AW: [HSF] tricuspid noncoaptation-Again Hal´s oppinion on TEE
Dr. Roberto Battellini
battr at medizin.uni-leipzig.de
Wed Feb 20 18:17:34 EST 2008
Hal,
Antegrade Bretschneider (which went through the native left ostium and
bypasses, the right ostium was closed) and after some minutes a second shot
of cardioplegia through the left ostium. No retrograde, but I could have
done it. There was no valve insufficiency, a very calcified stenosis. At 34
Grades. 58 minutes clamping time.I lost some minutes trying to cannulate the
grafts with the balloons for cardioplegia, they were very high implanted.May
be with another little aortic incision...for next case.
I don´t think that Salerno´s technique would have been cumbersome, the right
ostium was occluded and with left ostium perfused by a balloon would have
been OK. But, BUT, this operation was veeery simple!
Pro: simplicity CON: non beating heart.
But in my series of AVR beating heart 9 patients with good results, the last
patient was cumbersome, and came later before one year with a paravalvular
leak not detected by TEE, nor by first week echo, and this man was operated
by Tomas Walther who did what I did now. After that, Tomas Walther began to
make a Transapical replacement in all patients with previous CABG and
annulus under 25 . I apologize, this case got a 25 EPIC-St Jude Bio valve,
not a 23. He was considered not able for transapical.
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 16:43
An: OpenHeart-L at lists.hsforum.com
Betreff: Re: [HSF] tricuspid noncoaptation-Again Hal´s oppinion on TEE
Roberto,
In the case you did, was retrograde cardioplegia administered? Did you
cool any? Particularly in the small roots, Salerno's technique of beating
heart with continuous antegrade and retrograde blood would seem pretty
cumbersome to me.
Hal
-----Original Message-----
From: Dr. Roberto Battellini <battr at medizin.uni-leipzig.de>
To: OpenHeart-L at lists.hsforum.com
Sent: Wed, 20 Feb 2008 7:13 am
Subject: AW: [HSF] tricuspid noncoaptation-Again Hal´s oppinion on TEE
ABSOLUTELY, Hal.
y life in OR changed after TEE.
By the way, yesterday I operated an 82 old man with patent LIMA-LAD and
eins to right and obtuse marginal. The previous surgeon had left the LIMA
o long that was in film seen as retrosternal, as glued. I approached by
emorofemoral cannulation (long cannula for the vein, again controlled by
EE) and the sternal opening was very soft, the operation (AVR Bio 23 )very
asy, only when I tried to free that mammary from the sternum (I had
issected it from distal LAD anastomosis), I cut it 2 mm and repaired with 4
8 /0 Prolene single stitches. LIMA Flow after that was from 28 to 40.The
ld man is today extubated.
used to operate this cases on pump beating heart with retrograde sinus
oronarius perfusion and LIMA untouched (even I had published the technique
n the Annals). In this case I changed as I was sure I could hurt it. The
peration went very soft and quiet, really, NO STRESS!
oberto
-----Ursprüngliche Nachricht-----
on: openheart-l-bounces at lists.hsforum.com
mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von hgrmd at aol.com
esendet: Mittwoch, 20. Februar 2008 11:56
n: OpenHeart-L at lists.hsforum.com
etreff: Re: [HSF] tricuspid noncoaptation
Michael,
By having TEE, I've recognized inadequate repairs, SAM, paravalvular
eaks, occult air, new segmental wall abnormalities, new severe TR. The
ist goes on and on. Thinking back to my days before TEE, over 10 years
go, I'm sure that some bad outcomes could have been avoided if I had TEE.
Hal
----Original Message-----
rom: Michael Firstenberg <msfirst at gmail.com>
o: OpenHeart-L at lists.hsforum.com
ent: Tue, 19 Feb 2008 8:57 pm
ubject: Re: [HSF] tricuspid noncoaptation
ntra-operative TEE should be standard of care for all heart surgery -
rovided you have the resources locally to support it. I am amazed at the
umber of things I find that need to be fix - not to mention the role in
e-airing and sorting out problems (or making sure everything is ok) coming
ff pump.
michael
n 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
fter TEE for a repair case. Lot's of wasted time. It's a > much better
ystem now that the anesthesiologists do the TEE's. > Unlike the
ardiologists, they often stick around to see the actual > pathology in
rder to correlate their preoperative findings. In > addition, the
nterpersonal dynamic is better. I can't very well > tell a cardiologist
hat he's getting lousy views. Because my > caseload is so different than
he other cardiac surgeons, > anesthesiologists like doing my cases because
really emphasize > TEE. It's more interesting to them than an on pump
uadruple > CABG. Though a few of them are certified in TEE, I think this
ill > eventually become a requirement. One thing I know for sure, the >
outine use of TEE has helped me avoid a few deaths and suboptimal > results
ith 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
nes
ho are trained for it)> erdinc> But would we also say that because >
adiologists
re the ones trained for radiology that they should interpret our > xrays
nd CT
cans? Particularly in valve reconstruction, the echo has a similar >
eight with,
or instance, the CT scan for a lung cancer case - the surgeon > should not
o a
alve reconstruction without a proper study (by the surgeon) and >
nderstanding
f the lesions seen on the echocardiogram.
ogistical and economic limitations as to whether such standards are >
chievable
re another matter but I am sure most would agree with Hal's > statement
hat
ntraoperative echo done by those who make the intraoperative decisions
surgeons and anesthesiologists) provides the highest level of care > at
he
resent time. (This may not necessarily be the standard of care as > Ben
ointed
ut - however, the standard level of care is not necessarily, indeed > is
ften
ot, the best level of care).
