[HSF] Trip to Croatia
bbiocina at kbd.hr
bbiocina at kbd.hr
Sat Apr 7 08:54:46 EDT 2007
As Prasanna is polite and nice ( and I am little less of both of
that) , I would just like to clarify: second redo operation on patient
with Starr-Edwards was done at Harley Street ,London , UK , in 1998,
(the reason for op. was degenerated CE tissue valve) , when and where
the type of valve was chosen. Last Starr-Edwards valves were
implanted in Croatia in late 80's( being a registrar in general
surgery I can still remember those operations).
Other issues have been clearly explained by Prasanna , nothing more to
add.
Bojan
On 4/7/2007, "Prasanna Simha M" <prasannasimha at gmail.com> wrote:
>I do not think there would be a problem of accessing another valve for
>reimplantation in Croatia as the system is governmental paying and health
>care is born by the Government.
>There are three things that made me retain the valve.
>1) The valve on inspection was pristine with no clot and actually what
>worried me was there was not even a hint of pannus on the sewing rim.
>2) The mechanism of leak was due to suture failure (I could see the frayed
>suture with the ends popping out !! ) and had nothing to do with the valve.
>3) This patient had a very favorable event rate with the valve till the leak
>occurred. Some patients are "Thrombosers /Bleeders" and it is well known
>that the highest event rate is in the first 18 months after implantation.
>She was otherwise doing well till 9 months before. I am not so much against
>the Starr Edwards valve and frankly there is also equal literature as Ben
>says showing good durability and function so I am not inherently biased to
>replacing it.Also with the torque of the heart due to left hemidiaphragm
>elevation replacement would not have also been very easy and I was content
>in fixing the problem and did not want to "overdo" things.I feel that the
>problem that occurred was due to use of a continuous suture technique in a
>redo case were probably interrupted suture technique would have been more
>appropriate.
>Bojan will be sending me the scanned pictures of the CT and if you see it,
>you will appreciate that just approaching and visualizing the valve was
>difficult let alone operating on it.
>Prasanna
>
>On 4/7/07, Tea Acuff <tacuff at swbell.net> wrote:
>>
>> 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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>
>
>
>--
>Prasanna Simha M
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