AW: [HSF] tricuspid noncoaptation-Again Hal´s oppinion on TEE

Wed Feb 20 13:13:17 EST 2008

ABSOLUTELY, Hal.
My life in OR changed after TEE.

By the way, yesterday I operated an 82 old man with patent LIMA-LAD and
veins to right and obtuse marginal. The previous surgeon had left the LIMA
so long that was in film seen as retrosternal, as glued. I approached by
femorofemoral cannulation (long cannula for the vein, again controlled by
TEE) and the sternal opening was very soft, the operation (AVR Bio 23 )very
easy, only when I tried to free that mammary from the sternum (I had
dissected it from distal LAD anastomosis), I cut it 2 mm and repaired with 4
x 8 /0 Prolene single stitches. LIMA Flow after that was from 28 to 40.The
old man is today extubated.
I used to operate this cases on pump beating heart with retrograde sinus
coronarius perfusion and LIMA untouched (even I had published the technique
in the Annals). In this case I changed as I was sure I could hurt it. The
operation went very soft and quiet, really, NO STRESS!
Roberto

-----Ursprüngliche Nachricht-----
Von: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von hgrmd at aol.com
Gesendet: Mittwoch, 20. Februar 2008 11:56
An: OpenHeart-L at lists.hsforum.com
Betreff: Re: [HSF] tricuspid noncoaptation

Michael,
  By having TEE, I've recognized inadequate repairs, SAM, paravalvular
leaks, occult air, new segmental wall abnormalities, new severe TR.  The
list goes on and on.  Thinking back to my days before TEE, over 10 years
ago, I'm sure that some bad outcomes could have been avoided if I had TEE.

Hal

-----Original Message-----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Tue, 19 Feb 2008 8:57 pm
Subject: Re: [HSF] tricuspid noncoaptation

Intra-operative TEE should be standard of care for all heart surgery -
provided you have the resources locally to support it. I am amazed at the
number of things I find that need to be fix - not to mention the role in
de-airing and sorting out problems (or making sure everything is ok) coming
off pump. 

-michael 

On Feb 19, 2008, at 8:05 PM, hgrmd at aol.com wrote: 

