[HSF] tricuspid noncoaptation

[Nasser F. Abou'Seada]

Totally in agreement with Ani's perspective ...

NFA

On Feb 13, 2008 3:55 PM, Ani Anyanwu <anianyanwu at hotmail.com> wrote:

> Erdinc
>
> It concerns me that this ladies RV has remodelled so much in a period of
> less than a year.
>
> Before undertaking surgery to repair the tricuspid, I would first want to
> be certain that the TR is not a manifestation of progressive cardiomyopathy
> (in which case not operate) or an 'isolated' problem. What happened to the
> LV after the last operation? Is EF still 25% or more? What are the LV
> dimensions now compared to a year ago?
>
> I understand that your facilities may be limited but our approach would be
>
> 1) Do right heart catheter. If moderate to severe pulmonary hypertension,
> low SVO2, low cardiac index or high wedge pressure then I would be cautious
> about operating.
> 2) Do a cardiac MRI. If severe biventricular dysfunction and in particular
> if RV ejection fraction is below 25% then I would not operate.
>
> You did not tell us what the original disease necessitating MV repair was
> but my suspicion is that what you are dealing with here is progressive
> cardiomyopathy - if that is the case she has had her shot at surgery (which
> failed) and there is unlikely to be benefit in just treating her TR.
> Although others mention the issue of progression of 'functional' TR after
> mitral surgery, this usually takes several years to progress to the degree
> of ascites and hepatomegaly you describe in your patient. The rapid
> evolution into severe TR and right heart failure I think would most likely
> infer that the primary problem is progressive and severe RV dysfunction and
> dilatation rather than the TR (which is secondary to the former) - if so
> reoperative surgery is not likely to improve things.
>
> Obviously I am not privy to all the data but the little data you have
> provided do not suggest to me that fixing the TR will solve this patient's
> problem.
>
> Ani
>
>
>
>
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>
>
>
> > From: enaseri at hotmail.com.tr> To: openheart-l at lists.hsforum.com> Date:
> Tue, 12 Feb 2008 23:33:53 +0000> Subject: [HSF] tricuspid noncoaptation> > >
> Opinion requeted for the following case:> 67Y/O female . Previously operated
> by me for severe MR.Mitral semirigid ring annuloplasty 1 year ago.PreopEcho:EF 25%,severe MR ,PAP moderately increased,minimal TR (no measurement
> of annular diameter),CAG:normal.Intraoperative assessment of mitral valve
> showed only annular dilatation with normal mitral valvular
> structure.Nothing is noted about tricuspid valve( trans-septal approach)
> Readmitted 2 weeks ago with severe ascites and 15 cm palpable liver. TTE
> showed nil mitral insufficiency , severe TR with absolute noncoaptation of
> the leaflets.Both Rv and Ra dilated. tricuspid leaflets seem very
> defficient in tissue with restriction of motion.Tricuspid annular diameter
> 42 mm.> 1.Have I missed something in the 1.st operation?( I mean despite a
> nearly normal tricuspid valve reported in TTE)> 2.Shoul I try annuloplasty
> and which type or proceed directly with TVR?( 2.nd reop will be awfull)>
> BTW, since bioprostheses are about 40% reimbursed by social security
> institutions here ,how is the idea of implanting a metallic prosthesis in
> tricuspid position?> erdinc> PS: Prasanna had a similar case sveral days
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