RES: [HSF] MVR in dilated LV

Thu Oct 19 10:29:32 EDT 2006

Pretty well describes the state of affairs, including the "I'm close (to the truth)". As those that study ideas know, often ideas don't die until those that hold them do, (or conversely ideas don't live unless someone holds them.) As in everything it is easier to let some else suffer a little so we don't have to, particularly if we are shielded from the sight. 
tea

----- Original Message ----
From: "Salerno, Tomas" <TSalerno at med.miami.edu>
To: OpenHeart-L at lists.hsforum.com
Sent: Wednesday, October 18, 2006 3:49:31 PM
Subject: RE: RES: [HSF] MVR in dilated LV

Interesting that the aortic valve replacements and root procedures are
the very patients who benefit most from procedures in which the heart is
vulnerable to ischemia.Work from Angelini's group in England has shown
conclusively that none of the current myocardial protective strategies
currently in use are suboptimal in terms of myocardial protection.
Should we simply accept the status quo, or should we continue to search
for newer and more effective means of protection? There are those who
have learn one technique in the the 70's and 80's and have not changed,
and they seem to claim excellent results, both with crystalloid and
blood cardioplegia. There are those who have opted to continue to modify
their approach and to continue in the search for the elusive "ideal
solution" to the cardioplegic method.

We continue to repeat the issue of valvular repair versus replacement -
and I believe we all do more or less the same procedures, albeit not to
the same volume, have more emphasis on one than in the other type of
procedure. The issue of doing complex mitral valvular surgery comes done
to evaluation of the pathology, and deciding what is the best procedure.
Usually TEE gives the surgeon a fairly good idea of what needs to be
done. Whether this is insertion of new chordae for a variety of
pathologies, resection of the posterior leaflet for prolapse,
slidoplasty, variety of rings, and others, all can be done with the
heart beating. And if needed, brief periods of arrest is possible with
administration of potassium to the solution (Calafiore's warm
intermittent cardioplegia).  The fact remains that those surgeons who
aim for increased period of perfusion with blood, at least for the
periods of comfort, experience easier weaning and problems such as
fibrillation, arrhythmias and need for drugs. 

The process of change is painful... We need to continue the search for
superior methods of myocardial protection. I do not claim to have the
"ideal" method, but no doubt, my experience indicates that I am close.
Time will tell...

Tomas

-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of
hgrmd at aol.com
Sent: Wednesday, October 18, 2006 4:12 PM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: RES: [HSF] MVR in dilated LV

It's the same old debate.  I have yet to hear that complex mitral repair
cases are being done in significant numbers with warm beating heart.  I
don't give a hoot about replacements of either the mitral or aortic, nor
am I talking about root reconstructions.  I'm talking about complex
bileaflet mitral valve repair.  As I've stated before, I've seen Florida
state records on who is doing mitral repair in significant numbers.
"Show me the money!"
Hal 

-----Original Message-----
From: TSalerno at med.miami.edu
To: OpenHeart-L at lists.hsforum.com
Sent: Wed, 18 Oct 2006 9:51 AM
Subject: RE: RES: [HSF] MVR in dilated LV

Beating heart surgery represents a major development in the history of
myocardial protective strategies, in my view. However isolated I have
been, of all techniques of myocardial protection that I have used over
the years in my life, perfusion comes near the "ideal" method.  I have
come to realize that, the heart lung machine, developed for operations
in the heart and, implied, is heart and lung friendly, actually does not
protect the heart and the lung. The heart and lungs are the only organ
that suffer during operations in which the heart lung machine.

Early enthusiasm about retroperfusion of the brain, have led to elegant
studies indicating that only perfusion protects the brain during
circulatory arrest, and that other techniques are suboptimal. This does
not mean that one should not use retroperfusion, it simply means that
clinical outcomes are superior when perfusion is used.

Ischemia reperfusion injury is a complex subject, and one that we
understand little. All efforts so far have been at modifying the injury,
when in fact one should prevent it, by perfusion.

Those who are criticizing beating heart surgery, have actually not seen
or done it. Trained and indoctrinated into the cardioplegic method, it
is hard to change the view that there may be other methods of protecting
the heart. 

It is fair to say that surgeons should wait for results, which are
forthcoming. A large experience with 276 valvular cases including root
procedures, show that all parameters of outcome are at least comparable
to, if not superior to, conventional techniques of cold cardioplegia.
Hopefully you will this in press shortly.

Cardiac surgery, regardless of the procedure, is myocardial protection.
Injured hearts at time of surgery will suffer over the long period. May
be it is time to reassess this whole field. And that is what I am doing,
however controversial.

Tomas

-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of
hgrmd at aol.com
Sent: Wednesday, October 18, 2006 8:43 AM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: RES: [HSF] MVR in dilated LV

Ani,
  I've been watching master valve surgeons for the past week.  None of
them used beating heart.  Believe me, there's a reason.
Hal 

-----Original Message-----
From: anianyanwu at hotmail.com
To: OpenHeart-L at lists.hsforum.com
Sent: Wed, 18 Oct 2006 7:24 AM
Subject: Re: RES: [HSF] MVR in dilated LV

There are arguments for beating heart surgery which we have discussed 
extensively before. It is an excellent technique in the hands of those
who know 
how to do it. It is nothing new either - my previous chief Yacoub was
operating 
on the perfused heart till the early 1990s. Salerno and others have
perfected 
the technique and shown that it likely provides better protection. I
agree that 
a heart that is not ischemic has to (by definition) function better than
one 
that was ischemic. That is not the debate. I was not beating heart
surgery is a 
bad technique, but that for surgeons who usually operate on the arrested
heart , 
a poor LV is not a reason to be worried about clamping the heart. Both 
techniques can be done safely. 

The reality is that beating heart surgery is a level of skill, or a
gift, that 
most of us do not have. I would be the first to admit that I cannot
carry out a 
detailed valve analysis and do a complex 2 to 3 hour Carpentier repair
on a 
Barlow's bileaflet valve with the heart beating. Because I am not that
skilled 
(and likely never will be), I have to resort to cardioplegic arrest.
Having said 
that, I am not alone as I do not know of any master of valve repair who
does 
repairs in big numbers (and rarely replaces) that does not use
cardioplegic 
arrest. I have been for several live courses and never seen an 'expert'
do a 
mitral repair with the heart beating away. Maybe there are other reasons
for 
this (?quality of repair, repair rates) but for a lot of us it is simply
beyond 
our skill set to do a complex repair on a beating heart.

Ani
  ----- Original Message ----- 
  From: Theofilo<mailto:gauze at brturbo.com.br> 
  To:
OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
  Sent: Wednesday, October 18, 2006 4:32 AM
  Subject: RES: RES: [HSF] MVR in dilated LV

  Dear Colleagues, 
  With all due respect, I'd like to point that talking about how
torturing is
  to operate on a beating heart for a valve replacement sounds to me the
same
  as talking over on X off pump CABG. And I would go further, why go to
the
  Moon if the Earth is easier to live with... As you have your believes,
one
  has theirs...
  Theofilo Gauze
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