[HSF] Kays stitch

Sun Jan 21 10:53:11 EST 2007

Dear Prasanna 
have you got photos ?
that would be nice indeed 

NFA

> From: prasannasimha
> Tea,
> Since I have gone through a whole gamut of supported and non supported
> annuloplasties and obviously have had to innovate on the way, the only
> time I will not use a ring is probably in a small child where a Kay/Mc
> Goon type of repair would be used to allow potential growth. Even in
> them , I would put a "split hemi band" with a loose knot in between
> which has allowed for growth without excessive annular dilatation
> obviating second surgery if a full rigid ring was in place. I have now
> started seeing these children growing into their teen spurt and the
> hemiband approach is working well in them with their concomitant
> increase in BSA.
> I have used a Mural annular suture , Pacemaker wire, steel wire ,
> Goretex, Dacron , Teflon etc etc for the rings and there is really not
> much of difference if good bites and a secure repair are done. Where do
> I not use a ring - I will elaborate with an example of a case done 2
> days back.
> Case of severe MS with an MVOA of 1.0 cm2 with a fixed orifice Grade III
> MR. I did an OMV and there was still a leak with this centrally as the
> release of the leaflet did not compensate for the  non coaptation
> despite extensive posterobasal chordal release.(That would have been
> obvious in this case). I then added a Carpentier magic stitch at the
> posteromedial commissure and got a good mitral competence. (If this did
> not work, I would have augmented the PMLwith a peice of pericardium at
> the point of noncoaptation and remodeled the annulus with a ring)
> Incidentally the patient required a bicuspidization + Goretex strip
> annuloplasty for the tricuspid valve - Pt had severe TR +TS requiring a
> tricuspid valvotomy  , a Kay type stitch to allow good leaflet contact
> followed by an annuloplasty to further improve contact. (I felt that
> doing a plain annuloplasty would have caused the leaflet to buckle
> rather than oppose due to its rheumatic nature.
>  I think that it is only in these cases with significant MS with fixed
> orifice MR were the annulus is thick and not dilated  (and thus acting
> as its own internal ring) that a magic stitch without annular support
> works. In these cases the pathology is not involving major annular
> dilatation anyway.
>  In no other case would I even attempt to do a case without annular
> support without a ring. Even in the afore mentioned case , If I needed
> anything more complex, I would have put  a MAS or some strip if the
> annulus had to be "remodeled"
> Remember, the ring doesn't just reduce the annulus, it relieves the load
> on the repair by increasing the area of coaptation of the leaflets and
> actually after the leaflets oppose, tension on the chordal apparatus
> actually comes down.
> prasanna
> 
> Tea Acuff wrote:
> > I don't think that i said there was no reason for annuloplasty. I did
say there were
> reasons that resection and annuloplasty might be harmful. I suspect there
are some
> repairs that might not require annuloplasty (a hypothesis only). The
problem is that
> primarily what has happened is that a "system" for repair has been
espoused loudly
> based on peculiar spectrums of etiologies, and for particular marketing
reasons with
> "standard", and not perfect, results. I am NOT a high volume of anything
except
> some contrary positions. Maybe I should call my experience "modest" which
is
> certainly true compared to some advocates. However, logically it would not
be
> surprising to me on a purely theoretical level that if we devised specific
solutions for
> specific etiogies and before end stage remodeling, annuloplasty would not
be
> required. If one does not need an annuloplasty, clearly one does not need
a
> prosthesis. If one needs an annuloplasty, one may not or may require a
prosthesis
> >  depending what one is expecting the prothesis to correct.
> >   Prasanna, did you change all of your repairs from one type (system) of
> annuloplasty to another?
> > tea
> >
> >
> > ----- Original Message ----
> > From: Prasanna Simha M <prasannasimha at gmail.com>
> > To: OpenHeart-L at lists.hsforum.com
> > Sent: Friday, January 19, 2007 11:01:38 PM
> > Subject: Re: [HSF] Kays stitch
> >
> >
> > Tea addressing chordal elongation /leaflet prolapse with neochordae
> > obviously will take care of one mechanical component - the leaflet
prolapse
> > but how will that help with annular dilatation ?? That is a second
component
> > of the problem. I have used the mural annular shortening suture or
Panneth
> > Burr annuloplasty for years (though now I make a complete Goretex
annular
> > ring now _ I used to initially place a U band when Chand came but now
have
> > shifted to a complete Goretex ring made from a patch as others had
> > experessed concerns about incomplete rings though frankly since I am not
> > dealing with many "ischemic myopathic" ventricles itdoesn't make much of
a
> > difference . I will photograph it some time.
> > Prasanna
> >
> > On 1/20/07, Tea Acuff <tacuff at swbell.net> wrote:
> >
> >> Trust me this is not the only lonely camp of theory that I have
visited.
> >> Occasionally I thrive there, but one has to do most of the work
oneself.
> >> Call me "out of phase". Remember that the white light of truth is made
up of
> >> many phases.
> >> Tea
> >>
> >>
> >> ----- Original Message ----
> >> From: "Hgrmd at aol.com" <Hgrmd at aol.com>
> >> To: OpenHeart-L at lists.hsforum.com
> >> Sent: Friday, January 19, 2007 8:42:13 PM
> >> Subject: Re: [HSF] Kays stitch
> >>
> >>
> >> Dear Tea,
> >>   If you are under the impression that it's often OK to repair a
mitral
> >> valve with Goretex chords and no ring, I think you are in a fairly
> >> lonely  camp.
> >> Without question, a prosthesis to stabilize the annulus improves the
> >> durability of the repair.  In the past year, I actually reoperated a
> >> failed  18 month
> >> old repair for myxomatous disease done by another surgeon.  Do you
think
> >> myxomatous mitral valves are immune to subsequent
> >> annular  dilatation?  Why
> >> subject a patient to surgery if you are planning to do a  procedure
that
> >> won't give
> >> them the best chance for a durable result?   Finally, if you had a
mitral
> >> repair for myxomatous disease, would you let the  surgeon do it without
a
> >> ring?
> >>   BTW, in just a few more days, I look forward to busting your chops
in
> >> person!
> >> Hal
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> >
> 
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