[HSF] Redo Radical Mitral Valvuloplasty

[Prasanna Simha M]

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.Didthe 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
> >
> >
> >
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>
> --
> Prasanna Simha M




-- 
Prasanna Simha M