From anianyanwu at hotmail.com Sat Sep 1 02:07:24 2007 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Fri Aug 31 21:07:53 2007 Subject: AW: [HSF] Mitral Repair with a Calcified Annulus In-Reply-To: References: Message-ID: Hal I am not binary in technique; neither is my chief who like you is using more and more non-resection approaches. However as far as it comes to philosophy it is difficult to have two philosophies. I subscribe to Carpentier's lesion based approach - if you identify the lesions then you can assign ways to treat it (which include neochords, which incidentally Carpentier has also used, though more infrequently than others, since the 1980s). With a lesion based approach one would then recognize that there should almost never be a need for a sliding plasty in true FED. The essence of a sliding plasty is to treat the lesion of excess leaflet tissue - this lesion does not generally (though occasionally may do) exist in FED. In contrast in Barlows there is excess tissue so some technique to manage the excess tissue is necessary (such as sliding plasty or imbrication when using gortex). With a lesion based approach, I could still chose to treat a single ruptured chord with a chordal replacement (with gortex or chordal transfer) and that still upholds the Carpentier principles without necessarily doing a resection. I know you also hold similar principles - that you use a lot of Gortex does not deviate you from the fundamental religion! As regards outcomes of gortex, because Dr David's series also included Carpentier type repair's from his early experience, one cannot tease out whether the failures were unique to either technique. Also that you have not heard of your failures since 1996 does not mean they are not there. In David's series, over half of patients with recurrent Moderate or severe MR never had reoperations and therefore remain "surgical successes". Reoperation rate is a poor indicator of outcome of mitral repair (as it is for CABG). The only existing series (Flameng and David) that systematically examined long term recurrence of MR after degenerative repair both found high recurrence rates (Flameng 37% and David 27%). It is very unlikely that any contemporary repair approach will yield much superior results - as we know David is one of the most skilled mitral surgeons. As you are a busy mitral surgeon and have been using Goretex for over a decade, you by definition must have many recurrences by now - at least 10 to 20% of the cases you did pre 1997; the thing is that as we (understandably) do not have systematic echo follow-up, we just never know about them. Fred Mohr does a lot but has not published any long term results on freedom from MR. Neither has Perrier, Chitwood, Lawrie or other Gortex proponents. That we don't see our 'failures' doesn't mean they are not there but just that we have not looked for them. Ani > From: Hgrmd@aol.com> Date: Fri, 31 Aug 2007 19:31:39 -0400> Subject: Re: AW: [HSF] Mitral Repair with a Calcified Annulus> To: OpenHeart-L@lists.hsforum.com> CC: > > Ani,> A lot of what you say makes sense, I just don't necessarily buy all of it. > This redistribution of forces may or may not be essential to a long term > result. I know that I've personally been using Goretex neochords since '95-96. > I've yet to reoperate any of those patients. I fully realize that followup > is incomplete, but I can assure you that if they were wholesale failing, I > would be hearing about it. In addition, I've not read in the literature large > numbers of Goretex failures. Tyrone David's experience with Goretex began > in the mid-80's, and I believe those repairs continue to compare favorably > with Carpentier's data. Fred Mohr has several hundred Goretex repairs over the > last 10 years, and I believe those have also held up well thus far. > Can you repair a FED valve with traditional resection techniques? Yes, > but it can be challenging. I can definitely remember failed attempts at > repairing FED's with P2 resection and sliding leaflet plasty. In those type > valves, P1 (in particular) and P3 can be nearly hypoplastic. Doing a sliding > leaflet plasty in this situation is like trying to put a condom on a mule. There > just isn't enough tissue to cover the annulus sufficiently to get a decent > depth of coaptation. I've also never been able to reliably do a papillary > muscle sliding for simultaneously correcting several attenuated chords. From > watching Dreyfus doing several live cases, I believe that is his main method of > correction.> I don't believe in your binary philosophy of either 100% Carpentier, or > you are some sort of traitor. I'm not 100% Carpentier or 100% Lawrey. Again, > I've always used a synthesis of the 2 schools, and try to tailor my approach > for each valve. The thing that hasn't changed is a religious exam of the > preop TEE and a thorough intraop valve analysis. > > Hal> > > > ************************************** Get a sneak peek of the all-new AOL at > http://discover.aol.com/memed/aolcom30tour> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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> ----------------------------------------- _________________________________________________________________ Get free emoticon packs and customisation from Windows Live. http://www.pimpmylive.co.uk From fazoury at ahdubai.com Sat Sep 1 15:56:54 2007 From: fazoury at ahdubai.com (Dr. Fouad Azoury) Date: Sat Sep 1 06:57:55 2007 Subject: [HSF] Quiz of the week Message-ID: <2BA88CF8F46D6540A15C7639498C6BB2D9EAE6@ahdexch.AHD.local> An RV infarct I guess....If correct, pretty bad smell in the air... Fouad M. Azoury, M.D. Chairman Department of Cardiothoracic Surgery American Hospital Dubai P.O.Box: 5566. Dubai U.A.E Switchboard: (971) 4 336 7777 Office: (971) 4 3096396 Fax: (971) 4 3096496 Website: www. ahdubai.com -----Original Message----- From: Prasanna Simha [mailto:prasannasimha@gmail.com] Sent: Friday, August 31, 2007 7:05 PM To: OpenHeart-L@lists.hsforum.com; ccm Subject: [HSF] Quiz of the week 13 year old girl -h/o endocarditis and underwent mitral valve repair.Preop in cardiogenic shock (BP in the low 80's and unable to sleep flat and in CHF). RV very bloated on opening the pericardium. Weaned of CPB with 3 mics dopa dobut and 0.35 mics Milrinone. ECG next day morning. Something fatal in the air ? (Misquoting ABBA - There was something fatal in the air that night The stars were bright Fernando" Prasanna From prasannasimha at gmail.com Sat Sep 1 18:05:16 2007 From: prasannasimha at gmail.com (psimha) Date: Sat Sep 1 07:35:54 2007 Subject: [HSF] Quiz of the week In-Reply-To: <2BA88CF8F46D6540A15C7639498C6BB2D9EAE6@ahdexch.AHD.local> References: <2BA88CF8F46D6540A15C7639498C6BB2D9EAE6@ahdexch.AHD.local> Message-ID: <46D94E74.9070206@gmail.com> Nope. I diagnosed this on the phone many a time .Many years back I did a similar diagnosis via the Internet across the globe !!! (A HSF member had posed a problem with his patient and it was diagnosed correctly) A clue The patient had a bout of VTach - Vfib which luckily converted spontaneously before Cardioversion was attempted. Wrong treatment can be fatal in this condition. Prasanna Dr. Fouad Azoury wrote: > An RV infarct I guess....If correct, pretty bad smell in the air... > > Fouad M. Azoury, M.D. > Chairman Department of Cardiothoracic Surgery > > American Hospital Dubai > P.O.Box: 5566. Dubai > U.A.E > Switchboard: (971) 4 336 7777 > Office: (971) 4 3096396 > Fax: (971) 4 3096496 > Website: www. ahdubai.com > > > -----Original Message----- > From: Prasanna Simha [mailto:prasannasimha@gmail.com] > Sent: Friday, August 31, 2007 7:05 PM > To: OpenHeart-L@lists.hsforum.com; ccm > Subject: [HSF] Quiz of the week > > 13 year old girl -h/o endocarditis and underwent mitral valve > repair.Preop in cardiogenic shock (BP in the low 80's and unable to > sleep flat and in CHF). RV very bloated on opening the pericardium. > Weaned of CPB with 3 mics dopa dobut and 0.35 mics Milrinone. > ECG next day morning. > Something fatal in the air ? > (Misquoting ABBA - > There was something fatal in the air that night > The stars were bright > Fernando" > Prasanna > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > > From fazoury at ahdubai.com Sat Sep 1 16:47:21 2007 From: fazoury at ahdubai.com (Dr. Fouad Azoury) Date: Sat Sep 1 07:47:52 2007 Subject: [HSF] Quiz of the week Message-ID: <2BA88CF8F46D6540A15C7639498C6BB2D9EAE7@ahdexch.AHD.local> All right....WPW Fouad M. Azoury, M.D. Chairman Department of Cardiothoracic Surgery American Hospital Dubai P.O.Box: 5566. Dubai U.A.E Switchboard: (971) 4 336 7777 Office: (971) 4 3096396 Fax: (971) 4 3096496 Website: www. ahdubai.com -----Original Message----- From: psimha [mailto:prasannasimha@gmail.com] Sent: Saturday, September 01, 2007 3:35 PM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Quiz of the week Nope. I diagnosed this on the phone many a time .Many years back I did a similar diagnosis via the Internet across the globe !!! (A HSF member had posed a problem with his patient and it was diagnosed correctly) A clue The patient had a bout of VTach - Vfib which luckily converted spontaneously before Cardioversion was attempted. Wrong treatment can be fatal in this condition. Prasanna Dr. Fouad Azoury wrote: > An RV infarct I guess....If correct, pretty bad smell in the air... > > Fouad M. Azoury, M.D. > Chairman Department of Cardiothoracic Surgery > > American Hospital Dubai > P.O.Box: 5566. Dubai > U.A.E > Switchboard: (971) 4 336 7777 > Office: (971) 4 3096396 > Fax: (971) 4 3096496 > Website: www. ahdubai.com > > > -----Original Message----- > From: Prasanna Simha [mailto:prasannasimha@gmail.com] > Sent: Friday, August 31, 2007 7:05 PM > To: OpenHeart-L@lists.hsforum.com; ccm > Subject: [HSF] Quiz of the week > > 13 year old girl -h/o endocarditis and underwent mitral valve > repair.Preop in cardiogenic shock (BP in the low 80's and unable to > sleep flat and in CHF). RV very bloated on opening the pericardium. > Weaned of CPB with 3 mics dopa dobut and 0.35 mics Milrinone. > ECG next day morning. > Something fatal in the air ? > (Misquoting ABBA - > There was something fatal in the air that night > The stars were bright > Fernando" > Prasanna > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > > From ebender001 at charter.net Sat Sep 1 18:15:48 2007 From: ebender001 at charter.net (Edward Bender) Date: Sat Sep 1 18:16:31 2007 Subject: [HSF] Native MV endocarditis In-Reply-To: <8C9BA567A44F206-8A4-27D5@mblk-d13.sysops.aol.com> References: <69CD0A3B-4EDF-4EB1-B760-043AFAA83173@charter.net> <8C9BA567A44F206-8A4-27D5@mblk-d13.sysops.aol.com> Message-ID: Tom: I agree with you. I am not 100% sure that the prosthetic aortic valve is clean. There is a very tiny paravalvular leak but no clear cut abnormal tissue or density at the aortic annulus. I think that the insufficiency jet is chronic, small, and high velocity - causing damage to the anterior leaflet and predisposing it to potential infection. I really need to take care of both problems. I am waiting for dental extraction. Ed Bender, MD On Aug 31, 2007, at 9:25 PM, tdmartin2000@aol.com wrote: > > Ed > > I would have to say yes it does influence your treatment. It sounds > as if he only has native endocarditis at this time, but with staph > aureus, if you wait he will progress and have prosthetic > endocarditis if?he doesn't ?already. > > > > Tom Martin > > U of Florida > > Gainesville > > > -----Original Message----- > From: Edward Bender > To: OpenHeart-L > Sent: Thu, 30 Aug 2007 8:25 pm > Subject: [HSF] Native MV endocarditis > > > > I performed a mechanical AVR in a 58 year old 6 years ago, and he > has had no problems up until 2 weeks ago when he developed fever, > malaise, and atrial fibrillation. He had a right thalamic CVA and > is now completely recovered. He was seen at an outside hospital, > where blood cultures were obtained on two occasions growing out > MRSA. He was transferred to my hospital yesterday. He is afebrile, > normal white blood cell count, neuro intact except for a slight > left arm drift. I did TEE today showing trivial paravalvular AI > ( one very tiny isolated jet - trace at best). He does however have > a vegetation on the anterior leaf of his native mitral valve. This > is mobile, about one-half cm in maximum dimension. Recent blood > cultures on vancomycin are negative so far. He has extremely bad > dentition and needs a full mouth extraction (I think this may be > the source of his endocarditis). Finding an oral surgeon to do this > on the Labor Day weekend is like (pardon the pun) pulling teeth > (Patien > t is uninsured). Does the presence of another prosthetic valve > influence the decision whether to and when to operate on native > valve endocarditis?? > ? > Ed Bender, MD _______________________________________________? > OpenHeart-L mailing list? > ? > Send postings to:? > OpenHeart-L@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 anddisclaimers posted at:? > http://www.hsforum.com/listdisclaim? > -----------------------------------------? > > > ______________________________________________________________________ > __ > Email and AIM finally together. You've gotta check out free AOL > Mail! - http://mail.aol.com > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From anianyanwu at hotmail.com Sat Sep 1 23:38:40 2007 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Sat Sep 1 18:39:32 2007 Subject: AW: [HSF] Mitral Repair with a Calcified Annulus In-Reply-To: References: Message-ID: Hal I don't think your recurrences are an inordinate number, but the fact is that the ordinate number is not insignificant. We have to come clean about this