[HSF] Access to AV groove area post bypass Bioprosthesis choice

Mon Jan 21 00:40:19 EST 2008

Thanks for the clarification Mike.

I am not doubting that chordal preservation cf no preservation may have a different physiological effect but I was questioning the dogma or certainty that chordal preservation is beneficial and not maintaining annulopapillary continuity is sacrilege. We have to be prepared (as David did) to continually question what we believe in and what we teach. It is more likely than not that the benefits of chordal sparing (like a lot of other things we do) has been overstated. We have to also be prepared to seek alternative explanations for benefits we ascribe to certain techniques we do as when we look closer we will see those benefits are also possible without application of the technique in question.

Ani

> Subject: RE: [HSF] Access to AV groove area post bypass Bioprosthesis choice> Date: Sun, 20 Jan 2008 12:48:12 -0500> From: Michael.Crittenden at va.gov> To: OpenHeart-L at lists.hsforum.com> CC: > > Ani,> > (1) Lillehei, not David first proposed the concept of chordal preservation. Dr. David did help to (re)popularize the concept. But there were others...> > (2) Craig Miller's lab in the late 80's and/or early 90's performed a series of elegant animal experiments that demonstrated improved/preserved LV function in animals post MVR when the subvalvular apparatus was preserved.> > (3) A long term article...> Mitral Valve Replacement With and Without Chordal Preservation in a Rheumatic Population: Serial Echocardiographic Assessment of Left> Ventricular Size and Function> Ujjwal K. Chowdhury, MCh, et al Ann Thor Surg 2005; 79:1926> > In my opinion, the wide acceptance of the concept of preserving the subvalvular apparatus in mitral valve replacements led to the (re)consideration of mitral valve repair as a better alternative to valve replacement for those surgeons who were not yet convinced by Carpentier, Frater et. al.> > Just my two cents...> > > -----Original Message-----> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Ani Anyanwu> Sent: Sunday, January 20, 2008 10:33 AM> To: openheart-l at lists.hsforum.com> Subject: RE: [HSF] Access to AV groove area post bypass Bioprosthesis choice> > > On the other side there are various series also showing a survival benefit>> > Is this true? Can you provide references showing superior long-term survival (NOT operative survival) with this approach? The essence of the technique is not to reduce operative mortality (studies showing this are likely demonstrating some form of bias) but to reduce late mortality from progressive LV dilatation. If your student in his thesis found an operative survival benefit from chord sparing there is likely an alternative explanation.> > Ani> > > > > Date: Sun, 20 Jan 2008 20:45:06 +0530> From: prasannasimha at gmail.com> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Access to AV groove area post bypass Bioprosthesis choice> CC: > > On the other side there are various series also showing a survival benefit> and anyway it does seem to negate the incidence of post MVR ventricular> rupture.> I can say I am a strong believer because we had done a study as a part of> one of my colleagues study for his MCH Thesis and we saw an obvious and> dramatic survival albeit we were using at that time voodoo cardioplegia.> Maybe the effect may be minimized with superior cardioplegic techniques> etc but I am not sure that they can totally be ignored.> Prasanna> > On Jan 20, 2008 8:31 PM, Ani Anyanwu <anianyanwu at hotmail.com> wrote:> > > > There is also no need to "excise" leaflets or more precisely disrupe> > the> annulopapillary contnuity . In fact I may make an inflammatory comment> > that it is> unethical not to preserve annulopappillary continuity in modern> > day mitral> valve surgery> > >> Prasanna> > Yes Prasanna, I would say that is a rather inflammatory comment! As you> > know this chordal sparing business was largely an invention of Dr David in> > the 1980s. There is however a paper (in press) from David's group> > questioning the validity of this technique. David et al looked at all MVRs> > done over 15 years in their institution and found no difference in patients> > who had chordal sparing (these procedures largely done by David who is an> > ardent believer like you) vs no chordal preservation (these largely done by> > his colleagues). Of course one would have expected chordal sparing to do> > better for two reasons - because the chords were spared and because they> > were operated by one of the most talented surgeons of the era...yet the data> > showed no difference.> >> > Ani> >> >> >> > > Date: Sun, 20 Jan 2008 19:35:01 +0530> From: prasannasimha at gmail.com>> > To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Access to AV groove> > area post bypass Bioprosthesis choice> CC: > > Two things, I do not think a> > 27 size valve is stenotic in an average> patient especially the one with> > your weight and height - there must be some> other problem.