[HSF] Low gradient AS

Tue Jan 1 17:10:07 EST 2008

last I heard they were putting an IABP in.....

It is interesting how patients refuse and refuse and refuse surgery  
for so many reasons - many are valid (my patients for example new  
several people who died after heart surgery) and then we they are in  
the jaws of death from ignoring their problems then eveything must be  
done and then it becomes a "let's do everything for grandma/pa  
because that is what he/she would have wanted" - I do not recall too  
many of these patients doing well.

But, how do you say no?
(an important learning point as I am sure I am going to see my LOL  
again...... and now here in the US you are dammed if you do and  
dammed if you dont).  It is a strike against you if you operate  
(especially an isolated valve) and they die within 30 days and it is  
a strike against you if they die within 30 days of a CHF admission.    
So, why not roll the dice and operate.... maybe you will get lucky  
and can keep them alive for 30 days until discharge....somehow I  
sense what is best for the patient is getting lost in these reporting  
systems???

-m

On Jan 1, 2008, at 4:55 PM, zzhoumd at pol.net wrote:

>
> This is the kind typical story when they are intubated or crashed  
> in cath lab, they are suddenly become candidate for any surgery.
>
> If no other major organ problems, the patient may be ok for  
> surgery. We can fix their heart, not their lungs, kidney or brain  
> or liver etc. most of my mortalities are due to other things.
>
> Good luck to your partner.
>
> Z
>
> Sent via BlackBerry by AT&T
>
> -----Original Message-----
> From: Michael Firstenberg <msfirst at gmail.com>
>
> Date: Tue, 1 Jan 2008 13:18:04
> To:OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] Low gradient AS
>
>
> 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
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