[HSF] Trip to Croatia
rwmfglycar at aol.com
rwmfglycar at aol.com
Sun Apr 8 04:15:45 EDT 2007
Last question first:
Yes.
The first two insertions of our Flexible Monocusp valve in June 1960 were "secured" with continuous 3-0 silk (it worked in the dogs). Both broke at 3 months in the patients' home towns and both died in hours.Both were autopsied. The healing from the rheumatic annulus had been poor in one case.
I had a patient helicoptered into Einstein in, I think the early 70's, with a totally detached aortic ball valve half in the LV and half in the aortic root. A continuous 2-0 polyester suture was attached to the sewing ring with one well tied knot. The former site of attachment to the patient was a well formed fibrous groove. The valve had been inserted in Texas. The patient had returned to New Jersey and was told immediately by his hometown cardiologist that he had residual insufficiency. Reassuring messages came from Texas until at one year postop he suddenly went into acute pulmonary edema. I took him straight to the OR from the helicopter and put him on bypass at the groin. He had some cardiac activity which bypass seemed to help so I went ahead and replaced his valve but he did not make it. I have nice 35 mm pictures which I must get digitised one of these days.
Otherwise the quite small number of cases all had various forms of interrupted sutures.
In reply to the question of whether some paravalvar leak implies something wrong with the whole suture line the answer is no. Poor exposure (classically the far left corner of the patient annulus at about the left commissure in a mitral) may account for poorly taken and badly spaced sutures; some surgeons faced with technical difficulty do less rather than spend more time and effort doing more. Thus the deficiency of the suture line is regional. The same can apply to endocarditis cases. This is true even after antibiotic sterilisation; the tissue is left damaged by the previous inflammatory process. This is where pericardial reconstruction can be helpful.
In the average case of valve insertion there is, after some months, fibrous overgrowth which, even if it is not growing into the cloth, has enough purchase on the cloth to add to the strength of attachment. The combination of imperfect sutures and imperfect incorporation are sufficient to hold the valve indefinitely. If you have replaced a quite modest number of structurally failed or thrombosed valves, with completely intact annular attachment, you may have found that incising the pannus over the ring and cutting the insertion sutures individually will allow the valve to be lifted out of its bed without much force. That observation makes me believe that it is not inevitable that in the presence of a segmented continuous suture that a leak at one spot means that the whole suture line is about to fall apart. This is very much a matter of inspection of the suture line and its healing and of judgment which includes a quite intimate knowledge of the device and its sewing ring. Obviously doubt and uncertainty must push you in the direction of replacement.
Finally the Silzone story is quite revealing. There were institutions following their cases carefully in which no valves developed a significant paravalvar leak. There were others in which the incidence was significant. I flew down South to see one case for myself. The reoperation was I think towards the end of the first year. There was no doubt in my mind that the healing was grossly abnormal around the whole circumference of the aortic annulus. I also counted the sutures and there were less than 2/3 of what I would have regarded as standard. As you may know what was thought to be a significant difference between silzone and nonsilzone case early in the randomised trial turned out, as time went by, not to be so. My conclusion was that the reaction to the silver was probably idiosyncratic, affecting some patients' healing process more than others, but also that the standard practices of insertion were substantially more robust in some surgeons' hands than others so that poor healing could be masked by superior technique.
A well written account of the circumstances at the first operation can be useful in these decisions. I cannot tell you how many case of paravalvar leak I have reviewed in my role as SJM medical director, in which there is no mention of the state of the tissue, no description of the number or caliber of sutures used, sometimes no mention of the suture technique and no notations of any difficulties or problems encountered. e.g. "at the middle of the posterior annulus a suture pulled through the tissue as soon as I tied it down. I reinserted two bolstered mattress sutures taking more tissue at this point etc. etc."
A Happy Easter to those to whom it applies and good wishes to all,
Bob
-----Original Message-----
From: anianyanwu at hotmail.com
To: OpenHeart-L at lists.hsforum.com
Sent: Sat, 7 Apr 2007 5:22 PM
Subject: Re: [HSF] Trip to Croatia
Thank you very much Dr Frater on your analysis of paravalvar leakage. You are
indeed an amazing source of knowledge and inspiration for young and
inexperienced students of surgery like myself and I keep several of your
contributions (such as this) for future reference. Your comment about lack of
ingrowth and permanent dependency on the suture for ring security is interesting
and likely explains some late leaks that occur with a continuous technique.
