[HSF] 25 mm valve

[psimha]

Tirone David may say so but when we were residents two of my colleagues 
had chordal preservation as their theses and we did see a striking 
benefit. (At that time we noted that cases which we would have dubbed as 
"goners" started flying off home (without any changes and with the same 
horrible cocktail cardioplegia we used to give then).  I had made one of 
my residents do a study on comparison of posterior versus total chordal 
preservation. We did find a significant difference in locoregional 
ventricular function . I would need much more convincing than one 
series. That may still be a statistical outlier. May be the attrition 
rate in the long term may be a function of thrombohemorhagic culling 
which may actually make any improved ventricular function a moot point 
as they may not survive long enough or else kill off those who would 
have survived (emphasizing the importance of repairs again).
Incidentally we do get old rheumatics too in small women too in addition 
to the younger ones (in fact they are the ones who may require 
replacement). I am not denying that some patients do need a 25 mm valve. 
I once had the misfortune of having to put a 23 size valve in a hefty 
man. The 23 sizer just fit in and even that implantation was difficult.I 
rate it as one of my most difficult implants - bad calcified small rock 
of a valve with poor exposure despite all the maneuvers I could think of 
at that time and me praying that the "night mare" just gets over.
Paradoxically there is  a paper recently on patient prosthesis mismatch 
in the mitral position - am not sure it really exists still (anyway I am 
happy if I can plonk in at least a 25 mm valve and I am not a big fan of 
implanting greater than 29 mm (in fact we don't keep it in the hospital) 
though I have seen some people implanting it.I feel that it actually 
does a disservice by fixing the valve in a larger annular diameter and 
thus increasing ventricular sphericity. No hard data but a hunch based 
on my ventricular wall acceleration studies that I was very fond of 
doing at one time.
The other side of the story is the so called late TR after MVR could 
that be actually (in some cases) a possible expression of patient 
prosthesis mismatch causing PH and TR ???
ps - can you please email me a copy of that paper.
Prasanna
Ani Anyanwu wrote:
> Prasanna,
>  
> We do not have the same young rheumatic population that you see. Most of our replacements are elderly women, not infrequently reoperations, with small ventricles. We have discussed in the past that we (like Hal and others) had two ventricular ruptures from placing the perimount valve in these patients. There is usually no perceived desire (by surgeon) or need to get in a valve bigger than a 25mm. I am not sure if there is really much difference between a 25mm and 27mm and I doubt the difference comes into play in the elderly patient. Valve replacements in young patients sometimes occurs but is uncommon. We did actually have a 23 year old Indian lady we placed a 25mm porcine valve last week and we actually did have to split the PML else it would not even accommodate the 25 mm sizer.
>  
> I note you stress the importance of ventriculo-annular continuity. You may not be aware but recent data from Tirone David's group (in press) does not show any difference in long-term outcomes between chordal sparing an non-chordal sparing valve replacements. He does not give explanations why but reports this a a surprise finding. The world goes round in circles.
>  
> Ani
>
>
>
>   
>> Date: Thu, 16 Aug 2007 21:47:34 +0530> From: prasannasimha at gmail.com> To: OpenHeart-L at lists.hsforum.com> CC: > Subject: [HSF] 25 mm valve> > I just went through our statistics wrt valve implantation and while I do > have a high repair rate (and that is primarily in a rheumatic > population) the commonest size was 27 , There were only a few 25 and 29 mm.> Incidentally Ani, while replacing rheumatic valves do you do a posterior > split of thePML.along with a commissurtomy. I find this springs open the > calcific valve allowing a larger size to be placed with AML PML > preservation with either native tissue or neochordae (depending on the > anatomy).Many a time I hae seen valves where people would have said that > a 25 mm valve would only fit and I have seen that the posterior split > allows a larger size to be implanted.> Prasanna> > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
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