when counselling patients for degenerative mitral valve repair - the reality is at least 20% will have recurrent MR within 10 to 15 years. At least this is what all the best available data show. If you do not know of any recurrences, they are either undiagnosed or simply not being brought to your attention. In the Mayo series remember over half were due to progression of natural disease which is invariable in some patients. In the fibroelastic deficiency case, however, i would argue that sliding plasty should not be a tool to allow a more aggressive resection but rather if one needs a sliding plasty in fibroelastic disease for the purpose of achieving reapposition then it means the resection was too excessive. The solution is not sliding plasty but not to over resect. If tissue is limited in P1 and P3 the resection should probably be minimal (even triangular) resecting part and not al of P2 and if the residual reapposed leaflet is unsupported then it can be resuspended with other means (chordal transfer or gortex). Remember that if you read Jebara's original paper on sliding plasty, the whole essence was to prevent SAM by reducing leaflet height and not to allow more aggressive resection. Dr Adams still plicates the annulus but is doing much less resection and plication than he used to - he now believes that the end result probably matters much more than the means used to achieve it, which is a change in thinking since our last mitral course. The proviso however is that the end results meet the essential Carpentier principles of restoring geometry and adequate surface of coaptation, so I would not say he is any less Carpenterian! Ani > From: Hgrmd@aol.com> Date: Fri, 31 Aug 2007 21:50:54 -0400> Subject: Re: AW: [HSF] Mitral Repair with a Calcified Annulus> To: OpenHeart-L@lists.hsforum.com> CC: > > Ani,> I've no idea how many actual significant recurrences I've had, because, > like nearly every surgeon, followup is incomplete. However, I feel confident > that if there were an inordinate number, this would have been brought to my > attention long ago. > I disagree that sliding plasty would almost never be needed for FED if > resection was undertaken. Sliding plasty isn't done just to reduce the height > of the posterior leaflet. It's also done if a large prolapsed section of the > posterior leaflet is removed so that the annulus isn't distorted by a > quadrangular resection. Using the sliding plasty, up to 50% of the posterior > leaflet can be resected. > On a related topic, does Dr. Adams still use that vertical compression > stitch technique in addition to the horizontal compression sutures when doing a > sliding plasty? I saw him use this at the Sinai valve meeting last October. > I understand the logic of further reducing the amount of annulus to be > covered with the slide, but it sure looked like the potential for kinking the > circumflex would be significant.> BTW, the fact that you say Adams now uses resuspension more frequently is > a testament to where things are headed. I guess he's no longer solely > "drinking the Kool-Aid" of Carpentier.> > Hal> > > > ************************************** Get a sneak peek of the all-new AOL at > http://discover.aol.com/memed/aolcom30tour> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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> ----------------------------------------- _________________________________________________________________ 100?s of Music vouchers to be won with MSN Music https://www.musicmashup.co.uk From damle at cableone.net Sat Sep 1 19:52:26 2007 From: damle at cableone.net (Ajit Damle) Date: Sat Sep 1 19:58:26 2007 Subject: [HSF] MV Repair Failure In-Reply-To: Message-ID: <002301c7ecf3$2660bab0$0201a8c0@yourg8he5gjrox> Ani, and Forum members, Can you quote the references for these? 1. Incidence of MR after repair 2. Re-operation after repair 3.Rosk factors for these. Thanks! Ajit -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Ani Anyanwu Sent: Saturday, September 01, 2007 5:39 PM To: openheart-l@lists.hsforum.com Subject: RE: AW: [HSF] Mitral Repair with a Calcified Annulus Hal I don't think your recurrences are an inordinate number, but the fact is that the ordinate number is not insignificant. We have to come clean about this when counselling patients for degenerative mitral valve repair - the reality is at least 20% will have recurrent MR within 10 to 15 years. At least this is what all the best available data show. If you do not know of any recurrences, they are either undiagnosed or simply not being brought to your attention. In the Mayo series remember over half were due to progression of natural disease which is invariable in some patients. In the fibroelastic deficiency case, however, i would argue that sliding plasty should not be a tool to allow a more aggressive resection but rather if one needs a sliding plasty in fibroelastic disease for the purpose of achieving reapposition then it means the resection was too excessive. The solution is not sliding plasty but not to over resect. If tissue is limited in P1 and P3 the resection should probably be minimal (even triangular) resecting part and not al of P2 and if the residual reapposed leaflet is unsupported then it can be resuspended with other means (chordal transfer or gortex). Remember that if you read Jebara's original paper on sliding plasty, the whole essence was to prevent SAM by reducing leaflet height and not to allow more aggressive resection. Dr Adams still plicates the annulus but is doing much less resection and plication than he used to - he now believes that the end result probably matters much more than the means used to achieve it, which is a change in thinking since our last mitral course. The proviso however is that the end results meet the essential Carpentier principles of restoring geometry and adequate surface of coaptation, so I would not say he is any less Carpenterian! Ani > From: Hgrmd@aol.com> Date: Fri, 31 Aug 2007 21:50:54 -0400> Subject: Re: AW: [HSF] Mitral Repair with a Calcified Annulus> To: OpenHeart-L@lists.hsforum.com> CC: > > Ani,> I've no idea how many actual significant recurrences I've had, because, > like nearly every surgeon, followup is incomplete. However, I feel confident > that if there were an inordinate number, this would have been brought to my > attention long ago. > I disagree that sliding plasty would almost never be needed for FED if > resection was undertaken. Sliding plasty isn't done just to reduce the height > of the posterior leaflet. It's also done if a large prolapsed section of the > posterior leaflet is removed so that the annulus isn't distorted by a > quadrangular resection. Using the sliding plasty, up to 50% of the posterior > leaflet can be resected. > On a related topic, does Dr. Adams still use that vertical compression > stitch technique in addition to the horizontal compression sutures when doing a > sliding plasty? I saw him use this at the Sinai valve meeting last October. > I understand the logic of further reducing the amount of annulus to be > covered with the slide, but it sure looked like the potential for kinking the > circumflex would be significant.> BTW, the fact that you say Adams now uses resuspension more frequently is > a testament to where things are headed. I guess he's no longer solely > "drinking the Kool-Aid" of Carpentier.> > Hal> > > > ************************************** Get a sneak peek of the all-new AOL at > http://discover.aol.com/memed/aolcom30tour> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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> ----------------------------------------- _________________________________________________________________ 100's of Music vouchers to be won with MSN Music https://www.musicmashup.co.uk_______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From Hgrmd at aol.com Sat Sep 1 21:01:59 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sat Sep 1 20:02:41 2007 Subject: AW: [HSF] Mitral Repair with a Calcified Annulus Message-ID: Ani, I don't think FED and sliding plasty should be uttered in the same sentence (there, I just did it.). All of the FED's I've seen do not have excess tissue. Therefore, I prefer new cords in this situation. I'm glad to hear Dave's mind is opening up to other repair techniques. That vertical compression technique is something I doubt will ever see wide application. The goal is a large surface of coaptation without SAM. How you get there is secondary. >From what I've read, seen, and believe, all this talk about redistribution of forces is theoretical and of little clinical importance. BTW, are you guys planning another valve symposium before too long? I really enjoyed the one last October. Hal ************************************** Get a sneak peek of the all-new AOL at http://discover.aol.com/memed/aolcom30tour From anianyanwu at hotmail.com Sun Sep 2 03:52:33 2007 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Sat Sep 1 23:06:38 2007 Subject: [HSF] MV Repair Failure In-Reply-To: <002301c7ecf3$2660bab0$0201a8c0@yourg8he5gjrox> References: <002301c7ecf3$2660bab0$0201a8c0@yourg8he5gjrox> Message-ID: References below Flamengs 2003 paper lists some risk factors for failure including non-use of annuloplasty, non-use of sliding plasty, use of flexible bands and chordal shortening. Ani Braunberger E, Deloche A, Berrebi A, Abdallah F, Celestin JA, Meimoun P, et al. Very long-term results (more than 20 years) of valve repair with carpentier's techniques in nonrheumatic mitral valve insufficiency. Circulation 2001 Sep 18;104(12 Suppl 1):I8-11. Flameng W, Herijgers P, Bogaerts K. Recurrence of mitral valve regurgitation after mitral valve repair in degenerative valve disease. Circulation 2003 Apr 1;107(12):1609-13. David TE, Ivanov J, Armstrong S, Christie D, Rakowski H. A comparison of outcomes of mitral valve repair for degenerative disease with posterior, anterior, and bileaflet prolapse. J Thorac Cardiovasc Surg 2005 Nov;130(5):1242-9. Flameng W, Meuris B, Herijgers P, Herregods MC. Durability of mitral valve repair in Barlow's disease versus fibroelastic deficiency. J Thorac Cardiovasc Surg 2007 in press. > From: damle@cableone.net> To: OpenHeart-L@lists.hsforum.com> Date: Sat, 1 Sep 2007 18:52:26 -0500> CC: > Subject: [HSF] MV Repair Failure> > Ani, and Forum members,> > Can you quote the references for these?> 1. Incidence of MR after repair> 2. Re-operation after repair> 3.Rosk factors for these.> > Thanks!> > Ajit> > > > > > -----Original Message-----> From: openheart-l-bounces@lists.hsforum.com> [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Ani Anyanwu> Sent: Saturday, September 01, 2007 5:39 PM> To: openheart-l@lists.hsforum.com> Subject: RE: AW: [HSF] Mitral Repair with a Calcified Annulus> > Hal> > I don't think your recurrences are an inordinate number, but the fact is> that the ordinate number is not insignificant. We have to come clean about> this when counselling patients for degenerative mitral valve repair - the> reality is at least 20% will have recurrent MR within 10 to 15 years. At> least this is what all the best available data show. If you do not know of> any recurrences, they are either undiagnosed or simply not being brought to> your attention. In the Mayo series remember over half were due to> progression of natural disease which is invariable in some patients.> > > In the fibroelastic deficiency case, however, i would argue that sliding> plasty should not be a tool to allow a more aggressive resection but rather> if one needs a sliding plasty in fibroelastic disease for the purpose of> achieving reapposition then it means the resection was too excessive. The> solution is not sliding plasty but not to over resect. If tissue is limited> in P1 and P3 the resection should probably be minimal (even triangular)> resecting part and not al of P2 and if the residual reapposed leaflet is> unsupported then it can be resuspended with other means (chordal transfer or> gortex). Remember that if you read Jebara's original paper on sliding> plasty, the whole essence was to prevent SAM by reducing leaflet height and> not to allow more aggressive resection.> > Dr Adams still plicates the annulus but is doing much less resection and> plication than he used to - he now believes that the end result probably> matters much more than the means used to achieve it, which is a change in> thinking since our last mitral course. The proviso however is that the end> results meet the essential Carpentier principles of restoring geometry and> adequate surface of coaptation, so I would not say he is any less> Carpenterian!> > Ani> > > > > > From: Hgrmd@aol.com> Date: Fri, 31 Aug 2007 21:50:54 -0400> Subject: Re:> AW: [HSF] Mitral Repair with a Calcified Annulus> To:> OpenHeart-L@lists.hsforum.com> CC: > > Ani,> I've no idea how many actual> significant recurrences I've had, because, > like nearly every surgeon,> followup is incomplete. However, I feel confident > that if there were an> inordinate number, this would have been brought to my > attention long ago.> > I disagree that sliding plasty would almost never be needed for FED if >> resection was undertaken. Sliding plasty isn't done just to reduce the> height > of the posterior leaflet. It's also done if a large prolapsed> section of the > posterior leaflet is removed so that the annulus isn't> distorted by a > quadrangular resection. Using the sliding plasty, up to 50%> of the posterior > leaflet can be resected. > On a related topic, does Dr.