[HSF] Trip to Croatia
bbiocina at kbd.hr
bbiocina at kbd.hr
Sat Apr 7 10:48:13 EDT 2007
Ani ,
to re-clarify , I do not have a preconception about the inferiority of
SE valve at all. Quite the opposite , leaving that valve in place
was at least partially motivated by the preconception that the valve
was good enough to be left ( as Prasanna pointed out ) , there was
no problem with the valve during the past 9 years , so the valve
was left rather than to face more dificult ( and potentially
dangerous) replacement. My clarification was directed to your
suggestion that the decision for primary implantation of SE valve ( and
subsequent decision not to re-replace it) was motivated with "
economic constraints" in Croatia , which do not exist ( at least
regarding the choice of valves) . In late 80's we switched to more
"modern" ( and definitely more expensive ) valves , whether it made
any benefit to our patients can still be debated.
Regarding the preoperative plan , as the nature of massive paravalvular
leak was unclear , all options ( patching , replacement , additional
sutures) were considered , and I think that Prasanna opted for the most
balanced solution.The last question about potential reimplantation of
another SE valve is theoretical , as SE valve has not been available
in Croatia for almost 20 years. However , I honestly think that any
valve would do well in this lady , and that the problem was of
completely different nature which you toroughly described.
It would be also very interesting to see Hal's oppinion on potential
legal implications of such suturing technique if this happened in U.S.
Bojan
On 4/7/2007, "Ani Anyanwu" <anianyanwu at hotmail.com> wrote:
>Now that explains it - prasanna's description of continuous prolene used in a reop MVR will sound as an odd choice of technique to many, but as anyone who trained in London (like I did) would understand as there are numerous surgeons who sadly still use this technique as method of choice for mitral valve implantation. This partly arises because there is a school of surgery in London that ascribes mainly to the (Cooley) philosophy that fast surgery and limited cardiac ischemia has to be the goal in all procedures - for valve surgery this means continuous sutures for all implants. I say sadly because there is evidence that patients who have a continuous suture technique have a higher incidence of paravalvar leakage - including data from presented but never published by the London St George's group a decade ago.
>
>Interesting though that reading through the lines Bojan seems to imply that SE is an inferior valve and suggests surprise that it was used in London in 1998 when it had been abandoned in Croatia 10 years earlier. If that is the preconception therefore why would one keep an 'inferior' valve? It is more than likely that the pre-operative plan was indeed to replace this valve and the decision to repair the defect was one made intraoperatively. I would then ask Bojan and Prasanna, assuming the decision had been to rereplace the valve would they have reimplanted the SE or placed a bileaflet valve?
>
>SE valves were used in London at least till 2000. I am not sure why but I did know of some surgeons stated advantages in the sewing ring and durability as the basis. Indeed Murday and Treasure from London randomized almost 400 patients to either a SE or a St Jude valve in both mitral and aortic positions between 1991 and 1997. This is one of few statistically powered randomized trials in cardiac surgery. Incidentally this trial which was published in the Annals (2003) showed no difference in valve related outcomes between the two groups. They conclude that it is important that we do not base our comparisons on valve prosthesis on historical control data - the outcomes of a SE valve in 1970 are different from those in 2000. As Tom Treasure always said, assuming discs valves came first and someone in 1995 suddenly invented the ball and cage a novel design which will prevent jammed disc, surgeons will all embrace it and we would probably all be placing SE valves now. That is why we have to scientifically study outcomes, randomizing where necessary - as Hunter said "when I did the experiment the result was different" - our preconceptions (of the 'archaic' SE) may not necessarily reflect the truth. Interestingly though, despite finding that the two valves were indifferent, the authors did not recommend continued use of SE and as far as I know that group ceased implanting the valves after the trial closed. This goes to say that there is a lot that is unsaid outside the realms of data, results and evidence, and often it is these unspoken observations and summations, rather than the evidence, that guide our choice of therapy.
>
>Ani
> ----- Original Message -----
> From: bbiocina at kbd.hr<mailto:bbiocina at kbd.hr>
> To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
> Sent: Saturday, April 07, 2007 2:54 AM
> Subject: Re: [HSF] Trip to Croatia
>
>
> 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<mailto: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<mailto: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<mailto:prasannasimha at gmailcom>>
> >> To: OpenHeart-L at lists.hsforum.com<mailto: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<mailto:prasannasimha at gmail.com>>
> >> > To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>>
> >> ; ccm<mailto:ccm-l at ccm-l.org<mailto:ccm-l at ccm-l.org>> ; Med-Events<mailto:med-events at ccm-l.org<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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