AW: [HSF] Mitral Repair with a Calcified Annulus

[Ani Anyanwu]

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 at aol.com> Date: Fri, 31 Aug 2007 19:31:39 -0400> Subject: Re: AW: [HSF] Mitral Repair with a Calcified Annulus> To: OpenHeart-L at 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 at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
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