> There is also> > no need to "excise" leaflets or more precisely disrupe the> annulopapillary> > contnuity . If you really need to do that then there are> alternatives like> > creating artificial neochordae and bivalving the PML. I> can say that I> > virtually do all cases with annulopappillary continuity> preservation in all> > mitrals (and have my fair share of calcified mitrals> with small LV's . In> > fact I may make an inflammatory comment that it is> unethical not to> > preserve annulopappillary continuity in modern day mitral> valve surgery> > since we can always construct neochordae (these can be> successfully be done> > with Ticron too - not necessarily Goretex)> I do not know the EOA for 27> > Epic can anyone give me the data). The patients> BSA by Dubois formula is> > 1.659 m2.> What was done for her Afib ?> Prasanna> > > On Jan 20, 2008> > 7:14 PM, Macbook <grescigno at mac.com> wrote:> > > Dear Hal,> >> > I agree> > 100% with you. However I recently operated on a very sick 76> > year-old> > woman who had undergone a previous open heart mitral> > commissurotomy for> > mitral stenosis. She had 80 mmHg systolic PAP and> > a severe tricuspid> > regurg (of course), giant left and right atria and> > continuous AFib. I put> > a 27 Epic prosthesis (the european equivalent> > of Biocor) and a n° 30 MC3> > tricuspid ring. BTW I had to resect both> > leaflet in order to obtain this> > valve size. She needed NO to be> > weaned from mechanical ventilation;> > subsequently she was transferred> > to the ward but she continued to show> > some degree of right heart> > failure (I should admit that she was not> > managed in a perfect way and> > I did not follow the patient strictly and> > personally as was probably> > needed....) After 20 days she was> > retransferred to our ICU and> > reintubated for severe hypercapnia (100> > mmHg!). All the subsequent> > attempts to wean were unsuccessful and the> > patient eventually died> > from pneumonia. A collegue of mine said that the> > Epic valve was the> > possible cause because of its small orifice area (the> > lady was 165 cm> > and 60 Kgms). Honestly I am not sure about his conclusion> > but I> > should say that next time I will put a mechanical SJM (she was> >> > already anticoagulated). I will appreciate your toughts and those of> > all> > the members about the orifice areas of Biocor/Epic prostheses and> > the> > possibility to create a patient/prosthesis mismatch in mitral> > position.>> > > Thank you> >> >> > Giuseppe> >> >> > Il giorno 20/gen/08, alle ore 13:14,> > Hgrmd at aol.com ha scritto:> >> > > Dear Yadav,> > > It's nice to hear a new> > voice on HSF. I understand your concern> > > about> > > lifting the heart to> > inspect the CX graft in the presence of a mitral> > > bioprosthesis.> > Excellent suggestions have been given by Drs. Asai> > > and Flege. In> > >> > addition, I would suggest that you use the smallest, lowest> > > profile> > bioprosthesis> > > available in order to lessen the likelihood of trauma to> > the> > > lateral wall> > > from the struts of the valve. That is why I've> > gone to using the> > > St. Jude> > > Biocor. The height of the Edwards> > porcine valve is 13mm, while> > > the Biocor is 9> > > mm. This also reduces> > the likelihood of important left> > > ventricular outflow> > > tract> > obstruction in small, hyperdynamic hearts. One valve I> > > would> > specifically> > > avoid is the Edwards Perimount. Years ago, I lost 2> > patients from> > > LV wall> > > rupture while using that valve. The reason> > is its high profile as> > > well as> > > extremely sharp struts.> > >> > >> > Hal> > >> > >> > >> > > **************Start the year off right. Easy ways to> > stay in shape.> > >> > http://body.aol.com/fitness/winter-exercise?NCID=aolcmp00300000002489> > >> > _______________________________________________> > > 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> >> > -----------------------------------------> >> > > > -- > Prasanna Simha M>> > _______________________________________________> 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>> > -----------------------------------------> > _________________________________________________________________> > Share what Santa brought you> >> > https://www.mycooluncool.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> > -----------------------------------------> >> > > > -- > Prasanna Simha M> _______________________________________________> 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> -----------------------------------------> _________________________________________________________________> Share what Santa brought you> https://www.mycooluncool.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> -----------------------------------------> _______________________________________________> 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> -----------------------------------------
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