[HSF] Tricuspid repair w/pulmonary hypertension

[Ani Anyanwu]

I think the key in these patients is the right ventricular function rather than the reversibility or otherwise of the pulmonary hypertension. It is the lack of the RV to cope with the increased afterload from the combination of a high PVR and a competent tricuspid valve that is the achille's heel of valve surgery in this scenario.

It is however difficult to evaluate RV function. Our approach is with cardiac MRI. If the RVEF is severely depressed (EF <20) or the RV wall is thinned out then we would not offer conventional surgery in this context and will evaluate for transplantation or destination VAD (probably not an option in your elderly patient). On the other hand if the RVEF is low (say around 30 to 40) but the wall is not thinned then we will proceed with high-risk surgery but this will be done with VAD standby. 

We have had a few bad experiences like yours in the last year and are now moving more towards planned implantation of temporary RVAD in patients with a low RVEF and pulm HTN, with a planned wean within two to three days of surgery.

Ani


  ----- Original Message ----- 
  From: James S Gammie<mailto:gammie at comcast.net> 
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
  Sent: Wednesday, February 28, 2007 11:18 PM
  Subject: [HSF] Tricuspid repair w/pulmonary hypertension


  HSF:
  elderly male 3vCAD, ef 50 %, severe mr (type I-dilated annulus), severe TR, 
  PA pressures systolic 90.

  operation:
  CABGx4, 28 physio for mitral, 26 mc3 for tricuspid;

  postpump tee: no mr, no tr, good lv function.  RV sick; unable to wean cpb 
  despite usual measures: RVAD outcome uncertain.

  Qs:  any reservations about correcting TR in face of near systemic pulm htn?
          any role for assessing "reversibility" of pulmonary vascular 
  resistance, like we do in transplant?
          what is forum's experience with outcomes for mv/tv ops in patients 
  with similar PA pressures?  Literature suggests up front mort of 10-15 
  percent but fairly old experience...

  jsg 


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