From drdharris at yahoo.co.uk Fri Jun 1 02:02:29 2007 From: drdharris at yahoo.co.uk (David Harris) Date: Thu May 31 20:02:57 2007 Subject: [HSF] Leaking thoraco-abdominal aneurysm. Message-ID: <117051.56174.qm@web26715.mail.ukl.yahoo.com> I have been referred a 32 yr old female patient who was turned down for surgery a year ago. She needed a root, ascending, and arch replacement, with elephant trunk, followed by repair of the descending part which stretches to the diaphragm. She was turned down as the aorta was heavily calcified. She now presents with symptoms from the thoraco, namely dyspnea, chest pain and hemoptysis. The distal half of the descending aorta is surrounded by a large round thrombus / contained leak, measuring 12 cm in diameter. The lumen of the desc aorta measures 5 cm, up to the diaphragm, where it is 3 cm, about 4cm above the celiac. Scan show ascending measuring 5cm, sinuses dilated (there is mild to moderate aortic regurg), arch measures 4cm, there is a neck of 3cm at the isthmus. The aorta is heavily calcified from halfway up the ascending, all the way to the T6 level. The ishmus is spared a bit and is POSSIBLY clampable. A stent would not be possible with peripheral access, as the left subclavian attaches to the aorta at an angle, and is a bit stenotic there, and the descending aorta makes a 90 degree turn at the level of the pulmonary ligament towards the right before bending back towards the left. The left external iliac artery is completely occluded. Any extra tips?(I think I have already made up my mind what to do, but some confirmation, and gleaming pearls would be greatly appreciated) Dave Harris Dr. David G. Harris, FCS, MMED, Cardiothoracic Surgeon Suite 207 Kuils River Private Hospital, PO Box 1200, Kuils River, 7579, Cape Town, South Africa. Tel +27-21-9006411 Fax +27-21-9006412 Mobile +27-83-3309587 From prasannasimha at gmail.com Fri Jun 1 07:22:50 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Thu May 31 21:02:00 2007 Subject: [HSF] HIT and CPB In-Reply-To: <4329c7e70705311605y30dbfdd6w87608b3fa78ed6f6@mail.gmail.com> References: <283594.4270.qm@web81610.mail.mud.yahoo.com> <465E3472.2080901@gmail.com> <4329c7e70705311605y30dbfdd6w87608b3fa78ed6f6@mail.gmail.com> Message-ID: <465F6DE2.1080906@gmail.com> Yes Prasanna Claudia Teles wrote: > Has anyone written my name? > > Claudia > > > 2007/5/30, prasannasimha : >> >> Bivaluridin for CPB and Claudia for the references. I think one of our >> HSF anesthesiologists had given a protocol (Andrew are you there ?) >> Prasanna >> Tea Acuff wrote: >> > I know we have discussed this before, but anyone have recent >> experience >> with preop HIT and need for CPB. Unfortunately this patient is a >> 50ish redo >> (operated age 9) with bicuspid aortic valve and dilated aorta mild MR >> and TR >> normal coronaries. I was unable to find our discussion in HSF. Will >> check my >> own emails (over 12000 messages!). I think my last thought on the >> subject >> theoretically was that would be a good case to refer to an expert if >> I could >> find one. Suggestions? >> > tea >> > _______________________________________________ >> > OpenHeart-L mailing list >> > >> > Send postings to: >> > OpenHeart-L@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 >> > ----------------------------------------- >> > >> > >> > >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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 >> ----------------------------------------- >> > > > From prasannasimha at gmail.com Fri Jun 1 07:57:45 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Thu May 31 23:09:14 2007 Subject: [HSF] Does the LIMA really string? Message-ID: <465F7611.4050408@gmail.com> This is a picture sent by David Harris of a case with a small LIMA and left main 50 % (If I remember right). No string !! David will complete the description. Prasanna -------------- next part -------------- A non-text attachment was scrubbed... Name: LIMA to LAD nonstring eml.jpg Type: image/jpeg Size: 35215 bytes Desc: not available Url : http://mmp.cjp.com/pipermail/openheart-l/attachments/20070601/de0b74d6/LIMAtoLADnonstringeml-0001.jpg From donross at bigpond.com Fri Jun 1 14:08:38 2007 From: donross at bigpond.com (Donald Ross) Date: Thu May 31 23:10:12 2007 Subject: [HSF] Provocative In-Reply-To: References: Message-ID: <06CD479F-D170-4180-A700-8BFD5ABD8D4D@bigpond.com> Aren't there some juicy bits on coronary flows you could share with us? Don On 31/05/2007, at 11:09 PM, Salerno, Tomas wrote: > This is not a paper. It is a book. Unfortunately I cannot PDF it. > > Sorry. > > Tomas > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com > [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Michael > Firstenberg > Sent: Thursday, May 31, 2007 7:41 AM > To: OpenHeart-L@lists.hsforum.com > Subject: RE: [HSF] Provocative > > Ding ding ding foul. > Dr Salerno you forgot a key rule of the forum of if you quote your own > paper (particularly something hard to find) you must supply the pdf > - or > at least part of it in pdf. > > > > Michael Firstenberg > > -----Original Message----- > From: "Salerno, Tomas" > To: OpenHeart-L@lists.hsforum.com > Sent: 5/31/2007 6:24 AM > Subject: RE: [HSF] Provocative > > Recommended reading: > > Intraoperative Graft Patency Verification in Cardiac and Vascular > Surgery > Editors D'Ancona, Karamanoukian, Ricci, Salerno, Bergsland. > Futura Publishing 2001 > > > Tomas > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com > [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Mark > Levinson > Sent: Wednesday, May 30, 2007 11:36 PM > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] Provocative > > > On May 25, 2007, at 12:34 AM, Ajit Damle wrote: > >> >> 1. How many of you record the flow in the OR note? Is it the >> standard of >> care in US? > > For many years, I measured flows, but I noticed that sometimes the > data was > either unhelpful, or confusing. One thing I did for years was > measure flow > in the LIMA before removal of the cross clamp, and then after weaning > from the pump. > Invariably, the flows were much higher when the cross clamp was still > on. It was not > unusual to see a LIMA go from 120 cc/min to 30 cc/min after release > of the clamp. > To me, this always implied 1) a correct anastomosis, and 2) > competitive flow. > > However, when trying to use this experience for OPCAB, it is more > confusing. > I do not snare the proximal in OPCAB, so I don't have a baseline > without competitive > flow. So, is 30 cc/min a great graft with competitive flow, or a > poor graft in the setting > of minimal competitive flow? > > I have tried to use the pulsatility index, but I find if I measue the > same vessel over and over, > I get different P.I. values, so this is not absolutely helpful. I > look at the diastolic waveforms now, > but I can't re-explore the graft just based on my limited > interpretation of these waves. > > In the few cases where I could tell a graft was bad, the audible > waveform sounded like > a hammer strike rather than a swishing flow signal. This was > helpful in 3 cases (all 3 > were kinks after resuming ventilation and resolving with tacking). > >> >> 2. Do you stipulate the perfusion pressure at the time of your >> record? > > No, I don't But I try not to make conclusion when the presssure > is lower than > what the patient will experience awake (120/80). If the patient > is hypotensive, > the flows are taken during a non-physiologic period, and I remeasure > when the > pressure is normal. > >> 3 Is it mandatory, or do you do anyway, include these in the OR >> note? > > No, I do not believe flows are mandatory. In some cases, they can > encourage you > to re-clamp and re-graft a vessel that is perfectly fine, but grafted > to a small target, or > one with diffuse disease, or competition. > >> >> 4. What do you accept as good flow vs bad flow"? >> > > I get nervous below 10 cc/min or with a bad sounding audible > waveform.... > >> >> >> On on-pumps, where is (usually) quality of anastomosis is not in >> question, >> how do you interpret the numbers? >> > > It can be subjective. Yes, we tend to believe a number and try to > make that > number correlate with something, especially by plugging the number > into a > database and then running an analysis. > > However, there are pitfalls of measuring flows. If the probe does > not fit the vessel > snugly, the flows are down. If the probe is at a bad angle to the > flow, the values are less. > If the pressure is down, if the probe is turned around, then the > results are spurious. > > I know that if I put the probe on 5 different times, I get 5 > different values. What does this mean? > I sometimes don't know. So, if the graft is mechanically perfect, > and the heart is doiing great, I > don't measure. If there is unusually contractility, arrythmias, > filling pressures, I start looking > and measure flows. But I rarely need to revise a graft. I usually > find something besides a bad > distal. Usually a kink. > > Hope this helps. > > > Mark > > >> >> >> I do want to elicit the response from American surgeons regarding >> the >> medico-legal implications. >> >> >> >> Thanks! >> >> >> >> Ajit Damle >> >> >> >> >> >> Also, >> >> >> >> How many of American surgeons routinely measure the flow, with what >> >> device, what criteria? >> >> >> >> Thans, guys, I nees help >> >> >> >> Ajit Damle >> >> >> >> >> >> >> >> >> >> >> >> -----Original Message----- >> From: openheart-l-bounces@lists.hsforum.com >> [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Donald >> Ross >> Sent: Thursday, May 24, 2007 6:40 PM >> To: OpenHeart-L@lists.hsforum.com >> Subject: [HSF] help with flow probe >> >> >> >> We have just acquired a Medistim flow probe ( partly in response to >> >> Thomas's credo ) and I have a few questions for the experts. >> >> What is the lower limit of flow which would trigger a re-anastomosis? >> >> Is this level modified by the size of the target artery? >> >> If the flow is at this low level for arterial grafts, would you wait >> >> for a while and retest incase the low flow is due to arterial spasm? >> >> Do you ever inject dilators in such a graft? >> >> Do you always test with proximal occlusion? >> >> Can you actually determine whether a coronary lesion is significant >> >> enough to support an arterial graft by comparing flow with and >> >> without proximal coronary occlusion. >> >> Would you ever replace such graft with a SVG? >> >> Thanks, >> >> Don >> >> _______________________________________________ >> >> OpenHeart-L mailing list >> >> >> >> Send postings to: >> >> OpenHeart-L@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 >> >> ----------------------------------------- >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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 >> ----------------------------------------- > > Mark M. Levinson, MD > Founder, Editor-in-Chief, > The Heart Surgery Forum > WWW: > Email: > > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From donross at bigpond.com Fri Jun 1 14:39:38 2007 From: donross at bigpond.com (Donald Ross) Date: Thu May 31 23:40:12 2007 Subject: [HSF] Does the LIMA really string? In-Reply-To: <465F7611.4050408@gmail.com> References: <465F7611.4050408@gmail.com> Message-ID: Thanks for the picture transfer Prasanna. David, Did you know the status of the LM stenosis at the time of the CT? Also, does anyone have any experience with the assessment of ima patency using percutaneous doppler or know of an authoritative reference? Don On 01/06/2007, at 11:27 AM, prasannasimha wrote: > This is a picture sent by David Harris of a case with a small LIMA > and left main 50 % (If I remember right). No string !! > David will complete the description. > Prasanna > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From enaseri at hotmail.com.tr Fri Jun 1 05:10:46 2007 From: enaseri at hotmail.com.tr (=?windows-1254?Q?erdin=E7_naseri?=) Date: Fri Jun 1 00:11:15 2007 Subject: [HSF] Endocarditis with splenic infarct Message-ID: Prasanna, this is not a splenic abcess.It is splenic infarct( proved by abdominal CT I think) and there isno indication of splenectomy. erdinc> Date: Thu, 31 May 2007 21:12:31 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] Endocarditis with splenic infarct> CC: > > Nand . there was a paper from Leipzig (Roberto's hospital) where they > found a higher mortality of a splenic abscess if a splenectomy is not done.> Prasanna> nand kejriwal wrote:> > Dear members> >> > 47 year man, admitted 2 weeks back with mitral valve endocarditis with> > vegetation. Blood culture - Enterococcus faecalis. Put on Gentamycin and> > Amoxycillin and discahrged. Readmitted 3 days ago with severe abdominal> > pain.> > CT - acute splenic infarct. No evidence of abscess formation. at this > > stage.> >> > Repeat TOE - vegetation still the same size.> > Referred to me today. I am planning to operate tomorrow.> >> > Opinion of the forum regarding splenic infarct. My plan is to leave the> > spleen alone and follow it up in the postop period. What are the > > chances of> > bleeding into the infarct during heparinisation? Would anyone recommend> > concomitant splenectomy?