[HSF] tricuspid noncoaptation

Thu Feb 14 05:55:19 EST 2008

"Contrary to frequently expressed truths on this Forum, the suture methods
seemed by his excellent 5 year survivals to work very well in his hands."

I do attest to excellent results using DeVega suture technique after 14
years ... it works well ..! .... Rheumatic cases? ... fibrosed annulus ?
.... different pathology .. ?? .... may be .. but it works well .
NFA

On Thu, Feb 14, 2008 at 1:25 AM, <rwmfglycar at aol.com> wrote:

> The annular dilatation of tricuspid insufficiency accompanying left sided
> valvular disease is not mysterious. It was beautifully shown by Ruediger
> Simon of Hoffschule fur Medizin (apologies to Battelini for probable German
> mispelling) in the late 70's. Much evidence from recent times has?shown the
> same.. The annular dilatation is present even with a still competent valve.
> Remember that tricuspid insufficiency is the most dynamic of valvular forms
> of insufficiency. It is very easily transformed from zero to severe and back
> again by medical manipulations. I have seen cases with virtually no tric.
> regurg on the table come back with gross right heart failure within a month
> of surgery in cases in which the valve was left alone.
> However,Ani is right to be suspicious of this case. If it was a case
> requiring only an annuloplasty on the left there must be strong suspicion
> that this was?ventricular mechanism mitral insufficiency which raises the
> question that there might have been in existence a primary ventricular
> mechanism on the right side. Note that I am distinguishing between a
> ventricular mechanism tricuspid insufficiency that is secondary to right
> sided ventricular dysfunction that occurs with chronically raised pulmonary
> resistance as opposed to bilateral primary myocardial disease.
> It is simply not true that removing the volume load by correcting the
> tricuspid insufficiency will kill the patient. There are sick ventricles
> that continue to be sick despite a fall in pulmonary restance until the
> volume load of insufficiency is corrected. I can attest to that. As I have
> warned in the past a high R ventricular diastolic pressure will cause
> symptoms of heart failure to persist despite the?complete correction?of
> tricuspid insufficiency.
> Of great interest is the experience of Radovanovich who routinely did left
> and right sided suture annuloplasties (Basically De Vega's on both sides)
> during the Yogoslav wars when he could not continue his transplant program.
> He did the right side whether or not there was tricuspid regurg on the basis
> that both ventricles were big in these cases. Contrary to frequently
> expressed truths on this Forum, the suture methods seemed by his excellent 5
> year survivals to work very well in his hands.
> Bob
> -----Original Message-----
> From: Donald Ross <donross at bigpond.com>
> To: OpenHeart-L at lists.hsforum.com
> Sent: Wed, 13 Feb 2008 6:23 pm
> Subject: Re: [HSF] tricuspid noncoaptation
>
>
>  I agree with Ani.?
> If TR is secondary to another pathology other than mysterious annular
> dilatation secondary to a successful mitral operation, attempted correction
> of the TR will be fatal.?
> Don?
> On 14/02/2008, at 8:55 AM, Ani Anyanwu 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?
> >?
> >?
> >?
> >?
> >?
> >?
> >?
> >?
> >> 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.Preop Echo: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 nea
>  rly >> 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 ago.> >>
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