[HSF] Low gradient AS

Michael Firstenberg msfirst at gmail.com
Tue Jan 1 13:18:04 EST 2008 

Well, after all of that.... she refused surgery.... discharged her  
home today...... very sad as I do not think she will do well (her  
Cardiologist, who is very nice, has been dealing with her for years  
and agrees) and she probably would have done well with surgery.  I do  
not talk patients into surgery they dont want.

My guess she will show up soon, somewhere, intubated in shock  
knocking on death's door.

My partner is doing a similar case today, 87 year/old intubated,  
shock, critical AS (but her gradient is around 100, but those are the  
only details)..... I have mixed feelings about "salvage AVR" in >80  
yr/old)

comments?


-michael




On Dec 30, 2007, at 4:50 PM, rwmfglycar at aol.com wrote:

>
> Michael,
>
> It is likely that this patient has a dilated heart with?reduced  
> systolic function. We saw these from the early days of aortic?valve  
> replacement?in our Bronx population. The approach was very simple.  
> What is her current cardiac output? What would be her cardiac  
> output at an index of 2.5 to 3.0 L/min/m2? Let's say that the  
> number is 4.2 L/min. Next question: what size valve of what model  
> will give a gradient close to zero at that cardiac output? We had  
> an idea of this because from the 60's we had been studying all  
> valves in pulse duplicators and had a routine of measuring in the  
> OR, post bypass, simultaneous ventricular and aortic pressures? and  
> dye dilution cardiac outputs.
> ??? Most of the valves when we started doing this were mechanical.  
> In the 70's the first bioprostheses came in. The standard insertion  
> technique was intra-annular. We knew what we called the mounting  
> size of each design with its designated size. We could get an idea  
> of the annular size from an ascending aorta angiogram. We would  
> know in advance then if?an?available device would have the desired  
> hemodynamic result of a very low transvalvar gradient. (We actually  
> also had what we called the Performance Index which related the  
> area of the device at the level of the annulus to the calculated  
> effective orifice area). But in our minds what counted was how much  
> pressure the ventricle would need to generate to produce a "normal"? 
> cardiac output .
> ??? In your example let us say that? to achieve this we would need  
> a size 21 of brand X. We fear however that even a size 19 will be a  
> tight fit and that the mean gradient will be 20mm Hg at a "normal"  
> resting cardiac output. What help would that give to this failing  
> sick ventricle? Answer simple: nothing. Putting in a 19 will not  
> help the patient shorterm or long term.
> ??? That left us two choices using a homograft or at least a size  
> 21. In the Bronx with a lousy coroner system homografts were  
> virtually unobtainable in the time we are talking about. For us the  
> option was root enlargement.The circumferences of 19, 21 and 23  
> annuli are 60, 66 and 72 mm. A patch will easily produce a 6 mm  
> enlargement of a 19 annulus. It is difficult to produce a 12 mm  
> increase in circumference. It is easy to go from 19 to 21 but hard  
> to go from 19 to 23.?But if 19 was not good enough the only basis  
> for offering surgery was aortic root enlargement.?
> We had good success with this approach. While cleaning out my  
> basement recently I came across records of mean gradients at normal  
> resting outputs achieved in a series of these patients. They varied  
> between 5 and 15.
> ?? The other critical fact shown by many surgeons was that low  
> ejection fractions due to aortic stenosis virtually always improved  
> post replacement with a hemodynamically adequate device.
> Go for it Michael. Just make sure to give the ventricle optimal  
> myocardial protection.
> ?? Note that in Padua pulse duplicator studies of modern devices  
> have been done. Unfortunately engineers love to describe the  
> results in terms of energy losses etc. All the ventricle knows is  
> how hard it has to push. Concentrate on mean gradients at normal  
> cardiac indices.
> ?Bob.
>
>
>
>
>
>
>
>
>
>
>
>
>
> Treat the patient, not the numbers, Michael.
> ;)
> tea
>
>
> ----- Original Message ----
> From: Michael Firstenberg <msfirst at gmail.com>
> To: OpenHeart-L at lists.hsforum.com
> Sent: Sunday, December 30, 2007 12:10:29 PM
> Subject: [HSF] Low gradient AS
>
> Not to curse myself, but we are seeing more and more "little old  
> ladies"
> with CHF, low EFs, low gradients (relative term), and severe AS  
> (like areas
> 0.5).  While these are known to be higher risk, has anyone turned  
> anyone
> down - and if so what are the true contraindications (besides the  
> usual
> failure of the eyeball test).  My take is anything you put in has  
> to be
> better than what they have and if you do nothing, then they are toast.
>
> A patient I am working up has a AVA of 0.4 with a peak of 42mmHg  
> and a mean
> of 24 mmHg with known CAD (moderate LAD disease from a cath in  
> 2001!).   I
> know we can get dobut stress echos and MRI, etc etc and ring up big  
> bills,
> but she has already been admitted 3 times with severe CHF problems  
> in the
> past 2 months and has an ankle fracture which no one will touch due  
> to her
> heart.  I get the sense that if we dont offer something they she  
> may not
> make it to the end of the year (yikes - that is in 2 days).
>
>
>
> -michael
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
> OpenHeart-L at lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the  
> policies and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
>  OpenHeart-L at lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the  
> policies and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------
>
>
> ______________________________________________________________________ 
> __
> More new features than ever.  Check out the new AOL Mail ! - http:// 
> webmail.aol.com
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
>  OpenHeart-L at lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the  
> policies and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------

More information about the OpenHeart-L mailing list