[HSF] Ao Wraping

Ani Anyanwu anianyanwu at hotmail.com
Sat Mar 31 22:13:42 EDT 2007 

Thanks Ajit

1. I presume then you then meant a hemiarch rather than total arch replacement or would you have replaced entire arch if you had intervened on aorta.

2. The issue of mechanical valves for those who do not want reoperation is debatable. At 19 his lifetime risk of reoperation on his mechanical valve (assuming he reaches 70 years of age) is not negligible and could even be as high as 20 to 30%. Some propose that the On-X valve will reduce reoperation rate (due to thrombosis, not endocarditis) - we have not used this valve but look to getting it on our shelves soon. There is an FDA trial of plavix and aspirin only on these valves and if indeed coumadin may be avoided they may change the algorithm for AVR choice in young patients.


3. We would not attemot repair either for thickened deformed leaflets. Otherwise usually AI is secondary to type II dysfunction (prolapse) and we would usually treat by triangular resection and commisural resuspension.

Ani
  ----- Original Message ----- 
  From: Ajit Damle<mailto:damle at cableone.net> 
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
  Sent: Friday, March 30, 2007 10:38 PM
  Subject: RE: [HSF] Ao Wraping


  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>
  [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<mailto: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<mailto:damle at cableone.net>> 
    To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com%3Cmailto:OpenHeart-L at lists.hsforum.com>> 
    Cc: 'Manoj Pradhan'<mailto:manojjpradhan at rediffmail.com<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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