[HSF] Calcified aortic stenosis

Wed Jul 4 22:15:40 EDT 2007

Mitch:
I strongly favor aortic valve bypass (apicoaortic conduit) surgery for
this patient.
We have done nearly 30 in the last few years and have had reasonable results.

Suggest:
-make sure sight of distal anastomosis is not totally calcified
-make the conduit as follows: 18 apical connector (from medtronic)
attached to 21 freestyle valve (re-oversew the coronary buttons)
attached to 20 hemashield graft with a 8 mm side branch
-put the hips at 45 degrees and shoulders in lat decubitus
-cannulate left groin with venous return cannula (21 or 23 biomedicus
is what we use)
-do the distal anastomosis first
-cannulate the side branch of the hemashield graft with a 3/8 inch
connector from the arterial inflow (from the pump)
-expose apex; make sure graft is sized properly before doing distal
-put pledgeted sutures around proposed hole in apex in a
circumferential fashion; take
DEEP bites (this is key - we had two pseudoaneurysms early because of
inadequate bites)
-put sutures through sewing ring of apical connector
-make a stab wound in apex; dilate with tonsil, put a foley catheter
in lv and inflate to slightly larger than chosen coring knife
-pull on foley, make hole with coring knife (knife should be a few mm
smaller in diam than apical connector)
-pull out core of myocardium, put thumb in hole, insert apical connector.
-tie down

We have used cpb on some cases and not on others;
advantages of this approach include avoidance of digging out
grafts/sternotomy, no ascending aortic
cannulation/manipulation/debridement of valve, minimal/no cpb, proven
track record (25 + years in some patients).

I learned the technique from John Brown.
I would be happy to speak with you by phone re details; good luck

full disclosure: am working on a device that cores and inserts apical
connector with zero blood loss

