[HSF] Redo Radical Mitral Valvuloplasty

[Hgrmd at aol.com]

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



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