> >> > Thanks> >> > nand> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@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> > -----------------------------------------> >> >> > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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> ----------------------------------------- From akganjoo at gmail.com Fri Jun 1 09:42:00 2007 From: akganjoo at gmail.com (Anoop Ganjoo) Date: Fri Jun 1 00:17:31 2007 Subject: [HSF] HIT and CPB In-Reply-To: <283594.4270.qm@web81610.mail.mud.yahoo.com> References: <283594.4270.qm@web81610.mail.mud.yahoo.com> Message-ID: <6e0e37110705312012j39df41eeoa37cd740077519a4@mail.gmail.com> We once used a heparin bonded circuit (Carmeda Bioactive Surface) for CPB, along with systemic enoxaparin for an on-pump CABG in a pt. with HIT. (J Thorac Cardiovasc Surg 1996;112:1390-2). On another occasion we used the heparinoid Orgaran for anticoagulation for CPB. (J Cardiothorac Vasc Anesth 1997;11:262-4). Both patients did well. Since both LMWHs and heparinoids are known to have cross-reactivity with standard heparin, it is important to test the pt.'s plasma for reaction with the agent being considered for use. Also, in case of excessive postop. drainage, one can try plasmapheresis if blood product transfusions and correction of any associated coagulopathies does not help. Anoop Ganjoo Apollo Hospital New Delhi, India On 5/31/07, Tea Acuff wrote: > I know we have discussed this before, but anyone have recent experience with preop HIT and need for CPB. Unfortunately this patient is a 50ish redo (operated age 9) with bicuspid aortic valve and dilated aorta mild MR and TR normal coronaries. I was unable to find our discussion in HSF. Will check my own emails (over 12000 messages!). I think my last thought on the subject theoretically was that would be a good case to refer to an expert if I could find one. Suggestions? > tea > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > From epsccv at arrakis.es Fri Jun 1 08:59:39 2007 From: epsccv at arrakis.es (EPS-CCV) Date: Fri Jun 1 02:01:54 2007 Subject: [HSF] HIT and CPB References: Message-ID: <00a101c7a412$0aa4af40$0601a8c0@Quique> Hal Prostacyclin does not prevent antibodies forming / resistance developing, obviously. The reasons why we use it are its short half-life (epoprostenol 6 minutes) and the complete inhibition of the heparin-dependent platelet aggregation induced by HIT-II. That way you can use heparin "safely". Of course we'd prefer not to use heparin. The thing is that neither bivalirudin nor ECT & TAS Analyzer are available here. In addition, "our" protocol seems to be safe and effective. Enrique P. de la Sota, FECTS Madrid - Spain From nkkejriwal at gmail.com Fri Jun 1 21:09:42 2007 From: nkkejriwal at gmail.com (nand kejriwal) Date: Fri Jun 1 04:10:12 2007 Subject: [HSF] Endocarditis with splenic infarct In-Reply-To: <8C97178A40069B4-71C-CE73@WEBMAIL-RE13.sysops.aol.com> References: <8C97178A40069B4-71C-CE73@WEBMAIL-RE13.sysops.aol.com> Message-ID: Bob The size of vegetation was 1 cm on initial echo. The radiologist's opinion was that the appearance on the CT was in keeping with infarct rather than an abscess. The ID consultant told us that the spleen was "likely to clear" the organisms and would not need intervention. The general surgeon also decided not to intervene at this stage. I therefore replaced his valve today. There was a large vegetation on the P1 segment. The gram stain from the vegetation was positive for gram +ve cocci. The patient is doing well in the ICU. I have made everyone aware to keep a close eye on the patient's abdomen. *Is it customary these days to treat active endocarditis as an outpatient?* Bob, It was a medical decision. This patient is from our township and has ready access to medical facilities. I believe he was taught to self-administer the antibiotics under close supervision of the district nurses. It appears from the responses that we do not have a consensus about the management, if this patient had a splenic abscess. All three options were suggested. A. Splenectomy first, followed by mitral, as suggested by Michael (with the risk that he could throw an embolus to brain) B. Concomitant splenectomy as suggested by Prasanna (Risk of bleeding splenic bed, as Tea mentioned) C. Mitral followed by splenectomy a few days later as suggested by Bob (Risk of seeding the prosthesis). If this patient were referred before splenic infarct, what would you have done? In other words, is one cm vegetation an indication for surgery by itself, even though he was well clinically and responding well to treatment with normalisation of inflammatory markers? Nand From msfirst at gmail.com Fri Jun 1 07:13:49 2007 From: msfirst at gmail.com (Michael Firstenberg) Date: Fri Jun 1 07:21:15 2007 Subject: [HSF] HIT and CPB Message-ID: <465fff66.30c89fd4.162e.6951@mx.google.com> The other question is does this patient really have HITS? Is the pf4 positive which i assume and someone (i.e. Someone who does not have to be there when you put them on pump) said 'hits pos' or did you do a serotonin release also (gold standard test i believe). Michael Firstenberg -----Original Message----- From: "EPS-CCV" To: OpenHeart-L@lists.hsforum.com Sent: 6/1/2007 12:59 AM Subject: Re: [HSF] HIT and CPB Hal Prostacyclin does not prevent antibodies forming / resistance developing, obviously. The reasons why we use it are its short half-life (epoprostenol 6 minutes) and the complete inhibition of the heparin-dependent platelet aggregation induced by HIT-II. That way you can use heparin "safely". Of course we'd prefer not to use heparin. The thing is that neither bivalirudin nor ECT & TAS Analyzer are available here. In addition, "our" protocol seems to be safe and effective. Enrique P. de la Sota, FECTS Madrid - Spain _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From Hgrmd at aol.com Fri Jun 1 08:23:00 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Fri Jun 1 07:28:09 2007 Subject: [HSF] HIT and CPB Message-ID: Enrique, Could I trouble you for a more detailed description of your use of epoprostenol and heparin during CPB? Specifically, dosing. Hal ************************************** See what's free at http://www.aol.com. From Hgrmd at aol.com Fri Jun 1 08:27:42 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Fri Jun 1 07:32:00 2007 Subject: [HSF] Endocarditis with splenic infarct Message-ID: Nand, Did you consider repairing, rather than replacing the mitral valve? Over the past 10 years, I've been able to repair probably 50% of my SBE cases. As far as I can recall, I've never seen a recurrence. If the vegetation is confined to one segment of the valve, then radical debridement and reconstruction using standard Carpentier techniques works well. Of course, if the infection is scattered in several segments, then replacement is required. Hal ************************************** See what's free at http://www.aol.com. From prasannasimha at gmail.com Fri Jun 1 18:25:40 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Fri Jun 1 08:04:32 2007 Subject: [HSF] Endocarditis with splenic infarct In-Reply-To: References: Message-ID: <4660093C.5000003@gmail.com> Hal - I Echo that statement. Prasanna Hgrmd@aol.com wrote: > Nand, > Did you consider repairing, rather than replacing the mitral valve? Over > the past 10 years, I've been able to repair probably 50% of my SBE cases. As > far as I can recall, I've never seen a recurrence. If the vegetation is > confined to one segment of the valve, then radical debridement and > reconstruction using standard Carpentier techniques works well. Of course, if the > infection is scattered in several segments, then replacement is required. > Hal > > > > ************************************** See what's free at http://www.aol.com. > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > > From prasannasimha at gmail.com Fri Jun 1 18:24:43 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Fri Jun 1 08:04:57 2007 Subject: [HSF] Endocarditis with splenic infarct In-Reply-To: References: <8C97178A40069B4-71C-CE73@WEBMAIL-RE13.sysops.aol.com> Message-ID: <46600903.8010908@gmail.com> A 1 cm vegetation is supposed to be an indication by itself due to its embolic risk. What is practiced or practical is different from what is preached which is a different issue. Prasanna nand kejriwal wrote: > Bob > > The size of vegetation was 1 cm on initial echo. > > The radiologist's opinion was that the appearance on the CT was in > keeping > with infarct rather than an abscess. The ID consultant told us that the > spleen was "likely to clear" the organisms and would not need > intervention. > The general surgeon also decided not to intervene at this stage. I > therefore > replaced his valve today. There was a large vegetation on the P1 segment. > The gram stain from the vegetation was positive for gram +ve cocci. The > patient is doing well in the ICU. I have made everyone aware to keep a > close > eye on the patient's abdomen. > > *Is it customary these days to treat active endocarditis as an > outpatient?* > > Bob, It was a medical decision. This patient is from our township and has > ready access to medical facilities. I believe he was taught to > self-administer the antibiotics under close supervision of the district > nurses. > > It appears from the responses that we do not have a consensus about the > management, if this patient had a splenic abscess. All three options were > suggested. > > A. Splenectomy first, followed by mitral, as suggested by Michael > (with the > risk that he could throw an embolus to brain) > > B. Concomitant splenectomy as suggested by Prasanna (Risk of bleeding > splenic bed, as Tea mentioned) > > C. Mitral followed by splenectomy a few days later as suggested by Bob > (Risk > of seeding the prosthesis). > > If this patient were referred before splenic infarct, what would you have > done? > > In other words, is one cm vegetation an indication for surgery by itself, > even though he was well clinically and responding well to treatment with > normalisation of inflammatory markers? > Nand > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > From prasannasimha at gmail.com Fri Jun 1 18:28:21 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Fri Jun 1 08:26:48 2007 Subject: [HSF] Does the LIMA really string? In-Reply-To: References: <465F7611.4050408@gmail.com> Message-ID: <466009DD.3020204@gmail.com> Transthoracic Doppler can be used to measure IMA flows. It is well described and known to echocardiographers. I think there were a lot of papers in the late 90's about this. Prasanna Donald Ross wrote: > Thanks for the picture transfer Prasanna. > David, > Did you know the status of the LM stenosis at the time of the CT? > > Also, does anyone have any experience with the assessment of ima > patency using percutaneous doppler or know of an authoritative reference? > > Don > On 01/06/2007, at 11:27 AM, prasannasimha wrote: > >> This is a picture sent by David Harris of a case with a small LIMA >> and left main 50 % (If I remember right). No string !! >> David will complete the description. >> Prasanna >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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 >> ----------------------------------------- > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 anddisclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > From TSalerno at med.miami.edu Fri Jun 1 10:23:12 2007 From: TSalerno at med.miami.edu (Salerno, Tomas) Date: Fri Jun 1 09:24:02 2007 Subject: [HSF] Provocative In-Reply-To: <06CD479F-D170-4180-A700-8BFD5ABD8D4D@bigpond.com> Message-ID: Flow measurements have been routine in my practice, and I would have difficulty in operating on coronary patients without flow measurements. The reason is that, despite experience, from time to time, a perfect anastomosis of LIMA-LAD has not flow. The usual reaction is that the probe is broken. This occurred to me last week. Regarding what to look for. LIMA flow is diastolic. I tend to pay more attention to the flow characteristics, ie, diastolic flow than to the amount of flow itself. When the flow is marginal or low, I usually go ahead and perform other grafts, and at the end return to the LIMA-LAD to determine whether the flow and flow characteristics have changed. Another important observation is that, usually the surgeon can predict whether the amount of flow is going to be large or small, depending on the coronary angiography and operative findings. If I expected high flows (size of the artery, degree of stenosis, and amount of collaterals), and found low flows, my threshold to redo the anastomosis is different than if I expected low flows. Please remember that lack of flow, low flows, or systolic flows may be due to other problems other than the distal anastomosis. In the LIMA, it can be due to distal anastomotic problems, obstruction of the LIMA somewhere along its length, and other problems. Same for veins. One cannot assume that lack of flow is due to distal anastomotic problems. In the RCA one usually finds some systolic and diastolic flows. Areas of the myocardium with low pressures, such as aneurismal areas, will have components of systolic flows. The size of the probe may have something to do with the characteristics of flow. I use Cardiosonics (Neoprobe) flowmeter, which has the advantage of one probe fitting all sizes of coronary grafts. This allows me to measure flows with different sizes of probes, and this may have an effect on flow characteristics. Finally, it is