[HSF] Trip to Croatia
Tea Acuff
tacuff at swbell.net
Tue Apr 10 12:15:36 EDT 2007
Ani,
In rereading your post, i think that you have it somewhat backwards. a continuous suture has less tension per stich since it slips the tension to the next suture instead of to the tissue as with an interrupted stich. However, if one stich tears or is broken in a continuous technique it tranfers the lack of tension down the line. Persumably in a valve one has enough stiches (bites) to avoid (distribute) tension, and that is not a problem. If your main worry is tension, use a continous technique (eg as musculofascial closure, or friable atrium.)
tea
----- Original Message ----
From: prasannasimha <prasannasimha at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Tuesday, April 10, 2007 8:34:53 AM
Subject: Re: [HSF] Trip to Croatia
Ani,
I did toy on the idea of placing sutures all around the annulus. The
other thought was to add a few pledgetted sutures in the middle of each
triangulated segment. The rest of the suture line was good and did not
show any evidence of wear and tear. Also I was worried about "pithing"
the previous suture line with the new needles and producing abrasion
injury where there was none. Also placing blind sutures in the posterior
annulus was not something I would have relished. Hence I chose to leave
the rest of the annulus as it was.
It appeared from inspection of the frayed suture that whatever that was
acting to cause the dehiscence was a local factor and so I though that
would be enough.
Prasanna
Ani Anyanwu wrote:
> 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
> > >_______________________________________________
> > >OpenHeart-L mailing list
> > >
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