> Adams still use that vertical compression > stitch technique in addition to> the horizontal compression sutures when doing a > sliding plasty? I saw him> use this at the Sinai valve meeting last October. > I understand the logic> of further reducing the amount of annulus to be > covered with the slide,> but it sure looked like the potential for kinking the > circumflex would be> significant.> BTW, the fact that you say Adams now uses resuspension more> frequently is > a testament to where things are headed. I guess he's no> longer solely > "drinking the Kool-Aid" of Carpentier.> > Hal> > > >> ************************************** Get a sneak peek of the all-new AOL> at > http://discover.aol.com/memed/aolcom30tour>> _______________________________________________> OpenHeart-L mailing list> >> Send postings to:> OpenHeart-L@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>> -----------------------------------------> _________________________________________________________________> 100's of Music vouchers to be won with MSN Music> https://www.musicmashup.co.uk_______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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> -----------------------------------------> > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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> ----------------------------------------- _________________________________________________________________ Feel like a local wherever you go. http://www.backofmyhand.com From benjamin.bidstrup at bigpond.com Sun Sep 2 14:14:34 2007 From: benjamin.bidstrup at bigpond.com (Ben Bidstrup) Date: Sat Sep 1 23:15:17 2007 Subject: [HSF] MV Repair Failure In-Reply-To: <002301c7ecf3$2660bab0$0201a8c0@yourg8he5gjrox> References: <002301c7ecf3$2660bab0$0201a8c0@yourg8he5gjrox> Message-ID: Good paper in Annals last month. I mentioned it a few days ago Dumont et al Ann Thorac Surg 2007. 84:444-450 It will be a somewhat skewed series as I suspect that the Clinic gets cases others have shunned. I do not know the incidence of repair failure in house but someone from the forum may be prepared to comment. Also the difference in aetiology must be considered. The results for IMR are different to repairs for Barlows and FED. This may be harder to tease out of these reports. >Ani, and Forum members, > >Can you quote the references for these? >1. Incidence of MR after repair >2. Re-operation after repair >3.Rosk factors for these. > >Thanks! > >Ajit > > > > > >-----Original Message----- >From: openheart-l-bounces@lists.hsforum.com >[mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Ani Anyanwu >Sent: Saturday, September 01, 2007 5:39 PM >To: openheart-l@lists.hsforum.com >Subject: RE: AW: [HSF] Mitral Repair with a Calcified Annulus > >Hal > >I don't think your recurrences are an inordinate number, but the fact is >that the ordinate number is not insignificant. We have to come clean about >this when counselling patients for degenerative mitral valve repair - the >reality is at least 20% will have recurrent MR within 10 to 15 years. At >least this is what all the best available data show. If you do not know of >any recurrences, they are either undiagnosed or simply not being brought to >your attention. In the Mayo series remember over half were due to >progression of natural disease which is invariable in some patients. > > >In the fibroelastic deficiency case, however, i would argue that sliding >plasty should not be a tool to allow a more aggressive resection but rather >if one needs a sliding plasty in fibroelastic disease for the purpose of >achieving reapposition then it means the resection was too excessive. The >solution is not sliding plasty but not to over resect. If tissue is limited >in P1 and P3 the resection should probably be minimal (even triangular) >resecting part and not al of P2 and if the residual reapposed leaflet is >unsupported then it can be resuspended with other means (chordal transfer or >gortex). Remember that if you read Jebara's original paper on sliding >plasty, the whole essence was to prevent SAM by reducing leaflet height and >not to allow more aggressive resection. > >Dr Adams still plicates the annulus but is doing much less resection and >plication than he used to - he now believes that the end result probably >matters much more than the means used to achieve it, which is a change in >thinking since our last mitral course. The proviso however is that the end >results meet the essential Carpentier principles of restoring geometry and >adequate surface of coaptation, so I would not say he is any less >Carpenterian! > >Ani > > > > >> From: Hgrmd@aol.com> Date: Fri, 31 Aug 2007 21:50:54 -0400> Subject: Re: >AW: [HSF] Mitral Repair with a Calcified Annulus> To: >OpenHeart-L@lists.hsforum.com> CC: > > Ani,> I've no idea how many actual >significant recurrences I've had, because, > like nearly every surgeon, >followup is incomplete. However, I feel confident > that if there were an >inordinate number, this would have been brought to my > attention long ago. >> I disagree that sliding plasty would almost never be needed for FED if > >resection was undertaken. Sliding plasty isn't done just to reduce the >height > of the posterior leaflet. It's also done if a large prolapsed >section of the > posterior leaflet is removed so that the annulus isn't >distorted by a > quadrangular resection. Using the sliding plasty, up to 50% >of the posterior > leaflet can be resected. > On a related topic, does Dr. >Adams still use that vertical compression > stitch technique in addition to >the horizontal compression sutures when doing a > sliding plasty? I saw him >use this at the Sinai valve meeting last October. > I understand the logic >of further reducing the amount of annulus to be > covered with the slide, >but it sure looked like the potential for kinking the > circumflex would be >significant.> BTW, the fact that you say Adams now uses resuspension more >frequently is > a testament to where things are headed. I guess he's no >longer solely > "drinking the Kool-Aid" of Carpentier.> > Hal> > > > >************************************** Get a sneak peek of the all-new AOL >at > http://discover.aol.com/memed/aolcom30tour> >_______________________________________________> OpenHeart-L mailing list> > >Send postings to:> OpenHeart-L@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> >----------------------------------------- >_________________________________________________________________ >100's of Music vouchers to be won with MSN Music >https://www.musicmashup.co.uk_______________________________________________ >OpenHeart-L mailing list > >Send postings to: > OpenHeart-L@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 >----------------------------------------- > >_______________________________________________ >OpenHeart-L mailing list > >Send postings to: > OpenHeart-L@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 >----------------------------------------- -- Ben Bidstrup FRACS FRCSEd FEBCTS Consultant Cardiothoracic Surgeon From Hgrmd at aol.com Sun Sep 2 09:33:29 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Sep 2 08:34:26 2007 Subject: [HSF] MV Repair Failure Message-ID: Ani, I'll be interested to read Flemeng's paper on the durabilitiy of Barlow's vs. FED. Don't keep me in suspense, which one is better? I'd predict Barlow's would be more durable due to the ability to fashion a large surface of coaptation from the excess leaflet tissue. Hal ************************************** Get a sneak peek of the all-new AOL at http://discover.aol.com/memed/aolcom30tour From Hgrmd at aol.com Sun Sep 2 09:41:24 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Sun Sep 2 08:41:53 2007 Subject: [HSF] MV Repair Failure Message-ID: Ben, Not only does the repair of IMR MR have inferior long term results compared to Barlow's and FED, but so does pure annular dilatation from nonischemic cardiomyopathies. I would also expect that Barlow's would hold up better than FED. To me, it's all a matter of the amount of tissue available to cover the hole. That's one of the reasons I currently rarely resect prolapse with FED. BTW, that lady with the failed Geoform I posted a couple of weeks ago went to rehab last Thursday. I'm hopeful that her IMR ETlogix ring will serve her well. Hal ************************************** Get a sneak peek of the all-new AOL at http://discover.aol.com/memed/aolcom30tour From prasannasimha at gmail.com Sun Sep 2 19:21:41 2007 From: prasannasimha at gmail.com (psimha) Date: Sun Sep 2 08:52:19 2007 Subject: [HSF] MV Repair Failure In-Reply-To: References: Message-ID: <46DAB1DD.6000000@gmail.com> Hal, I am not familiar with the system - what exactly does "went to rehab" mean - do they go to some other rehabilitation hospital or some nursing home or home and attend a rehabilitation/physiotherapy clinic ? (For us discharge can only be discharge to home or up into heaven !!) Prasanna Hgrmd@aol.com wrote: > Ben, > Not only does the repair of IMR MR have inferior long term results > compared to Barlow's and FED, but so does pure annular dilatation from nonischemic > cardiomyopathies. I would also expect that Barlow's would hold up better than > FED. To me, it's all a matter of the amount of tissue available to cover > the hole. That's one of the reasons I currently rarely resect prolapse with > FED. > BTW, that lady with the failed Geoform I posted a couple of weeks ago went > to rehab last Thursday. I'm hopeful that her IMR ETlogix ring will serve > her well. > > Hal > > > > ************************************** Get a sneak peek of the all-new AOL at > http://discover.aol.com/memed/aolcom30tour > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > > From msfirst at gmail.com Sun Sep 2 10:04:26 2007 From: msfirst at gmail.com (Michael Firstenberg) Date: Sun Sep 2 09:04:52 2007 Subject: [HSF] MV Repair Failure In-Reply-To: <46DAB1DD.6000000@gmail.com> References: <46DAB1DD.6000000@gmail.com> Message-ID: For me (us) - DC to rehab usually means some type of skilled nursing facility - with services that reflect the needs of the patient. Spectrum: Out-patient rehab ---- home, going to a nearby place to get a little extra physical therapy/tune-up LTAC --- Long Term Acute Care Facilty typically for PEG/Trach/Dialysis disasters. I would say only about 2/3 of our patients get discharged to home....... fortunately most make it home at some point. What do you do with those patients whose families can not (will not? unable?) take them home? -michael On 9/2/07, psimha wrote: > > Hal, > I am not familiar with the system - what exactly does "went to rehab" > mean - do they go to some other rehabilitation hospital or some nursing > home or home and attend a rehabilitation/physiotherapy clinic ? (For us > discharge can only be discharge to home or up into heaven !!) > Prasanna > Hgrmd@aol.com wrote: > > Ben, > > Not only does the repair of IMR MR have inferior long term results > > compared to Barlow's and FED, but so does pure annular dilatation > from nonischemic > > cardiomyopathies. I would also expect that Barlow's would hold up > better than > > FED. To me, it's all a matter of the amount of tissue available to > cover > > the hole. That's one of the reasons I currently rarely resect prolapse > with > > FED. > > BTW, that lady with the failed Geoform I posted a couple of weeks ago > went > > to rehab last Thursday. I'm hopeful that her IMR ETlogix ring will > serve > > her well. > > > > Hal > > > > > > > > ************************************** Get a sneak peek of the all-new > AOL at > > http://discover.aol.com/memed/aolcom30tour > > _______________________________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@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 > > ----------------------------------------- > > > > > > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > From hgrmd at aol.com Sun Sep 2 14:11:39 2007 From: hgrmd at aol.com (hgrmd@aol.com) Date: Sun Sep 2 09:13:11 2007 Subject: [HSF] MV Repair Failure In-Reply-To: <46DAB1DD.6000000@gmail.com> References: <46DAB1DD.6000000@gmail.com> Message-ID: <465713443-1188738701-cardhu_decombobulator_blackberry.rim.net-541898696-@bxe106.bisx.prod.on.blackberry> UHJhc2FubmEsICByZWhhYiBpcyBhIGZhY2lsaXR5IHdoZXJlIHRoZSBwYXRpZW50IGlzIGhvdXNl ZCB1bnRpbCB0aGV5IGFyZSBzdHJvbmcgZW5vdWdoIHRvIGdvIGhvbWUuICBXaGVuIEkgZmlyc3Qg bWV0IHRoaWQgbGFkeSwgc2hlIHdhcyBub25hbWJ1bGF0b3J5IGFuZCB3ZWFyaW5nIGEgZGlhcGVy LiAgV2hlbiBzaGUgbGVmdCwgc2hlIGNvdWxkIHdhbGsgdGhlIGhhbGxzIHdpdGggYXNzaXN0YW5j ZS4gDQoNCkhhbA0KU2VudCBmcm9tIG15IFZlcml6b24gV2lyZWxlc3MgQmxhY2tCZXJyeQ0KDQot LS0tLU9yaWdpbmFsIE1lc3NhZ2UtLS0tLQ0KRnJvbTogcHNpbWhhIDxwcmFzYW5uYXNpbWhhQGdt 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Message-ID: Hal the paper was presented at AATS this year so you can se the summary in the abstract book if you have it. In absolute numbers Barlow had a higher recurrence rate but then when he excluded what he called risk factors (such as those patients where sliding plasty was not used, no ring was used etc) the recurrence rate did not seem to differ (barlow 2.9% per year, Fibroelastic deficiency 2.2% per year). The paper did have a lot of flaws though and the total recurrence rate was high (35% had at least moderate MR 10 years post repair). I would expect Barlow valves to have worse outcome though - the entire valve is undoubtedly diseased here so I think the possibility of continued chordal elongation, new rupture, chordal fusion causing IIIA dysfunction, calcification etc would exceed that of fibroelastic deficiency. It is interesting that although you believe the reverse (that Barlow repairs are most durable), Barlow remains a common indication for valve replacement on the presumed premise that they cannot be repaired durably. Ani > From: Hgrmd@aol.com> Date: Sun, 2 Sep 2007 08:33:29 -0400> Subject: Re: [HSF] MV Repair Failure> To: OpenHeart-L@lists.hsforum.com> CC: > > Ani,> I'll be interested to read Flemeng's paper on the durabilitiy of Barlow's > vs. FED. Don't keep me in suspense, which one is better? I'd predict > Barlow's would be more durable due to the ability to fashion a large surface of > coaptation from the excess leaflet tissue.