important to measure flow in all grafts before and after protamine, prior to closure of the sternotomy. Anastomotic problems usually lead to occlusion of the graft after protamine, and the flow characteristics change. Once the surgeon starts to measure flows during coronary surgery, it becomes more and more difficult to practice without these devices that measure flows. Furthermore, a print out of flows in each graft is part of the medical records of the patient. I hope that some of these hints will help. The book on flows describes on great details most of the circumstances surrounding problems with flow and flow measurements. Tomas age----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Donald Ross Sent: Thursday, May 31, 2007 11:09 PM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Provocative Aren't there some juicy bits on coronary flows you could share with us? Don On 31/05/2007, at 11:09 PM, Salerno, Tomas wrote: > This is not a paper. It is a book. Unfortunately I cannot PDF it. > > Sorry. > > Tomas > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com > [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Michael > Firstenberg > Sent: Thursday, May 31, 2007 7:41 AM > To: OpenHeart-L@lists.hsforum.com > Subject: RE: [HSF] Provocative > > Ding ding ding foul. > Dr Salerno you forgot a key rule of the forum of if you quote your own > paper (particularly something hard to find) you must supply the pdf > - or > at least part of it in pdf. > > > > Michael Firstenberg > > -----Original Message----- > From: "Salerno, Tomas" > To: OpenHeart-L@lists.hsforum.com > Sent: 5/31/2007 6:24 AM > Subject: RE: [HSF] Provocative > > Recommended reading: > > Intraoperative Graft Patency Verification in Cardiac and Vascular > Surgery > Editors D'Ancona, Karamanoukian, Ricci, Salerno, Bergsland. > Futura Publishing 2001 > > > Tomas > > -----Original Message----- > From: openheart-l-bounces@lists.hsforum.com > [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Mark > Levinson > Sent: Wednesday, May 30, 2007 11:36 PM > To: OpenHeart-L@lists.hsforum.com > Subject: Re: [HSF] Provocative > > > On May 25, 2007, at 12:34 AM, Ajit Damle wrote: > >> >> 1. How many of you record the flow in the OR note? Is it the >> standard of >> care in US? > > For many years, I measured flows, but I noticed that sometimes the > data was > either unhelpful, or confusing. One thing I did for years was > measure flow > in the LIMA before removal of the cross clamp, and then after weaning > from the pump. > Invariably, the flows were much higher when the cross clamp was still > on. It was not > unusual to see a LIMA go from 120 cc/min to 30 cc/min after release > of the clamp. > To me, this always implied 1) a correct anastomosis, and 2) > competitive flow. > > However, when trying to use this experience for OPCAB, it is more > confusing. > I do not snare the proximal in OPCAB, so I don't have a baseline > without competitive > flow. So, is 30 cc/min a great graft with competitive flow, or a > poor graft in the setting > of minimal competitive flow? > > I have tried to use the pulsatility index, but I find if I measue the > same vessel over and over, > I get different P.I. values, so this is not absolutely helpful. I > look at the diastolic waveforms now, > but I can't re-explore the graft just based on my limited > interpretation of these waves. > > In the few cases where I could tell a graft was bad, the audible > waveform sounded like > a hammer strike rather than a swishing flow signal. This was > helpful in 3 cases (all 3 > were kinks after resuming ventilation and resolving with tacking). > >> >> 2. Do you stipulate the perfusion pressure at the time of your >> record? > > No, I don't But I try not to make conclusion when the presssure > is lower than > what the patient will experience awake (120/80). If the patient > is hypotensive, > the flows are taken during a non-physiologic period, and I remeasure > when the > pressure is normal. > >> 3 Is it mandatory, or do you do anyway, include these in the OR >> note? > > No, I do not believe flows are mandatory. In some cases, they can > encourage you > to re-clamp and re-graft a vessel that is perfectly fine, but grafted > to a small target, or > one with diffuse disease, or competition. > >> >> 4. What do you accept as good flow vs bad flow"? >> > > I get nervous below 10 cc/min or with a bad sounding audible > waveform.... > >> >> >> On on-pumps, where is (usually) quality of anastomosis is not in >> question, >> how do you interpret the numbers? >> > > It can be subjective. Yes, we tend to believe a number and try to > make that > number correlate with something, especially by plugging the number > into a > database and then running an analysis. > > However, there are pitfalls of measuring flows. If the probe does > not fit the vessel > snugly, the flows are down. If the probe is at a bad angle to the > flow, the values are less. > If the pressure is down, if the probe is turned around, then the > results are spurious. > > I know that if I put the probe on 5 different times, I get 5 > different values. What does this mean? > I sometimes don't know. So, if the graft is mechanically perfect, > and the heart is doiing great, I > don't measure. If there is unusually contractility, arrythmias, > filling pressures, I start looking > and measure flows. But I rarely need to revise a graft. I usually > find something besides a bad > distal. Usually a kink. > > Hope this helps. > > > Mark > > >> >> >> I do want to elicit the response from American surgeons regarding >> the >> medico-legal implications. >> >> >> >> Thanks! >> >> >> >> Ajit Damle >> >> >> >> >> >> Also, >> >> >> >> How many of American surgeons routinely measure the flow, with what >> >> device, what criteria? >> >> >> >> Thans, guys, I nees help >> >> >> >> Ajit Damle >> >> >> >> >> >> >> >> >> >> >> >> -----Original Message----- >> From: openheart-l-bounces@lists.hsforum.com >> [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Donald >> Ross >> Sent: Thursday, May 24, 2007 6:40 PM >> To: OpenHeart-L@lists.hsforum.com >> Subject: [HSF] help with flow probe >> >> >> >> We have just acquired a Medistim flow probe ( partly in response to >> >> Thomas's credo ) and I have a few questions for the experts. >> >> What is the lower limit of flow which would trigger a re-anastomosis? >> >> Is this level modified by the size of the target artery? >> >> If the flow is at this low level for arterial grafts, would you wait >> >> for a while and retest incase the low flow is due to arterial spasm? >> >> Do you ever inject dilators in such a graft? >> >> Do you always test with proximal occlusion? >> >> Can you actually determine whether a coronary lesion is significant >> >> enough to support an arterial graft by comparing flow with and >> >> without proximal coronary occlusion. >> >> Would you ever replace such graft with a SVG? >> >> Thanks, >> >> Don >> >> _______________________________________________ >> >> OpenHeart-L mailing list >> >> >> >> Send postings to: >> >> OpenHeart-L@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 >> >> ----------------------------------------- >> >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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 >> ----------------------------------------- > > Mark M. Levinson, MD > Founder, Editor-in-Chief, > The Heart Surgery Forum > WWW: > Email: > > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From rwmfglycar at aol.com Fri Jun 1 11:56:09 2007 From: rwmfglycar at aol.com (rwmfglycar@aol.com) Date: Fri Jun 1 11:00:30 2007 Subject: [HSF] Endocarditis with splenic infarct In-Reply-To: <46600903.8010908@gmail.com> References: <8C97178A40069B4-71C-CE73@WEBMAIL-RE13.sysops.aol.com> <46600903.8010908@gmail.com> Message-ID: <8C972741F67794D-1704-3DA5@WEBMAIL-MA16.sysops.aol.com> Dear Nand, We saw a lot of endocarditis in the Bronx and began doing surgery for endocarditis quite early. Our first patients were generally in terminal acute heart failure. We realised that many of these had had features in the preceding week or two that?could be used as?markers for earlier intervention. We were also frustrated?by being sent patients after they had had serious embolic incidents. Joel Strom, (great clinical cardiologist and superb echocardiographer) and??I started keeping track of these patients. We came to the conclusion that with vegetations of 1cm or more, embolism, leaflet tears and failure to sterilise with antibiotics were all more likely. Patients without or with small?vegetations mostly were succesfully treated with antibiotics (provided of course that they had organisms senditive to antibiotics). The obvious pathologic point here is that the organisms continue to thrive within a large vegetation unreached by the antibiotics. Yes , I would have operated. The results of following this policy were excellent.? Several times I had the sad experience of advising surgery in a patient with large vegetations detected?in the first week after diagnosis, only to have a?smart ?cardiologist/ID combo put off referring the patient until one or more of the the events underlined above suddenly occurred and?induced them, finally,?to refer the patient. Needless to say the ID guys can describe a case with a 1.2 cm vegetation that was finally sterilised without needing surgery My experience with patients of this kind?was that they often came to surgery eventually?anyhow. It is interesting that organisms were present in the vegetation. Did you send any of it for culture? Commonly there is no growth even with histologicallyvisible organisms?but, sometimes there is even though the patient seems to have been doing well. Refs. (sorry Michael no pdf's) Strom and I are on all these papers but the first author is the only one whose name I give: Davis...Demonstration of vegetations by echocardiography in Bacterial Endocarditis; an indication for early surgery. Am J. Med. 1980;?69:57-68, Strom...Echocardiographic and surgical correlations in Bacterial Endocarditis. Circulation 1980;69:57-63 Strom...Effects of vegetation size on the outcome of patients with infective endocarditis.Circulation 1982;66(supp II):103. Robbins...Influence of vegetation size on the clinical outcome of R sided endocarditis. Am. J. Med,1986;80(2):165-171. asannasimha To: OpenHeart-L@lists.hsforum.com Sent: Fri, 1 Jun 2007 7:54 am Subject: Re: [HSF] Endocarditis with splenic infarct A 1 cm vegetation is supposed to be an indication by itself due to its embolic risk. What is practiced or practical is different from what is preached which is a different issue.? Prasanna? nand kejriwal wrote:? > Bob? >? > The size of vegetation was 1 cm on initial echo.? >? > The radiologist's opinion was that the appearance on the CT was in > keeping? > with infarct rather than an abscess. The ID consultant told us that the? > spleen was "likely to clear" the organisms and would not need > intervention.? > The general surgeon also decided not to intervene at this stage. I > therefore? > replaced his valve today. There was a large vegetation on the P1 segment.? > The gram stain from the vegetation was positive for gram +ve cocci. The? > patient is doing well in the ICU. I have made everyone aware to keep a > close? > eye on the patient's abdomen.? >? > *Is it customary these days to treat active endocarditis as an > outpatient?