm Intact bioprosthesis, as he was reluctant to take
> warfarin. Recently he presented with endocarditis and grew Streptococcus.
He
> has completed the full course of antibiotics and is now afebrile with
> normalisation of the lab parameters. A recent TOE revealed a small healed
> vegetation with severe MR. The problem is that his LV is markedly dilated
> with impaired systolic function. The ESD is 5.96cm and EDD 7.49 cm. EF 40%
> FS 20.4%. Gradient across prosthesis 19mm, mean 8.8. RV syst pr are 47.6.
> Initially, the feeling was that the LV had dilated acutely due to acute
> degeneration of the prosthesis because of endocarditis. But on scanning
his
> previous echo reports, it appears that his LV was quite dilated even when
> the prosthesis was intact. The ESD was 5.2 in 2004 (EDD 6.82) and
6.1(EDD7.3)
> last year. There was no MR then. . He is now in AF and is on warfarin now.
> He has NYHA class II symptoms, but otherwise does not have significant
> co-morbidies. Should this patient be accepted for MVR or should I refer
him
> to the transplant team?.
> 
> Thanks for your opinion.
> 
> Nand
> 
> Nand K Kejriwal
> Consultant Cardiothoracic Surgeon
> Waikato Hospital
> Hamilton, New Zealand

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