[HSF] Trip to Croatia

Sat Apr 7 08:53:39 EDT 2007

Taking her previous event rate and our experience in India with a Starr 
Edwards valve , I would really contest its "Higher" thrombogenicity. I 
can tell for sure that there have been less "fatal" events with this 
valve compared to  the newer ones. Usually any valve thrombosis with the 
Starr Edwards is "symptomatic"  and allows them to reach the Hospital 
such that thrombolysis can be instituted as "complete" valve choke is 
less often seen. In fact in India it was very popular compared to other 
mono/bileaflet valves for this very reason .
I see a specific role for the Mitrofast in patients with retracted PML's 
in rheumatics where P3 retraction does not allow delamellation, old 
ladies with calcified MAC and PML pathology where posterior pathology 
may be more difficult to repair and salvage of some patients with 
attempted repairs where there is a failure of the repair . This 
technique could be a useful adjunct to a surgeon if used wisely and 
appropriately.
Prasanna

Ani Anyanwu wrote:
> 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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