*? >? > Bob, It was a medical decision. This patient is from our township and has? > ready access to medical facilities. I believe he was taught to? > self-administer the antibiotics under close supervision of the district? > nurses.? >? > It appears from the responses that we do not have a consensus about the? > management, if this patient had a splenic abscess. All three options were? > suggested.? >? > A. Splenectomy first, followed by mitral, as suggested by Michael > (with the? > risk that he could throw an embolus to brain)? >? > B. Concomitant splenectomy as suggested by Prasanna (Risk of bleeding? > splenic bed, as Tea mentioned)? >? > C. Mitral followed by splenectomy a few days later as suggested by Bob > (Risk? > of seeding the prosthesis).? >? > If this patient were referred before splenic infarct, what would you have? > done?? >? > In other words, is one cm vegetation an indication for surgery by itself,? > even though he was well clinically and responding well to treatment with? > normalisation of inflammatory markers?? > Nand? > _______________________________________________? > OpenHeart-L mailing list? >? > Send postings to:? > OpenHeart-L@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? > -----------------------------------------? >? >? ? _______________________________________________? OpenHeart-L mailing list? ? Send postings to:? OpenHeart-L@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? -----------------------------------------? ________________________________________________________________________ AOL now offers free email to everyone. Find out more about what's free from AOL at AOL.com. From rwmfglycar at aol.com Fri Jun 1 12:15:40 2007 From: rwmfglycar at aol.com (rwmfglycar@aol.com) Date: Fri Jun 1 11:16:13 2007 Subject: [HSF] Endocarditis with splenic infarct In-Reply-To: <516412.59720.qm@web81605.mail.mud.yahoo.com> References: <516412.59720.qm@web81605.mail.mud.yahoo.com> Message-ID: <8C97276D9CC8486-1704-3E9B@WEBMAIL-MA16.sysops.aol.com> Tea that is a perceptive question. Interestingly enough, despite the prevalence of racism in South African society at the time, a genetic cause for the difference was never suggested, and all the blame was put on a diet high in?saturated fats. This tied in with the cholesterol levels in the patients. Ironically about a decade later a high incidence of familial hypercholesterolemia was discovered in people of white Afrikaner descent. It was also apparent by then?that?there were other factors in play in people of Indian descent, (which ,of course, has been seen in many transplanted Indian populations around the world).?This did not detract from the dominant influence of diet. Today with the adoption of Western diets people of indigenous African descent now have plenty of coronary disease. Bob -----Original Message----- From: Tea Acuff To: OpenHeart-L@lists.hsforum.com Sent: Thu, 31 May 2007 5:03 pm Subject: Re: [HSF] Endocarditis with splenic infarct So was his conclusion that it was diet, it was genetic, or both. ea ---- Original Message ---- rom: "rwmfglycar@aol.com" o: OpenHeart-L@lists.hsforum.com ent: Thursday, May 31, 2007 10:51:27 AM ubject: Re: [HSF] Endocarditis with splenic infarct ohn Brock at the University of Cape Town. Together with others the major esearch work he did was to define the relationship between the dramatically ifferent incidences of coronary artery disease of European descended, native frican and mixed race people and the dfferent diets they ate. ob ----Original Message----- rom: Michael Firstenberg o: OpenHeart-L@lists.hsforum.com ent: Thu, 31 May 2007 11:30 am ubject: RE: [HSF] Endocarditis with splenic infarct Who was 'your' wise professor? Michael Firstenberg ----Original Message----- om: rwmfglycar@aol.com : OpenHeart-L@lists.hsforum.com nt: 5/31/2007 10:20 AM bject: Re: [HSF] Endocarditis with splenic infarct ear Michael, ou may well be right that, during the tenure of one or other committee of nscientous colleagues setting board exams, the edict was promulgated that the leen gets attention first in these circumstances. I dare say that another mmittee might come up with a different answer. You would be hard put to find lid "evidence based" data to justify one opinion or another. There is perficial logic in what you thought the "correct board answer" is or was, but at would you do if the patient was in heart failure? ise professor of mine some 55 years ago said to me "I am not here to get you rough your exams; for that you need low cunning. I am here to teach you how to arn and how to think; that will last you the rest of your life". u may realise from my reply that, as a teacher, I was never satisfied by an swer to a question that started with "for the boards the answer is...". yway, in the circumstances of the case described, doing the heart first worked my hands. It would not be difficult to come up with a scenario that dictated ifferent order. One of the problems with exams is that questions and expected swers that fit the structure of exams inevitably do not do justice to the mplexities of real life b ----Original Message----- om: Michael Firstenberg : OpenHeart-L@lists.hsforum.com nt: Thu, 31 May 2007 7:07 am bject: RE: [HSF] Endocarditis with splenic infarct hought the 'board' answer was take the spleen out first. One less pussed out gan to seed your new valve? chael Firstenberg ---Original Message----- m: rwmfglycar@aol.com OpenHeart-L@lists.hsforum.com t: 5/31/2007 3:55 AM ject: Re: [HSF] Endocarditis with splenic infarct ar Nand, at was the size of the vegetation? If more than 1 cm there was an indication surgery before discharge. (I am well aware that ID people ignore the d won lessons of the past and that they get away with their negligence en).The fact that he had a large enough splenic infarct to be clinically dent obviously says something about the size of the vegetation, and suggests o that it was growing if despite shedding a substantial embolus it remains same size (antibiotics do not easily sterilise large vegetations). Isn't the ient lucky that it didn't hit the brain? ractice was to get the heart done first and do the spleen electively in a k or so. The worry is that manipulation of the spleen post op might produce teremia and recurrent endocarditis. I never saw this happen under the igatory continued antibiotic cover. It is quite possible that the infarct l resolve wthout intervention but that needs very careful following. t customary these days to treat active endocarditis as an outpatient? I have ell you that I regard that as irresponsible, feckless, stupid and more, but n perhaps I am just a grumpy oldtimer. ---Original Message----- m: nand kejriwal OpenHeart-L@lists.hsforum.com t: Thu, 31 May 2007 4:30 am ject: Re: [HSF] Endocarditis with splenic infarct ear members year man, admitted 2 weeks back with mitral valve endocarditis with etation. Blood culture - Enterococcus faecalis. Put on Gentamycin and xycillin and discahrged. Readmitted 3 days ago with severe abdominal n. acute splenic infarct. No evidence of abscess formation. at this stage. peat TOE - vegetation still the same size. erred to me today. I am planning to operate tomorrow. inion of the forum regarding splenic infarct. My plan is to leave the een alone and follow it up in the postop period. What are the chances of eding into the infarct during heparinisation? Would anyone recommend comitant splenectomy? anks nd ____________________________________________ nHeart-L mailing list nd postings to: nHeart-L@lists.hsforum.com UNSUBSCRIBE, to CHANGE email address, or to view archives: p://mmp.cjp.com/mailman/listinfo/openheart-l l messages transmitted by the OpenHeart-L are subject to the policies and claimers posted at: p://www.hsforum.com/listdisclaim -------------------------------------- ______________________________________________________________________ now offers free email to everyone. 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Find out more about what's free from AOL at AOL.com. From epsccv at arrakis.es Fri Jun 1 19:28:11 2007 From: epsccv at arrakis.es (EPS-CCV) Date: Fri Jun 1 12:30:16 2007 Subject: [HSF] HIT and CPB References: Message-ID: <006701c7a469$d8a28780$0601a8c0@Quique> Hal, our protocol is as follows: * Aprotinin (2 million KIU iv loading dose, 2 million KIU into the pump prime volume and 500,000 KIU per hour as continuous iv infusion). * After induction of anesthesia: Continuous infusion of epoprostenol sodium (FLOLAN) is started at a rate of 5 ng/kg/min, infusion rate increased by stages of 5 ng/kg every 5 minutes until the infusion rate of 30 ng/kg/min is reached. At this time * Standard heparin dose (bolus of 300 U/kg IV). * CPB is started when ACT exceeds 480-500 seconds and after weaning from CPB, heparin is reversed with protamine. * Norepinephrine (0.05 to 0.1 microg/kg/min) is infused when required. Epoprostenol sodium infusion is mantained until rewarming is begun. Then it is decreased by stages of 5 ng/kg every 5 minutes until stopped. Enrique P. de la Sota MD, FETCS Madrid (Spain) From drdharris at yahoo.co.uk Sat Jun 2 00:18:27 2007 From: drdharris at yahoo.co.uk (David Harris) Date: Fri Jun 1 18:18:58 2007 Subject: [HSF] Does the LIMA really string? In-Reply-To: Message-ID: <638950.39332.qm@web26713.mail.ukl.yahoo.com> Many thanks again Prasanna for the picture transfer. Tha patient had a 60 to 70% proximal LAD lesion. The LAD was relatively larger than the LIMA. After injecting (I never do!) the LIMA and clipping it distally , the flow was not great, and it did not dilate well. There was a prominant spurt of blood from the LAD after opening it. I left the bulldog on the LIMA (proximally) for a while after completing the graft, and this caused it to dilate nicely. Before closing the chest the graft looked fine. I am sure that bidirectional flow in these grafts keep them open, until the stenosis progresses, and the LIMA dominates. It would be nice to know exactly how much, which direction, and relatively during which part of the cardiac cycle. David Harris --- Donald Ross wrote: > Thanks for the picture transfer Prasanna. > David, > Did you know the status of the LM stenosis at the > time of the CT? > > Also, does anyone have any experience with the > assessment of ima > patency using percutaneous doppler or know of an > authoritative > reference? > > Don > On 01/06/2007, at 11:27 AM, prasannasimha wrote: > > > This is a picture sent by David Harris of a case > with a small LIMA > > and left main 50 % (If I remember right). No > string !! > > David will complete the description. > > Prasanna > > > > _______________________________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@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 > > ----------------------------------------- > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > Dr. David G. Harris, FCS, MMED, Cardiothoracic Surgeon Suite 207 Kuils River Private Hospital, PO Box 1200, Kuils River, 7579, Cape Town, South Africa. Tel +27-21-9006411 Fax +27-21-9006412 Mobile +27-83-3309587 From drdharris at yahoo.co.uk Sat Jun 2 01:03:10 2007 From: drdharris at yahoo.co.uk (David Harris) Date: Fri Jun 1 19:03:39 2007 Subject: [HSF] HIT and CPB In-Reply-To: <465F6DE2.1080906@gmail.com> Message-ID: <514789.37135.qm@web26706.mail.ukl.yahoo.com> There is also a good review article in anaesthesia UK. Go to www.anaesthesiauk.com David --- prasannasimha wrote: > Yes > Prasanna > Claudia Teles wrote: > > Has anyone written my name? > > > > Claudia > > > > > > 2007/5/30, prasannasimha > : > >> > >> Bivaluridin for CPB and Claudia for the > references. I think one of our > >> HSF anesthesiologists had given a protocol > (Andrew are you there ?) > >> Prasanna > >> Tea Acuff wrote: > >> > I know we have discussed this before, but > anyone have recent > >> experience > >> with preop HIT and need for CPB. Unfortunately > this patient is a > >> 50ish redo > >> (operated age 9) with bicuspid aortic valve and > dilated aorta mild MR > >> and TR > >> normal coronaries. I was unable to find our > discussion in HSF. Will > >> check my > >> own emails (over 12000 messages!). I think my > last thought on the > >> subject > >> theoretically was that would be a good case to > refer to an expert if > >> I could > >> find one. Suggestions? > >> > tea > >> > _______________________________________________ > >> > OpenHeart-L mailing list > >> > > >> > Send postings to: > >> > OpenHeart-L@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 > >> > ----------------------------------------- > >> > > >> > > >> > > >> > >> _______________________________________________ > >> OpenHeart-L mailing list > >> > >> Send postings to: > >> OpenHeart-L@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 > >> ----------------------------------------- > >> > > > > > > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > Dr. David G. Harris, FCS, MMED, Cardiothoracic Surgeon Suite 207 Kuils River Private Hospital, PO Box 1200, Kuils River, 7579, Cape Town, South Africa. Tel +27-21-9006411 Fax +27-21-9006412 Mobile +27-83-3309587 From cvteles at gmail.com Fri Jun 1 22:15:55 2007 From: cvteles at gmail.com (Claudia Teles) Date: Fri Jun 1 20:16:25 2007 Subject: [HSF] HIT and CPB In-Reply-To: <00a101c7a412$0aa4af40$0601a8c0@Quique> References: <00a101c7a412$0aa4af40$0601a8c0@Quique> Message-ID: <4329c7e70706011715r5036f6ch522c173e5b9347ef@mail.gmail.com> Enrique, How is the incidence of post surgical thrombosis in the patients who received the protocol? Have you performed doppler follow up for the next 3-6 months? Thanks, Claudia Teles 2007/6/1, EPS-CCV : > > Hal > > Prostacyclin does not prevent antibodies forming / resistance developing, > obviously. The reasons why we use it are its short half-life (epoprostenol 6 > minutes) and the complete inhibition of the heparin-dependent platelet > aggregation induced by HIT-II. That way you can use heparin "safely". > > Of course we'd prefer not to use heparin. The thing is that neither > bivalirudin nor ECT & TAS Analyzer are available here. In addition, "our" > protocol seems to be safe and effective. > > Enrique P. de la Sota, FECTS > Madrid - Spain > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > -- Claudia Teles Hemostasis Section - Instituto Estadual de Cardiologia Aloysio de Castro Hemostasis Lab coordinator - Diagnosticos da America From cvteles at gmail.com Fri Jun 1 22:18:56 2007 From: cvteles at gmail.com (Claudia Teles) Date: Fri Jun 1 20:26:23 2007 Subject: [HSF] HIT and CPB In-Reply-To: References: Message-ID: <4329c7e70706011718l2eeae9f4od9a23bdd543633d2@mail.gmail.com> 2007/5/31, Hgrmd@aol.com : > > Enrique, > Thanks for your input. Does the prostacyclin somehow make heparin safe > to > use in the presence of HIT? Yes, but it does not prevent heparin to elicit the immune response. And the patient will be sensitive to heparin for the next 6 months after receiving the epoprostanol. If this is a stupid question, please forgive my > relative lack of knowledge in the more arcane aspects of hematology. > Hal No, it is an important question. - also I would like to see if these patients have the same incidence of venous and/or arterial thrombotic events as the patients who received DTIs for the bypass. Best, Claudia Teles ************************************** See what's free at http://www.aol.com > . > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > -- Claudia