[HSF] Prosthetic Valve Endocarditis in setting of severe LV dysfunction

[Tea Acuff]

Fair enough on the Bentall, but I would suspect that some would find a less radical solution. Debridement is good and required, but it seems this sepsis case is already an example of the truism that replacement has its own set of liabilities.
 
I share your concern that this patient in RV failure may have passed by any option without cardiac replacement and most with it. Presumably as in many of your end stage patients there were along the way unchosen paths that may have led to different outcomes. This is my thrust.
 
It remains surprising to me, although not an uncommon claim, to be "unable to find SVR candidates" in transplant centers. A few programs find many, and others make a side business in standard cardiac interventions in patients not yet ready for the transplant list. I can not speak specifically to your situation, but as always a determined mind and specific diagnostic tools makes for more success when opportunities do arise. I am shocked (although less so) when I hear presentations that are theoretically (by history and description of defect) ideal for SVR for which the "heart failure specialist" does not even put the option out for theoretical consideration much less choose it for selection.
 
I do agree that Dor should be given credit for the concept of SVR (surgical ventricular restoration), but Gerald Buckberg probably should be given credit as an apologist for the concept in the USA (STS and AATS)  if not also the phrase. Menicanti is a protegee of Dor, who has modified the technique and educated a hundred(s) surgeons directly. Marisa Di Donato is the cardiologist who has studied both Dor and Menicanti patients (approximately a thousand each) longitudinally and made this experience not a series but a (many) study(ies). IABP is not a standard feature of this operation. Dr. Menicanti is not aware that suture transventicular annuloplasty is an anathema. Marisa did find that in this group of patients a spherical reconstruction tended to beget later MR and is one of the reasons that a conical maniquen is used by many surgeons (but not Dor who still uses a "party" balloon to measure the restored volume).
 
tea


----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Thursday, September 13, 2007 8:51:40 AM
Subject: RE: [HSF] Prosthetic Valve Endocarditis in setting of severe LV dysfunction


If the lesion involves the aortic annulus where it meets the trigone then debridement will likely require a Bentall to reconstruct.

I know you are a believer in the SVR but I think in reality there are few patients in whom it is a solution. Thus far I have never seen a patient referred for transplant for whom SVR is a reasonable option. Would you advocate SVR in patient with severe RV dysfunction and dilatation and global LV dilatation with all major regions hypokinetic, akinetic or dyskinetic who has a prosthetic mitral valve? I suppose you could do an SVR on the RV too but doubt that will help either. Also in reality I suspect his cardiomyopathy is non-ischemic as it is out of proportion to his single vessel CAD (LAD occluded in midcourse).

I also have my views on the relevance of ICD as sudden death is not the commonest mode of death in these patients, however if you read the literature it would seem that one life is saved for 16 ICDs placed (not a fair statistic though as some lives are saved numerous times over and over again so the true lives saved may be much less).

Ani



> Date: Wed, 12 Sep 2007 20:12:40 -0700> From: tacuff at swbell.net> Subject: Re: [HSF] Prosthetic Valve Endocarditis in setting of severe LV dysfunction> To: OpenHeart-L at lists.hsforum.com> CC: > > Why would you need to do a Bentall for this? Why or why not was SVR not a solution instead of ICD other than the usual brainless protocols and guidelines?> tea> > > ----- Original Message ----> From: Ani Anyanwu <anianyanwu at hotmail.com>> To: openheart-l at lists.hsforum.com> Sent: Wednesday, September 12, 2007 9:44:15 AM> Subject: [HSF] Prosthetic Valve Endocarditis in setting of severe LV dysfunction> > > Would be interested in forum members opinion on this case.> > This 58 yr old with hypertensive nephropathy, on dialysis for five years and on waiting list for kidney transplantation first presented to us December 2005 with an acute MI. Catheter showed occluded LAD which caused a massive anteroseptal MI with severe LV dysfunction. Echo showed mitral valve
 endocarditis with large vegetation. Cultures grew an enterococcus. Coronaries were otherwise pristine with no collateral LAD filling suggesting the occlusion was secondary to embolisation from the mitral. He underwent MV replacement and vein graft to LAD, also tricuspid repair. LV dysfunction however persisted following surgery and heart continued to remodel with dilated 7cm LV and LVEF ranging 10 to 15%. He was evaluated for heart transplant at another institution earlier this year but turned down (i think because he was too well - VO2 max 23). LV dysfunction was managed medically and for most part he is in NHYA II.> > Patient now admitted under our care because of prosthetic valve endocarditis. Cultures are positive for Staph Aureus sensitive to methicillin and echo shows probable abscess around trigone and may involve aortic annulus around non-coronary cusp. There is no valvar incompetence (of either aortic or mitral). Infection may have been
 triggered by a recent transvenous defibrillator (2 months ago) or a dialysis access cathether. Has been on antibiotics in outside hospital for 3 weeks before being transferred to us this week. Transesophageal echo here confirms EF around 10%, also severe RV dilatation and dysfunction. There is also echodensity at tip of RV defibrillator lead and previously described abscess but stable prosthesis. CT Angio shows patent vein graft. Right heart cath is notable for a wedge of 34, PA 40/30, RA 10, SVO2 50%. Patient is stable, no active heart failure and sepsis well controlled on antibiotics. > > Surgical therapy for this condition we expect will require radical debridement of trigone, redo MV replacement, likely Bentall, also will explant defibrillator and dialysis catheter. Patient is likely to bleed and require transfusions hence compounding existing RV dysfunction. > > Considering that this is not an operation for heart failure, but surgery in the midst
 of heart failure, it will invariably worsen rather than improve function of the heart; I would be keen to hear from forum members how they would deal with this case. Would anybody operate and at what do you think is the chance of success (by success I do not mean our usual 'extubated the next morning' criteria' but return to good quality of life) and at what risk of operative mortality? > > My current leaning is to offer this patient combined transplantation of the heart and kidney as the strategy most likely to result in mid-term survival - would also be keen to hear thoughts from transplant surgeons and others about this option.> > Thanks> > Ani> _________________________________________________________________> 100ʼs of Music vouchers to be won with MSN Music> https://www.musicmashup.co.uk_______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email
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