> 
> Ani, 
> 
> Years ago, we used to wait for the cardiologist to do the before > and
after TEE for a repair case. Lot's of wasted time. It's a > much better
system now that the anesthesiologists do the TEE's. > Unlike the
cardiologists, they often stick around to see the actual > pathology in
order to correlate their preoperative findings. In > addition, the
interpersonal dynamic is better. I can't very well > tell a cardiologist
that he's getting lousy views. Because my > caseload is so different than
the other cardiac surgeons, > anesthesiologists like doing my cases because
I really emphasize > TEE. It's more interesting to them than an on pump
quadruple > CABG. Though a few of them are certified in TEE, I think this
will > eventually become a requirement. One thing I know for sure, the >
routine use of TEE has helped me avoid a few deaths and suboptimal > results
with my patients. 
> 
> Hal 
> 
> 
> -----Original Message----- 
> From: Ani Anyanwu <anianyanwu at hotmail.com> 
> To: openheart-l at lists.hsforum.com 
> Sent: Tue, 19 Feb 2008 10:42 am 
> Subject: RE: [HSF] tricuspid noncoaptation 
> 
> 
> 
> 
>> My Knowledge about echo of any type is provided by cardiologists >> ( the
ones 
> ho are trained for it)> erdinc> But would we also say that because >
radiologists 
> re the ones trained for radiology that they should interpret our > xrays
and CT 
> cans? Particularly in valve reconstruction, the echo has a similar >
weight with, 
> or instance, the CT scan for a lung cancer case - the surgeon > should not
do a 
> alve reconstruction without a proper study (by the surgeon) and >
understanding 
> f the lesions seen on the echocardiogram. 
> 
> ogistical and economic limitations as to whether such standards are >
achievable 
> re another matter but I am sure most would agree with Hal's > statement
that 
> ntraoperative echo done by those who make the intraoperative decisions 
> surgeons and anesthesiologists) provides the highest level of care > at
the 
> resent time. (This may not necessarily be the standard of care as > Ben
pointed 
> ut - however, the standard level of care is not necessarily, indeed > is
often 
> ot, the best level of care). 
> 
> have worked in hospitals where cardiologists (who often will > simply
report on 
> mages) provide this service and have found it less helpful that > those
where 
> naesthesiologists do the echo (as they more often report on the > image in
the 
> ontext of the patient and of what you as a surgeon have done, can > do or
should 
> o). Of course there are notable exceptions where a cardiologist > works
very 
> losely with a surgeon in the OR and so gives only surgically relevant 
> nterpretation (like in Carpentier's group) but i think the best > model
has to 
> e that in which the surgeon and anaesthesiologist do the echo and 
> nterpretation. 
> 
> ni 
> 
> 
> 
>> From: enaseri at hotmail.com.tr> To: openheart-l at lists.hsforum.com> >>
Subject: RE: 
> HSF] tricuspid noncoaptation> Date: Tue, 19 Feb 2008 07:56:12 > +0000> > >
Hal, > 
> o disrespect intended. My Knowledge about echo of any type is > provided
by 
> ardiologists ( the ones who are trained for it)> erdinc> To: 
> penHeart-L at lists.hsforum.com> Subject: Re: [HSF] tricuspid >
noncoaptation> Date: 
> un, 17 Feb 2008 17:54:49 -0500> From: hgrmd at aol.com> CC: > > > Erdinc,>
You can 
> oubt the validity of TEE with respect to the tricuspid valve all > you
want, but 
> he overwhelming evidence supporting its use in evaluating the > tricuspid
is 
> here if you want to believe it. In addition, I've got tons of > experience
using 
> EE to evaluate the tricuspid. No question, it has helped me and my >
patients.> > 
> al> > > -----Original Message-----> From: erdinç naseri >
<enaseri at hotmail.com.tr>> 
> o: openheart-l at lists.hsforum.com> Sent: Sun, 17 Feb 2008 3:09 pm> >
Subject: RE: 
> HSF] tricuspid noncoaptation> > > > > al,> .You are right. never >
compared it to 
> ny other assessment method.> .I doubt the validity of TEE data wrt >
tricuspid 
> alve.> rdinc> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] >
tricuspid 
> oncoaptation> > ate: Fri, 15 Feb 2008 21:03:01 -0500> From: >
hgrmd at aol.com> CC: 
>>> Nasser, > > rasanna, Erdinc,> > I've been reading this never >>> ending
thread 
> ith a little > kepticism regarding the validity of finger palpation in 
> ssessing TR. How do > ou know this technique is any good? > Certainly,
that was 
> he way I was taught > ver 20 years ago, but we didn't have routine > TEE.
Have 
> ny of you done this > inger palpation, made an assessment, and then >
compared it 
> o TEE? I would bet > ot.> > > > Hal> > > -----Original Message-----> >
From: 
> asser F. Abou'Seada > nfaabouseada at gmail.com>> To: OpenHeart->
L at lists.hsforum.com> 
> ent: Fri, 15 Feb > 008 2:29 pm> Subject: Re: [HSF] tricuspid >
noncoaptation> > > 
>> Dear erdinc> - > have no doubt of your judgement. I share with you >>
the 
> ilemma of not> eing > e-imbursed for whatever you do in an > operation
......... 
> elieve me> .. even > ith international insurrance > companies ......... I
had 
> he> xperience of a big > uropean insurance company.... respectable > name
... 
> ot> aying me AFTER the > peration ... it is not only in a certain > > part
of 
> he> orld .... it is > verywhere ........ the issue is .... we can > not
just 
> top> here unable to do > omething ....... hence my advocation for a > no
cost> 
> chnique ..... like a > eVega annuloplasty ........ especially in a> >
heumatic 
> ibrosed annulus ...... > o in a case like yours .. -I have> > xperienced
many- I 
> ould have trusted my > inger after all - sure I did> ithout TEE > many
times- and 
> ould have performed a > uture annuloplasty based> n the SENSITIVE > and
SPECIFIC 
> mpressions of my finger > ......... we> urgeons have our minds at > the
tip of 
> ur fingers ... isn't it ??? > > ifference between a good anastomist > and
another 
> ies in where the> upination > omes from .. the wrist?.. or the MCP >
joints?- .. 
> ight ? .. ..> orry for the > xtension ...> 2 - that is another > reason
that I 
> ould have advocated doing an > SI approach> .. especially that you > are
aware of 
> he technique and its > mplications and> dvantages .... no much >
difference in 
> ime .... in fact might > e less> ....> ut better exposure ...> 3 - > I
totally 
> gree with you .... > onsensus is always changing .... I asked> arc > de
Laval 
> nce about what he > hinks of the TCPC .... he answered ...that> E > did
not know 
> .. !!!! .......... > now" he said ... consensus is that it> s a > good
operation 
> ... in a few years > ime ... who knows .... might be> etter > improved .. 
> uperceeded by another > echnique .... might be otherwise> ... > consensus
is 
> lways changing ... no dogma > hatsoever .... no technique> or > concept
is 
> evelated no divine role .... it is > hat we infere from> > xperience ....
whether 
> cientifically controlled with Stat > .. or just> nferences ...> 4- > as
for 
> eVega .... I quiet agree ......... yet, > MHO .... we can not be> >
ogmatic .. 
> hether with or against ..... certainly to > ondemn DeVega> > echnique ...
is a 
> otal arrogance ...... and to presume it is > he best> echnique .... > is
even 
> orse ... ignorance .... as we were taught in> > ementary ABC in > ENGLAND
.... 
> it is ACCORDING > TO ...... according to the> ype > f patient, >
pathological 
> rocess affecting the ventricle and valve ....> > ailable logistics ->
rings e.g.- 
> ... consensus of opinion .... and above> ll ... > tate of funding and 
> e-imbursement .....> certainly it is a marvelous technique > hat > has
saved a 
> ot .... and still> as got a place in our surgical > > rmamentarium .... at
least 
> or me .....> according to the situation- ...!!!> > hank you for your 
> ommunication> Yours> NFA> > > On Fri, Feb 15, 2008 at 12:11 > M, > erdinç
naseri 
> enaseri at hotmail.com.tr>> rote:> >> Dear Nasser,> 1. My > ingertip > data
showed 
> rivial Tr at 1.st operation> 2.For me there is a > ifference of 10 >
minutes 
> etween closing a L atriotomy> in single row and > losing LA roof and 
> nteratrial septum in 2 rows before> declamping.> 3.There is > ot > always
a 
> oncensus in every situation between the 2> circles.e.g long chain > > f
postings 
> n this forum about the treatment of> CAD by stents and surgery.> 4. > >
here are 
> any studie> s which show no long term benefit of DeVega (> and many > >
tudies on 
> he contrary)> erdinc> > > _______________________________________________>
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