[HSF] Small Aortic Annulus and Root

[Nasser F. Abou'Seada]

so we may call you Bob "common sense literal description" Frater??

tea );
Dear Tea ..
 are you sure you do not have a vacant fellowship ...surgical, philosophical
... and otherwise ?? .... I am the first applicant.

NFA

On Thu, Feb 14, 2008 at 8:54 PM, Tea Acuff <tacuff at swbell.net> wrote:

> so we may call you Bob "common sense literal description" Frater??
>
> tea );
>
>
> ----- Original Message ----
> From: "rwmfglycar at aol.com" <rwmfglycar at aol.com>
> To: OpenHeart-L at lists.hsforum.com
> Sent: Thursday, February 14, 2008 2:34:17 AM
> Subject: Re: [HSF] Small Aortic Annulus and Root
>
>  NO?? Call it the "Common sense literal description rule" and don't make
> an acronym outof it.
> Bob
>
>
> -----Original Message-----
> From: Tea Acuff <tacuff at swbell.net>
> To: OpenHeart-L at lists.hsforum.com
> Sent: Wed, 13 Feb 2008 7:57 pm
> Subject: Re: [HSF] Small Aortic Annulus and Root
>
>
>
> You are correct, I think. Should we call the literal description rule
> (whatever
> oriented dimensions we might use), the Frater rule?
>
> tea
>
>
> ----- Original Message ----
> From: "rwmfglycar at aol.com" <rwmfglycar at aol.com>
> To: OpenHeart-L at lists.hsforum.com
> Sent: Tuesday, February 12, 2008 10:00:01 AM
> Subject: Re: [HSF] Small Aortic Annulus and Root
>
> I am intrigued that Blount and Pupello tagged their names on to Nicks'.
> Perhaps
> because he was from an obscure island in the South Pacific called New
> Zealand .
> I may be wrong but I believe?you will find that he described it first.
> As for the Manougian I have read his original paper and I believe I am
> right. If
> you cut through the middle of the ?non coronary sinus you will be past the
> subaortic curtain and will cut into a functioning part of the mitral
> anterior
> leaflet. The whole point of his operation was that by cutting between the
> left
> and on coronary leaflets he could get the maximum possible distance before
> reaching the hinge line of the antreior leaflet along the intervalvar
> trigone. I
> would not be surprised if Prasanna could give us the references.
> This exchange reinforces my objection to eponyms. Far better to have a
> literal
> description of the procedure? without possibility of confusion.
> Bob
>
>
> -----Original Message-----
> From: hgrmd at aol.com
> To: OpenHeart-L at lists.hsforum.com
> Sent: Tue, 12 Feb 2008 7:47 am
> Subject: Re: [HSF] Small Aortic Annulus and Root
>
>
>
> Bob,
>  I'm hesitant to take issue with someone of your stature, but I'm pretty
> sure
> the Manougian involves incising down the noncoronary anulus into the
> anterior
> mitral leaflet.  The Nicks-Blount-Pupello incision is the left-noncoronary
> commisure.
>
> Hal
> Sent from my Verizon Wireless BlackBerry
>
> -----Original Message-----
> From: rwmfglycar at aol.com
>
> Date: Mon, 11 Feb 2008 15:56:54
> To:OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] Small Aortic Annulus and Root
>
>
> Shahid,
> The important information is the site at which the 15 mm measurement was
> taken?
> and the orientation of the originally inserted bileaflet valve. If it is
> the
> distance from the subannular septum to the anterior leaflet base and
> especially
> if there is a distinct bulge under the aortic basal annulus, how close? is
> maximum part of the bulge to?the opposite part of the basal aortic
> annulus? We
> found years ago that this distance needed to be 1.0 cm or less to produce
> significant gradient. (all of this is very obvious). !.5 cm is not nearly
> tight
> enough to be significantly obstructive. However the situation is not as
> simple
> as this. If this was a bileaflet valve and inserted with its interhinge
> axis so
> aligned that one orifice overlay the septal bulge, it is possible that the
> leaflet has moved very little?since insertion and developed thrombus and
> or
> pannus.
> Without detailed anatomy we cannot tell what the problem is. It seems
> unlikely
> that there is the sort of ouflow tract tunnel that requires a Konno. If I
> were
> sure that Konno was unlikely, my aortic incision would aim at the site of
> the
> previous?commissure between left coronary and non coronary leaflets to
> allow me
> to do a Manougian. I would then cut the valve out cleanly at the margin of
> the
> sewing ring? (remove all the sutures first and it will peal out), remove
> all
> pannus and then inspect the subaortic region for a septal bulge. A
> distance of
> <1cm from the mitral anterior leaflet would lead me to do a myectomy. A
> cylindrical sizer will give the dimension of the basal annulus. Knowing
> this
> dimension and knowing also the performance of the valve of your choice you
> will
> be able to decide what size to choose? and whether supraannular insertion
> and/or
>
> an aortic root enlargement is needed.
> In the best of all possible worlds the original op report would have given
> you
> far more information and there would have been early and late echo studies
> recording the history of the development of this situation.
> Best of luck
> Bob
>
>
>
> -----Original Message-----
> From: Shahid Mahmud Malik <smmalik at brain.net.pk>
> To: OpenHeart-L at lists.hsforum.com
> Sent: Mon, 11 Feb 2008 2:38 pm
> Subject: Re: [HSF] Small Aortic Annulus and Root
>
>
> Ani,?
> I got the op notes.Not a great detail is recorded.There is mention of
> getting
> the prosthesis in with a slight tilt towards the RCC and some difficulty
> .No
> hemodynamic data recorded.There is mention of friability of ascending
> aorta and
