[HSF] tricuspid noncoaptation

Thu Feb 14 11:50:26 EST 2008

Finger assessment of the tricuspid valve can be very accurate ..... depends
on who is doing the assessment ...........
Forget not that Finger "release of fused commissures" of the MV is - in fact
was- considered the first cause of iatrogenic MR - now I guess it is BMV-
Still ... ECHO assessment depends on the operator's experience ......... not
just the equipment ....
I doubt not that Erdinc took the appropriate decision as regarding the
findings in the first procedure, subject to current concept and
perspective. Probably TEE would have not produced more than the information
he's got through the very well "trained" multi-thousands of receptors at the
tip of his left index.  all the difference exist in the ruling concept. !!

NFA

On Thu, Feb 14, 2008 at 10:38 AM, Prasanna Simha M <prasannasimha at gmail.com>
wrote:

> The finger was good for CMV's but bad for TR.
> Prasanna
>
> On Thu, Feb 14, 2008 at 9:44 PM, <rwmfglycar at aol.com> wrote:
>
> > Dear Erdinc,
> > You are clearly trying but I found the finger not very precise. Do you
> > have trans esophageal echo in the OR? In the days before transesoph.
> echo,
> > we used an epicardial probe on the RA and the IVC with  Right
> ventricular
> > sonicated saline injection as a measure of the severity of the tric.
> regurg.
> > We also used a flow probe around the IVC, (we had the latter because of
> > research we were doing in the lab)
> > I am sure by now you have got the message from Zhou and Hal and
> > Prasanna that when it comes to the tricuspid prevention is better than
> cure.
> > It is a bit like the old adage about tracheostomy. Do it when you think
> > about it not when everything has fallen to pieces. The measurement of
> the
> > annulus is the modern standard.
> > Set up your operation's on the left side with bicaval cannulation and in
> > my view go transseptal so that you will automatically have a look at the
> > tricuspid valve. The objections that some have to this approach are
> > outweighed by the avoidance of late reops on the right side.
> > Bob
> >
> >
> > -----Original Message-----
> > From: zzhoumd at pol.net
> > To: OpenHeart-L at lists.hsforum.com
> > Sent: Thu, 14 Feb 2008 9:44 am
> > Subject: Re: [HSF] tricuspid noncoaptation
> >
> >
> >
> >
> > evere TR in the absence of other etiology is a difficult repair.
> However,
> > econdary TR from MR is a easy repair.
> > I had a patient whom I operated on for CABG three years ago, she then
> > developed
> > evere TR with multiple admissions to the hospital for right heart
> failure,
> > ncluding liver failure and ascites. Her PA pressure is normal (less than
> > 30). I
> > ut a small ring without success as the RV is so large and severe
> tethering
> > of
> > he valve. I endup replaced the valve. The post op course was difficult
> due
> > to
> > arge amount fluid shift coming back to the lungs. She required multiple
> re
> > ntubations and aggressive diuresis. Now she is doing great.
> > I was able to do the surgery through right chest with snaring IVC and
> SVC
> > and
> > lamping of the aorta. it is not easy to isolate IVC, but if you can do
> it,
> > the
> > est of surgery is a lot easier.
> > I looked at our experience not long ago, the mortality for isolated TR
> is
> > very
> > igh and most of them are redo.
> >  Zhou
> >
> > ent via BlackBerry by AT&T
> > -----Original Message-----
> > rom: erdinç naseri <enaseri at hotmail.com.tr>
> > Date: Thu, 14 Feb 2008 13:33:37
> > o:<openheart-l at lists.hsforum.com>
> > ubject: RE: [HSF] tricuspid noncoaptation
> >
> > Dear Dr. Frater,
> > .She didn't have history of TR before the first operation.
> > .As a routine part of any intracardiac surgery I check TR by left index
> > finger
> > hru Ra appendix.Though a crude method it still gives some  idea about
> the
> > amout
> > nd distance of TR jet.
> > . Obviously we have missed something in the 1.st operation or there
> after.
> > rdinc> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] tricuspid
> > oncoaptation> Date: Wed, 13 Feb 2008 04:20:04 -0500> From:
> > rwmfglycar at aol.com>
> > C: > > Erdinc,> Did your patient have a history of tricuspid
> insufficiency
> > efore the first operation? Whatever the state of the tricuspid valve at
> > surgery
> > he history is a definite indication for annuloplasty. You clearly
> > recognise
> > hat a dilated annulus would have been a surefire indication for an
> > nnuloplasty. Your case is a typical experience of cases in which the
> > tricuspid
> > alve is ignored. Only half the cases without annuloplasty have had a
> > return to
> > ormal of the dilated annulus one year after surgery even when the
> > pulmonary
> > ypertension has resolved.> You should have success with annuloplasty. >
> > apanese surgeons have reported success with mechanical valves on the
> > right. I
> > sed tissue valves myself. But so long as you have a succesful repair on
> > the
> > eft it would be preferable to keep away from replacement on the right
> >  unless there is severe organic tricuspid disease.> Bob> > > >
> > -----Original
> > essage-----> From: Prasanna Simha M <prasannasimha at gmail.com>> To:
> > penHeart-L at lists.hsforum.com> Sent: Tue, 12 Feb 2008 6:43 pm> Subject:
> Re:
> > HSF] tricuspid noncoaptation> > > > Incidentally in my case post op the
> TR
> > was
> > rade 1 which became Trivial by> ay 4. Transthoracic Echo.> would not
> > recommend
> >  metallic prosthesis on the right side - seen people> o it and patients
> > coming
> > ack early with thrombosis way too often.> f there was original
> coaptation
> > eading then this must be due to annular> ilatation so I would think
> > placing a
> > ing (undersized) should bring about> oaptation. If the immediate TEE or
> > picardial is bad then you could> onsider either leaflet extension as was
> > uggested or a biporsthesis.> rasanna> On Feb 13, 2008 5:03 AM, erdinç
> > naseri
> > enaseri at hotmail.com.tr> wrote:> >> Opinion requeted for the following
> > case:>
> > 7Y/O female . Previously operated by me for severe MR.Mitral semirigid
> > > ring annuloplasty 1 year ago.Preop Echo:EF 25%,severe MR ,PAP
> > moderately>
> > ncreased,minimal TR (no measurement of annular diameter),CAG:>
> > ormal.Intraoperative assessment of mitral valve showed only annular>
> > dilatation
> > ith normal mitral valvular structure.Nothing is noted about> tricuspid
> > valve(
> > rans-septal approach) Readmitted 2 weeks ago with severe> ascites and 15
> > cm
> > alpable liver. TTE showed nil mitral insufficiency ,> severe TR with
> > absolute
> > oncoaptation of the leaflets.Both Rv and Ra> dilated. tricuspid leaflets
> > seem
> > ery defficient in tissue with restriction> of motion.Tricuspid annular
> > diameter
> > 2 mm.> 1.Have I missed something in the 1.st operation?( I mean despite
> a
> > early> normal tricuspid valve reported in TTE)> 2.Shoul I try
> annuloplasty
> > and
> > hich type or proceed directly with TVR?(> 2.nd reop will be awfull)>
> BTW,
> > since
> > ioprostheses are about 40% reimbursed by social security> institutions
> > here
> > how is the idea of implanting a metallic prosthesis in> tri
> > cuspid position?> erdinc> PS: Prasanna had a similar case sveral days
> > ago.>
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