[HSF] Low gradient AS, Salvage

Wed Jan 2 06:19:18 EST 2008

You can fix the heart. In the case you describe the need for this is acute.?Long term benefit is dependent on the comorbidities.
Bob

-----Original Message-----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Tue, 1 Jan 2008 1:18 pm
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.?
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My guess she will show up soon, somewhere, intubated in shock knocking on death's door.?
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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)?
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comments??
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-michael?
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On Dec 30, 2007, at 4:50 PM, rwmfglycar at aol.com wrote:?
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>?
> 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.?
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> 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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