AW: [HSF] Mitral Repair with a Calcified Annulus

[Ani Anyanwu]

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 at aol.com> Date: Fri, 31 Aug 2007 21:50:54 -0400> Subject: Re: AW: [HSF] Mitral Repair with a Calcified Annulus> To: OpenHeart-L at 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 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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