have worked in hospitals where cardiologists (who often will > simply
eport on
mages) provide this service and have found it less helpful that > those
here
naesthesiologists do the echo (as they more often report on the > image in
he
ontext of the patient and of what you as a surgeon have done, can > do or
hould
o). Of course there are notable exceptions where a cardiologist > works
ery
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
as 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> >>
ubject: RE:
HSF] tricuspid noncoaptation> Date: Tue, 19 Feb 2008 07:56:12 > +0000> > >
al, >
o disrespect intended. My Knowledge about echo of any type is > provided
y
ardiologists ( the ones who are trained for it)> erdinc> To:
penHeart-L at lists.hsforum.com> Subject: Re: [HSF] tricuspid >
oncoaptation> Date:
un, 17 Feb 2008 17:54:49 -0500> From: hgrmd at aol.com> CC: > > > Erdinc,>
ou can
oubt the validity of TEE with respect to the tricuspid valve all > you
ant, but
he overwhelming evidence supporting its use in evaluating the > tricuspid
s
here if you want to believe it. In addition, I've got tons of > experience
sing
EE to evaluate the tricuspid. No question, it has helped me and my >
atients.> >
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> >
ubject: RE:
HSF] tricuspid noncoaptation> > > > > al,> .You are right. never >
ompared it to
ny other assessment method.> .I doubt the validity of TEE data wrt >
ricuspid
alve.> rdinc> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] >
ricuspid
oncoaptation> > ate: Fri, 15 Feb 2008 21:03:01 -0500> From: >
grmd at aol.com> CC:
>> Nasser, > > rasanna, Erdinc,> > I've been reading this never >>> ending
hread
ith a little > kepticism regarding the validity of finger palpation in
ssessing TR. How do > ou know this technique is any good? > Certainly,
hat was
he way I was taught > ver 20 years ago, but we didn't have routine > TEE.
ave
ny of you done this > inger palpation, made an assessment, and then >
ompared it
o TEE? I would bet > ot.> > > > Hal> > > -----Original Message-----> >
rom:
asser F. Abou'Seada > nfaabouseada at gmail.com>> To: OpenHeart->
@lists.hsforum.com>
ent: Fri, 15 Feb > 008 2:29 pm> Subject: Re: [HSF] tricuspid >
oncoaptation> > >
> Dear erdinc> - > have no doubt of your judgement. I share with you >>
he
ilemma of not> eing > e-imbursed for whatever you do in an > operation
........
elieve me> .. even > ith international insurrance > companies ......... I
ad
he> xperience of a big > uropean insurance company.... respectable > name
..
ot> aying me AFTER the > peration ... it is not only in a certain > > part
f
he> orld .... it is > verywhere ........ the issue is .... we can > not
ust
top> here unable to do > omething ....... hence my advocation for a > no
ost>
chnique ..... like a > eVega annuloplasty ........ especially in a> >
eumatic
ibrosed annulus ...... > o in a case like yours .. -I have> > xperienced
any- I
ould have trusted my > inger after all - sure I did> ithout TEE > many
imes- and
ould have performed a > uture annuloplasty based> n the SENSITIVE > and
PECIFIC
mpressions of my finger > ......... we> urgeons have our minds at > the
ip of
ur fingers ... isn't it ??? > > ifference between a good anastomist > and
nother
ies in where the> upination > omes from .. the wrist?.. or the MCP >
oints?- ..
ight ? .. ..> orry for the > xtension ...> 2 - that is another > reason
hat I
ould have advocated doing an > SI approach> .. especially that you > are
ware of
he technique and its > mplications and> dvantages .... no much >
ifference in
ime .... in fact might > e less> ....> ut better exposure ...> 3 - > I
otally
gree with you .... > onsensus is always changing .... I asked> arc > de
aval
nce about what he > hinks of the TCPC .... he answered ...that> E > did
ot know
.. !!!! .......... > now" he said ... consensus is that it> s a > good
peration
... in a few years > ime ... who knows .... might be> etter > improved ..
uperceeded by another > echnique .... might be otherwise> ... > consensus
s
lways changing ... no dogma > hatsoever .... no technique> or > concept
s
evelated no divine role .... it is > hat we infere from> > xperience ....
hether
cientifically controlled with Stat > .. or just> nferences ...> 4- > as
or
eVega .... I quiet agree ......... yet, > MHO .... we can not be> >
gmatic ..
hether with or against ..... certainly to > ondemn DeVega> > echnique ...
s a
otal arrogance ...... and to presume it is > he best> echnique .... > is
ven
orse ... ignorance .... as we were taught in> > ementary ABC in > ENGLAND
...
it is ACCORDING > TO ...... according to the> ype > f patient, >
athological
rocess affecting the ventricle and valve ....> > ailable logistics ->
ings e.g.-
... consensus of opinion .... and above> ll ... > tate of funding and
e-imbursement .....> certainly it is a marvelous technique > hat > has
aved a
ot .... and still> as got a place in our surgical > > rmamentarium .... at
east
or me .....> according to the situation- ...!!!> > hank you for your
ommunication> Yours> NFA> > > On Fri, Feb 15, 2008 at 12:11 > M, > erdinç
aseri
enaseri at hotmail.com.tr>> rote:> >> Dear Nasser,> 1. My > ingertip > data
howed
rivial Tr at 1.st operation> 2.For me there is a > ifference of 10 >
inutes
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
oncensus in every situation between the 2> circles.e.g long chain > > f
ostings
n this forum about the treatment of> CAD by stents and surgery.> 4. > >
ere are
any studie> s which show no long term benefit of DeVega (> and many > >
udies on
he contrary)> erdinc> > > _______________________________________________>
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