> > Hal> > > > ************************************** Get a sneak peek of the all-new AOL at > http://discover.aol.com/memed/aolcom30tour> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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> ----------------------------------------- _________________________________________________________________ Feel like a local wherever you go. http://www.backofmyhand.com From Hgrmd at aol.com Mon Sep 3 10:18:00 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Mon Sep 3 09:18:34 2007 Subject: [HSF] MV Repair Failure Message-ID: Ani, Unfortunately, I didn't get to attend the AATS, but I look forward to reading this paper. A 35% moderate or worse MR at 10 years does seem a bit high. The fact that the chords in Barlow's have an inherent connective tissue defect is all the more reason it makes sense to me to replace those chords with Goretex. As you know, this isn't an original thought at all, and was first espoused by Tirone David in his original neochord papers. Hal ************************************** Get a sneak peek of the all-new AOL at http://discover.aol.com/memed/aolcom30tour From toruasai at belle.shiga-med.ac.jp Tue Sep 4 09:11:03 2007 From: toruasai at belle.shiga-med.ac.jp (Tohru Asai) Date: Mon Sep 3 19:11:37 2007 Subject: [HSF] EACTS In-Reply-To: Message-ID: Members I was wondering if any members have a plan for gathering in Geneva when EACTS meeting is taken place. If there is a HSF cocktail party or any satellite meeting, I would like to join! My hospital will be refurbishing our surgical ward, and I cannot operate whole this week. So I decided to go Geneva. -- Tohru Asai Shiga University of Medical Science Otsu, Japan From mmlevinson at hsforum.com Mon Sep 3 21:26:24 2007 From: mmlevinson at hsforum.com (Mark Levinson) Date: Mon Sep 3 21:27:01 2007 Subject: [HSF] Curious mitral lesion Message-ID: Forum members: I was asked to see a 50 yo diabetic woman who presented to the hospital with an acute CVA (hemiparesis, expressive aphasia). Workup was entirely normal except for a round sessile mass in the posterior left atrium, about 7 or 8 mm diameter seen in multiple views, presumed to be a myxoma. The mass did not move much, did not prolapse through the mitral valve, and appeared solid by echo criteria. Unlike most myxomas, it was appeared to be located near annular portion of P2... I operated thinking this was a myxoma, just in an atypical location. However, when I opened the atrium, it was normal !! Empty! Nada! I inspected the orifices of each pulmonary vein, and inverted the left atrial appendage. No tumor ! I looked into the LV cavity (transvalvar) and did not see anything. There was no stalk-like or sessile lesion, and importantly, normal endocardium throughout with no stain or color change to indicate something might have once been there, and then dislodged. I was puzzled, and somewhat embarrased to close this case and be told "its still there" on postop echo, so I ran my finger along the left atrial tissue and mitral apparatus....and I felt a soft lump under the posterior mitral leaflet. There was no question on palpation that this was the lesion seen on echo because it was in the exact location (behind the attachment point of P2). The endocardium was slightly whiter, or more pale, in this location, and once I had retraction sutures in place, I could now see a bulge appearing to come from under the endocardium and lifting the endocardium, forming a mass that protruded slightly into the cavity. However, it was soft, not hard. I wondered if this was a lipoma, as can be seen in the septum, but the echo would suggest something more dense. And I had to try to explain her stroke. So, I incised the endocardium to take a look at the mass, and I was greeted with a liquified white cheezy material similar to what you see coming from an old caseous granuloma. For a brief moment, I thought I has just opened a sebaceous cyst! About 1 or 2 cc of this liquified material was expressed. It was not purulent in my opinion, but reminded me of the "milk of calcium" I had heard about in my training years back. I scooped it up and sent for gram stain (negative). I cleaned the cavity out with swabs and suction. Visually, the interior of the cavity demonstrated muscle fibers and spicules of calcium. The cavity clearly traveled into the subvalvar myocardium. There was no other evidence of SBE, so I did not see an indication to resect the P2, and try to reconstruct this area. I was concerned that I would nail the Cx, coronary sinus, or induce a posterior AV separation if I ventured too far. So, excised some tissue for biopsy, then packed the cavity with "milk of Vancomycin" (home-made) and closed it with interrupted Prolenes, ligated the LA appendage, and closed. She has done very well, with all cultures negative and a normal post-operative course. However, I can't explain what I saw. The pathologists have indicated this is probably a granuloma, but it is not a very satisfying diagnosis. What caused her stroke? Could this liquified material have escaped at some point and embolized? Has anyone seen anything like this before. I apologize that my still camera photos are not suitable...I do have movies but can't seem to get them loaded on my Mac for editing....sorrry. Thanks, Mark Mark M. Levinson, MD Founder, Editor-in-Chief, The Heart Surgery Forum WWW: Email: From mmlevinson at hsforum.com Mon Sep 3 21:42:57 2007 From: mmlevinson at hsforum.com (Mark Levinson) Date: Mon Sep 3 21:43:24 2007 Subject: [HSF] Video In-Reply-To: References: Message-ID: On Aug 20, 2007, at 6:37 PM, Edward Bender wrote: > This is for Jon. Maybe we can revisit the issue of video for the > forum. Perhaps limited storage of proscribed size/format. Failing > that, how about a forum sponsored You Tube private group. I think > we all want it. > Ed: I could not agree more. The issue is file size...upload time.... and compression Many home edited digital movie files are huge....200 megs or more. If you compress them before uploading, the compression may not be ideal for re-broadcast on the Web. When we process movies at the HSF, our production staff adjust the frame rate, bit rate, and compression CODEC to get best preformance for web broadcast. You Tube solves this by converting all uploads to Flash media, and there is open source code that can do this conversion. Still, very large source files take a very long time to upload. Many of the You Tube videos were taken with pocket (point and shoot) video cameras taking MPEG2 at 15 frames / second at 320 x 140 resolution, and which are manageable in short sequences for file upload. However, my Luxtex OR camera takes at 640 x 480 at 30 fps, which is more than 8 times the amount of data per second. I have wanted for some time to be able to have any Forum member upload surgical videos to our site automatically. I can only say that it is a technical challenge to get the file uploaded to the server, convert it to a quality suitable for web broadcast, and then post it. We could set up a You Tube section, but I have not found it easy to get back in to see You Tube videos which people have notified me about. I posted a video there of my multiple metastatice resection technique...but I can't find it!. There is a great deal of spam-like chatter on You-Tube as well. So, its do- able, but messy IMHO. I will ask again amoungst my staff if this can be done via the HSF.....it is definately a great suggestion.. Thanks, Mark Mark M. Levinson, MD Founder, Editor-in-Chief, The Heart Surgery Forum WWW: Email: From prasannasimha at gmail.com Tue Sep 4 08:11:03 2007 From: prasannasimha at gmail.com (psimha) Date: Mon Sep 3 21:48:40 2007 Subject: [HSF] Curious mitral lesion In-Reply-To: References: Message-ID: <46DCB7AF.4030906@gmail.com> Did it look something like this (a blood cyst ?) These can at times calcify too. Prasanna Mark Levinson wrote: > > I was asked to see a 50 yo diabetic woman who presented to the > hospital with an acute CVA (hemiparesis, expressive aphasia). Workup > was entirely normal except for a round sessile mass in the posterior > left atrium, about 7 or 8 mm diameter seen in multiple views, presumed > to be a myxoma. > The mass did not move much, did not prolapse through the mitral valve, > and appeared solid by echo criteria. Unlike most myxomas, > it was appeared to be located near annular portion of P2... > > I operated thinking this was a myxoma, just in an atypical location. > However, when I opened the atrium, it was normal !! Empty! Nada! > I inspected the orifices of each pulmonary vein, and inverted the left > atrial appendage. No tumor ! I looked into the LV cavity > (transvalvar) and did not see anything. There was no stalk-like or > sessile lesion, and importantly, normal endocardium throughout > with no stain or color change to indicate something might have once > been there, and then dislodged. > > I was puzzled, and somewhat embarrased to close this case and be told > "its still there" on postop echo, so I ran my finger along > the left atrial tissue and mitral apparatus....and I felt a soft lump > under the posterior mitral leaflet. There was no question on palpation > that this was the lesion seen on echo because it was in the exact > location (behind the attachment point of P2). > > The endocardium was slightly whiter, or more pale, in this location, > and once I had retraction sutures in place, I could now see a bulge > appearing to come from under the endocardium and lifting the > endocardium, forming a mass that protruded slightly into the cavity. > However, it was soft, not hard. I wondered if this was a lipoma, as > can be seen in the septum, but the echo would suggest something > more dense. And I had to try to explain her stroke. > > So, I incised the endocardium to take a look at the mass, and I was > greeted with a liquified white cheezy material similar to what you see > coming from an old caseous granuloma. For a brief moment, I thought > I has just opened a sebaceous cyst! About 1 or 2 cc of this liquified > material was expressed. It was not purulent in my opinion, but > reminded me of the "milk of calcium" I had heard about in my training > years back. I scooped it up and sent for gram stain (negative). I > cleaned > the cavity out with swabs and suction. Visually, the interior of the > cavity demonstrated muscle fibers and spicules of calcium. The cavity > clearly traveled into the subvalvar myocardium. There was no other > evidence of SBE, so I did not see an indication to resect the P2, and try > to reconstruct this area. I was concerned that I would nail the Cx, > coronary sinus, or induce a posterior AV separation if I ventured too > far. > > So, excised some tissue for biopsy, then packed the cavity with "milk > of Vancomycin" (home-made) and closed it with interrupted Prolenes, > ligated the LA appendage, and closed. She has done very well, with all > cultures negative and a normal post-operative course. > > However, I can't explain what I saw. The pathologists have > indicated this is probably a granuloma, but it is not a very > satisfying diagnosis. > > What caused her stroke? Could this liquified material have escaped > at some point and embolized? > > Has anyone seen anything like this before. > > I apologize that my still camera photos are not suitable...I do have > movies but can't seem to get them loaded on my Mac for editing....sorrry. > > Thanks, > > Mark > > > Mark M. Levinson, MD > Founder, Editor-in-Chief, > The Heart Surgery Forum > WWW: > Email: > > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 anddisclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > > -------------- next part -------------- A non-text attachment was scrubbed... Name: Interatrial blood cysteml.jpg Type: image/jpeg Size: 29809 bytes Desc: not available Url : http://mmp.cjp.com/pipermail/openheart-l/attachments/20070904/7ff42438/Interatrialbloodcysteml-0001.jpg From mmlevinson at hsforum.com Mon Sep 3 21:50:48 2007 From: mmlevinson at hsforum.com (Mark Levinson) Date: Mon Sep 3 21:51:25 2007 Subject: [HSF] Test In-Reply-To: <46CA3F2A.8010201@gmail.com> References: <41BBA40B-9205-4186-86AB-CF1876528062@charter.net> <46CA3F2A.8010201@gmail.com> Message-ID: On Aug 20, 2007, at 8:26 PM, psimha wrote: > It won't . The server is set to allow only JPEG's and I think also > GIF's. The rest are stripped off. > Prasanna Let me remind the group once again about why we do this. About 5 years ago, in the hey-day of email viruses, attachments were the mechanism for getting viruses into everyones computer. We blocked all but the essential attachments to reduce our risk of propogating a virus. But there is another reason for not allowing movie file attachemnts. A typical movie file of 50 megs would simply take down our server. Although it is not readily apparent, each person on the OpenHeart-L receives an exact duplicate of the original message, including a copy of any attached file. For a jpeg of 40 kbytes, making 2000 copies and sending them to everyone is not too big of a task for modern hardware. However, making 2000 copies of a 50 meg movie would take all the CPU power we have, and it would take so long that everyone would notice that their message volume had stopped while our servers try to grind out several thousand copies of these huge files and still keep