Teles Hemostasis Section - Instituto Estadual de Cardiologia Aloysio de Castro Hemostasis Lab coordinator - Diagnosticos da America From Hgrmd at aol.com Sat Jun 2 01:10:55 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sat Jun 2 00:15:17 2007 Subject: [HSF] HIT and CPB Message-ID: Dear Enrique, Thanks for the detailed protocol. I will definitely keep it in my files. Hal ************************************** See what's free at http://www.aol.com. From Hgrmd at aol.com Sat Jun 2 01:36:13 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sat Jun 2 00:42:13 2007 Subject: [HSF] Redo Radical Mitral Valvuloplasty Message-ID: Dear Members, Today's case was unusual. About 2 years ago, I repaired a myxomatous mitral in a 38 yo lady. I placed 4 Goretex neochords in A1 and A2. I closed the P2-P3 interscallop leak, and performed a postero-medial commissuroplasty. A 32 mm Physio ring was used. She did well until a few months ago when she was noted to have a recurrent MR murmur that was asymptomatic. TEE revealed mod-severe MR with a broad, largely central jet. I couldn't appreciate any recurrent prolapse. There was mod TR, normal coronaries, and an EF of 40%. I operated this morning and found the ring was intact and there was no prolapse. I removed the ring, debrided away the pannus, and inserted a 28 mm Physio. Saline test now revealed broad restriction of P2 and P3. I made a radial slit, 2mm from the ring, along P2 and P3. Gluteraldehyde treated autologous pericardium was then used for posterior leaflet extension. This was done with continuous 5-0 Cardionyl. I also repaired the tricuspid (26mm MC3). The post-CPB TEE showed no MR or TR with an EF of 30%. She was extubated on the table, and did well thus far. The main points are that rerepairing a valve is quite feasible. Certainly, with her already depressed LV function, a replacement with a mechanical prosthesis would have severely clouded her future. Hopefully, this repair will hold up, though it worries me that the posterior leaflet restriction developed in the first place. I presume it was due to adverse ventricular remodeling. Also, Dave Adams recently had a paper in Annals in which he advocated using large rings for myxomatous repairs. However, I think this is potentially a mistake when doing myxomatous repairs in hearts with impaired LV's. For the myxomatous repairs in hearts with relatively poor LV function, you should probably undersize the ring much as you would for MR due to pure annular dilatation. Hal ************************************** See what's free at http://www.aol.com. From prasannasimha at gmail.com Sat Jun 2 11:32:35 2007 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sat Jun 2 01:03:00 2007 Subject: [HSF] Redo Radical Mitral Valvuloplasty In-Reply-To: References: Message-ID: <89c4ed2d0706012202q2a795b05w53482fa2f8128c7c@mail.gmail.com> I agree that downsizing is probably wise if it will not lead to SAM. The normal mitral circumference is 10cms and that means you would not need to have a diameter more than that. Also an MVOA of > 2.0 sq cm will always have acceptable gradients even with exercise.One important thing is that bigger is not necessarily better, Thus placing a large prosthesis in the mitral position may not be better (and an article in JVHD corroborates this). My reasoning is that having a smaller prosthesis or a ring will allow remodeling of the ventricle and will reduce its spherecity so implanting a large prosthesis (where leaflet weight versus flow will not necessarily reduce gradients (unlike in an aortic position where prostheses are generally smaller) and will "splint" the annulus in a "diastolic" position which will increase ventricular spherecity and would thus decrease ventricular function.The sphincteric function of the mitral annulus is lost with all rigid / semirigid repairs (I have pictures with radioopaque flexible rings showing annular motion being preserved - I think I showed them once in HSF) and so I think it is better to fix it at predicted systolic circumference/ dimensions compared to diastolic diastolic / flaccid dimensions. Myxomatous valves can be rerepaired and I congratulate you on this. Unfortunately the rheumatic ones which have progressed have all been due to posteromedial pericommissural (p3 retraction) which I have not been able to rerepair. Did you by any chance do a sliding plasty in your original repair ? One possible cause in my mind could due to fibrosis after a sliding plasty.Didthe pannusby any chance extend on to the leaflet ? Prasanna On 6/2/07, Hgrmd@aol.com wrote: > > Dear Members, > Today's case was unusual. About 2 years ago, I repaired a myxomatous > mitral in a 38 yo lady. I placed 4 Goretex neochords in A1 and A2. I > closed the > P2-P3 interscallop leak, and performed a > postero-medial commissuroplasty. A > 32 mm Physio ring was used. She did well until a few months ago when she > was noted to have a recurrent MR murmur that was asymptomatic. TEE > revealed > mod-severe MR with a broad, largely central jet. I couldn't appreciate > any > recurrent prolapse. There was mod TR, normal coronaries, and an EF of > 40%. I > operated this morning and found the ring was intact and there was no > prolapse. > I removed the ring, debrided away the pannus, and inserted a 28 mm > Physio. > Saline test now revealed broad restriction of P2 and P3. I made a radial > slit, 2mm from the ring, along P2 and P3. Gluteraldehyde treated > autologous > pericardium was then used for posterior leaflet extension. This was done > with > continuous 5-0 Cardionyl. I also repaired the tricuspid (26mm MC3). The > post-CPB TEE showed no MR or TR with an EF of 30%. She was extubated on > the > table, and did well thus far. The main points are that rerepairing a > valve is > quite feasible. Certainly, with her already depressed LV function, a > replacement with a mechanical prosthesis would have severely clouded > her future. > Hopefully, this repair will hold up, though it worries me that > the posterior > leaflet restriction developed in the first place. I presume it was due > to > adverse ventricular remodeling. Also, Dave Adams recently had a paper in > Annals > in which he advocated using large rings for myxomatous repairs. However, > I > think this is potentially a mistake when doing myxomatous repairs in > hearts > with impaired LV's. For the myxomatous repairs in hearts with relatively > poor > LV function, you should probably undersize the ring much as you would for > MR > due to pure annular dilatation. > Hal > > > > ************************************** See what's free at > http://www.aol.com. > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > -- Prasanna Simha M From prasannasimha at gmail.com Sat Jun 2 11:40:34 2007 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sat Jun 2 01:11:03 2007 Subject: [HSF] Redo Radical Mitral Valvuloplasty In-Reply-To: <89c4ed2d0706012209o58bb432ci1cbdf44eb2c72e37@mail.gmail.com> References: <89c4ed2d0706012202q2a795b05w53482fa2f8128c7c@mail.gmail.com> <89c4ed2d0706012209o58bb432ci1cbdf44eb2c72e37@mail.gmail.com> Message-ID: <89c4ed2d0706012210m1acf8513u4c5ee3d1524fd5a9@mail.gmail.com> If you could send me the TEE recording (pre and post surgery)I could grab the frames and post them.Also I would like to see the TEE's if possible to learn from them. On 6/2/07, Prasanna Simha M wrote: > > Hal, any photos ? They would prove to be very instructive. > Prasanna > > On 6/2/07, Prasanna Simha M wrote: > > > > I agree that downsizing is probably wise if it will not lead to SAM. > > The normal mitral circumference is 10cms and that means you would not need > > to have a diameter more than that. Also an MVOA of > 2.0 sq cm will > > always have acceptable gradients even with exercise.One important thing > > is that bigger is not necessarily better, Thus placing a large prosthesis > > in the mitral position may not be better (and an article in JVHD > > corroborates this). My reasoning is that having a smaller prosthesis or a > > ring will allow remodeling of the ventricle and will reduce its spherecity > > so implanting a large prosthesis (where leaflet weight versus flow will not > > necessarily reduce gradients (unlike in an aortic position where prostheses > > are generally smaller) and will "splint" the annulus in a "diastolic" > > position which will increase ventricular spherecity and would thus decrease > > ventricular function.The sphincteric function of the mitral annulus is > > lost with all rigid / semirigid repairs (I have pictures with radioopaque > > flexible rings showing annular motion being preserved - I think I showed > > them once in HSF) and so I think it is better to fix it at predicted > > systolic circumference/ dimensions compared to diastolic diastolic / flaccid > > dimensions. > > > > Myxomatous valves can be rerepaired and I congratulate you on this. > > Unfortunately the rheumatic ones which have progressed have all been due to > > posteromedial pericommissural (p3 retraction) which I have not been able to > > rerepair. > > Did you by any chance do a sliding plasty in your original repair ? One > > possible cause in my mind could due to fibrosis after a sliding > > plasty.Did the pannusby any chance extend on to the leaflet ? > > Prasanna > > > > > > On 6/2/07, Hgrmd@aol.com < Hgrmd@aol.com> wrote: > > > > > > Dear Members, > > > Today's case was unusual. About 2 years ago, I repaired > > > a myxomatous > > > mitral in a 38 yo lady. I placed 4 Goretex neochords in A1 > > > and A2. I closed the > > > P2-P3 interscallop leak, and performed a > > > postero-medial commissuroplasty. A > > > 32 mm Physio ring was used. She did well until a few months ago when > > > she > > > was noted to have a recurrent MR murmur that was asymptomatic. TEE > > > revealed > > > mod-severe MR with a broad, largely central jet. I couldn't > > > appreciate any > > > recurrent prolapse. There was mod TR, normal coronaries, and an EF > > > of 40%. I > > > operated this morning and found the ring was intact and there was no > > > prolapse. > > > I removed the ring, debrided away the pannus, and inserted a 28 mm > > > Physio. > > > Saline test now revealed broad restriction of P2 and P3. I made a > > > radial > > > slit, 2mm from the ring, along P2 and P3. Gluteraldehyde treated > > > autologous > > > pericardium was then used for posterior leaflet extension. This was > > > done with > > > continuous 5-0 Cardionyl. I also repaired the tricuspid (26mm > > > MC3). The > > > post-CPB TEE showed no MR or TR with an EF of 30%. She was extubated > > > on the > > > table, and did well thus far. The main points are that rerepairing a > > > valve is > > > quite feasible. Certainly, with her already depressed LV function, a > > > replacement with a mechanical prosthesis would have severely clouded > > > her future. > > > Hopefully, this repair will hold up, though it worries me that > > > the posterior > > > leaflet restriction developed in the first place. I presume it was > > > due to > > > adverse ventricular remodeling. Also, Dave Adams recently had > > > a paper in Annals > > > in which he advocated using large rings for > > > myxomatous repairs. However, I > > > think this is potentially a mistake when doing myxomatous repairs in > > > hearts > > > with impaired LV's. For the myxomatous repairs in hearts with > > > relatively poor > > > LV function, you should probably undersize the ring much as you would > > > for MR > > > due to pure annular dilatation. > > > Hal > > > > > > > > > > > > ************************************** See what's free at > > > http://www.aol.com. > > > _______________________________________________ > > > OpenHeart-L mailing list > > > > > > Send postings to: > > > OpenHeart-L@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 > > > ----------------------------------------- > > > > > > > > > > > -- > > Prasanna Simha M > > > > > -- > Prasanna Simha M -- Prasanna Simha M From epsccv at arrakis.es Sat Jun 2 09:34:37 2007 From: epsccv at arrakis.es (EPS-CCV) Date: Sat Jun 2 02:37:09 2007 Subject: [HSF] HIT and CPB References: <4329c7e70706011718l2eeae9f4od9a23bdd543633d2@mail.gmail.com> Message-ID: <008001c7a4e0$17dc1f80$0601a8c0@Quique> Dr. Teles Neither intraoperative nor postop thrombotic complications were encountered. The follow up 3 months later didn't show any thrombosis incidence neither there were clinical findings. I agree, the patient will be sensitive to heparin for the next 6 months after receiving the epoprostanol but we didn't have another option. The surgery indication was urgent (cardiac transplant, endocarditis, ...) in all cases. If the TAS Analyzer were available here, anticoagulation with lepirudin and on-line determination of the Ecarin Clotting Time during CPB would be my first choice, of course. Enrique P. de la Sota, FECTS Madrid - Spain From prasannasimha at gmail.com Sat Jun 2 11:39:26 2007 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Sat Jun 2 02:46:42 2007 Subject: [HSF] Redo Radical Mitral Valvuloplasty In-Reply-To: <89c4ed2d0706012202q2a795b05w53482fa2f8128c7c@mail.gmail.com> References: <89c4ed2d0706012202q2a795b05w53482fa2f8128c7c@mail.gmail.com> Message-ID: <89c4ed2d0706012209o58bb432ci1cbdf44eb2c72e37@mail.gmail.com> Hal, any photos ? They would prove to be very instructive. Prasanna On 6/2/07, Prasanna Simha M wrote: > > I agree that