[HSF] Ao Wraping

[Ajit Damle]

Ani,

1. I was considering arch replacement because the dilatation involved
a segment from just proximal to takeoff of brachiocephalic to the proximal
aortic arch.

2. I did offer the Ross procedure. I do not do them but I know a center that
does. I have sent two patients out but this limited experience has not been
good. The patient's father had done a lot of reading and internet search and
already talked to another surgeon. One of the reasons for mechanical valve
was to avoid repeat valve procedures.

3. The valve was primarily regurgitant but also mildly stenotic. The aortic
leaflets were thickened and deformed and I did not think repair would have
worked. I also have not done aortic repairs (I can recall just two and they
both were very simple). 

Can you describe of your method of valve repair? And how you evaluate a
valve intra-op for repair?

Ajit Damle


-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Ani Anyanwu
Sent: Friday, March 30, 2007 7:37 PM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Ao Wraping

Dear Dr Damle

Regarding your operative plan

1) Why were you considering an arch replacement?

2) Was repair of the aortic valve an option? It was not stated explicitly in
your mail but I presume this was a regurgitant valve? In a young patient a
repair may be a viable option and could give him even a decade without
warfarin and also leave him open in the future to the percutaneous
interventions Dr Schor seems so keen on!

3) Was the choice of mechanical valve a patient driven one? Was the patient
offered the option of a Ross? What are the forum members views on this
procedure for this indication and age group? Although we do not offer a Ross
in my center, we discuss this with all young adults and give them option of
referral to a surgeon who does them.

Thank you

A Anyanwu
  ----- Original Message ----- 
  From: Ajit Damle<mailto:damle at cableone.net> 
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
  Cc: 'Manoj Pradhan'<mailto:manojjpradhan at rediffmail.com> 
  Sent: Friday, March 30, 2007 1:24 AM
  Subject: [HSF] Ao Wraping


  I operated on a 19 year old last week to replace his aortic valve. (What a
  treat! A change from my usual 84 yr old dialysis dependent valves and
  CABGs!)

  He was known to have a bicuspid valve. In the past few months, he started
to
  become symptomatic (with LV dilatation) so this was a good time to replace
  his valve. He looked Marphanoid, so I had a pre-op CT. That showed, a
smooth
  fusiform aneurysm starting in the distal ascending aorta, from 1cm below
the
  brachiocephalic takeoff to proximal arch. The diameter was 3.8cms. For
  comparison, the proximal ascending aorta was 2..6 cms and the descending
  Aorta was 2.3 cms. The patient is 6' tall and a BSA of 2.3. I was prepared
  to replace his arch. I am very confident and comfortable replacing aortic
  arches, and touch wood, very lucky. But I had some nagging doubts
regarding
  the risk/reward ratio in this man.

  At surgery, to I found that his aortic tissue strength was quite good. I
did
  cannulate the undersurface of aortic arch, instead the femoral cannulation
I
  had planned (I had the fem artery exposed). I replaced the bi-cuspid valve
  with a 27 Carbomedics. I used a 28 Hemashield graft to externally wrap the
  aorta and sutured it to to the aortic adventitia meticulously, with
  substantial dissection,  from just above the coronary ostia to the
take-off
  of brachio-cephalic laterally and well past it medially, past my aortic
  input site.

  Before I did the wrapping,  I may point out  that the aortotomy suture
line,
  the cardioplegia and aortic cannula input site, none required any
additional
  sutures, indicating that the aortic tissue quality  was good.

  Did I do the right thing? I will have this man under CT surveillance for
  ever, but still................. 


  Ajit Damle
  Fargo ND

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