up with the other emails.....not likely.... The better answer is the Web.... One movie file is posted in one place, and viewed by anyone who logs on. A temporary stream is opened to transfer blocks of movie data at a speed the receiver is capable of handling...known as video streaming. The HSF servers are set up for streaming QuickTime, and we are doing this now for the movies we offer on the Web site. However, not everyone has QuickTime installed on their machines. and we may need to offer Flash at some point. Just my thoughts..... Mark M. Levinson, MD Founder, Editor-in-Chief, The Heart Surgery Forum WWW: Email: From Hgrmd at aol.com Mon Sep 3 23:01:01 2007 From: Hgrmd at aol.com (Hgrmd@aol.com) Date: Mon Sep 3 22:01:35 2007 Subject: [HSF] Curious mitral lesion Message-ID: Mark, I've seen an identical lesion in 2 patients. The last one was about 8 years ago. Both were in the P2 area. The first one I saw, I merely drained the lesion as you did and the patient came back with MR probably 5 years later. I ended up replacing the valve. On the 2nd case, I temporarily detached the posterior leaflet, unroofed the collection, and then covered it with autologous pericardium. She did well and was eventually lost to followup. I've no idea what this sterile goop is, but suspect this is a variant of the process producing calcification of the posterior annulus. Instead of a hard plaque, it is soft and cheesy. Quite honestly, I doubt an unruptured collection would produce embolization, and suspect your patient had another cause for the stroke. Hal ************************************** Get a sneak peek of the all-new AOL at http://discover.aol.com/memed/aolcom30tour From mmlevinson at hsforum.com Mon Sep 3 22:04:27 2007 From: mmlevinson at hsforum.com (Mark Levinson) Date: Mon Sep 3 22:04:52 2007 Subject: [HSF] Fast tracking In-Reply-To: <936866.35713.qm@web81613.mail.mud.yahoo.com> References: <936866.35713.qm@web81613.mail.mud.yahoo.com> Message-ID: On Aug 24, 2007, at 9:43 PM, Tea Acuff wrote: > I agree with your sentiments. However, this is the number that > comes back from my STS data Tea: I watch my bi-annual STS reports, and I have noticed that the average (mean) LOS for CABG has not changed in 12 years! It was 7 days in 1995 and still today....Curious. I know that many of us are trying hard to get patients out of the hospital early, but the average does not budge (nationwide). So, my fealing is that we are succeeding in the younger patients, and this is offset by longer LOS in the increasingly older and sicker elderly patients. For the sake of calculating the mean, these older patients erase the gain we can achieve in the younger. In order to get patients out earlier than day 3, we must educate them prior to surgery that we expect them to go home on day 2 or day 1. Their response to that information will quickly determine if you are going to succeed or fail...the patient that wants to go home early often does. More typically, the patient that does *not* want to go home early never will! Mark Mark M. Levinson, MD Founder, Editor-in-Chief, The Heart Surgery Forum WWW: Email: From prasannasimha at gmail.com Tue Sep 4 08:48:41 2007 From: prasannasimha at gmail.com (psimha) Date: Mon Sep 3 22:19:15 2007 Subject: [HSF] Curious mitral lesion In-Reply-To: References: Message-ID: <46DCC081.5080400@gmail.com> Hal, I also have seen these calcium collections when debriding a calcified annulus though I have not seen it in isolation. Probably this may (as you have hypothesized) represent the first or early stages of MAC. Prasanna Hgrmd@aol.com wrote: > Mark, > I've seen an identical lesion in 2 patients. The last one was about 8 > years ago. Both were in the P2 area. The first one I saw, I merely drained the > lesion as you did and the patient came back with MR probably 5 years later. > I ended up replacing the valve. On the 2nd case, I temporarily detached the > posterior leaflet, unroofed the collection, and then covered it with > autologous pericardium. She did well and was eventually lost to followup. > I've no idea what this sterile goop is, but suspect this is a variant of > the process producing calcification of the posterior annulus. Instead of a > hard plaque, it is soft and cheesy. Quite honestly, I doubt an unruptured > collection would produce embolization, and suspect your patient had another cause > for the stroke. > > Hal > > > > > ************************************** Get a sneak peek of the all-new AOL at > http://discover.aol.com/memed/aolcom30tour > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > > From prasannasimha at gmail.com Tue Sep 4 08:44:29 2007 From: prasannasimha at gmail.com (Prasanna Simha) Date: Mon Sep 3 23:17:57 2007 Subject: [HSF] Fast tracking In-Reply-To: References: <936866.35713.qm@web81613.mail.mud.yahoo.com> Message-ID: <46DCBF85.3070809@gmail.com> That is very true. Just now we have a patient in the ward who just doesn't want to go home (day 8) and I told him that all we are doing is saying hello to each other and he would be better off eating home food.(He has still not gone home as of this AM). I do agree that if we tell them we will discharge them on day 3 that they will go home on day 5. I think part of the blame is on their perceived comparison to say, GI surgery with postoperative ileus etc where patients go home much later . They find it difficult to comprehend that they are getting what can be considered more "complex" surgery and yet are being sent home earlier. Inf fact when I was new cardiac surgery resident I was surprised that patients are up and about much faster than general surgery patients with major abdominal surgery ( for e.g major resections / Whipple's etc). Prasanna Mark Levinson wrote: > > On Aug 24, 2007, at 9:43 PM, Tea Acuff wrote: > >> I agree with your sentiments. However, this is the number that comes >> back from my STS data > > Tea: > > I watch my bi-annual STS reports, and I have noticed that the average > (mean) LOS for CABG has not changed > in 12 years! It was 7 days in 1995 and still today....Curious. > > I know that many of us are trying hard to get patients out of the > hospital early, but the average does not budge (nationwide). > So, my fealing is that we are succeeding in the younger patients, and > this is offset by longer LOS in the increasingly > older and sicker elderly patients. For the sake of calculating the > mean, these older patients erase the gain we can > achieve in the younger. > > In order to get patients out earlier than day 3, we must educate them > prior to surgery that we expect them to go > home on day 2 or day 1. Their response to that information will > quickly determine if you are going to succeed > or fail...the patient that wants to go home early often does. > More typically, the patient that does *not* want to go > home early never will! > > Mark > > Mark M. Levinson, MD > Founder, Editor-in-Chief, > The Heart Surgery Forum > WWW: > Email: > > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 anddisclaimers posted at: > http://www.hsforum.com/listdisclaim > ----------------------------------------- > From ecdouville at orclinic.com Mon Sep 3 20:55:19 2007 From: ecdouville at orclinic.com (Douville, Chuck) Date: Mon Sep 3 23:19:01 2007 Subject: [HSF] hypothyroidism Message-ID: <4F8309F68D37E844B4C23BDD075C8C6E0375C8E8@tocexch01.tocad.orclinic.com> I was asked to see a pt today who has amiodarone induced hypothyroidsm. His TSH was 70 and is now down to 20. What TSH level would you all insist on before offering this pt CABG with EF 25% and left main and class $ angina.? My preferecence is to wait, of course until it is normal, but that may not be possible. Any suggestions? thanks chuckdouville From prasannasimha at gmail.com Tue Sep 4 15:28:06 2007 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Tue Sep 4 04:58:35 2007 Subject: [HSF] hypothyroidism In-Reply-To: <4F8309F68D37E844B4C23BDD075C8C6E0375C8E8@tocexch01.tocad.orclinic.com> References: <4F8309F68D37E844B4C23BDD075C8C6E0375C8E8@tocexch01.tocad.orclinic.com> Message-ID: <89c4ed2d0709040158r3d634c4ar69d62152be503db6@mail.gmail.com> It is advisable to wait till the TSH comes down to the reference normal range. It is well documented that hypothyroidism can cause refractory low output post op and a host of endocrinological problems. We always see to it that they are normalized.They can stay in hospital during this period if required under monitoring Prasanna On 9/4/07, Douville, Chuck wrote: > > I was asked to see a pt today who has amiodarone induced hypothyroidsm. > His TSH was 70 and is now down to 20. What TSH level would you all insist > on before offering this pt CABG with EF 25% and left main and class $ > angina.? My preferecence is to wait, of course until it is normal, but that > may not be possible. Any suggestions? thanks chuckdouville > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > -- Prasanna Simha M From prasannasimha at gmail.com Tue Sep 4 15:28:06 2007 From: prasannasimha at gmail.com (Prasanna Simha M) Date: Tue Sep 4 04:58:36 2007 Subject: [HSF] hypothyroidism In-Reply-To: <4F8309F68D37E844B4C23BDD075C8C6E0375C8E8@tocexch01.tocad.orclinic.com> References: <4F8309F68D37E844B4C23BDD075C8C6E0375C8E8@tocexch01.tocad.orclinic.com> Message-ID: <89c4ed2d0709040158r3d634c4ar69d62152be503db6@mail.gmail.com> It is advisable to wait till the TSH comes down to the reference normal range. It is well documented that hypothyroidism can cause refractory low output post op and a host of endocrinological problems. We always see to it that they are normalized.They can stay in hospital during this period if required under monitoring Prasanna On 9/4/07, Douville, Chuck wrote: > > I was asked to see a pt today who has amiodarone induced hypothyroidsm. > His TSH was 70 and is now down to 20. What TSH level would you all insist > on before offering this pt CABG with EF 25% and left main and class $ > angina.? My preferecence is to wait, of course until it is normal, but that > may not be possible. Any suggestions? thanks chuckdouville > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > -- Prasanna Simha M From damle at cableone.net Tue Sep 4 05:25:05 2007 From: damle at cableone.net (Ajit Damle) Date: Tue Sep 4 05:31:06 2007 Subject: [HSF] Fast tracking In-Reply-To: Message-ID: <001a01c7eed5$7addcef0$0201a8c0@yourg8he5gjrox> Mark, I put a posting sometime ago on this subject. The Medicare has changed rules. Medicare correctly suspected, that hospitals achieved lower LOS by shifting care to another facility (home nursing care, nursing homes, rehab units, transitional care units etc). Medicare then ended up paying both for the hospital and the skilled care facility. On paper LOS was lower, but hospitals and the skilled care facilities profited more and more, increasing the total costs. Therefore, now Medicare has a proscribed LOS for each patient that comes to surgery. If the patient is discharged from the hospital to any skilled care facility before the proscribed LOS, Medicare will cut the DRG payment to the hospital by a proportionate amount. This can be huge, anywhere from 5 to 30%. If the patient is discharged home early without the need for skilled care, then the payment is full. At our hospital, we have a very effective case management system, and our LOS for CABGs were very low, 5.1 days, (all patients). We now have deliberately increased our LOS to avoid loss of revenue from early discharges. Earlier, to encourage surgeons to cut costs, LOS was associated with a good care "Bench Mark". Implicitly, if your patients had higher LOS, it was because you had more complications. Sometimes, but of course not always, true. Keeping the patients in longer is not excessively expensive for the hospital, unless there is a bed crunch. Ninety percent of a heart surgical cost is incurred on the first day (OR and ICU). The next one is the day of discharge, whenever that is, with all the flurry of activity and take home meds. Ajit Damle . -----Original Message----- From: openheart-l-bounces@lists.hsforum.com [mailto:openheart-l-bounces@lists.hsforum.com] On Behalf Of Mark Levinson Sent: Monday, September 03, 2007 9:04 PM To: OpenHeart-L@lists.hsforum.com Subject: Re: [HSF] Fast tracking On Aug 24, 2007, at 9:43 PM, Tea Acuff wrote: > I agree with your sentiments. However, this is the number that > comes back from my STS data Tea: I watch my bi-annual STS reports, and I have noticed that the average (mean) LOS for CABG has not changed in 12 years! It was 7 days in 1995 and still today....Curious. I know that many of us are trying hard to get patients out of the hospital early, but the average does not budge (nationwide). So, my fealing is that we are succeeding in the younger patients, and this is offset by longer LOS in the increasingly older and sicker elderly patients. For the sake of calculating the mean, these older patients erase the gain we can achieve in the younger. In order to get patients out earlier than day 3, we must educate them prior to surgery that we expect them to go home on day 2 or day 1. Their response to that information will quickly determine if you are going to succeed or fail...the patient that wants to go home early often does. More typically, the patient that does *not* want to go home early never will! Mark Mark M. Levinson, MD Founder, Editor-in-Chief, The Heart Surgery Forum WWW: Email: _______________________________________________ OpenHeart-L mailing list Send postings to: OpenHeart-L@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 ----------------------------------------- From ebender001 at charter.net Tue Sep 4 07:16:20 2007 From: ebender001 at charter.net (ebender001@charter.net) Date: Tue Sep 4 