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

Mon Jan 21 20:21:47 EST 2008

I fully agree with your point as far as repairability is concerned but then
we all do not have a 100 % repairability rate and in thoose we do end up
replacing we would have to consider valve preservation.
Having said that  I end up replacing the valve in the last two cases - one
was the 95 % CTR case with hepatic renal and respiratory dysfunction where I
felt I would need to do a prolonged  complex repair and voted to do a
bioprosthetic valve replacement (though my heart did bleed while excising
the valve) The patient was too sick and I did not think the patient would
survive a rerun if my repair was less than perfect.(At least the patient is
so far alive though still on tube feeds but getting to be mobile). The other
rheumatic lady had too thick  leaflets right at the hinge point (while the
rest of the valve leaflets where thin so the valve competence appeared
compromised in the initial attempts at repair so I went ahead and replaced
it. In such a situation I would and do bileaflet preservation.
Obviously I think that Barlow's should be repairable in at least 95 % of
cases andI agree that the operation of choice  should and must be a repair.
Prasanna

On Jan 21, 2008 8:07 PM, Ani Anyanwu <anianyanwu at hotmail.com> wrote:

> > 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> >
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-- 
Prasanna Simha M