[HSF] Posterior Post-Infarction VSD, SAM, and other Misery

[Tea Acuff]

I agree with all (both?) your assertions. However your query neglects the consideration that not only is there centrifugal (ie inward to outward force) with contraction, but there is lateral strain and twisting motion inherent in (but not necessarily coherent to) the outer walls and patch. Sometimes it is difficult to get to normal tissue. For those of us with less than perfect suture placement and tension, and perhaps a limited number of pledgets, the glue provides the required cohesion.
By the way you should look at the biology of the Cor Matrix patch. It is not polyester. It is quite interesting. One should be aware that I have a "confluence (so called conflict) of interest". After all the reason we like to hear your opinions on valves and pericardium is that you have worked with them for decades, not because you are "objective" (ie disinterested in the results). Caveat empetor.
tea 


----- Original Message ----
From: "Rwmfglycar at aol.com" <Rwmfglycar at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Sunday, July 8, 2007 10:08:14 PM
Subject: Re: [HSF] Posterior Post-Infarction VSD, SAM, and other Misery


In a message dated 7/8/2007 7:31:48 P.M. Eastern Daylight Time,  
Hgrmd at aol.com writes:
Hal,
Thye principle that we applied was to place the largest patch that we could  
find space for over the defect with the idea that ventricular pressure would  
drive the patch against the defect and that the sutures would be between  
patch and normal uninfarcted tissue. We always used pericardium because a) its  
burst strength is by far in excess of the pressure it will meet; b) it is  
impermeable and c) the host heals to it very quickly. 
It is not clear to me what glue and another layer of polyester adds to this  
approach
Bob

Tea,
I appreciate your contribution to this thread.  The  outcome of  your 
patient was expected and no reflection on your  technique.  As we all  know, 
these 
are desperately ill patients  in deep cardiogenic shock.  The  best we can do 
is 
offer prompt  surgery that doesn't later fall apart.  
As for your technique,  why did you attach the septal patch to the  
nonseptal side of the  ventriculotomy?  Otherwise, from your description,  
you employ a  
2 patch closure as originally described by Daggett.  The one   I'm describing 
is actually 3 patches, 2 for the septum (autologous  pericardium  covered by 
a 
larger patch of Hemashield with Bioglue in  between) and 1 for the  
ventriculotomy.  By using 2 patches over  the septum, this provides a nice  
space for the 
Bioglue to be  injected without it being directly exposed to either  
ventricular  cavity.  Use of the Embol-X cannula further protects from  
Bioglue  emboli.  
As best I can remember, I've used this technique on  the  last 4 VSD's I've 
had, and they've all survived with no  dehiscences.   This extremely small 
series 
is nothing to brag  about, but it looks   promising.

Hal



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