Could future changes to the left ventricle or annulus also impact on the
security of an implanted valve? Could the fractured suture occur secondary to
such change (the tension on the continuous suture is presumably more than on the
individual interrupted sutures)?
Based on your analysis though within a semi-continuous suture line with 3 or 4
independent sutures (strictly speaking they are not even independent as they are
tied to one another) there are 3 reasons why the suture line could have failed
i) Knots were not tied properly
ii) Either of your listed factors 1 to 6 were in operation or
iii) Inadvertent damage to the suture material during surgery.
My question therefore is as before - if either of these had caused the leak in
one of the 3 or 4 segments of continuous prolene, then is it safe to assume the
same factors are not in operation - or might in future be in operation - in the
seemingly unaffected prolene segments? Were any of the repairs of paravalvar
leak you have done in valves previously implanted with a continuous technique?
Ani
----- Original Message -----
From: rwmfglycar at aol.com<mailto:rwmfglycar at aol.com>
To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
Sent: Saturday, April 07, 2007 4:49 PM
Subject: Re: [HSF] Trip to Croatia
Think Ani.
Assuming that the tensile strength and durability of the suture chosen is
adequate to hold the closed valve in situ against the downstream pressure
indefinitely, and that the knots are tied properly, then Paravalvar Leak is the
consequence of one or more of the following factors :
1) Too few suture connections between the tissue and the sewing ring (whether
interrupted or continuous).
2) Too little tissue encompassed by the suture, so that the tissue strength is
inadequate to hold the closed valve in situ against the downstream pressure.
3) General pathology of the tissue that makes it too weak even with a normal
depth of suture to withstand the load it is supposed to carry.
4) Local pathology of the tissue, with focal weakness that does the same as in
4) above.
5) A sewing ring that does not allow healing of the host to the ring material.
(many rings fit this category so that insertion is indefinitely dependent on the
original sutures and some overgrowth rather than incorporation).
6) A tissue annulus that does not heal to the sewing ring and may in addition
abrade the sutures. (An inadequately debrided calcified annulus is an example of
this. Note too that abrasion of the suture may take time).
I would also make the following generalisations:
i) Small, trivial paravalvar leaks are common early (probably due to factor 1)
above and often heal quite soon
ii) Most significant paravalvar leaks are also evident early if you search for
them and unless they produce hemolysis, tend to be followed until they have made
the ventricle sick.
iii) The single biggest danger of continuous suture technique is that if
factors 1), 2), 3), 4) are present in one way or another, implying poor
technique (including inadequate exposure), or poor analysis of the pathology,
once the first loosening of the suture occurs the stress on the adjacent
tissue/suture combination inevitably increases and tends to cause progressive
pulling loose of the whole suture line.
This, of course, is why users of continuous sutures took to making
interruptions.
If the causes are analysed in the way I am suggesting there is no general
statement to be made that "the standard of care is replacement". In my time I
replaced some and repaired some. In fact there were two cases in which cardiac
surgeons had already replaced the valve for paravalvar leak in which, when they
were sent to me with once again significant paravalvar leaks, I did succesful
repairs that I know never recurred.
I am intrigued by Prasanna's observation of a fractured prolene suture. 2-0
prolene does not do this unless it was damaged. I suspect the surgeon grabbed it
with a clamp to pull the loops tight. I would not be surprised if the history
shows some leak duringthe first 6 months after surgery.
Bob
-----Original Message-----
From: anianyanwu at hotmail.com<mailto:anianyanwu at hotmail.com>
To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
Sent: Sat, 7 Apr 2007 9:01 AM
Subject: Re: [HSF] Trip to Croatia
Bojan/Prasanna
Thanks for the clarification. My question regarding replacing the valve was
misunderstood. My question was that assuming you decided you had to explant
the
valve and rereplace, would you then reuse the same explanted SE valve - with
its
nine year history of reliability in the patient - or would you use a new
non-SE
valve?
