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

[Ani Anyanwu]

> Ani, based on that one study would you stop preserving the chordal> apparatus?> > Prasanna
Prasanna
 
I never said I practiced chordal preservation. My feeling, and certainly is the case in our practice, is that chordal preservation is (or should be) largely a historical technique. I suspect its usefulness was more in the dilated ventricle with severe MR and maybe it helped prevent further remodeling. However in our practice we do not as a rule perform valve replacement in these scenarios. All type I (except severe endocarditis), type II and type IIIb patients would have a valve repair in our practice so the issue of chordal preservation does not arise. The elegant descriptions of chordal preservation were predominantly from patients with Barlows or cardiomyopathy (IIIb) and such patients should all receive repairs. 
 
The valve replacements we do are almost exclusively rereplacements (where the determination has been made at previous surgery) or for IIIa rheumatic, radiation induced, lupus etc, where as Dr Frater suggested, the observations on chordal preservation may not hold so strongly, and in those cases one often has to cut out part (or occasionally all) the subvalvar apparatus to allow good placement and function of the prosthesis. Of course one can restore continuity with goretex (excellent in concept but questionable whether makes a difference). I do try to preserve what I can though (just for the reason as I have said in other discussions that I do not believe in cutting out tissue just because we can, cut or disrupt only what is necessary to achieve surgery and leave rest alone, also for the previously described advantages of non-radical excision such as less groove ruptures and maintaining LV geometry). However, my feeling is if a surgeon could truly preserve both anterior and posterior apparatus then that is a repairable valve that had no business being replaced. I have excised prosthesis at reoperation to see a well preserved valve of clear degenerative etiology. I think the chordal preservation teaching did a lot to slow uptake of mitral repair as it gave an illusion one was doing a superior or advanced operation in a similar way endoscopic vein harvest stunted the growth of arterial grafting in the USA.
 
To answer your question though, I would not stop preserving the chordal apparatus based on one study. However if that study came from one of the major proponents I would think very hard as to whether I have been brainwashed all along (such as in the stentless valve and patient prosthesis mismatch myths - both inventions of a collusion between industry and a select few doctors; as Hal alluded stentless valves were once touted as our salvation but now largely rejected by even the pioneers).
 
Ani



> Date: Mon, 21 Jan 2008 07:22:29 +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: > > Also unfortunately fashions come and go and also history has a nagging habit> of repeating itself !!!> A few years back I did a loco regional wall motion study of patients who> received and did not receive total versus partial leaflet preservation and> this was presented in our national conference by one of out students . We> noted a striking difference in locoregional contractiltiy with total> chordal preservation . I am not sure I will be completely convinced by "one"> study. We saw a dramatic increase in survival when we were using inferior> cardioplegia (as I mentioned previously and that was when I was a student )> and may be other things have compensated for this difference over time but> dismissing chordal preservation as useless based on one observer may be> premature and sends out the wrong message.> Incidentally the basic work on mitro-annular continuity was based on the> work of Cobb et al and so it is also called as "Cobb's cycle"> Ani, based on that one study would you stop preserving the chordal> apparatus?> > Prasanna> > On Jan 21, 2008 7:04 AM, <Hgrmd at aol.com> wrote:> > > Dear Ani,> > I can't wait to read that paper! Unfortunately, a lot of what we've> > been> > taught as gospel has ultimately turned out not to be so true.> >> > 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> > -----------------------------------------> >> > > > -- > 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> -----------------------------------------
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