downsizing is probably wise if it will not lead to SAM. The > normal mitral circumference is 10cms and that means you would not need to > have a diameter more than that. Also an MVOA of > 2.0 sq cm will always > have acceptable gradients even with exercise.One important thing is that > bigger is not necessarily better, Thus placing a large prosthesis in the > mitral position may not be better (and an article in JVHD corroborates > this). My reasoning is that having a smaller prosthesis or a ring will > allow remodeling of the ventricle and will reduce its spherecity so > implanting a large prosthesis (where leaflet weight versus flow will not > necessarily reduce gradients (unlike in an aortic position where prostheses > are generally smaller) and will "splint" the annulus in a "diastolic" > position which will increase ventricular spherecity and would thus decrease > ventricular function.The sphincteric function of the mitral annulus is > lost with all rigid / semirigid repairs (I have pictures with radioopaque > flexible rings showing annular motion being preserved - I think I showed > them once in HSF) and so I think it is better to fix it at predicted > systolic circumference/ dimensions compared to diastolic diastolic / flaccid > dimensions. > > Myxomatous valves can be rerepaired and I congratulate you on this. > Unfortunately the rheumatic ones which have progressed have all been due to > posteromedial pericommissural (p3 retraction) which I have not been able to > rerepair. > Did you by any chance do a sliding plasty in your original repair ? One > possible cause in my mind could due to fibrosis after a sliding plasty.Didthe pannusby any chance extend on to the leaflet ? > Prasanna > > > On 6/2/07, Hgrmd@aol.com wrote: > > > > Dear Members, > > Today's case was unusual. About 2 years ago, I repaired a myxomatous > > mitral in a 38 yo lady. I placed 4 Goretex neochords in A1 and A2. I > > closed the > > P2-P3 interscallop leak, and performed a > > postero-medial commissuroplasty. A > > 32 mm Physio ring was used. She did well until a few months ago when > > she > > was noted to have a recurrent MR murmur that was asymptomatic. TEE > > revealed > > mod-severe MR with a broad, largely central jet. I couldn't appreciate > > any > > recurrent prolapse. There was mod TR, normal coronaries, and an EF of > > 40%. I > > operated this morning and found the ring was intact and there was no > > prolapse. > > I removed the ring, debrided away the pannus, and inserted a 28 mm > > Physio. > > Saline test now revealed broad restriction of P2 and P3. I made a > > radial > > slit, 2mm from the ring, along P2 and P3. Gluteraldehyde treated > > autologous > > pericardium was then used for posterior leaflet extension. This was > > done with > > continuous 5-0 Cardionyl. I also repaired the tricuspid (26mm > > MC3). The > > post-CPB TEE showed no MR or TR with an EF of 30%. She was extubated > > on the > > table, and did well thus far. The main points are that rerepairing a > > valve is > > quite feasible. Certainly, with her already depressed LV function, a > > replacement with a mechanical prosthesis would have severely clouded > > her future. > > Hopefully, this repair will hold up, though it worries me that > > the posterior > > leaflet restriction developed in the first place. I presume it was due > > to > > adverse ventricular remodeling. Also, Dave Adams recently had a paper > > in Annals > > in which he advocated using large rings for > > myxomatous repairs. However, I > > think this is potentially a mistake when doing myxomatous repairs in > > hearts > > with impaired LV's. For the myxomatous repairs in hearts with > > relatively poor > > LV function, you should probably undersize the ring much as you would > > for MR > > due to pure annular dilatation. > > Hal > > > > > > > > ************************************** See what's free at > > http://www.aol.com. > > _______________________________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@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 > > ----------------------------------------- > > > > > > -- > Prasanna Simha M -- Prasanna Simha M From otto at iafrica.com Sat Jun 2 10:09:37 2007 From: otto at iafrica.com (Otto Thaning) Date: Sat Jun 2 03:09:50 2007 Subject: [HSF] Endocarditis with splenic infarct References: Message-ID: <002601c7a4e4$fe08d940$0200a8c0@your35b02f5053> Nand! Am puzzled about the management of the patient who has a vegetation, positive blood culture and was treated on IV antibiotics and discharged from hospital within the 2 week period after diagnosis. It is thus assumed the antibiotic treatment was shorter than ideal. The vegetation needs to be removed and I would recommend a 6 week course of appropriate antibiotic in hospital - a time that would allow you to monitor the splenic infarct. The danger there is the possible development of a splenic abscess. Otto Thaning Cape Town ----- Original Message ----- From: "nand kejriwal" To: Sent: Thursday, May 31, 2007 10:30 AM Subject: Re: [HSF] Endocarditis with splenic infarct > Dear members > > 47 year man, admitted 2 weeks back with mitral valve endocarditis with > vegetation. Blood culture - Enterococcus faecalis. Put on Gentamycin and > Amoxycillin and discahrged. Readmitted 3 days ago with severe abdominal > pain. > CT - acute splenic infarct. No evidence of abscess formation. at this stage. > > Repeat TOE - vegetation still the same size. > Referred to me today. I am planning to operate tomorrow. > > Opinion of the forum regarding splenic infarct. My plan is to leave the > spleen alone and follow it up in the postop period. What are the chances of > bleeding into the infarct during heparinisation? Would anyone recommend > concomitant splenectomy? > > Thanks > > nand > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From rwmfglycar at aol.com Sat Jun 2 08:45:05 2007 From: rwmfglycar at aol.com (rwmfglycar@aol.com) Date: Sat Jun 2 07:49:41 2007 Subject: [HSF] Redo Radical Mitral Valvuloplasty In-Reply-To: <89c4ed2d0706012202q2a795b05w53482fa2f8128c7c@mail.gmail.com> References: <89c4ed2d0706012202q2a795b05w53482fa2f8128c7c@mail.gmail.com> Message-ID: <8C973229913E991-E24-5E6F@FWM-M38.sysops.aol.com> Hal and Prasanna you raise interesting points. Hal: 1) Was the pannus that you removed covering the polyester cloth of the ring? Had it involved the base of the posterior leaflet? When you describe the posterior scallops as "restricted". I presume you mean the leaflet tissue was tethered, so?that when you lifted the edge of the leaflet with a leaflet retractor it was held down in the ventricular cavity. Theoretically this could occur from leaflet shrinkage (? pannus effect), chordal shrinkage (unknown in degenerative disease) or papillary displacement. I find the latter hard to attribute to correction of mitral insufficiency. If anything the ventricle should have gotten smaller with a lessening of the interpapillary and the papillary base to annular distances. (There was a study about 15 years ago of myopathic hearts in which mitral?prolapse was shown to improve as the heart dilated and to?get worse?with improvement? in?ventricular function). Is it possible that the ventricle suffered during the first operation, made enzymes or was needed? a lot of support coming off bypass? Annoying questions, I know, but it may be worth examining echo tapes from before the first op, shortly after the first op and now, and looking specifically for interpapillarydistance in systole and diastole. 2) I worry that you used autogenous pericardium in a redo. Presumably it had adhesions to the epicardium . I had bad experience with untanned?pericardium that had formed adhesions due to rheumatic inflammation. There was a very rapid development of a severe sclerotic change. However the use of a brief?glutaraldehyde exposure?may well have eliminated a possible excessive inflammatory response. 3) I believe that leaflet enhancement was the right solution to this problem and could have been done without changing the ring. Hal and Prasanna: Ring size in the presence of a myopathy secondary to degenerative valvular insufficiency presents interesting questions. First let me say that I do not think that?a tight annuloplasty in a myopathic ventricle restores the increased ?interpapillary distance to normal. To suggest, as has been done, that a tight annuloplasty restores ventricular dimensions is a hope not a fact. The problem with Barlow's is excess tissue and the reason for the very definite move by many surgeons to use larger rings is the recognition that, for years, by using intertrigonal distance as the criterion for ring choice the annulus was being reduced to a systolic dimension suitable for the leaflet dimension of a normal valve when what was needed was a larger dimension to accomodate the increased leaflet area of Barlow's pathology. Since most of the patient's with Barlow's operated these days have a compensated ventricular enlargement with good systolic function,?if the ring chosen produces a?systolic dimension?that is the?right one? to produce a?proper amount of coaptation it does not matter if it? is a little larger than the dimension of systole in a normal heart. You have suggested that, if the heart in a Barlow's case is myopathic (and?thus no longer compensated), there is a case to be made for a smaller annuloplasty. ?I would suggest that smaller annuloplasties in ventricular mechanism mitral insufficiency are done because that is what is needed to produce partial compensation for the papillary displacement and leaflet tethering and reestablish at least some degree of coaptation. If ventricular improvement follows it?is related to the correction of the insufficiency, but there is no evidence that annular narrowing by itself is a suitable correction for myopathy. ( What a bonanza it would be if mechanical annular reduction in the absence of mitral insufficiency was an accepted therapy for cardiomyopathy). Prasanna I think the paper you refer to on?the better ventricular? function with larger rather than?smaller prostheses was in the Asian Journal and referred to valvular prostheses, not rings. The point is appropriately made, but here we are talking about annuloplasty. I agree with you that the notion of fixing the annulus in a diastolic position is absurd. All annuloplasties that are doing their job of restoring coaptation have to be fixing the annulus in a systolic dimension.? If in fact Barlow's is present with a severely myopathic ventricle then this would be the case for significant leaflet reduction or. perish the thought, for? backing away from the 100% repair rate ?and placing a fairly small prosthesis within the native valve with due attention paid for keeping the anterior leaflet away from the septum, Bob :02 am Subject: Re: [HSF] Redo Radical Mitral Valvuloplasty I agree that downsizing is probably wise if it will not lead to SAM. The? normal mitral circumference is 10cms and that means you would not need to? have a diameter more than that. Also an MVOA of > 2.0 sq cm will always? have acceptable gradients even with exercise.One important thing is that? bigger is not necessarily better, Thus placing a large prosthesis in the? mitral position may not be better (and an article in JVHD corroborates? this). My reasoning is that having a smaller prosthesis or a ring will? allow remodeling of the ventricle and will reduce its spherecity so? implanting a large prosthesis (where leaflet weight versus flow will not? necessarily reduce gradients (unlike in an aortic position where prostheses? are generally smaller) and will "splint" the annulus in a "diastolic"? position which will increase ventricular spherecity and would thus decrease? ventricular function.The sphincteric function of the mitral annulus is lost? with all rigid / semirigid repairs (I have pictures with radioopaque? flexible rings showing annular motion being preserved - I think I showed? them once in HSF) and so I think it is better to fix it at predicted? systolic circumference/ dimensions compared to diastolic diastolic / flaccid? dimensions.? ? Myxomatous valves can be rerepaired and I congratulate you on this.? Unfortunately the rheumatic ones which have progressed have all been due to? posteromedial pericommissural (p3 retraction) which I have not been able to? rerepair.? Did you by any chance do a sliding plasty in your original repair ? One? possible cause in my mind could due to fibrosis after a sliding? plasty.Didthe pannusby any chance extend on to the leaflet ?? Prasanna? ? On 6/2/07, Hgrmd@aol.com wrote:? >? > Dear Members,? > Today's case was unusual. About 2 years ago, I repaired a myxomatous? > mitral in a 38 yo lady. I placed 4 Goretex neochords in A1 and A2. I? > closed the? > P2-P3 interscallop leak, and performed a? > postero-medial commissuroplasty. A? > 32 mm Physio ring was used. She did well until a few months ago when she? > was noted to have a recurrent MR murmur that was asymptomatic. TEE? > revealed? > mod-severe MR with a broad, largely central jet. I couldn't appreciate? > any? > recurrent prolapse. There was mod TR, normal coronaries, and an EF of? > 40%. I? > operated this morning and found the ring was intact and there was no? > prolapse.? > I removed the ring, debrided away the pannus, and inserted a 28 mm? > Physio.? > Saline test now revealed broad restriction of P2 and