[HSF] Ao Wraping, One more question!

[rwmfglycar at aol.com]

Sorry for the unfinished posting.
I started doing wrapping with or without partial aortic wall excision in the 80's for aortic valve insufficiency due to ascending aorta dilatation or aneurysm. The aortic valve insufficiency was due to sinotubular dilatation wth normal aortic leaflets (actually the commonest pathologic cause of aortic incompetence, the commonest associated condition being systemic hypertension). I did it only for this indication. (Frater, Circulation: 74( Supp I); I:136-142, Sep 1986).
I definitely did NOT do it for Marfan's since I had seen sinus dilatation and basal aortic annular dilatation in Marfan's with Aortic Insuff. I did not do it if there was any sinus or basal dilatation. My reason was that wrapping ( or root replacement) removes aortic compliance and  increases impedance to aortic ejection. This almost certainly could accelerate sinus and basal aortic valve dilatation. I never tested this fear, believing that physics and known pathology  trumped randomisation in this case. I personally never saw a failure in this small series (which is no proof of anything needless to say).
With regard to your second case if there is any chance that 1+ aortic insuff. is due to the mechanism described above there is surely no advantage to mechanical or biologic valve replacement.
Bob
 
 
-----Original Message-----
From: damle at cableone.net
To: OpenHeart-L at lists.hsforum.com
Sent: Fri, 30 Mar 2007 10:44 AM
Subject: RE: [HSF] Ao Wraping, One more question!



Thank you Igor, Michael, Prasanna, Hal, Ed and Manoj for your thoughtful
replies.

I do not know what to make of the diameter as a threshold for an operation.
Is it 4.0, as Igor recommends? In a 19 year old, who has plenty of time to
plot against us, my threshold would be lower still. But replacing the
ascending aorta without (or a brief) circulatory arrest is a different deal
than replacing the arch with a longer circ arrest. I must admit, though,
that I am astonished every time that patients wake up without a detectable
neurological deficit!

Part of the reason is the relative ease and absolute success rate of arch
replacements in low risk patients. I did lose a patient some years ago, who
I treated with a Cabrol shunt for coronary ostial implantation. I could not
prove it, but I do think that the shunt somehow (twisted or compressed)
induced coronary insufficiency. Since then,  I have switched to the Valsalva
graft and direct coronary implantation, and have been just giddy with
success.

I had never considered wrapping to be a serious option, but there was a
recent paper that showed external wrapping was a viable option, and that got
me thinking.

BTW, I have yet another aortic aneurysm coming up. 52 yr man, non-ischemic
cardiomyopathy, QRS 110 ms, EF 25-30%, NYHA II, PAP 55/20, new onset A.Fib.
MR 2+, AI 1+, tricuspid aortic valve, no coronary angiogram yet, Asc Ao 6.1
cms.(not arch, I think I can do him without, or a brief, circ arrest). My
plan is to replace the asc aorta, repair mitral, do a maze, excise the LA
appendage, and CABG if needed. I wonder if I should replace his aortic valve
as well, because he may be on coumadin anyway and, with his cardiomyopathy I
may not have the luxury to bring him back in 5-10 years.

What do you think? Too much an operation for this man? Should I replace his
aortic valve?

Ajit Damle
Fargo ND





 




_______________________________________________
OpenHeart-L mailing list

Send postings to:
 OpenHeart-L at 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.