[HSF] Trip to Croatia

[Ani Anyanwu]

Prasanna

Interesting narrative.

I am keen to know your honest opinion of the Mitrofast having now witnessed it. It seems to me counterintuitive that one would repair the (more difficult) anterior leaflet and yet treat the posterior leaflet with a device that allows successful repair where the surgeon is not skilled in repair. Surely if one can repair an anterior leaflet he can also repair the posterior too rather than placing a prosthesis?

Also while I acknowledge the economic constraints in Crotia may have forced it, in general would you recommend repair of dehiscence in a patient with a SE valve coming back with paravalvar leak? Is this not a lost opportunity to switch to a less thrombogenic valve (if you believe the SE is more thrombogenic that is)?

Ani
  ----- Original Message ----- 
  From: prasannasimha<mailto:prasannasimha at gmail.com> 
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> ; ccm<mailto:ccm-l at ccm-l.org> ; Med-Events<mailto:med-events at ccm-l.org> 
  Sent: Thursday, April 05, 2007 12:06 PM
  Subject: [HSF] Trip to Croatia


  On the invitation of Bojan Biocina, I had been to Hospital Dubrava , 
  Zagreb ,Croatia.
  I had the opportunity to see and experience another culture and interact 
  with  surgeons from another land.
  All the members of the cardiac surgical team are avid followers of the HSF.
  We did  quite a few interesting cases.(repairs, adult congenital and 
  redo's).
  I had the opportunity to demonstrate the electrocautery maze there and 
  also the use of indigenous rings using material that they had at hand ( 
  used split pieces of Goretex tube grafts) which are excellent.
  We had  a redo post subaortic membrane resection. I did an initial mini 
  Konno procedure and when we weaned I found an unacceptable gradient . On 
  analysis of the TEE I saw the appearance of new SAM, mitral 
  regurgitation and gradient in the upper part which failed to disappear 
  with removal of all inotropes and volume loading (which was previously 
  "Open" and so we went back and I did an extensive "Morrow" type" of 
  resection after which the gradient came down to 15 mm Hg on pressure 
  recording, the SAM and MR also disappeared.

  There was another very sick lady who had multiple surgeries (OMV via a 
  left thoracotomy ( bioprostheses and a SE valve implantation). The last 
  surgery was the SE implantation and she now had major paravalvar leak, 
  TR and also AFib. She was extremely sick and I was really wondering 
  whether she needed emergent surgery at night.She also had left 
  diaphragmatic paralysis and so we decided not to use a right thoracotomy 
  in case we damage the right phrenic too !! As per my usual protocol , I 
  did her with femoral arterial and venous cannula in place and backed up 
  volume into the reservoir to allow the BP to drop to the 60's  while 
  opening the sternum allowing the heart to fall back. I had given 
  instructions to go on CPB if there is persistent difficulty in 
  maintaining hemodynamics . With this method I am able to dissect the RV 
  easily and can immediately go on CPB when the dissection becomes 
  difficult.(With this  we can combine the advantages of both limiting CPB 
  and using it to advantage when we want things to "collapse" as the 
  situation demands.
  We dissected most of the "required" area  without CPB and then went on 
  CPB. Due to left diaphragmatic elevation the RA was in the position of 
  the  regular LA (the heart was torted - we had seen that too in the CT). 
  We used a balloon cannula for the SVC and that did not matter so much as 
  we had vacuum assist. We  endoclamped the aorta with a Foley balloon   
  after beating heart TV repair and right emaze lesions.
  On opening the LA transeptally, we found that the surgeon who did the 
  redo had used a continuous suture (3 suture Prolene technique) and the 
  prolene had unraveled off one third the annulus. I did not explant the 
  valve as there was no evidence of endocarditis and I did not have to 
  patch the annulus (we were contemplating either valve reimplantation or 
  patching the paravalvar leak with a double patch initially) as the 
  mechanism was clear as I could see the frayed suture broken in the 
  middle !!- there was also no evidence of previous endocarditis.
  Using liberal felt supplemetation and mattress sutures the leak was 
  closed (In the meanwhile the balloon burst so I used intermittent 
  dropping of flows at 22 Deg as this patient had AR (not requiring 
  replacement   but significant enough to trouble us !!). The leak was 
  tested intraop as thereAR leak allowed easy visualization of the 
  original leak and also after suturing).
  We were able to come off CPB uneventfuly and she is extubated and doing 
  well !!

  Other cases done included 2 repairs including bileaflet prolapse 
  (myxomatous) one ascending aortic replacement with David procedure  and 
  also I got to see a Mitrofast implantation- incidentally this patient on 
  table had billeaflet prolapse so I placed artificial anterior chords and 
  Bojan placed the Mitrofast and we got good coaptation.
  I did an elective  MVR on a lady who had some suspicion of SLE but the 
  Echo looked "rheumatic" on table did not fit into either and since the 
  "verrucous" lesions (confined only atrially) was bileaflet in nature , I 
  felt it was not wise to attempt a repair (I thought that if it was 
  mainly confined to the AML , I would be able to excise that and patch 
  that area) so we replaced that valve after reconfirming that the valve 
  would possibly require an extensive repair with possibility of 
  questionable results in the long term.

  This was a good experience and with international cooperation.
  This would not have been possible without the "invention" of the HSF by 
  Marc Levinson and I should congratulate him for starting the list serve 
  without which  this would never  been possible.
  I was extremely honored to be invited to conduct the workshop and share 
  my views and opinions and also to learn new approaches and solutions to 
  different problems and the wonderful case mix that I got to see.
  Prasanna
   

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