P3. I made a radial? > slit, 2mm from the ring, along P2 and P3. Gluteraldehyde treated? > autologous? > pericardium was then used for posterior leaflet extension. This was done? > with? > continuous 5-0 Cardionyl. I also repaired the tricuspid (26mm MC3). The? > post-CPB TEE showed no MR or TR with an EF of 30%. She was extubated on? > the? > table, and did well thus far. The main points are that rerepairing a? > valve is? > quite feasible. Certainly, with her already depressed LV function, a? > replacement with a mechanical prosthesis would have severely clouded? > her future.? > Hopefully, this repair will hold up, though it worries me that? > the posterior? > leaflet restriction developed in the first place. I presume it was due? > to? > adverse ventricular remodeling. Also, Dave Adams recently had a paper in? > Annals? > in which he advocated using large rings for myxomatous repairs. However,? > I? > think this is potentially a mistake when doing myxomatous repairs in? > hearts? > with impaired LV's. For the myxomatous repairs in hearts with relatively? > poor? > LV function, you should probably undersize the ring much as you would for? > MR? > due to pure annular dilatation.? > Hal? >? >? >? > ************************************** See what's free at? > http://www.aol.com.? > _______________________________________________? > OpenHeart-L mailing list? >? > Send postings to:? > OpenHeart-L@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? > -----------------------------------------? >? ? ? -- Prasanna Simha M? _______________________________________________? OpenHeart-L mailing list? ? Send postings to:? OpenHeart-L@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? -----------------------------------------? ________________________________________________________________________ AOL now offers free email to everyone. Find out more about what's free from AOL at AOL.com. From nkkejriwal at gmail.com Sun Jun 3 00:47:42 2007 From: nkkejriwal at gmail.com (nand kejriwal) Date: Sat Jun 2 08:14:39 2007 Subject: [HSF] Endocarditis with splenic infarct In-Reply-To: References: Message-ID: Hal & Prasanna *Did you consider repairing, rather than replacing the mitral valve?* Yes, I did consider repairing the valve, but the positive gram staining put me off. I thought the best chance the patient had was to get rid of all the potential infected foci. Therefore, I removed the entire valve apparatus and placed Gore-Tex chordae to restore the annulo-papillary continuity. Bob & Prasanna Needless to say the ID guys can describe a case with a 1.2 cm vegetation that was finally sterilised without needing surgery My experience with patients of this kind was that they often came to surgery eventually anyhow. It is interesting that organisms were present in the vegetation. Did you send any of it for culture? Thanks for your comments. Yes, I sent the entire valve for culture. I am awaiting the final results. Most likely, it will be the same organism. Interestingly, I had a similar patient last week, who also had enterococcus faecalis mitral endocarditis. He was in the hospital for 4 weeks on antibiotics and was never referred for surgery. One fine morning he developed a tender spot near the right wrist. An ultrasound revealed occlusion of the right radial artery, most likely from embolic vegetation. He also had kissing vegetations on the aortic valve and underwent double valve replacement. Both these patients were lucky that the vegetations did not embolise to the brain. I shall be talking to the cardiologists next week to ensure that the surgeons are involved in the management of endocarditis right from the beginning. I had to cancel my routine cases in both these instances to accommodate their ill-managed cases. Otto the antibiotic treatment was shorter than ideal. The patient was sent home with arrangements to complete full six weeks of antibiotics. As long as the antibiotic course is completed, I do not think it matters whether it is done in-hospital or as an outpatient. Nand From Hgrmd at aol.com Sat Jun 2 09:52:38 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sat Jun 2 08:57:39 2007 Subject: [HSF] Redo Radical Mitral Valvuloplasty Message-ID: Prasanna, You made some really excellent points. I particularly like the one that true sizing the mitral orifice in a replacement could prevent possible reverse remodeling. I'm amazed at some of the repairs you've been able to do with your rheumatics. Retraction of the P3 area is a major issue as well in ischemic MR. However, MR in ischemic cardiomyopathy occurs in mitrals with leaflets that are normal or thinned out. This makes patching even more difficult. The case I did yesterday had leaflet that was thickened as with typical myxomatous degeneration. According to my op note, I had merely closed a P2-P3 interscallop leak as well as a postero-medial commissuroplasty, in addition to resuspending A1 and A2. There was no evidence of pannus overgrowth. I did not do a sliding leaflet plasty or any other type of posterior leaflet resection. At operation, I could see no trace of that P2-P3 repair, and I suspect it broke down. In fact, that was the worst area of leaflet retraction and source of leak on the initial saline test. Parenthetically, this case was especially significant to me, because it was the first case of myxomatous repair that I ever had to reoperate. I'm not naive enough to believe that it's the only case that ever redeveloped a significant leak, but it's the only one that had been brought to my attention. Hal ************************************** See what's free at http://www.aol.com. From prasannasimha at gmail.com Sat Jun 2 18:57:50 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Sat Jun 2 08:57:47 2007 Subject: [HSF] Redo Radical Mitral Valvuloplasty In-Reply-To: <8C973229913E991-E24-5E6F@FWM-M38.sysops.aol.com> References: <89c4ed2d0706012202q2a795b05w53482fa2f8128c7c@mail.gmail.com> <8C973229913E991-E24-5E6F@FWM-M38.sysops.aol.com> Message-ID: <46616246.4060103@gmail.com> What I meant that ventricular curvature has to increase- considering the LV from annulus to annulus (length wise as a part of a circle chord) shortening the chord will increase its curvature. Prasanna rwmfglycar@aol.com wrote: > Hal and Prasanna you raise interesting points. > > Hal: 1) Was the pannus that you removed covering the polyester cloth of the ring? Had it involved the base of the posterior leaflet? When you describe the posterior scallops as "restricted". I presume you mean the leaflet tissue was tethered, so that when you lifted the edge of the leaflet with a leaflet retractor it was held down in the ventricular cavity. Theoretically this could occur from leaflet shrinkage (? pannus effect), chordal shrinkage (unknown in degenerative disease) or papillary displacement. I find the latter hard to attribute to correction of mitral insufficiency. If anything the ventricle should have gotten smaller with a lessening of the interpapillary and the papillary base to annular distances. (There was a study about 15 years ago of myopathic hearts in which mitral prolapse was shown to improve as the heart dilated and to get worse with improvement in ventricular function). Is it possible that the ventricle suffered during the first operation, made enzymes or was needed a lot of support coming off bypass? Annoying questions, I know, but it may be worth examining echo tapes from before the first op, shortly after the first op and now, and looking specifically for interpapillarydistance in systole and diastole. > 2) I worry that you used autogenous pericardium in a redo. Presumably it had adhesions to the epicardium . I had bad experience with untanned pericardium that had formed adhesions due to rheumatic inflammation. There was a very rapid development of a severe sclerotic change. However the use of a brief glutaraldehyde exposure may well have eliminated a possible excessive inflammatory response. > 3) I believe that leaflet enhancement was the right solution to this problem and could have been done without changing the ring. > Hal and Prasanna: Ring size in the presence of a myopathy secondary to degenerative valvular insufficiency presents interesting questions. First let me say that I do not think that a tight annuloplasty in a myopathic ventricle restores the increased interpapillary distance to normal. To suggest, as has been done, that a tight annuloplasty restores ventricular dimensions is a hope not a fact. The problem with Barlow's is excess tissue and the reason for the very definite move by many surgeons to use larger rings is the recognition that, for years, by using intertrigonal distance as the criterion for ring choice the annulus was being reduced to a systolic dimension suitable for the leaflet dimension of a normal valve when what was needed was a larger dimension to accomodate the increased leaflet area of Barlow's pathology. Since most of the patient's with Barlow's operated these days have a compensated ventricular enlargement with good systolic function, if the ring chosen produces a systolic dimension that is the right one to produce a proper amount of coaptation it does not matter if it is a little larger than the dimension of systole in a normal heart. > You have suggested that, if the heart in a Barlow's case is myopathic (and thus no longer compensated), there is a case to be made for a smaller annuloplasty. I would suggest that smaller annuloplasties in ventricular mechanism mitral insufficiency are done because that is what is needed to produce partial compensation for the papillary displacement and leaflet tethering and reestablish at least some degree of coaptation. If ventricular improvement follows it is related to the correction of the insufficiency, but there is no evidence that annular narrowing by itself is a suitable correction for myopathy. ( What a bonanza it would be if mechanical annular reduction in the absence of mitral insufficiency was an accepted therapy for cardiomyopathy). > Prasanna I think the paper you refer to on the better ventricular function with larger rather than smaller prostheses was in the Asian Journal and referred to valvular prostheses, not rings. The point is appropriately made, but here we are talking about annuloplasty. I agree with you that the notion of fixing the annulus in a diastolic position is absurd. All annuloplasties that are doing their job of restoring coaptation have to be fixing the annulus in a systolic dimension. > If in fact Barlow's is present with a severely myopathic ventricle then this would be the case for significant leaflet reduction or. perish the thought, for backing away from the 100% repair rate and placing a fairly small prosthesis within the native valve with due attention paid for keeping the anterior leaflet away from the septum, > Bob > > > > > > > > :02 am > Subject: Re: [HSF] Redo Radical Mitral Valvuloplasty > > > > I agree that downsizing is probably wise if it will not lead to SAM. The > normal mitral circumference is 10cms and that means you would not need to > have a diameter more than that. Also an MVOA of > 2.0 sq cm will always > have acceptable gradients even with exercise.One important thing is that > bigger is not necessarily better, Thus placing a large prosthesis in the > mitral position may not be better (and an article in JVHD corroborates > this). My reasoning is that having a smaller prosthesis or a ring will > allow remodeling of the ventricle and will reduce its spherecity so > implanting a large prosthesis (where leaflet weight versus flow will not > necessarily reduce gradients (unlike in an aortic position where prostheses > are generally smaller) and will "splint" the annulus in a "diastolic" > position which will increase ventricular spherecity and would thus decrease > ventricular function.The sphincteric function of the mitral annulus is lost > with all rigid / semirigid repairs (I have pictures with radioopaque > flexible rings showing annular motion being preserved - I think I showed > them once in HSF) and so I think it is better to fix it at predicted > systolic circumference/ dimensions compared to diastolic diastolic / flaccid > dimensions. > > Myxomatous valves can be rerepaired and I congratulate you on this. > Unfortunately the rheumatic ones which have progressed have all been due to > posteromedial pericommissural (p3 retraction) which I have not been able to > rerepair. > Did you by any chance do a sliding plasty in your original repair ? One > possible cause in my mind could due to fibrosis after a sliding > plasty.Didthe pannusby any chance extend on to the leaflet ? > Prasanna > > On 6/2/07, Hgrmd@aol.com wrote: > >> >> Dear Members, >> Today's case was unusual. About 2 years ago, I repaired a myxomatous >> mitral in a 38 yo lady. I placed 4 Goretex neochords in A1 and A2. I >> closed the >> P2-P3 interscallop leak, and performed a >> postero-medial commissuroplasty. A >> 32 mm Physio ring was used. She did well until a few months ago when she >> was noted to have a recurrent MR murmur that was asymptomatic. TEE >> revealed >> mod-severe MR with a broad, largely central jet. I couldn't appreciate >> any >> recurrent prolapse. There was mod TR, normal coronaries, and an EF of >> 40%. I >> operated this morning and found the ring was intact and there was no >> prolapse. >> I removed the ring, debrided away the