[HSF] Redo Radical Mitral Valvuloplasty

[Prasanna Simha M]

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 <prasannasimha at gmail.com> wrote:
>
> Hal, any photos ? They would  prove to be very instructive.
> Prasanna
>
> On 6/2/07, Prasanna Simha M <prasannasimha at gmail.com > 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 at aol.com < Hgrmd at 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.
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> >
> >
> >
> > --
> > Prasanna Simha M
>
>
>
>
> --
> Prasanna Simha M




-- 
Prasanna Simha M