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

[Ani Anyanwu]

Hal
 
You use the term aneurysm repeatedly. In your practice are you seeing many true LV aneurysms still? My understanding is that these are increasingly rare in the era of early revascularization post MI. I thought that part of the reason that drove change in terminology to SVR etc was to stress its applicability to cases where there is no aneurysm.
 
We use MRI quite liberally and if there is a dilated ventricle with an akinetic segment with reasonable viability in other segments then we will do a Dor-type procedure. With MRI one can project the residual volume of the ventricle after excision of the dyskinetic or akinetic portion. That said such patients are rare in our practice but I suspect our practice is skewed as we do not see that many patients with ischemic heart disease and the heart failure ones are often too advanced for any form of conventional surgery when they get to us.
 
The commercially available Chase Medical balloon I think makes a difference as we have seen a more elliptical shape and better reverse remodelling post-op MRI but we do not use it routinely because of the prohibitive cost.
 
Excluding discrete aneurysms, the indications for this procedure as Guiseppe says are vague and far from defined. Working in New York I have certainly seen questionable interventions on the LV apex in CABG cases and I suspect you will find a higher incidence of Dor type procedures in areas where CABG results are scrutinised, or where the surgeon or program has an incentive - financial or otherwise - to add a Dor type operation to a conventional CABG.
 
Ani



> From: Hgrmd at aol.com> Date: Sat, 15 Sep 2007 07:12:34 -0400> Subject: Re: [HSF] Prosthetic Valve Endocarditis in setting of severe LV dysfunction> To: OpenHeart-L at lists.hsforum.com> CC: > > Ani,> Those are very valid questions of the Dor/SVR. I currently don't have > MRI, but should have it in place within the next few months. From the lectures > I've seen, it is very valuable in assessing the texture of the aneurysm. TEE > is usually fairly limited in its ability to demonstrate the aneurysmal LV > apex. I mainly go by a conventional LV-gram. One aspect that will keep you > from killing patients is avoiding doing the operation if more than one > territory is involved. One of my 2 fatalities was due to misjudging the fact that > the aneurysm involved the LAD and CX territories. > As for marketing, I don't do that other than to tell my referrals that I > think it is valuable in the armamentarium of CHF treatment. I've definitely > seen some dramatic improvements in EF with the procedure. From what you > describe, I suspect your institution underutilizes the technique. It's easy to > do, and I would recommend you reexamine it's merits. The mannequin is overly > expensive, but it definitely helps the surgeon decide the optimal shape and > size of the LV. The old technique was to exclude all of the endocardium that > was scarred. Doing this risked producing a "bird heart" where the patient is > left with an overly small LV and a resting tachycardia.> Finally, using the Dor to avoid a CABG mortality is a well known trick by > New York surgeons in their quest to avoid a CABG death. I think that is one > of the many reasons why publishing individual surgeon's mortality is a flawed > concept. If a surgeon's mortality rate is excessive, it should be dealt with > by the hospital's committees as well as by the referrals. It's not a perfect > solution, but I've seen it work pretty well in dealing with dangerous > surgeons. It's also well known, and I've operated on a few of these patients, that > lots of NY patients get turned down in NY and are forced to go to other > states to get life saving surgery.> > Hal> > > > ************************************** See what's new at http://www.aol.com> _______________________________________________> 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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