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

Tea Acuff tacuff at swbell.net
Sun Jan 20 18:57:43 EST 2008 

To Bob, Prasanna,  Mike or others,

Does preservation of annular-papillary continuity mean complete perservation? That is, is most (all) of the evidence of harm of release of conitnuity based on both posterior and anterior leaflet resection? Is the small ventricle with its own set of prosthesis ventricle "reverse mismatch" (prothesis too large for ventricle) problems including the LVOT problem an exemption to this general rule?

tea 


----- Original Message ----
From: "rwmfglycar at aol.com" <rwmfglycar at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Sunday, January 20, 2008 4:30:57 PM
Subject: Re: [HSF] Access to AV groove area post bypass Bioprosthesis choice

Thank you Michael. 
Actually it was Morris Levy, Walt's resident who did the study. The whole purpose of the exercise at that time was to improve operative mortality of mitral valve replacement, which certainly happened in Walt's cases. The sceptics said "Walt finally learned how to replace a mitral valve without killing the patient".  Kirklin and Rastelli published a dog study alleging that there was no difference in ventricular function between animals after  mitral replacement with or without total excision of the native valve. Examination of the data shows that there were indeed changes in the ventricles of the animals whose natural valves had been excised, which Gianni Rastelli and John Kirklin had missed (both now dead, but knowing them I believe they would acknowlege the error).
All of my experience, all our lab and clinical observations , all of the work done by many others on the subject tells me that we ignore the relationship between annular-papillay connection at our patient's peril. We had this debate before and I am repeating myself but let me make a couple of points.
I will state with confidence that 1) acute consequences of interruption of annular-papillary connection have been clearly and securely shown. 
2) in patients with mitral insuffriciency ventricular function in the first few years is superior if the annular -paillary connection is preserved.
3) in patients with mitral stenosis comparison of patients with the native valve excised and those with at least partial preservation of the  native valve has been much less dramatic and harder to determine.
4) in my longterm follow up of rheumatic stenosis patients , there was a small group who had had thier valves excised as part of the replacement. 10-15years later their ventricular function appeared to have changed little.
   My suspicion is that two factors may explain the difference between the ventricular response of patients who have their stenotic or insufficient native valves excised:
a) the ventricles at the start are completely different
b) I have noticed in the presence of rheumatic stenosis that there can be visible endocardial fibrosis behind the posterior leaflet.
Could this prevent ventricular dilatation after loss of ann-pap connection?
Finally I agree completely with Prasanna that any size 27 mitral bioprosthesis can be used without resulting in maintenance of pulmonary hypertension.
Giuseppe's description of the case shows a very late stage of disease with fixed pulmonary vascular resistance, and a right ventricle with a certainty of continuing in failure. Correction of the tricuspid insufficiency in these cases commonly fails to improve the right sided consequences of pulmonary vascular change or the cardiac output, whatever is done on the left side. It was my practice to reconnect the papillary muscles to the annulus with goretex chordae. I have no proof that this made a difference in my cases.
Bob.





.Crittenden at va.gov>
To: OpenHeart-L at lists.hsforum.com
Sent: Sun, 20 Jan 2008 12:48 pm
Subject: RE: [HSF] Access to AV groove area post bypass Bioprosthesis choice



Ani,
(1) Lillehei, not David first proposed the concept of chordal preservation.  Dr. 
avid 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 
legant animal experiments that demonstrated improved/preserved LV function in 
nimals post MVR when the subvalvular apparatus was preserved.
(3) A long term article...
itral Valve Replacement With and Without Chordal Preservation in a Rheumatic 
opulation: Serial Echocardiographic Assessment of Left
entricular Size and Function
jjwal K. Chowdhury, MCh, et al  Ann Thor Surg 2005; 79:1926
In my opinion, the wide acceptance of the concept of preserving the subvalvular 
pparatus in mitral valve replacements led to the (re)consideration of mitral 
alve repair as a better alternative to valve replacement for those surgeons who 
ere not yet convinced by Carpentier, Frater et. al.
Just my two cents...

----Original Message-----
rom: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-bounces at lists.hsforum.com] 
n Behalf Of Ani Anyanwu
ent: Sunday, January 20, 2008 10:33 AM
o: openheart-l at lists.hsforum.com
ubject: RE: [HSF] Access to AV groove area post bypass Bioprosthesis choice
> On the other side there are various series also showing a survival benefit>

s this true? Can you provide references showing superior long-term survival 
NOT operative survival) with this approach? The essence of the technique is not 
o reduce operative mortality (studies showing this are likely demonstrating 
ome form of bias) but to reduce late mortality from progressive LV dilatation. 
f your student in his thesis found an operative survival benefit from chord 
paring there is likely an alternative explanation.