09:16:51 2007 Subject: [HSF] Video Message-ID: <961234513.1188911780144.JavaMail.root@fepweb01> Mark: Thanks for the response. As a first step, perhaps allowing small quicktime files. I am mostly interested in showing echo cine loops. We can compress the hell out of them with the resultant product still being readable. Ed Bender, MD ---- Mark Levinson wrote: > > On Aug 20, 2007, at 6:37 PM, Edward Bender wrote: > > > This is for Jon. Maybe we can revisit the issue of video for the > > forum. Perhaps limited storage of proscribed size/format. Failing > > that, how about a forum sponsored You Tube private group. I think > > we all want it. > > > Ed: > > I could not agree more. The issue is file size...upload time.... > and compression > > Many home edited digital movie files are huge....200 megs or more. > If you compress them before uploading, the compression may > not be ideal for re-broadcast on the Web. When we process > movies at the HSF, our production staff adjust the frame rate, bit rate, > and compression CODEC to get best preformance for web broadcast. > > You Tube solves this by converting all uploads to Flash media, and > there is open source code that can do this conversion. > Still, very large source files take a very long time to upload. > Many of the You Tube videos were taken with pocket (point and shoot) > video cameras taking MPEG2 at 15 frames / second at 320 x 140 > resolution, and which are manageable in short sequences for file upload. > However, my Luxtex OR camera takes at 640 x 480 at 30 fps, which is > more than 8 times the amount of data per second. > > I have wanted for some time to be able to have any Forum member > upload surgical videos to our site automatically. I can > only say that it is a technical challenge to get the file uploaded to > the server, convert it to a quality suitable for web broadcast, and then > post it. > > We could set up a You Tube section, but I have not found it easy to > get back in to see You Tube videos which people have > notified me about. I posted a video there of my multiple > metastatice resection technique...but I can't find it!. There is > a great deal of spam-like chatter on You-Tube as well. So, its do- > able, but messy IMHO. > > I will ask again amoungst my staff if this can be done via the > HSF.....it is definately a great suggestion.. > > Thanks, > > Mark > > Mark M. Levinson, MD > Founder, Editor-in-Chief, > The Heart Surgery Forum > WWW: > Email: > > > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From msfirst at gmail.com Tue Sep 4 10:49:02 2007 From: msfirst at gmail.com (Michael Firstenberg) Date: Tue Sep 4 09:55:31 2007 Subject: [HSF] Video In-Reply-To: <961234513.1188911780144.JavaMail.root@fepweb01> References: <961234513.1188911780144.JavaMail.root@fepweb01> Message-ID: What happened to the YouTube option? This sounds like the best - afterall, that is why Google did buy them for billions. We do not need to invent the wheel. -michael On 9/4/07, ebender001@charter.net wrote: > > Mark: > Thanks for the response. As a first step, perhaps allowing small > quicktime files. I am mostly interested in showing echo cine loops. We can > compress the hell out of them with the resultant product still being > readable. > > Ed Bender, MD > > > ---- Mark Levinson wrote: > > > > On Aug 20, 2007, at 6:37 PM, Edward Bender wrote: > > > > > This is for Jon. Maybe we can revisit the issue of video for the > > > forum. Perhaps limited storage of proscribed size/format. Failing > > > that, how about a forum sponsored You Tube private group. I think > > > we all want it. > > > > > Ed: > > > > I could not agree more. The issue is file size...upload time.... > > and compression > > > > Many home edited digital movie files are huge....200 megs or more. > > If you compress them before uploading, the compression may > > not be ideal for re-broadcast on the Web. When we process > > movies at the HSF, our production staff adjust the frame rate, bit rate, > > and compression CODEC to get best preformance for web broadcast. > > > > You Tube solves this by converting all uploads to Flash media, and > > there is open source code that can do this conversion. > > Still, very large source files take a very long time to upload. > > Many of the You Tube videos were taken with pocket (point and shoot) > > video cameras taking MPEG2 at 15 frames / second at 320 x 140 > > resolution, and which are manageable in short sequences for file upload. > > However, my Luxtex OR camera takes at 640 x 480 at 30 fps, which is > > more than 8 times the amount of data per second. > > > > I have wanted for some time to be able to have any Forum member > > upload surgical videos to our site automatically. I can > > only say that it is a technical challenge to get the file uploaded to > > the server, convert it to a quality suitable for web broadcast, and then > > post it. > > > > We could set up a You Tube section, but I have not found it easy to > > get back in to see You Tube videos which people have > > notified me about. I posted a video there of my multiple > > metastatice resection technique...but I can't find it!. There is > > a great deal of spam-like chatter on You-Tube as well. So, its do- > > able, but messy IMHO. > > > > I will ask again amoungst my staff if this can be done via the > > HSF.....it is definately a great suggestion.. > > > > Thanks, > > > > Mark > > > > Mark M. Levinson, MD > > Founder, Editor-in-Chief, > > The Heart Surgery Forum > > WWW: > > Email: > > > > > > > > _______________________________________________ > > OpenHeart-L mailing list > > > > Send postings to: > > OpenHeart-L@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 > > ----------------------------------------- > > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > From Jbflegejr at aol.com Tue Sep 4 11:53:19 2007 From: Jbflegejr at aol.com (Jbflegejr@aol.com) Date: Tue Sep 4 10:57:44 2007 Subject: [HSF] Fast tracking Message-ID: Often the hospital owned the extended care facility so was highly motivated to influence the early discharge from the hospital sooner than the LOS calculated in the DRG determination and start collecting for the extended care days. A blatant example of "double-dipping", John Flege ************************************** Get a sneak peek of the all-new AOL at http://discover.aol.com/memed/aolcom30tour From Jbflegejr at aol.com Tue Sep 4 11:58:50 2007 From: Jbflegejr at aol.com (Jbflegejr@aol.com) Date: Tue Sep 4 10:59:35 2007 Subject: [HSF] Fast tracking Message-ID: I heard a lecture given by Larry Bonchek on fast-tracking a few years ago. He emphasized the importance of educating the patient before operation. He said that he told them that the average patient stayed 3 or 4 days but there were the wimps, the faint of heart, the weak-spirited that stayed longer. John Flege ************************************** Get a sneak peek of the all-new AOL at http://discover.aol.com/memed/aolcom30tour From enaseri at hotmail.com.tr Tue Sep 4 17:11:36 2007 From: enaseri at hotmail.com.tr (=?windows-1254?Q?erdin=E7_naseri?=) Date: Tue Sep 4 12:12:08 2007 Subject: [HSF] aortic root reimplantation and Rv dysfx In-Reply-To: References: <961234513.1188911780144.JavaMail.root@fepweb01> Message-ID: Would like to have the forum members opinion regarding the following case: 62 Y/O male with history of HT,CAD and COPD.( heavy smoker) CXR:Bilateral multiple bullae in the upper lobes, EKG:previous inferior MI and LVH. CAG:LAD90%,OM2 80%,RCA totaly occluded no ante or retrograde filling,no LV graphy TTE:AR 2-3 +,Aortic annulus 3.5 cm,Valsalva 4.3 cm,LVEDD 6.3 cm, Trival MR,TR 1 +,EF ( Simpson 's method) 25%,LV inferolateral akinesia Operation( hours ago): aortic and single stage venous cannulation,preparation of root during cooling showed dilataton of valsalva sinuses.Prox. RCA was at least 1.5 cm in diameter.on-pump beating heart LAD anastomosis while cooling. Trial of OM2 anastomosis lead to severe LV dilation .Anastomosis aborted and cross clamp with antegrade aortic root cardioplegia with periods of aortic root suction and LV compression. when the heart showed electromechanical arrest ante through LAD graft and retro through CS.Cooled to 24 degrees( operation room temp 28 ,air condition out of work!) and finished OM anastomosis and started giving cardioplegia through it .Exploration and arteriotomy of RCA showed a totally occluded vessel with very small (<1 mm )PDA.Opened the aorta : oozing of desaturated blood from LC but nil from RC ostium.Aortic annular ,valsalva and STJ dilated but leaflets of good quality and coaptation.Decided to do root reimplantation .I was trying to be fast because of the inability to give cardioplegia to RV .Still further cooled to 24.Aortic root reimplantation and OM CABG in 121 minutes : gave hot shot and declamped .Heart started beating spontaneously at 28 degrees and after 10 minutes"of declamping.Continued with the proximals( LAD and Cabrol graft )to graft and OM to proximal arch).Everyting looked OK with Lv contracting good with no dilation( no TEE available)Tried to wean and BP dropped with RV-RA dilation .CPB again and RCA endatrterectomy and by-pass to it with poor backflow distaly.30 more minutes on CPB and tried to wean but the same story.Changed the venous drainage to selective caval and did a warm beating tricuspid ring annuloplasty.Actually the leaflets were in good shape and coaptation before annuloplasty but I remebered Hal's advices regarding TR.CPB > 300 minutes and tried weaning with the following findings: LV small and contracting well,direct LA pressure 8 mmHg , RV stand still ,RA dilated;CVP 20 mmHg.Had started inotopics already ,increased the doses to suprapharmacologic levels ,put IABP ( it increased the MAP) and closed the sternum.ICU findings: MAP 65-70,ABG reasoable,good urination . My comment: ?nappropriate RV preservation .Any additional measures could been taken ??? erdinc From prasannasimha at gmail.com Tue Sep 4 22:56:44 2007 From: prasannasimha at gmail.com (psimha) Date: Tue Sep 4 14:21:59 2007 Subject: [HSF] aortic root reimplantation and Rv dysfx In-Reply-To: References: <961234513.1188911780144.JavaMail.root@fepweb01> Message-ID: <46DD8744.3050000@gmail.com> In a desperate circumstance you can try to do a BD Glenn if the PA pressure is OK.Another option is to perforate the IAS so that you get an adequate LV preload at the cost of desaturation. These are the some of the things that may work in the presence of RV dysfunction when we do not have a mechanical support for the RV. Incidentally what is the CVP and PA pressures and do you have access to Milrinone and NO ? Prasanna erdin? naseri wrote: > Would like to have the forum members opinion regarding the following case: > 62 Y/O male with history of HT,CAD and COPD.( heavy smoker) > CXR:Bilateral multiple bullae in the upper lobes, > EKG:previous inferior MI and LVH. > CAG:LAD90%,OM2 80%,RCA totaly occluded no ante or retrograde filling,no LV graphy > TTE:AR 2-3 +,Aortic annulus 3.5 cm,Valsalva 4.3 cm,LVEDD 6.3 cm, Trival MR,TR 1 +,EF ( Simpson 's method) 25%,LV inferolateral akinesia > Operation( hours ago): aortic and single stage venous cannulation,preparation of root during cooling showed dilataton of valsalva sinuses.Prox. RCA was at least 1.5 cm in diameter.on-pump beating heart LAD anastomosis while cooling. Trial of OM2 anastomosis lead to severe LV dilation .Anastomosis aborted and cross clamp with antegrade aortic root cardioplegia with periods of aortic root suction and LV compression. when the heart showed electromechanical arrest ante through LAD graft and retro through CS.Cooled to 24 degrees( operation room temp 28 ,air condition out of work!) and finished OM anastomosis and started giving cardioplegia through it .Exploration and arteriotomy of RCA showed a totally occluded vessel with very small (<1 mm )PDA.Opened the aorta : oozing of desaturated blood from LC but nil from RC ostium.Aortic annular ,valsalva and STJ dilated but leaflets of good quality and coaptation.Decided to do root reimplantation .I was trying to be fast because of > the inability to give cardioplegia to RV .Still further cooled to 24.Aortic root reimplantation and OM CABG in 121 minutes : gave hot shot and declamped .Heart started beating spontaneously at 28 degrees and after 10 minutes"of declamping.Continued with the proximals( LAD and Cabrol graft )to graft and OM to proximal arch).Everyting looked OK with Lv contracting good with no dilation( no TEE available)Tried to wean and BP dropped with RV-RA dilation .CPB again and RCA endatrterectomy and by-pass to it with poor backflow distaly.30 more minutes on CPB and tried to wean but the same story.Changed the venous drainage to selective caval and did a warm beating tricuspid ring annuloplasty.Actually the leaflets were in good shape and coaptation before annuloplasty but I remebered Hal's advices regarding TR.CPB > 300 minutes and tried weaning with the following findings: LV small and contracting well,direct LA pressure 8 mmHg , RV stand still ,RA dilated;CVP 20 mmHg.Had started i > notopics already ,increased the doses to suprapharmacologic levels ,put IABP ( it increased the MAP) and closed the sternum.ICU findings: MAP 65-70,ABG reasoable,good urination . > My comment: ?nappropriate RV preservation .Any additional measures could been taken ??? > erdinc > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > > From enaseri at hotmail.com.tr Tue Sep 4 19:51:56 2007 From: enaseri at hotmail.com.tr (=?windows-1254?Q?erdin=E7_naseri?