pannus, and inserted a 28 mm >> Physio. >> Saline test now revealed broad restriction of P2 and P3. I made a radial >> slit, 2mm from the ring, along P2 and P3. Gluteraldehyde treated >> autologous >> pericardium was then used for posterior leaflet extension. This was done >> with >> continuous 5-0 Cardionyl. I also repaired the tricuspid (26mm MC3). The >> post-CPB TEE showed no MR or TR with an EF of 30%. She was extubated on >> the >> table, and did well thus far. The main points are that rerepairing a >> valve is >> quite feasible. Certainly, with her already depressed LV function, a >> replacement with a mechanical prosthesis would have severely clouded >> her future. >> Hopefully, this repair will hold up, though it worries me that >> the posterior >> leaflet restriction developed in the first place. I presume it was due >> to >> adverse ventricular remodeling. Also, Dave Adams recently had a paper in >> Annals >> in which he advocated using large rings for myxomatous repairs. However, >> I >> think this is potentially a mistake when doing myxomatous repairs in >> hearts >> with impaired LV's. For the myxomatous repairs in hearts with relatively >> poor >> LV function, you should probably undersize the ring much as you would for >> MR >> due to pure annular dilatation. >> Hal >> >> >> >> ************************************** See what's free at >> http://www.aol.com. >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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 >> ----------------------------------------- >> >> > > > -- Prasanna Simha M > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > > ________________________________________________________________________ > AOL now offers free email to everyone. Find out more about what's free from AOL at AOL.com. > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > > -------------- next part -------------- A non-text attachment was scrubbed... Name: large versus small rings.jpg Type: image/jpeg Size: 56269 bytes Desc: not available Url : http://mmp.cjp.com/pipermail/openheart-l/attachments/20070602/906c45d7/largeversussmallrings-0001.jpg From Hgrmd at aol.com Sat Jun 2 09:56:29 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sat Jun 2 09:00:51 2007 Subject: [HSF] Redo Radical Mitral Valvuloplasty Message-ID: Prasanna, Monday, I'm leaving for Rome to attend ISMICS, followed by Vanerman's 7th Annual Endoscopic Techniques Course-Master of Valve Repair Program in Belgium, followed by the Society of Heart Valve Disease in NY. I won't be home for 2 weeks. However, when I get back, I will try to send you those before and after TEE's. Hal ************************************** See what's free at http://www.aol.com. From Hgrmd at aol.com Sat Jun 2 10:00:14 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sat Jun 2 09:05:55 2007 Subject: [HSF] Redo Radical Mitral Valvuloplasty Message-ID: Prasanna, No, I didn't take any photos. I've really got to become better at that. It's just that I had to do that case, 4 pacemakers, and all the rounds at our main hospital before a dinner with friends at 2030. I didn't have a lot of spare time. In addition, the case took about an extra hour due to heparin resistance precluding CPB, which was eventually treated with FFP. Hal ************************************** See what's free at http://www.aol.com. From prasannasimha at gmail.com Sat Jun 2 19:34:51 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Sat Jun 2 09:13:12 2007 Subject: [HSF] Redo Radical Mitral Valvuloplasty In-Reply-To: References: Message-ID: <46616AF3.3010209@gmail.com> Hal, How many sutures had you put to close the cleft ? Do you have any recollection ? There seems to be a lot to learn from this case. By a posteromedial commissuroplasty was it a Carpentier's magic stitch ? Prasanna. Hgrmd@aol.com wrote: > Prasanna, > You made some really excellent points. I particularly like the one that > true sizing the mitral orifice in a replacement could prevent possible reverse > remodeling. > I'm amazed at some of the repairs you've been able to do with your > rheumatics. Retraction of the P3 area is a major issue as well in ischemic MR. > However, MR in ischemic cardiomyopathy occurs in mitrals with leaflets that are > normal or thinned out. This makes patching even more difficult. The case I > did yesterday had leaflet that was thickened as with typical myxomatous > degeneration. According to my op note, I had merely closed a P2-P3 interscallop > leak as well as a postero-medial commissuroplasty, in addition to resuspending > A1 and A2. There was no evidence of pannus overgrowth. I did not do a > sliding leaflet plasty or any other type of posterior leaflet resection. At > operation, I could see no trace of that P2-P3 repair, and I suspect it broke down. > In fact, that was the worst area of leaflet retraction and source of leak > on the initial saline test. > Parenthetically, this case was especially significant to me, because it > was the first case of myxomatous repair that I ever had to reoperate. I'm not > naive enough to believe that it's the only case that ever redeveloped a > significant leak, but it's the only one that had been brought to my attention. > Hal > > > > ************************************** See what's free at http://www.aol.com. > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > From Hgrmd at aol.com Sat Jun 2 10:15:33 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sat Jun 2 09:19:49 2007 Subject: [HSF] Redo Radical Mitral Valvuloplasty Message-ID: Bob, Many thanks for weighing in on my case. To me, your insight is the best part of HSF. As for the case in question, pannus covered only the ring and not the leaflets. I think the restriction was from subsequent adverse remodeling and consequent tethering. From reading the original op note, the LV was moderately impaired at the time of the initial surgery (EF 45%). As you well know, EF's less than 60% are now considered impaired with severe MR. My original op note didn't describe any difficulty with weaning, though the post-CPB EF was 40% on moderate inotropes. Obviously, the original operation required a nearly 2 hour clamp time, which could explain the eventual continued adverse remodeling (yes, Tomas, maybe it would have been better to do this your way, though I think a repair of this magnitude would have been hell under those conditions.). I note your concern about using autologous pericardium for the patch. My hope is that the gluteraldehyde tanning will prevent it. As for downsizing the ring from 32 to 28mm, I firmly think that was the right decision since TEE revealed that the mitro-aortic angle was wide, and there was plenty of room in the LVOT. Thus, the likelihood of SAM was practically nonexistent. I figured in this myopathic ventricle that downsizing would aid in obtaining a good depth of coaptation (It looked to be 15 mm when I finished). Hal ************************************** See what's free at http://www.aol.com. From Hgrmd at aol.com Sat Jun 2 10:19:12 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sat Jun 2 09:23:35 2007 Subject: [HSF] Endocarditis with splenic infarct Message-ID: Dear Nand, Though it sounds scary, repairing a mitral valve in the face of active endocarditis is safe with a low likelihood of recurrence in my experience. After doing the radical debridement, I then hand off the instruments used to resect the infected tissue. Next, I paint the resected area with Betadine. Finally, I reconstruct as per usual. This policy works quite well if the infection is relatively confined. Hal ************************************** See what's free at http://www.aol.com. From Hgrmd at aol.com Sat Jun 2 10:24:36 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sat Jun 2 09:28:56 2007 Subject: [HSF] Redo Radical Mitral Valvuloplasty Message-ID: Prasanna, I don't know how many sutures I used to close the cleft at the original operation, but I suspect I used a double row of 3-4 sutures of 5-0 Cardionyl. I've since changed my technique and use simple interrupted, avoiding the last 1-2 mm of the leaflet edge in order to allow the very edge to billow up and seal the furrow. This was a great point made at Dave Adam's last valve repair course at Mt. Sinai. The postero-medial commissuroplasty was indeed a Carpentier's "magic stitch". Hal ************************************** See what's free at http://www.aol.com. From prasannasimha at gmail.com Sat Jun 2 20:05:56 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Sat Jun 2 09:37:46 2007 Subject: [HSF] Redo Radical Mitral Valvuloplasty In-Reply-To: <466171C9.3080200@gmail.com> References: <466171C9.3080200@gmail.com> Message-ID: <4661723C.3010309@gmail.com> Correction "Point of bend" Prasanna prasannasimha wrote: > I am also finding it safer to take multiple single simple sutures. > Probably the stress is higher initially till healing occurs so > multiple sutures seem to be better compared to a continuous row. Also > I do leave the last few mm free for another reason - it is needed to > allow coaptation at the "Buckled area" as this is a pint of bend > actually. Actually the inferior noncoaptation area can be free. > Prasanna > > Hgrmd@aol.com wrote: >> Prasanna, >> I don't know how many sutures I used to close the cleft at the >> original operation, but I suspect I used a double row of 3-4 sutures >> of 5-0 Cardionyl. I've since changed my technique and use simple >> interrupted, avoiding the last 1-2 mm of the leaflet edge in order >> to allow the very edge to billow up and seal the furrow. This was a >> great point made at Dave Adam's last valve repair course at Mt. Sinai. >> The postero-medial commissuroplasty was indeed a Carpentier's >> "magic stitch". >> Hal >> >> >> >> ************************************** See what's free at >> http://www.aol.com. >> _______________________________________________ >> OpenHeart-L mailing list >> >> Send postings to: >> OpenHeart-L@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 >> ----------------------------------------- >> >> > From prasannasimha at gmail.com Sat Jun 2 19:59:59 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Sat Jun 2 09:38:10 2007 Subject: [HSF] Endocarditis with splenic infarct In-Reply-To: References: Message-ID: <466170D7.4010606@gmail.com> It has a lower rate of recurrence if debridement is radical and you can use a Glutaraldehyde treated pericardial ring too to reduce the amount of foreign material. Tirone David and Calafiore have published their results which are excellent. It is important to remove all infected tissue. Also I have tanned edges of flimsy tissues with Glutaradehyde when there is particularly flimsy areas so sutures hold well.(In fact I also saw Carpentier doing the same in a live teleworkshop.). The caveat is excise first adequately and then decide what you will do. Obviously this is not what you would like to do as an early repair case or if done infrequently but then becomes appealing (and in fact seems safer) when repair becomes the norm in ones armamentarium. Prasanna Hgrmd@aol.com wrote: > Dear Nand, > Though it sounds scary, repairing a mitral valve in the face of active > endocarditis is safe with a low likelihood of recurrence in my experience. > After doing the radical debridement, I then hand off the instruments used to > resect the infected tissue. Next, I paint the resected area with Betadine. > Finally, I reconstruct as per usual. This policy works quite well if the > infection is relatively confined. > Hal > > > > ************************************** See what's free at http://www.aol.com. > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > > From Hgrmd at aol.com Sat Jun 2 10:43:53 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sat Jun 2 09:45:10 2007 Subject: [HSF] Redo Radical Mitral Valvuloplasty Message-ID: Prasanna, I think we are actually saying the same thing. The last few mm's are left open so as to allow the leaflet edge to billow up and seal the furrow. Hal ************************************** See what's free at http://www.aol.com. From prasannasimha at gmail.com Sat Jun 2 20:28:28 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Sat Jun 2 10:00:24 2007 Subject: [HSF] Redo Radical Mitral Valvuloplasty In-Reply-To: References: Message-ID: <46617784.7050702@gmail.com> Yes. The only place where we need to completely close upto the edge (and even there rarely it may be necessary to avoid it (ie complete cleft closure) in case stenosis will result) is in a primum ASD. Of course the mechanism and pathology are different. Prasanna Hgrmd@aol.com wrote: > Prasanna, > I think we are actually saying the same thing. The last few mm's are left > open so as to allow the leaflet edge to billow up and seal the furrow. > Hal > > > > ************************************** See what's free at http://www.aol.com. > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > > From prasannasimha at gmail.com Sat Jun 2 20:04:01 2007 From: prasannasimha at gmail.com (prasannasimha) Date: Sat Jun 2 10:04:50 2007 Subject: [HSF] Redo Radical Mitral Valvuloplasty In-Reply-To: References: Message-ID: <466171C9.3080200@gmail.com> I am also finding it safer to take multiple single simple sutures. Probably the stress is higher initially till healing occurs so multiple sutures seem to be better compared to a continuous row. Also I do leave the last few mm free for