jim gammie

On 7/4/07, Tea Acuff <tacuff at swbell.net> wrote:
> I have heard of taking time for tea during a case , but never a nite out.
> Does anyone really recommend this?
> tea
>
>
> ----- Original Message ----
> From: Mitch Lirtzman <drmitch at cox.net>
> To: OpenHeart-L at lists.hsforum.com
> Sent: Wednesday, July 4, 2007 1:06:08 PM
> Subject: Re: [HSF] Calcified aortic stenosis
>
>
> That was in two separate sentences.
> >From a lung cancer standpoint, if this indeed is a Ca, she is clinically
> Stage 1.
> And trying to think ahead, and I try not to be inarticulate, if the
> mediastinum is really stuck and we are planning a Bentall/arch, might it be
> prudent to open, take down adhesions, close and return the next day to
> complete the job if opening gets too messy. This has been mentioned on the
> Forum previously. Or does an apical conduit seem a better approach?
> Mitch
> e:
> >Although Vancover has a center, the only site in the US is Dallas
> >presently. All trans apical approaches are on hold (complete), but thirty
> >more may be available in 60 days. There are trans femoral slots left, but
> >they are randomized, and if your lady is small will not likely be a candidate.
> >
> >Eight transapical cases were done with one death which occurred when the
> >patient requested to be taken off dialysis due to contrast injury and not
> >wanting chronic dialysis even though stable hemodynamically. Most patients
> >(over 50 were turned down and 10 operated conventially) are not
> >appropiate, but porcelin aorta was present in a couple. Did not ask about
> >stroke.
> >
> >I did not understand your staging for lysis of adhesions remark, or if I
> >did, I can't believe it. What do you mean?
> >
> >tea
> >
> >
> >
> >
> >----- Original Message ----
> >From: Mitch Lirtzman <drmitch at cox.net>
> >To: OpenHeart-L at lists.hsforum.com
> >Sent: Monday, July 2, 2007 9:19:43 PM
> >Subject: Re: [HSF] Calcified aortic stenosis
> >
> >
> >I've re-reviewed the CT and PET on this woman. The aorta is totally
> >calcified from valve to the proximal DTA. This includes the coronary ostia
> >and 2 proximal svg sites. The LUL lesion is 1.5cm, close to the
> >surface,  and is the only hot spot on PET. There are no mediastinal nodes
> >or other lesions. Clinically, stage 1. Remember, her LCCA is occluded as
> >well. PFT shows normal spirometry except for the 25-75 is ~44%. Normal RV
> >and DLCO~45.
> >I agree with Dr Martin that a percutaneous valve carries a much higher risk
> >of stroke, but as stated, I would like to see the data.
> >The options as I see them are: DHCA w/ Bentall and arch or apical conduit.
> >Remember, this is a re-do. Could she be better served with opening and
> >lysis of adhesions followed by resection the next day, as has been
> >previously discussed? She's coming to see me in two weeks after I get back
> >from Yellowstone. I gotta get some trout fishing under my belt before I
> >lose it.
> >Mitch Lirtzman At 07:08 PM 7/1/2007, you wrote:
> >
> > >Prasanna
> > >
> > >A percutaneous valve for calcified aortic stenosis???? From a surgical
> > >standpoint, even if I were to replace her root ascending and arch with
> > >individual head vessel reimplantation I would say her survival is in the
> > >90%?range with her greatest major morbidity coming from a stroke (5-7%).
> > >The question here, in my opinion, is how to deal with the pulm lesion and
> > >in what order.
> > >Someone on the forum must know the data on the perc valves so far, if so,
> > >speak up and educate us. I would think that a calcified aorta with
> > >calcific AS in a small female would be hard to do and would be at a
> > >significant risk of stroke- maybe more so than with an open procedure.
> > >
> > >Tom Martin
> > >U of Florida
> > >Gainesville
> > >
> > >
> > >-----Original Message-----
> > >From: prasannasimha <prasannasimha at gmail.com>
> > >To: OpenHeart-L at lists.hsforum.com
> > >Sent: Sat, 30 Jun 2007 10:33 pm
> > >Subject: Re: [HSF] Calcified aortic stenosis
> > >
> > >
> > >
> > >Smoker with ? lung Ca?
> > >Is the valve replacement worth it ? if worth it then - probably would be a
> > >candidate for those percut valves. Why chop her up excessively ??
> > >Prasanna?
> > >tdmartin2000 at aol.com wrote:?
> > > > Need a biopsy of lung lesion and then staging if pos for CA. If no
> > > carcinoma or something possibley cureable? and no AI, then an apical
> > > aortic conduit would be a consideration along with either a wedge
> > > resection or lobectomy. You certainly can replace the entire root,
> > > ascending?and arch with reasonable results as long as there is something
> > > to sew to either in the distal arch or the prox descending.?
> > > >?
> > > > Tom Martin?
> > > > U of Florida?
> > > > Gainesville?
> > > >?
> > > >?
> > > > -----Original Message-----?
> > > > From: Mitch Lirtzman <drmitch at cox.net>?
> > > > To: OpenHeart-L at hsforum.com?
> > > > Sent: Sat, 30 Jun 2007 7:48 pm?
> > > > Subject: [HSF] Calcified aortic stenosis?
> > > >?
> > > >?
> > > > To the forum. I know we've covered this type of problem in previous
> > > discussions, but...??
> > > > ??
> > > > An old patient of mine, 62yo petite diabetic female, unrepentant smoker
> > > 2ppd x 50yrs, had successful CABx3 in 2001- LIMA/ 2 veins. She's been
> > > complaining of increasing dyspnea for several months and referred her
> > > back to her cardiologist to investigate. The bottom line is she has
> > > critcal AS with AVA 0.3cms, normal EF, normal chambers, and all grafts
> > > are patent. She just had her left subclavian stent redone to improve LIMA
> > > flow. The problem is she is now totally calcified from valve through arch
> > > and LCCA is occluded just after the origin. Additionally, she now has a
> > > 1.5cm LUL nodule which lights up on PET. Surprisingly, her PFT is
> > > remarkably good but she always reminds me that she had a difficult post
> > > op course from a pulmonary standpoint.??
> > > > Any thoughts besides the word NO???
> > > > Thanks ahead of time.??
> > > > Mitch Lirtzman??
> > > > ??
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