=) Date: Tue Sep 4 14:52:26 2007 Subject: [HSF] aortic root reimplantation and Rv dysfx In-Reply-To: <46DD8744.3050000@gmail.com> References: <961234513.1188911780144.JavaMail.root@fepweb01> <46DD8744.3050000@gmail.com> Message-ID: Prasanna, 1.CVP is 25 mmHg 2.PO2 is already 65 mmHg (FIO2 70%) .He is very close to end-stage lung disease with severe bilateral hyperinflated black lungs. 3.No milrinone is not available. erdinc > Date: Tue, 4 Sep 2007 21:56:44 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] aortic root reimplantation and Rv dysfx> CC: > > In a desperate circumstance you can try to do a BD Glenn if the PA > pressure is OK.Another option is to perforate the IAS so that you get an > adequate LV preload at the cost of desaturation. These are the some of > the things that may work in the presence of RV dysfunction when we do > not have a mechanical support for the RV. Incidentally what is the CVP > and PA pressures and do you have access to Milrinone and NO ?> Prasanna> erdin? naseri wrote:> > Would like to have the forum members opinion regarding the following case:> > 62 Y/O male with history of HT,CAD and COPD.( heavy smoker)> > CXR:Bilateral multiple bullae in the upper lobes, > > EKG:previous inferior MI and LVH.> > CAG:LAD90%,OM2 80%,RCA totaly occluded no ante or retrograde filling,no LV graphy> > TTE:AR 2-3 +,Aortic annulus 3.5 cm,Valsalva 4.3 cm,LVEDD 6.3 cm, Trival MR,TR 1 +,EF ( Simpson 's method) 25%,LV inferolateral akinesia> > Operation( hours ago): aortic and single stage venous cannulation,preparation of root during cooling showed dilataton of valsalva sinuses.Prox. RCA was at least 1.5 cm in diameter.on-pump beating heart LAD anastomosis while cooling. Trial of OM2 anastomosis lead to severe LV dilation .Anastomosis aborted and cross clamp with antegrade aortic root cardioplegia with periods of aortic root suction and LV compression. when the heart showed electromechanical arrest ante through LAD graft and retro through CS.Cooled to 24 degrees( operation room temp 28 ,air condition out of work!) and finished OM anastomosis and started giving cardioplegia through it .Exploration and arteriotomy of RCA showed a totally occluded vessel with very small (<1 mm )PDA.Opened the aorta : oozing of desaturated blood from LC but nil from RC ostium.Aortic annular ,valsalva and STJ dilated but leaflets of good quality and coaptation.Decided to do root reimplantation .I was trying to be fast because of > > the inability to give cardioplegia to RV .Still further cooled to 24.Aortic root reimplantation and OM CABG in 121 minutes : gave hot shot and declamped .Heart started beating spontaneously at 28 degrees and after 10 minutes"of declamping.Continued with the proximals( LAD and Cabrol graft )to graft and OM to proximal arch).Everyting looked OK with Lv contracting good with no dilation( no TEE available)Tried to wean and BP dropped with RV-RA dilation .CPB again and RCA endatrterectomy and by-pass to it with poor backflow distaly.30 more minutes on CPB and tried to wean but the same story.Changed the venous drainage to selective caval and did a warm beating tricuspid ring annuloplasty.Actually the leaflets were in good shape and coaptation before annuloplasty but I remebered Hal's advices regarding TR.CPB > 300 minutes and tried weaning with the following findings: LV small and contracting well,direct LA pressure 8 mmHg , RV stand still ,RA dilated;CVP 20 mmHg.Had started i> > notopics already ,increased the doses to suprapharmacologic levels ,put IABP ( it increased the MAP) and closed the sternum.ICU findings: MAP 65-70,ABG reasoable,good urination .> > My comment: ?nappropriate RV preservation .Any additional measures could been taken ???> > erdinc > > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@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> > -----------------------------------------> >> >> > > > > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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> ----------------------------------------- From josegale at orbit.net.mt Wed Sep 5 00:13:34 2007 From: josegale at orbit.net.mt (Joseph Galea) Date: Tue Sep 4 17:14:03 2007 Subject: [HSF] Hypothyroidism Message-ID: <001d01c7ef38$747992c0$0100000a@joseph> had a patient 2 weeks ago who was diagnosed with hypothyroidism (TSH >75) 6 weeks earlier (not related to amiodarone). He actually had myxoedema. He was started on thyroxine and I waited for 6 weeks until his TSH went down to 25. I performed CABG at this time without any problems. He went home 5 days after surgery but his left ventricular function was moderate to good. Joe Galea From Jbflegejr at aol.com Tue Sep 4 18:51:50 2007 From: Jbflegejr at aol.com (Jbflegejr@aol.com) Date: Tue Sep 4 17:52:21 2007 Subject: [HSF] aortic root reimplantation and Rv dysfx Message-ID: Pulmonary artery counterpulsation may be used. A 20mm graft is sewn to the main pulmonary artery which is essentially a diverticulum or pumping chamber. An intraortic balloon is inserted into the graft with the end in the pulmonary artery and counterpulsation applied just like to an intraortic balloon. This was first described by Craig Miller who used in without success and the first success was reported by me. (Flege JB, Jr., Wright CB, Reisinger TJ. Successful balloon counterpulsation for right ventricular failure. Ann Thorac Surg 1984;37:167-8.) (Miller's paper is cited in the references.) I have used it successfully for two patients with mitral stenosis and severe pulmonary hypertension having MVR and one patient with biventricular failure resulting from extensive acute inferior RV and LV infarction without pulmonary hypertension who required an intraortic balloon as well. None of the three could be weaned from CPB even with industrial dosage of ionotropes and all were dependent on the balloon support for two or three days. I reopened the sternum to remove the balloon and grafts. All three made good recoveries. I have used this support several other times without success in equally desperate circumstances. John Flege ************************************** Get a sneak peek of the all-new AOL at http://discover.aol.com/memed/aolcom30tour From ebender001 at charter.net Tue Sep 4 18:32:36 2007 From: ebender001 at charter.net (Edward Bender) Date: Tue Sep 4 18:33:08 2007 Subject: [HSF] aortic root reimplantation and Rv dysfx In-Reply-To: References: <961234513.1188911780144.JavaMail.root@fepweb01> Message-ID: Leave the sternum open (usually you can close the skin over the open wound). This alleviates mediastinal compression somewhat. In cases of severe RV failure, obviously volume loading is required, but I have squeaked by with a mechanical assist for 6 - 12 hours (I have used the A-Med pump which Tea has blessed in the past or, in the absence of that, use smal cannulae in the RA and PA, and flow with a biomedicus or roller pump 2 - 3 liters per minute to help unload the RV. I have been surprised at how effective this can be. Good luck. Let us know how things turn out. Ed Bender, MD On Sep 4, 2007, at 11:11 AM, erdin? naseri wrote: > > Would like to have the forum members opinion regarding the > following case: > 62 Y/O male with history of HT,CAD and COPD.( heavy smoker) > CXR:Bilateral multiple bullae in the upper lobes, > EKG:previous inferior MI and LVH. > CAG:LAD90%,OM2 80%,RCA totaly occluded no ante or retrograde > filling,no LV graphy > TTE:AR 2-3 +,Aortic annulus 3.5 cm,Valsalva 4.3 cm,LVEDD 6.3 cm, > Trival MR,TR 1 +,EF ( Simpson 's method) 25%,LV inferolateral akinesia > Operation( hours ago): aortic and single stage venous > cannulation,preparation of root during cooling showed dilataton of > valsalva sinuses.Prox. RCA was at least 1.5 cm in diameter.on-pump > beating heart LAD anastomosis while cooling. Trial of OM2 > anastomosis lead to severe LV dilation .Anastomosis aborted and > cross clamp with antegrade aortic root cardioplegia with periods of > aortic root suction and LV compression. when the heart showed > electromechanical arrest ante through LAD graft and retro through > CS.Cooled to 24 degrees( operation room temp 28 ,air condition out > of work!) and finished OM anastomosis and started giving > cardioplegia through it .Exploration and arteriotomy of RCA > showed a totally occluded vessel with very small (<1 mm ) > PDA.Opened the aorta : oozing of desaturated blood from LC but nil > from RC ostium.Aortic annular ,valsalva and STJ dilated but > leaflets of good quality and coaptation.Decided to do root > reimplantation .I was trying to be fast because of > the inability to give cardioplegia to RV .Still further cooled to > 24.Aortic root reimplantation and OM CABG in 121 minutes : gave > hot shot and declamped .Heart started beating spontaneously at 28 > degrees and after 10 minutes"of declamping.Continued with the > proximals( LAD and Cabrol graft )to graft and OM to proximal > arch).Everyting looked OK with Lv contracting good with no dilation > ( no TEE available)Tried to wean and BP dropped with RV-RA > dilation .CPB again and RCA endatrterectomy and by-pass to it with > poor backflow distaly.30 more minutes on CPB and tried to wean but > the same story.Changed the venous drainage to selective caval and > did a warm beating tricuspid ring annuloplasty.Actually the > leaflets were in good shape and coaptation before annuloplasty but > I remebered Hal's advices regarding TR.CPB > 300 minutes and tried > weaning with the following findings: LV small and contracting > well,direct LA pressure 8 mmHg , RV stand still ,RA dilated;CVP 20 > mmHg.Had started i > notopics already ,increased the doses to suprapharmacologic > levels ,put IABP ( it increased the MAP) and closed the > sternum.ICU findings: MAP 65-70,ABG reasoable,good urination . > My comment: ?nappropriate RV preservation .Any additional measures > could been taken ??? > erdinc > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From anianyanwu at hotmail.com Wed Sep 5 00:35:02 2007 From: anianyanwu at hotmail.com (Ani Anyanwu) Date: Tue Sep 4 19:35:55 2007 Subject: [HSF] aortic root reimplantation and Rv dysfx In-Reply-To: References: <961234513.1188911780144.JavaMail.root@fepweb01> Message-ID: > a biomedicus or roller pump 2 - 3 liters per minute to help unload the RV> I have been surprised at how effective this can be. > Ed Bender, MD Ed when you say how effective this can be, are you saying you have salvaged patients in this manner or do you mean effective hemodynamically? Thanks Ani > From: ebender001@charter.net> Subject: Re: [HSF] aortic root reimplantation and Rv dysfx> Date: Tue, 4 Sep 2007 17:32:36 -0500> To: OpenHeart-L@lists.hsforum.com> CC: > > Leave the sternum open (usually you can close the skin over the open > wound). This alleviates mediastinal compression somewhat. In cases > of severe RV failure, obviously volume loading is required, but I > have squeaked by with a mechanical assist for 6 - 12 hours (I have > used the A-Med pump which Tea has blessed in the past or, in the > absence of that, use smal cannulae in the RA and PA, and flow with > > > On Sep 4, 2007, at 11:11 AM, erdin? naseri wrote:> > >> > Would like to have the forum members opinion regarding the > > following case:> > 62 Y/O male with history of HT,CAD and COPD.( heavy smoker)> > CXR:Bilateral multiple bullae in the upper lobes,> > EKG:previous inferior MI and LVH.> > CAG:LAD90%,OM2 80%,RCA totaly occluded no ante or retrograde > > filling,no LV graphy> > TTE:AR 2-3 +,Aortic annulus 3.5 cm,Valsalva 4.3 cm,LVEDD 6.3 cm, > > Trival MR,TR 1 +,EF ( Simpson 's method) 25%,LV inferolateral akinesia> > Operation( hours ago): aortic and single stage venous > > cannulation,preparation of root during cooling showed dilataton of > > valsalva sinuses.Prox. RCA was at least 1.5 cm in diameter.on-pump > > beating heart LAD anastomosis while cooling. Trial of OM2 > > anastomosis lead to severe LV dilation .Anastomosis aborted and > > cross clamp with antegrade aortic root cardioplegia with periods of > > aortic root suction and LV compression. when the heart showed > > electromechanical arrest ante through LAD graft and retro through > > CS.Cooled to 24 degrees( operation room temp 28 ,air condition out > > of work!) and finished OM anastomosis and started giving > > cardioplegia through it .Exploration and arteriotomy of RCA > > showed a totally occluded vessel with very small (<1 mm ) > > PDA.Opened the aorta : oozing of desaturated blood from LC but nil > > from RC ostium.Aortic annular ,valsalva and STJ dilated but > > leaflets of good quality and coaptation.Decided to do root > > reimplantation .I was trying to be fast because of> > the inability to give cardioplegia to RV .Still further cooled to > > 24.Aortic root reimplantation and OM CABG in 121 minutes : gave > > hot shot and declamped .Heart started beating spontaneously at 28 > > degrees and after 10 minutes"of declamping.Continued with the > > proximals( LAD and Cabrol graft )to graft and OM to proximal > > arch).Everyting looked OK with Lv contracting good with no dilation > > ( no TEE available)Tried to wean and BP dropped with RV-RA > > dilation .CPB again and RCA endatrterectomy and by-pass to it with > > poor backflow distaly.30 more minutes on CPB and tried to wean but > > the same story.Changed the venous drainage to selective caval and > > did a warm beating tricuspid ring annuloplasty.Actually the > > leaflets were in good shape and coaptation before annuloplasty but > > I remebered Hal's advices regarding TR.CPB > 300 minutes and tried > > weaning with the following findings: LV small and contracting > > well,direct LA pressure 8 mmHg , RV stand still ,RA dilated;CVP 20 > > mmHg.Had started i> > notopics already ,increased the doses to suprapharmacologic > > levels ,put IABP ( it increased the MAP) and closed the > > sternum.ICU findings: MAP 65-70,ABG reasoable,good urination .