ni

> Date: Sun, 20 Jan 2008 20:45:06 +0530> From: prasannasimha at gmail.com> To: 
penHeart-L at lists.hsforum.com> Subject: Re: [HSF] Access to AV groove area post 
ypass Bioprosthesis choice> CC: > > On the other side there are various series 
lso showing a survival benefit> and anyway it does seem to negate the incidence 
f post MVR ventricular> rupture.> I can say I am a strong believer because we 
ad done a study as a part of> one of my colleagues study for his MCH Thesis and 
e saw an obvious and> dramatic survival albeit we were using at that time 
oodoo cardioplegia.> Maybe the effect may be minimized with superior 
ardioplegic techniques> etc but I am not sure that they can totally be 
gnored.> Prasanna> > On Jan 20, 2008 8:31 PM, Ani Anyanwu <anianyanwu at hotmail.com> 
rote:> > > > There is also no need to "excise" leaflets or more precisely 
isrupe> > the> annulopapillary contnuity . In fact I may make an inflammatory 
omment> > that it is> unethical not to preserve annulopappillary continuity in 
odern> > day mitral> valve surgery> > >> Prasanna> > Yes Prasanna, I would say 
hat is a rather inflammatory comment! As you> > know this chordal sparing 
usiness was largely an invention of Dr David in> > the 1980s. There is however 
paper (in press) from David's group> > questioning the validity of this 
echnique. David et al looked at all MVRs> > done over 15 years in their 
nstitution and found no difference in patients> > who had chordal sparing 
these procedures largely done by David who is an> > ardent believer like you) 
s no chordal preservation (these largely done by> > his colleagues). Of course 
ne would have expected chordal sparing to do> > better for two reasons - 
ecause the chords were spared and because they> > were operated by one of the 
ost talented surgeons of the era...yet the data> > showed no difference.> >> > 
ni> >> >> >> > > Date: Sun, 20 Jan 2008 19:35:01 +0530> From: 
rasannasimha at gmail.com>> > To: OpenHeart-L at lists.hsforum.com> Subject: Re: 
HSF] Access to AV groove> > area post bypass Bioprosthesis choice> CC: > > Two 
hings, I do not think a> > 27 size valve is stenotic in an average> patient 
specially the one with> > your weight and height - there must be some> other 
roblem.> There is also> > no need to "excise" leaflets or more precisely 
isrupe the> annulopapillary> > contnuity . If you really need to do that then 
here are> alternatives like> > creating artificial neochordae and bivalving the 
ML. I> can say that I> > virtually do all cases with annulopappillary 
ontinuity> preservation in all> > mitrals (and have my fair share of calcified 
itrals> with small LV's . In> > fact I may make an inflammatory comment that it 
s> unethical not to> > preserve annulopappillary continuity in modern day 
itral> valve surgery> > since we can always construct neochordae (these can be> 
uccessfully be done> > with Ticron too - not necessarily Goretex)> I do not 
now the EOA for 27> > Epic can anyone give me the data). The patients> BSA by 
ubois formula is> > 1.659 m2.> What was done for her Afib ?> Prasanna> > > On 
an 20, 2008> > 7:14 PM, Macbook <grescigno at mac.com> wrote:> > > Dear Hal,> >> > 
agree> > 100% with you. However I recently operated on a very sick 76> > 
ear-old> > woman who had undergone a previous open heart mitral> > 
ommissurotomy for> > mitral stenosis. She had 80 mmHg systolic PAP and> > a 
evere tricuspid> > regurg (of course), giant left and right atria and> > 
ontinuous AFib. I put> > a 27 Epic prosthesis (the european equivalent> > of 
iocor) and a n° 30 MC3> > tricuspid ring. BTW I had to resect both> > leaflet 
n order to obtain this> > valve size. She needed NO to be> > weaned from 
echanical ventilation;> > subsequently she was transferred> > to the ward but 
he continued to show> > some degree of right heart> > failure (I should admit 
hat she was not> > managed in a perfect way and> > I did not follow the patient 
trictly and> > personally as was probably> > needed....) After 20 days she was> 
retransferred to our ICU and> > reintubated for severe hypercapnia (100> > 
mHg!). All the subsequent> > attempts to wean were unsuccessful and the> > 
atient eventually died> > from pneumonia. A collegue of mine said that the> > 
pic valve was the> > possible cause because of its small orifice area (the> > 
ady was 165 cm> > and 60 Kgms). Honestly I am not sure about his conclusion> > 
ut I> > should say that next time I will put a mechanical SJM (she was> >> > 
lready anticoagulated). I will appreciate your toughts and those of> > all> > 
he members about the orifice areas of Biocor/Epic prostheses and> > the> > 
ossibility to create a patient/prosthesis mismatch in mitral> > position.>> > > 
hank you> >> >> > Giuseppe> >> >> > Il giorno 20/gen/08, alle ore 13:14,> > 
grmd at aol.com ha scritto:> >> > > Dear Yadav,> > > It's nice to hear a new> > 
oice on HSF. I understand your concern> > > about> > > lifting the heart to> > 
nspect the CX graft in the presence of a mitral> > > bioprosthesis.> > 
xcellent suggestions have been given by Drs. Asai> > > and Flege. In> > >> > 
ddition, I would suggest that you use the smallest, lowest> > > profile> > 
ioprosthesis> > > available in order to lessen the likelihood of trauma to> > 
he> > > lateral wall> > > from the struts of the valve. That is why I've> > 
one to using the> > > St. Jude> > > Biocor. The height of the Edwards> > 
orcine valve is 13mm, while> > > the Biocor is 9> > > mm. This also reduces> > 
he likelihood of important left> > > ventricular outflow> > > tract> > 
bstruction in small, hyperdynamic hearts. One valve I> > > would> > 
pecifically> > > avoid is the Edwards Perimount. Years ago, I lost 2> > 
atients from> > > LV wall> > > rupture while using that valve. The reason> > is 
ts high profile as> > > well as> > > extremely sharp struts.> > >> > >> > Hal> 
>> > >> > >> > > **************Start the year off right. Easy ways to> > stay 
n shape.> > >> > http://body.aol.com/fitness/winter-exercise?NCID=aolcmp00300000002489> 
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