[HSF] MVR in dilated LV

[Nasser F. Abou'Seada]

best treatment for PVE is to replace the valve, remove the source of
infection "prosthesis in this case", aggressive surgical and antibiotics
regimen. losing time equates losing best chance. 
I use an aggressive 4 antibiotics coverage regimen ... modulated according
to C/S results and commonly identifiable local hospital pathogenic flora. 
I'd treat as a potential MOF candidate ..... guarding against that from the
start. 

*INFECTION CONTROL 
*AGGRESSIVE SURGICAL time sparing policy 
	*Excellent Myocardial perfusion "cont retrograde / a la Salerno" 
*Guarding against potential MOF 

Time factor is most crucial. 
good luck with your patient ....

NFA

> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
> bounces at lists.hsforum.com] On Behalf Of nand kejriwal
> Sent: Monday, October 16, 2006 8:31 PM
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] MVR in dilated LV
> 
> Thanks for all the responses. Infection does seem to be an issue now. The
> reasons I posted this case are:
> 
> 1. My feeling in this case is that the LV dilatation and impairment is at
> least partly due to cardiomyopathy, as pointed out by Prasanna. I am not
> sure how much of that would be reversed after MVR.
> 
> 2. In the recent ACC/AHA Practice guidelines (JACC 48,2006:e1-148), the
> management strategy (page e65) states that surgery should not be offered
if
> ESD > 55 mm and chordal preservation is unlikely. This man had his first
> replacement in 1970. I do not have the op notes. Therefore, I am not sure
if
> chordae were preserved at that time, perhaps not.
> 
> 3. The main question that I wanted to ask is at what LV dimension would
MVR
> do more harm than good? Do we have any cut-off numbers? Is there evidence
on
> this?
> 
> Nand
> 
> 
> 
> On 10/17/06, hgrmd at aol.com <hgrmd at aol.com> wrote:
> >
> > MVR with mechanical.  Cryomaze.
> > Hal
> >
> >
> > -----Original Message-----
> > From: nkkejriwal at gmail.com
> > To: OpenHeart-L at lists.hsforum.com
> > Sent: Mon, 16 Oct 2006 5:16 AM
> > Subject: [HSF] MVR in dilated LV
> >
> >
> > 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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