> trouble at the cannulation and aortotomy sites.Suturing and waiting with
> chest
> open is mentioned..Basically not much else.Schduled for a CT.?
> Shahid Malik?
> ?
> ----- Original Message ----- From: "Ani Anyanwu" <anianyanwu at hotmail.com>?
> To: <openheart-l at lists.hsforum.com>?
> Sent: Monday, February 11, 2008 11:32 PM?
> Subject: RE: [HSF] Small Aortic Annulus and Root?
> ?
> Shahid?
> ?
> Are you aware of or able to obtain the imaging and hemodynamic data of the
> this
> patient *before* her 2004 operation??
> ?
> I must say from the story you present I am not convinced that this ladies
> problems lie beneath her valve. Does she certainly have a subvalvar
> problem and
> exactly what is the nature (and measurements) of this problem. In your OP
> you
> said the annulus was 15mm but never mentioned the subvalvar region was
> narrowed
> - somehow the latter has crept into the discussion. Also you said the
> prosthesis
>
> was above the annulus which does not seem to fit in. If the valve size is
> 19mm
> should the true size of the annulus by definition not also be at least
> 19mm (and
>
> not 15mm)? Maybe you could clarify. We must not to make what is already a
> difficult reoperation more complicated than it already is. I would look at
> the
> old data preceding the last operation to find out what this lady started
> with,
> but somehow I feel that this 49 year old lady whose LVOT has taken her
> through
> 49 years of life can have this problem solved without need to resort to
> the
> comparatively radical Konno approach.?
> ?
> You did not say her height - is she obese? Unless she is a tall woman, at
> 85kg
> she is likely obese and maybe her small aortic root is compatible with her
> nature intended size, so lifestyle modification (weight loss, including
> diabetic
>
> control and smoking cessation) might be a useful adjunct to any approach
> you
> take.?
> ?
> Ani?
> ?
> ?
> > From: smmalik at brain.net.pk> To: OpenHeart-L at lists.hsforum.com> Subject:
> > Re:
> [HSF] Small Aortic Annulus and Root> Date: Mon, 11 Feb 2008 22:14:12 >
> +0500>
> CC: > > Bill,Prasana,Hal,Tohru and all,> Extremely useful > suggestions by
> forum
>
> members.There is more information.The > previous > surgeon hand trouble
> with
> aorta as it was "thin".He waited much > extra > time in OT for "
> hemostasis.This
> thin Aorta was not addresed beyond > > fixing .Bill the post operative
> resting
> gradient has been around the > > thirtees,and I beliive that she was not
> very
> active.We are a group which > has > two pediatric surgeons also.I have
> been
> doing Bentalls,Redo > > Bentalls,Manougian but no Konno procedure as yet.Iwill
> consult my > pediatric > partners as well.Sounds like we heading for a >
> redo-Bental-Konno type of > procedure,if it can be called such an opertion
> > .>
> Your views please.Thank you.> Shahid Malik> ----- Original > Message -----
> >
> From: <ICHFNO at aol.com>> To: > <OpenHeart-L at lists.hs
> forum.com>> Sent: Monday, February 11, 2008 6:54 PM> > Subject: Re: [HSF]
> Small
> Aortic Annulus and Root> > > > Interesting > situation. You have an 85 kg
> woman
> in whom someone > > (presumably> > not > you, since you did not have the
> op note
>
> available) placed a 19 mm> > > bileaflet mechanical valve, who has pannus
> ingrowth, which is inhibiting > > > one leaflet> > from opening. She has a
> 105
> mm Hg gradient and an echo > measurement that> > shows a 15 mm annulus.
> Some are
>
> suggesting in this 49 > year old (85 kg) > > that you> > simply replace
> the 19
> valve, resect the > pannus and everything will be > > fine. No> > one has
> asked
> what was the > discharge gradient from the initial procedure?> >
> Physiologically
>
> she has > patient prothesis mismatch, 85 kgs will require > > more> > than
> a 19
> > valve, unless she sits on the couch all day. I certainly agree > > that>
> > >
> it is sometimes an underestimate with the echo of the annulus size, but >
> > > 15
>
> is> > absolutely to small. There h
> ave been a number of other cases > posted where> > surgeons without
> significant
> experience in a particular > procedure have > > been> > criticized for
> operating
>
> on someone who would > benefit from a more complex> > procedure. A number
> of
> forum members have > suggested that under those > > conditions the> >
> patients
> should be cared > for by the experts. Specifically Hal has been a> >
> proponent
> of this with > regards to Mitral valve repairs.> >> > So, if you are not
> skilled
>
> in > aortic root enlargement it seems to me that> > this patient would be
> >
> better served by someone who is, otherwise it is > > highly> > likely that
> > she
>
> will re-appear in another 3-4 years with exactly the same> > > situation.
> The
> Konno operation is a specialized operation, but it allows > > > for very>
> >
> significant annular enlargement depending upon how far down > the septum >
> >
> you> > make your incision. We recently did a Konno-Ross on > a child who
> was 9 >
>
> > months> > old, had previously had a ballo
> on aortic > valvotomy, she had an annulus > > that was> > 7 mm, and we
> were
> able to > enlarge it with the Konno to insert her 15 mm> > pulmonary
> valve!> >>
> > Be > prepared to perform some form of annular enlargement, otherwise you
> > > >
>
> will> > see this woman back in a short time.> >> > WNovick> >> >> >> > >
> **************Biggest Grammy Award surprises of all time on AOL Music.> >
> >
> (
> http://music.aol.com/grammys/pictures/never-won-a-grammy?NCID=aolcmp003000000025
> >
>
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