I would however argue with the logic (in general) to leave previously
implanted
valves in situ. If your argument was to leave a time tested reliable valve
which
is compatible with the patient in situ, how would it be logical to leave a
time-tested unreliable (because it has failed once) suture line in situ which
was cause of the patient's reoperation? It is true that the suture technique
was
to blame, but then you have left a valve which in two-thirds of its
circumference relies on an insecure technique. If the suture technique is to
blame then does the whole suture line not need a cure? And if we chose to talk
of biology, the patient and suture line have shown incompatibility by failure
of
part of the suture line (for whatever reason). Have we not lost an opportunity
to cure her of this problem? She remains at unquantifiable, but not
insignificant risk of paravalvar leakage, for the rest of her life - a risk
that
could have been grossly reduced by rereplacement with interrupted sutures. I
was
trained with the philosophy that the treatment for paravalvar leak is always
rereplacement as whatever factor caused the leak could precipitate either
failure of repair or new leakage - by definition one has to assume (even with
interrupted sutures) that the whole suture line is at risk. In training I saw
few patients who came back with leaks after attempted repair of paravalvar
defects. Of course if repairing the defect vs replacement was a life-death
decision, repair is preferable to embarking on a fatal or technically
impossible
rereplacement, but I think it is correct to say that the standard of care
should
be valve rereplacement (I assume so and stand to be corrected)?
Having worked at a hospital very close to Harley Street where her surgery was
performed (and with surgeons who operate in Harley Street), I will tell you
that
we saw a LOT of mitral (and even aortic) reoperations on patients who had
continuous suture MVR. No data to prove but it is my conception that this by
far
outnumbered (proportionally) those patients coming back with interrupted
sutures. Patients with continuous sutures were unique though because unlike
most
interrupted paravalvar leaks which presented early after replacement,
paravalvar
leaks after continuous sutures developed at any time after implantation from
days to years. We saw some continuous suture valves developing new leaks many
years after implant as was case in your patient. If she is young enough, any
part of the remaining suture can fail in the future and she will develop a new
leak (especially considering that SE sutures were placed in rereplacement
setting).
For all the talk about data on the SE and non-inferiority, there is one
problem
- who here would honestly have such a valve implanted on themselves or their
family? For all our talk, and maybe we are brainwashed by industry, we deep
inside do not see the two designs (ball and cage vs disc) as equivalent. I
will
be the first to own up that I would not have a SE valve put in me even though
I
accept (and have stated) there is no evidence it is inferior.
Ani
----- Original Message -----
From: bbiocina at kbd.hr<mailto:bbiocina at kbd.hr<mailto:bbiocina at kbd.hr<mailto:bbiocina at kbd.hr>>
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>>
Sent: Saturday, April 07, 2007 4:48 AM
Subject: Re: [HSF] Trip to Croatia
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<mailto:anianyanwu at hotmail.com<mailto:anianyanwu at hotmail.com<mailto: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<mailto:bbiocina at kbd.hr<mailto:bbiocina at kbd.hr<mailto:bbiocina at kbd.hr<mailto:bbiocina at kbd.hr<mailto:bbiocina at kbd.hr<mailto:bbiocina at kbd.hr>>>
> 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<mailto: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>>>
> 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<mailto:prasannasimha at gmail.com<mailto:prasannasimha at gmail.com<mailto:prasannasimha at gmail.com<mailto:prasannasimha at gmail.com<mailto: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<mailto:tacuff at swbell.net<mailto:tacuff at swbell.net<mailto:tacuff at swbell.net<mailto:tacuff at swbell.net<mailto: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<mailto:prasannasimha at gmail.com<mailto:prasannasimha at gmailcom<mailto:prasannasimha at gmail.com<mailto:prasannasimha at gmailcom<mailto:prasannasimha at gmail.com<mailto:prasannasimha at gmailcom>>>>
> >> 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<mailto: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>>>
> >> 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<mailto:prasannasimha at gmail.com<mailto:prasannasimha at gmail.com<mailto:prasannasimha at gmail.com<mailto:prasannasimha at gmail.com<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<mailto: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<mailto: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<mailto: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<mailto:ccm-l at ccm-l.org<mailto:ccm-l at ccm-l.org<mailto:ccm-l at ccm-l.org<mailto:ccm-l at ccm-l.org<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<mailto:med-events at ccm-l.org<mailto:med-events at ccm-l.org<mailto:med-events at ccm-lorg<mailto:med-events at ccm-l.org<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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