[HSF] Trip to Croatia
Tea Acuff
tacuff at swbell.net
Fri Apr 6 22:37:36 EDT 2007
This trip was quite a feat, Prasanna. Your immediate results are highly commendable.
The critiques, however, highlight one of the wrinkles of dialect that we discuss in various forms usually as evidence, authority or experience. The problem is comparing each patient that we see to the populations or individual other patients. Medicine is face to face, or borrowing Dr. Frater's expression, one on one. Not that we should experience each patient as if there is no connection whatsoever to the last or the many, but each patient is as unique as each surgeon's capacity and context. It is similar to the appellation of the infectious disease specialty (as we commonly use in the US) instead of geographical medicine. TB in Tennessee is not TB all over the world, nor is a rash. The latter moniker, geographical medicine, expresses literally a whole new world view. As for infectious disease, wait a while and the world will change around you. Cardiac surgery, while not as dramatic geographically or temporally, likely has many of the same lessons.
We don't operate specifically on patients with mitral regurgiation, or even posterior leaflets, but specific (even if unknown) disease etiologies and confirmations by surgeons in different systems with different resources. In rheumatics it is likely that the posterior leaflet is the most deformed and the least fixable by hacks like me. Ani has pointed out that a variety of techniques have come, gone and persisted, but assuming the actual result is dependent strictly based on technique or anatomical location, or even type of prothesis is a myopic fantasy. Prasanna gives very suitable reasons to ignore our "best practices". Only his actual, observed results will justify his thinking, or his best practice, not my guidelines.
The same journal that Tomas recently suggested (Canadian Journal of Cardiology March 2007?) had an article about ED evaluation of chest pain that dealt with the problems and successes of protocols, guidelines and scoring systems in the actual practice of matching specific patients to theoretical and actual populations. I thought it was more interesting than the one that he recommended, because it was about an area that I could understand but not blinded by my own biases and information. Sometimes we can not see what the others describe because we use the same words but actually have a different "dialect", ie use the same words to describe somewhat different situations. We tend to rest well knowing that we did what the experts or our last success say. Our patients may rest better if we study each patient result that we encounter. High risk is often the mirror image of poor selection.
Nice job, Prasanna.
Sorry for the lecture.
tea
----- Original Message ----
From: prasannasimha <prasannasimha at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Friday, April 6, 2007 9:23:39 PM
Subject: Re: [HSF] Trip to Croatia
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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