[HSF] tricuspid noncoaptation

Nasser F. Abou'Seada nfaabouseada at gmail.com
Fri Feb 15 09:10:01 EST 2008 

Prasanna
I am NOT doubting the magnificent value of the TEE nor the Epicardial  ....
I'm just delineating that finger palpation can be as accurate as the
sensitivity of the palpating Surgeon ... subject to training and experience
.... and that there can NOT be a generalized role that palpation of the TV
is of limited value ........ of course there is a frame within which we move
.... I am sure you yourself ... having performed countless numbers of TVMC
have got a very sensitive finger ... may be why you are aware of the
limitation of the palpatory method ............... nevertheless
........ "ADDED" TEE and Epicardial are certainly a gain ....... still ...
subjective to the examining training & experience "Sensitivity and
Specificity" ..
NFA
On Thu, Feb 14, 2008 at 8:43 PM, Prasanna Simha M <prasannasimha at gmail.com>
wrote:

> Nasser, I specificaly said the left heart TR which has a high veliocity
> jet
> is easily palpable but there has been documentation in older literature
> that
> palpation of TR did not correlate with echocardiographic findings. Yes
> gross
> hypertensive TR's are easily palpated but normotensive TR's are
> notoriously
> inaccurate to palpate. I have done this with TEE and epicardial control
> and
> trust me it it is true !! The problem is the "diffusivity of the TR jet at
> low velocities" which gives a palpatory error. Your finger can only be so
> much sensitive. If TEE is not available do an epicardial yourself. It
> doesn't take much time and is easily learnt.
> Prasanna
>  On Thu, Feb 14, 2008 at 11:20 PM, Nasser F. Abou'Seada <
> nfaabouseada at gmail.com> wrote:
>
> > 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.Mitralsemirigid
> > > > > 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.Tricuspidannular
> > > > 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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> > > --
> > > Prasanna Simha M
> > >  _______________________________________________
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