[HSF] PO MVR -LA Thrombus

Thu Feb 14 16:43:48 EST 2008

Thank You Dave ...
I have enjoyed your comment till the last "drop" ...

NFA

On Thu, Feb 14, 2008 at 4:34 PM, David Harris <drdharris at yahoo.co.uk> wrote:

> No, there are three issues.
> The third is the arrogant surgeon issue (I`m not
> pointing at you, Ani. You are the humblest and have
> the best academic answers, especially the recent
> comments about the tricuspid). But all of us, myself
> included. We are all quick to blame the patient, the
> cardiologist, etc. Me too.
>
> Instead of why the cardiologist stented the mainstem
> (the surgeon was on holiday - and when he gets back he
> just puts veins), or why Miss St Jude `refused` to
> take her warfarin (she had PMT and then menorrhagia),
> we should ponder whether we can do anything better to
> prevent these happenings. Such as using bilateral
> IMA`s on all our patients (there is no excuse, come on
> guys, this should be routine in everyone, you are all
> too LAZY), exploring better options for mitral
> replacement in young patients, such as the Ross II
> procedure, or Bob frater`s Quattro valve.
>
> By the way, what was the indication for the valve
> replacement in this patient? Was the valve repairable?
> If so, I am quite sure she needed a psychiatrist
> afterwards when she found out how her prognosis had
> been irreversibly changed!!!
>
> David Harris
>
>
> --- Ani Anyanwu <anianyanwu at hotmail.com> wrote:
>
> > There are two issues here
> >
> > First is she stopped taking warfarin. Her active
> > problem now is a clot within the LA and the
> > treatment is anticoagulation. She will probably need
> > anticoagulation (because of LA thrombus) for at
> > least a few weeks post-operatively regardless of
> > what prosthesis we use.
> >
> > The second issue is she stopped taking ALL her
> > medications. A patient with an EF of 25% needs
> > cardiac medications. A valve replacement alone will
> > not 'cure' her disease.
> >
> > For that reason, unless we have a patient who is
> > willing or able to take prescription medication
> > regularly, I believe benefit of further surgery will
> > be short-lived. This patient has heart failure and
> > the therapy is multimodal - if one of those modes
> > (oral medicines) is missing then treatment will not
> > work.
> >
> > We exercise this discretion, for example, in
> > transplantation where we would not do a transplant
> > on anyone who is unwilling (e.g. compliance) or
> > unable (e.g. poverty) to comply with a strict post
> > transplant medication regime. On the other hand, if
> > the post-op medication regime was less exacting
> > (such as for aortic stenosis) then I would fully
> > agree with offering life-saving surgery to a
> > non-compliant patient.
> >
> > Ani
> >
> >
> >
> >
> >
> >
> > > Date: Thu, 14 Feb 2008 14:26:32 -0600> From:
> > nfaabouseada at gmail.com> To:
> > OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] PO
> > MVR -LA Thrombus> CC: > > "if the reason is still
> > active then this surgery will likely end up the way>
> > of the last one (even if you place a
> > bioprosthesis)."> > How much likely is "likely" here
> > ?? especially with placement of a> non-coumadin
> > requiring bioprosthesis ??> > NFA> > On Thu, Feb 14,
> > 2008 at 12:11 PM, Ani Anyanwu
> > <anianyanwu at hotmail.com>> wrote:> > > > > She
> > underwent MVR 2 months back and stopped all her
> > medications >> > >including warfarin for 20days.> >>
> > >> > How will further surgery solve this? A patient
> > who stops all her> > medication within a month of
> > open heart surgery? I would say get a> >
> > psychiatrist. If she does not have any psychiatric
> > disorder or a good reason> > for not taking her
> > medication then whatever operation you do, her life>
> > > expectancy will likely be limited. There is only
> > so much we can do as> > surgeons, the patient has
> > their part to play too - it looks to me that this> >
> > patient either lacks the ability or desire to be
> > compliant with medical> > instructions.> >> > I
> > would address the reason behind why she didnt take
> > her medications for 3> > weeks - if it is a
> > reversible one then I would operate - if the reason
> > is> > still active then this surgery will likely end
> > up the way of the last one> > (even if you place a
> > bioprosthesis).> >> > Ani> >> >> >> >> >> > > Date:
> > Fri, 15 Feb 2008 00:02:32 +1000> To:
> > OpenHeart-L at lists.hsforum.com>> > From:
> > benjamin.bidstrup at bigpond.com> Subject: Re: [HSF] PO
> > MVR -LA> > Thrombus> CC: > > >We have a patient
> > admitted with LA thrombus.> > > > She> > underwent
> > MVR 2 months back and stopped all her medications >
> > >including> > warfarin for 20days. She was seen at
> > some other hospital > >in cardiogenic> > shock and
> > was intubated. Echo showed LA thrombus and > >one
> > leaflet of> > carbomedics valve not moving
> > normally.> > > > She was transferred to us> > after
> > 2 days stay in that hospital . > >Repeat echo at our
> > hospital showed> > normally functioning vlave , >
> > >large LA thrombus and EF 25%. She was in> >
> > hepatic[ bilirubin 18] , > >and renal
> > failure[creatinine 2.5] at admission> > which
> > improved over > >next 2 days and was extubated.> > >
> > > Should we> > operate her for LA Thrombus?> >> > >
> > >--------------------------------->> > >Looking for
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> > >-----------------------------------------> Continue
> > warfarin. It should> > disappear.> > -- > Ben
> > Bidstrup FRACS FRCSEd FEBCTS> Consultant> >
> > Cardiothoracic Surgeon>
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>
> Dr. David G. Harris, FCS, MMED,
> Cardiothoracic Surgeon
> Suite 207
> Kuils River Private Hospital,
> PO Box 1200, Kuils River, 7579, Cape Town, South Africa.
> Tel +27-21-9006411
> Fax +27-21-9006412      Mobile +27-83-3309587
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