[HSF] tricuspid noncoaptation

Fri Feb 15 09:28:46 EST 2008

Dear Sir
of course your point is true ... but there are other faces and aspects to
the issue ......
in a redo sternotomy for a TV procedure ... no taking down of adhesions is
required .... no dissection ... no freeeing up of the apex .... nor the
right ventricle ..... with a fem-fem and SSI ... it is just a piece of cake
... of course for those familiar with the procedure ........

on the other hand ... yes ...... a thoracotomy can obviate all of these
adverse incidents that you have mentioned ......... still ... at what price
?? .... compromised access - compared to a redo sternotomy- and sacrifice of
a virgin right chest ... in case a future procedure is required ..- mitral
procedure e.g.- .......

I am NOT Dogmatic ....... and am very much aware that the BEST incision is
the BEST you can perform and handle .... but certainly I am not claiming
that every surgeon would be YOU ... having no complications with a right
thoracotomy APPROACH - Not saying INCISION- especially those having no
exposure - not even saying experience- with thoracotomy ...

How many of your Trainees Sir were trained in Thoracic Surgery ??

Still ... a redo approach in not time consuming ... for those who are
familiar with it ...... which takes us back to square one ........ THE BEST
INCISION IS WHAT YOU CAN PERFORM BEST ...

thank you for your communications

Yours

NFA

On Fri, Feb 15, 2008 at 12:28 AM, <zzhoumd at pol.net> wrote:

>
> Dear Nasser,
>
> To answer your second question, the recovery of a patient does not depend
> on the size of the incision or how much muscle you spare, it has a lot to do
> if the right surgery was performed. In redo patients, a lot of times,
> patients not doing well is due to the collateral damage inflicted during
> re-entry and taking down adhesions. Thoracotomy can avoid most of these
> collateral damages.
>
> Z Zhou
>
> Sent via BlackBerry by AT&T
>
> -----Original Message-----
> From: "Nasser F. Abou'Seada" <nfaabouseada at gmail.com>
>
> Date: Thu, 14 Feb 2008 21:03:01
>  To:OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] tricuspid noncoaptation
>
>
> "a little better if you have done some."
>
> Dear Z
> Certainly one thing I have learnt during my thoracic training in Liverpool
> & Blackpool, that thoracotomy is far away from being non-painful .. even
> with a muscle sparing incision- ... yet to my mind, the issue is not just
> the pain ... nor the SCAR ..... -whereas we already do have an old
> incision-
> but in the MUSCLE CUTTING involved in thoracotomy ...... please correct me
> if I am wrong ..... such a right thoracotomy would certainly entail muscle
> cutting ... the RA will be in the DEPTH of the wound .... plus the known
> difficulties in securing the aorta and the cavae .....
> I am not saying it is a wrong incision ........ might even be better in
> case
> of a primary incision ... in the hands of those acquainred with it
> ..........
> yet
> the issue is WHY should there be another incision where we do already have
> one ???? any special reason ? ,,....
> certainly a rib fracturing incision is NOT less painful than a sternotomy
> ...
>  and for those who have seen patients coming to postoperative clinics
> after
> thoracotomy incisions ..... -especially in a total thoracic practice I
> mean-
> . they would understand the feelings and the defects of patients having a
> CUT muscle, a weak limb .... a new scar ..... for no cosmetic reason !!!!
> apart from that ....... the issue elegantly raised by ANI ........ what IF
> the patient should require another intervention for another procedure on
> the
> mitral later on ???? ........... would not the designated surgeon  -then-
> have wished the right thoracotomy approach is virgin ???  ........
> sure we are ALL aware of the lung adhesion problems after thoracotomy
> ........ !! ...
>
> all the time I do feel grateful to my magnificent teachers .... J.D.
> Drakeley, R.D.Donnelly, J.L.Mercer ..... R.K Khan, and R.G. Gandhi ....
> real
> masters of thoracic surgery .... high volume load .... wide real practice
> ... and extra-ordinary professionals ...
>
> NFA
> On Thu, Feb 14, 2008 at 7:43 AM, Zhandong Zhou <zzhoumd at pol.net> wrote:
>
> >
> > The recovery from thoracotomy is a little better if you have done some.
> >
> >
> > ----- Original Message -----
> > From: "Nasser F. Abou'Seada" <nfaabouseada at gmail.com>
> > To: <OpenHeart-L at lists.hsforum.com>
> >  Sent: Thursday, February 14, 2008 8:58 AM
> > Subject: Re: [HSF] tricuspid noncoaptation
> >
> >
> > > Very well Said Sir
> > >
> > > NFA
> > >
> > > On Feb 13, 2008 4:06 PM, Ani Anyanwu <anianyanwu at hotmail.com> wrote:
> > >
> > >> Hal and Dave
> > >>
> > >> Why would we do a right thoracotomy here (other than because we can
> or
> > to
> > >> make life easier for ourselves)? Why should we give this lady another
> > scar
> > >> and how would it benefit her?
> > >>
> > >> A resternotomy here to repair the tricuspid is a low risk procedure
> and
> > is
> > >> not complicated (by low risk I refer to the resternotomy and NOT the
> > >> tricuspid repair) . Using Hals technique of peripheral bypass, all
> one
> > needs
> > >> to do is go on bypass, the large empty RV/RA will fall back, spilt
> the
> > >> sternum (or just the lower half), free the heart and then the large
> > right
> > >> atrium is most likely staring you in the face. Open it and fix the
> > valve,
> > >> close atrium then close sternum. The risks of resternotomy are
> minimal
> > >> particularly if you use peripheral bypass and there is no need to
> > dissect
> > >> the heart and great vessels.
> > >>
> > >> I can understand a right thoracotomy if this was a primary operation,
> > or
> > >> if additional indication such as patent IMAs, multiple reoperations,
> > aorta
> > >> in proximity to sternum etc., but not sure there is justification to
> > give
> > >> this lady a second scar in this case. Also a thoracotomy is not an
> > innocuous
> > >> incision. Maybe too when in few years she comes for her mitral
> > reoperation,
> > >> you might wish you had left her right thorax virgin!
> > >>
> > >> Ani
> > >>
> > >>
> > >>
> > >> > To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] tricuspid
> > >> noncoaptation> Date: Wed, 13 Feb 2008 16:06:45 -0500> From:
> > hgrmd at aol.com>
> > >> CC: > > Dave,> ? I wouldn't risk a DeVega on any tricuspid repair,
> > because
> > >> I've seen trivial TR become torrential in a very short time frame.?
> If
> > the
> > >> annulus is dilated, it deserves a ring.> ? Your suggestion to
> approach
> > the
> > >> tricuspid, beating heart, via the right chest is exactly what I would
> > do.> >
> > >> Hal> > > -----Original Message-----> From: David Harris <
> > >> drdharris at yahoo.co.uk>> To: OpenHeart-L at lists.hsforum.com> Sent: Wed,
> > 13
> > >> Feb 2008 2:58 pm> Subject: Re: [HSF] tricuspid noncoaptation> > > > I
> > agree
> > >> with you Hal. In this case definitely a ring.> Do you think a De Vega
> > will
> > >> suffice in cases of> trivial TR (at the time of mitral repair)?> >
> > Also,
> > >> what about a mini-thoracotomy approach in this> patient. This will be
> > the
> > >> simplest approach,> especially as one does not need to access or
> clamp
> > the>
> > >> aorta.> > Dave> > --- Hgrmd at aol.com wrote:> > > Erdinc,> > Your
> > patient's
> > >> plight supports my current policy> > of doing tricuspid > >
> > valvuloplasty on
> > >> around 70% of my mitral procedures.> > I totally agree with Bob that
> >
> > > any
> > >> documentation of moderate or worse TR on a preop> > echo is a solid >
> >
> > >> indication for annuloplasty. In addition, if the> > systolic annular
> > >> diameter exceeds > > 40 mm on the pre-CPB TEE, regardless of the
> > degree> >
> > >> of TR, the patient gets a > > ring. I always use the C-E MC3 ring. It
> > >> conforms> > to the natural 3D geometry > > of the tricuspid annulus.
> > Better,
> > >> more flexible,> > rings will be coming out > > soon.> > > > Hal> > >
> >
> > > > >
> > >> > **************The year's hottest artists on the red> > carpet at
> the
> > >> Grammy > > Awards. Go to AOL Music. > >> (
> > >> http://music.aol.com/grammys?NCID=aolcmp00300000002565)> >
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> > >> -----------------------------------------> > > > > Dr. David G.
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