> > My comment: ?nappropriate RV preservation .Any additional measures > > could been taken ???> > erdinc> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@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> > -----------------------------------------> > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@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> ----------------------------------------- _________________________________________________________________ The next generation of MSN Hotmail has arrived - Windows Live Hotmail http://www.newhotmail.co.uk From ebender001 at charter.net Tue Sep 4 18:36:55 2007 From: ebender001 at charter.net (Edward Bender) Date: Tue Sep 4 19:59:34 2007 Subject: [HSF] Native MV endocarditis with prosthetic avr - follow-up Message-ID: <5141CDC6-C6CB-4159-A79B-A44079C09A5A@charter.net> Patient grew out meth sensitive staph from blood cultures (1 bottle only). Awaiting oral surgeon consult. As I was starting another heart this morning, patient went into complete heart block, taken to cath lab by cardiology for temporary pacing wire with effective capture. Patient required intubation in ICU after this and arrested and died about 30 minutes post pacemaker placement. Not a very good outcome. Not sure what the cause of death was - no autopsy obtained. Ed Bender, MD From ebender001 at charter.net Tue Sep 4 20:20:28 2007 From: ebender001 at charter.net (Edward Bender) Date: Tue Sep 4 20:21:15 2007 Subject: [HSF] aortic root reimplantation and Rv dysfx In-Reply-To: References: <961234513.1188911780144.JavaMail.root@fepweb01> Message-ID: <912925FE-1C51-4424-9C64-21DF32B4016D@charter.net> Both. And by both, I mean I have had two cases where I have used the right sided pump, both improved dramatically however one died remotely from the acute insult of prior co-morbid conditions. Ed Bender, MD On Sep 4, 2007, at 6:35 PM, Ani Anyanwu wrote: >> a biomedicus or roller pump 2 - 3 liters per minute to help unload >> the RV> I have been surprised at how effective this can be. > Ed >> Bender, MD > Ed when you say how effective this can be, are you saying you have > salvaged patients in this manner or do you mean effective > hemodynamically? > > Thanks > > Ani > > > >> From: ebender001@charter.net> Subject: Re: [HSF] aortic root >> reimplantation and Rv dysfx> Date: Tue, 4 Sep 2007 17:32:36 -0500> >> To: OpenHeart-L@lists.hsforum.com> CC: > > Leave the sternum open >> (usually you can close the skin over the open > wound). This >> alleviates mediastinal compression somewhat. In cases > of severe >> RV failure, obviously volume loading is required, but I > have >> squeaked by with a mechanical assist for 6 - 12 hours (I have > >> used the A-Med pump which Tea has blessed in the past or, in the > >> absence of that, use smal cannulae in the RA and PA, and flow >> with > > > On Sep 4, 2007, at 11:11 AM, erdin? naseri wrote:> > >> >> > Would like to have the forum members opinion regarding the > >> > following case:> > 62 Y/O male with history of HT,CAD and COPD. >> ( heavy smoker)> > CXR:Bilateral multiple bullae in the upper >> lobes,> > EKG:previous inferior MI and LVH.> > CAG:LAD90%,OM2 >> 80%,RCA totaly occluded no ante or retrograde > > filling,no LV >> graphy> > TTE:AR 2-3 +,Aort > ic annulus 3.5 cm,Valsalva 4.3 cm,LVEDD 6.3 cm, > > Trival MR,TR 1 > +,EF ( Simpson 's method) 25%,LV inferolateral akinesia> > Operation > ( hours ago): aortic and single stage venous > > > cannulation,preparation of root during cooling showed dilataton of > > > valsalva sinuses.Prox. RCA was at least 1.5 cm in diameter.on- > pump > > beating heart LAD anastomosis while cooling. Trial of OM2 > > > anastomosis lead to severe LV dilation .Anastomosis aborted and > > > cross clamp with antegrade aortic root cardioplegia with > periods of > > aortic root suction and LV compression. when the > heart showed > > electromechanical arrest ante through LAD graft > and retro through > > CS.Cooled to 24 degrees( operation room temp > 28 ,air condition out > > of work!) and finished OM anastomosis and > started giving > > cardioplegia through it .Exploration and > arteriotomy of RCA > > showed a totally occluded vessel with very > small (<1 mm ) > > PDA.Opened the aorta : oozing of desaturated > blood from LC but nil >>> from RC ostium.Aortic annular ,valsalva and STJ dilated but > > >>> leaflets of good quality and coaptation.Decided to do root > > >>> reimplantation .I was trying to be fast because of> > the >>> inability to give cardioplegia to RV .Still further cooled to > > >>> 24.Aortic root reimplantation and OM CABG in 121 minutes : gave > >>> > hot shot and declamped .Heart started beating spontaneously at >>> 28 > > degrees and after 10 minutes"of declamping.Continued with >>> the > > proximals( LAD and Cabrol graft )to graft and OM to >>> proximal > > arch).Everyting looked OK with Lv contracting good >>> with no dilation > > ( no TEE available)Tried to wean and BP >>> dropped with RV-RA > > dilation .CPB again and RCA >>> endatrterectomy and by-pass to it with > > poor backflow distaly. >>> 30 more minutes on CPB and tried to wean but > > the same >>> story.Changed the venous drainage to selective caval and > > did >>> a warm beating tricuspid ring annuloplasty.Actually the > > >>> leaflets were in good shape and coaptation before annu > loplasty but > > I remebered Hal's advices regarding TR.CPB > 300 > minutes and tried > > weaning with the following findings: LV small > and contracting > > well,direct LA pressure 8 mmHg , RV stand > still ,RA dilated;CVP 20 > > mmHg.Had started i> > notopics > already ,increased the doses to suprapharmacologic > > levels ,put > IABP ( it increased the MAP) and closed the > > sternum.ICU > findings: MAP 65-70,ABG reasoable,good urination .> > My comment: > ?nappropriate RV preservation .Any additional measures > > could > been taken ???> > erdinc> > > _______________________________________________> > OpenHeart-L > mailing list> >> > Send postings to:> > OpenHeart- > L@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> > > ----------------------------------------- >>> _______________________________________________> OpenHeart-L >>> mailing list> > Send postings to:> OpenHeart-L@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> >>> ----------------------------------------- > _________________________________________________________________ > The next generation of MSN Hotmail has arrived - Windows Live Hotmail > http://www.newhotmail.co.uk > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- From prasannasimha at gmail.com Wed Sep 5 08:11:19 2007 From: prasannasimha at gmail.com (psimha) Date: Tue Sep 4 21:41:59 2007 Subject: [HSF] aortic root reimplantation and Rv dysfx In-Reply-To: References: <961234513.1188911780144.JavaMail.root@fepweb01> <46DD8744.3050000@gmail.com> Message-ID: <46DE093F.7070301@gmail.com> Glenn will not help if the PA pressures are high (Not CVP). You have to consider either septostomy or RVAD (roller at least as Ed has suggested - we have also used it variably)and lots of prayers. If you do not have Milrinone try a theophylline infusion. It works at times. I would consider keeping the chest open . It will be a tough call.You can also consider inhaled SNP since you do not have NO. Lots of prayers required. I haven't been able to do PA counterpulsation (basically because we don't get offhand zero porosity grafts. Prasanna erdin? naseri wrote: > Prasanna, > 1.CVP is 25 mmHg 2.PO2 is already 65 mmHg (FIO2 70%) .He is very close to end-stage lung disease with severe bilateral hyperinflated black lungs. 3.No milrinone is not available. > erdinc > Date: Tue, 4 Sep 2007 21:56:44 +0530> From: prasannasimha@gmail.com> To: OpenHeart-L@lists.hsforum.com> Subject: Re: [HSF] aortic root reimplantation and Rv dysfx> CC: > > In a desperate circumstance you can try to do a BD Glenn if the PA > pressure is OK.Another option is to perforate the IAS so that you get an > adequate LV preload at the cost of desaturation. These are the some of > the things that may work in the presence of RV dysfunction when we do > not have a mechanical support for the RV. Incidentally what is the CVP > and PA pressures and do you have access to Milrinone and NO ?> Prasanna> erdin? naseri wrote:> > Would like to have the forum members opinion regarding the following case:> > 62 Y/O male with history of HT,CAD and COPD.( heavy smoker)> > CXR:Bilateral multiple bullae in the upper lobes, > > EKG:previous inferior MI and LVH.> > CAG:LAD90%,OM2 80%,RCA totaly occluded no ante or retrograde filling,no LV graphy> > TTE:AR 2-3 +,Aortic annulus 3.5 > cm,Valsalva 4.3 cm,LVEDD 6.3 cm, Trival MR,TR 1 +,EF ( Simpson 's method) 25%,LV inferolateral akinesia> > Operation( hours ago): aortic and single stage venous cannulation,preparation of root during cooling showed dilataton of valsalva sinuses.Prox. RCA was at least 1.5 cm in diameter.on-pump beating heart LAD anastomosis while cooling. Trial of OM2 anastomosis lead to severe LV dilation .Anastomosis aborted and cross clamp with antegrade aortic root cardioplegia with periods of aortic root suction and LV compression. when the heart showed electromechanical arrest ante through LAD graft and retro through CS.Cooled to 24 degrees( operation room temp 28 ,air condition out of work!) and finished OM anastomosis and started giving cardioplegia through it .Exploration and arteriotomy of RCA showed a totally occluded vessel with very small (<1 mm )PDA.Opened the aorta : oozing of desaturated blood from LC but nil from RC ostium.Aortic annular ,valsalva and STJ dilated but leaflets > of good quality and coaptation.Decided to do root reimplantation .I was trying to be fast because of > > the inability to give cardioplegia to RV .Still further cooled to 24.Aortic root reimplantation and OM CABG in 121 minutes : gave hot shot and declamped .Heart started beating spontaneously at 28 degrees and after 10 minutes"of declamping.Continued with the proximals( LAD and Cabrol graft )to graft and OM to proximal arch).Everyting looked OK with Lv contracting good with no dilation( no TEE available)Tried to wean and BP dropped with RV-RA dilation .CPB again and RCA endatrterectomy and by-pass to it with poor backflow distaly.30 more minutes on CPB and tried to wean but the same story.Changed the venous drainage to selective caval and did a warm beating tricuspid ring annuloplasty.Actually the leaflets were in good shape and coaptation before annuloplasty but I remebered Hal's advices regarding TR.CPB > 300 minutes and tried weaning with the following findings: LV smal > l and contracting well,direct LA pressure 8 mmHg , RV stand still ,RA dilated;CVP 20 mmHg.Had started i> > notopics already ,increased the doses to suprapharmacologic levels ,put IABP ( it increased the MAP) and closed the sternum.ICU findings: MAP 65-70,ABG reasoable,good urination .> > My comment: ?nappropriate RV preservation .Any additional measures could been taken ???> > erdinc > > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L@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> > -----------------------------------------> >> >> > > > > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBS > CRIBE, 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> ----------------------------------------- > _______________________________________________ > OpenHeart-L mailing list > > Send postings to: > OpenHeart-L@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 > ----------------------------------------- > > > From enaseri at hotmail.com.tr Wed Sep 5 05:49:47 2007 From: enaseri at hotmail.com.tr (=?windows-1254?Q?erdin=E7_naseri?=) Date: Wed Sep 5 00:50:26 2007 Subject: [HSF] aortic root reimplantation and Rv dysfx In-Reply-To: References: Message-ID: Dear DR. Flege, I have previously used the technique mentioned by you in 2 patients without success and this was the reason for not using it.Having heard of its successful use by you I will use it in the future( hope I won't need it). erdinc> From: Jbflegejr@aol.com> Date: Tue, 4 Sep 2007 17:51:50 -0400> Subjects the reason for: Re: [HSF] aortic root reimplantation and Rv dysfx> To: OpenHeart-L@lists.hsforum.com> CC: > > Pulmonary artery counterpulsation may be used. A 20mm graft is sewn to the > main pulmonary artery which is essentially a diverticulum or pumping chamber. An > intraortic balloon is inserted into the graft with the end in the pulmonary > artery and counterpulsation applied just like to an intraortic balloon. This > was first described by Craig Miller who used in without success and the first > success was reported by me. > (Flege JB, Jr., Wright CB, Reisinger TJ. Successful balloon counterpulsation > for right ventricular failure. Ann Thorac Surg 1984;37:167-8.) (Miller's paper > is cited in the references.) I have used it successfully for two patients > with mitral stenosis and severe pulmonary hypertension having MVR and one patient > with biventricular failure resulting from extensive acute inferior RV and LV > infarction without pulmonary hypertension who required an intraortic balloon > as well. None of the three could be weaned from CPB even with industrial dosage > of ionotropes and all were dependent on the balloon support for two or three > days. I reopened the sternum to remove the balloon and grafts. All three made > good recoveries. I have used this support several other times without success > in equally desperate circumstances. John Flege> > > > ************************************** Get a sneak peek of the all-new AOL at > http://discover.aol.com/memed/aolcom30tour> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L@lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l>