[HSF] Traumatic tricuspid regurg
Nasser F. Abou'Seada
nfaabouseada at gmail.com
Fri Jan 5 10:28:00 EST 2007
yes prasanna
the techniques well described. Carpentier Repair of Ebstein anomaly.
would you elaborate more on the Clover leaf stitch?
Did you do chordal -GorTex replacements in paeds and neonates? ... would you
elaborate more on follow up and growth ? ?
NFA
> From: prasannasimha
> Ani,
> Both are well described in pediatric literature and I have used both..
> For papillary muscle reimplantation often ATL basically you pass a
> pledgetted suture through the ruptured papillary muscle and then through
> the RV free wall and place another pledget. I have always added a
> neochord placed from the RV free wall to the leaflet in addition but
> have seen some do it wthout it. The same can be done with Goretex suture
> pretty easily (neochordal construction). Another thing is to use a
> clover leaf Alfieri type of stitch which I have used in desperate
> circumstances rather than placing a tricuspid prosthesis. it seems to
> work well there well probably because of the lower pressures. I have
> done it with a Goretex band placed along with the Alfieri.
> I have done the Goretex repairs for children with neonatal sepsis etc
> and TV endoocarditis and placing a Goretex cord or transposition of the
> posterior leaflet with annuloplasty are two easy options.
> Prasanna
>
>
> Ani Anyanwu wrote:
> > I am curious to know the anecdotal experience of list members in two
suggested
> methods of repair - papillary muscle reattachment and gortex neochordae.
Have list
> members actually applied these techniques in the scenario described? I ask
this
> because my (very) limited observation is that the tricuspid leaflets are
thin and
> deficient in this circumstance such that any plastic procedures on the
leaflets are not
> as easy as said. I have seen one case of papillary muscle reattachment
only - in that
> case the repair failed on the first post-operative day (having been
competent on post-
> op TEE) and outcome was later fatal.
> >
> > What are the chances of durability of repair? Given the history, would
replacement
> not be a surer option?
> >
> > Thanks
> >
> > Ani
> > ----- Original Message -----
> > From: prasannasimha<mailto:prasannasimha at gmail.com>
> > To:
OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
> > Sent: Thursday, January 04, 2007 8:57 PM
> > Subject: Re: [HSF] Traumatic tricuspid regurg
> >
> >
> >
> > I am coming in late.
> > If there is no systemic signs of infection - counts cultures etc
> > negative which is very likely if there is gross TR came during lead
> > removal) then re implanting the papillary muscle would be easy if it
> > involves the AML. If the chordae are on the posterior leaflet - it can
> > be safely removed and the valve bicuspidised. Neo chordae can also be
> > easily placed.
> > I would do an Echo TAPSE to see the RV function.
> > As far as the need for RVOT pacing, I will get the data out tonight or
> > when free in the Hospital The RV free wall is stimulated normally
first
> > via the pathway through the moderator band and so placing it in the
> > region of the moderator band ensures free wall contraction best. This
is
> > the rational for placing it in the RVOT (though it should be placed
> > lower down and not next to the PA. In fact there is some data for
> > multilead RV pacing.). The site of moderator band implantation to the
> > free wall can be identified epicardially using a combination of
> > palpation + TEE (using 4 chamber view)
> > When are you taking the case.
> > If you are taking it today I will try to squeeze in some time to get
the
> > data at the hospital.
> > Prasanna
> >
> > Rwmfglycar at aol.com<mailto:Rwmfglycar at aol.com> wrote:
> > > In a message dated 1/4/2007 4:12:16 A.M. Eastern Standard Time,
> > > nkkejriwal at gmail.com<mailto:nkkejriwal at gmail.com> writes:
> > >
> > > Dear members
> > >
> > > An interesting case has been referred to me. The patient is a 65
year old
> > > lady who underwent dual chamber pacing a few years ago. Recently
she
> > > presented to the cardiologist with pacemaker pocket site infection.
The
> > > cultures did not grow any bug, but the generateor was eroding
through the
> > > skin. Last week the cardiologist pulled out all the hardwares.
Apparently he
> > > tore one of the pap m of the TV while removing the RV lead. Now the
patient
> > > has severe TR. I am enclosing the echo frames showing the bit of
pap m with
> > > attached chordae flopping in & out of RV resulting in severe TR.
The patient
> > > had mild to mod TR before the lead removal. There is no evidence of
TV
> > > endocarditis on echo. The annulus measures 40mm. Normal coronaries.
> > >
> > > What is the best option?
> > > Repair by suturing the muscle back and putting an annuloplasty
ring? Will it
> > > work? My concern is that if the lead were infected, would it be
wise to
> > > leave the leaflets behind?
> > >
> > > Or, remove all the leaflets with chordae and insert a
bioprosthesis?
> > > Dear Nand: she had some TricReg before the trauma. This may have
been due
> to
> > > the lead but may imply that she already has an abnormal RV.
Certainly the
> > > annulus is dilated. She has severe TR now and there is absolutely
no doubt in
> > > my mind that despite the publications from Detroit in the past
significant TR
> > > is not a normal state. We were very much involved, 20 years ago, in
the
> > > debates on valve excision versus valve replacement for tricuspid
endocarditis.
> We
> > > came down firmly on the side of valve replacement or repair. We
found poor
> > > outcomes with neglected or deliberately produced severe Tric Reg.
Futhermore
> as
> > > with all endocarditis we found that appropriate antibiotics for
only a few
> > > days protected against recurrent infection whether we were doing
replacement
> > > or repair. ( We came to this opinion from left sided cases with
severe failure
> > > as an imperative indication for surgery without delay).
> > >
> > >
> > > I suspect this may have been erosion rather than infection. In the
absence
> > > of vegetations virtually all cases of endocarditis due to a
sensitive organism
> > > respond to antibiotics. Where do you think the infection is? The
lead is
> > > already out. The reason why the pap muscle tore is because the lead
was
> > > connected to it by fibrous healing. I believe you do not need to
wait for some
> > > arbitrary 4wks of time on antibiotics, which in the absence of a
positive culture
> > > may be useless anyhow. What you do when you get inside depends on
the
> > > pathology. If the ruptured pap muscle is giving rise to chordal
support of only a
> > > small part of a leaflet (I could not evaluate this because I could
not open
> > > your attachment) you can do an excision and annuloplasty and feel
better
> about
> > > any unlikely possibilty of leaving residual infection behind.
Neochordae are
> > > an option as is leaflet and chordal replacement with pericardium
(properly
> > > treated xenograft or briefly tanned autogenous)
> > > I am also planning to attach RV & LV epicardial leads. I shall sew
the LV
> > > lead close to the 1st OM artery posteriorly. What is the best spot
for the
> > > RV lead?
> > >
> > > I always thought the apex site gave better RV performance but
others have
> > > advocated an RV ouflow site. (It made no sense for me for the
ouflow part of
> > > the ventricle to contract first).
> > > Yours
> > > Bob
> > >
> > >
> > > Thanks
> > >
> > > Nand
> > >
> > >
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