[HSF] Access to AV groove area post bypass Bioprosthesis choice
Tea Acuff
tacuff at swbell.net
Mon Jan 21 20:36:37 EST 2008
Thanks for the reply, Bob.
I can appreciate your distaste for ugly verbiage. Funny how in English the vulgar tends toward the latin-azation (speaking of the same!) of the common or vulgar explanation.
If you can't follow that loop, consider "reverse mismatch" as a form of Lilliputian satire. A literary form that deserves much greater reverence and observance when medical literature is mentioned.
tea
----- Original Message ----
From: "rwmfglycar at aol.com" <rwmfglycar at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Monday, January 21, 2008 12:10:42 AM
Subject: Re: [HSF] Access to AV groove area post bypass Bioprosthesis choice
Dear Tea,
Your question illustrates some of the problems. The answer is it is a mixed bag which makes the clinical data difficult to compare. Horstkotte's large randomised study from Germany which showed a difference was posterior chordal preservation only. Obviously if you preserve the posterior annnularpapillary connection and then put in a three pronged valve with one strut in the middle of the outflow tract, while the patient may survive, he may also be one of the patients with a poor result on longterm followup. You can bet your bottom dollar that that risk factorfor poor long term survival or poor long term ventricular performance will not be picked up in a retrospecdtive data base study.
Ani is right that everything we do needs constant reexamination. Science evolves continually and eventually the paradigms are found wanting and are inevitably replaced with a new paradigm. However one retrospective database study showing a failure to demonstrate benefit (I have not seen the paper and I don't know what the endpoints are and whether they are robust or not) needs examination but does not change the current paradigm. I would say "it is too early to panic" to quote Abe Segal the tennis player.
If the study is good, then, given the good laboratory and clinical shortterm evidence of the importance of ann-pap connection, what are we missing that takes a long time to become evident? We may find that the result is due to confounding factors related to the passing of time. You can be sure that there is much we do not yet know.
Tea I always disliked the ugly term "patient-prosthesis mismatch". Any term that needs explaining is not good. "Reverse mismatch" is truly awful and I sincerely hope that it doesn't instantly, like a meme, achieve universal adoption.
Bob
-----Original Message-----
From: Tea Acuff <tacuff at swbell.net>
To: OpenHeart-L at lists.hsforum.com
Sent: Sun, 20 Jan 2008 9:57 pm
Subject: Re: [HSF] Access to AV groove area post bypass Bioprosthesis choice
To Bob, Prasanna, Mike or others,
Does preservation of annular-papillary continuity mean complete perservation?
hat is, is most (all) of the evidence of harm of release of conitnuity based on
oth posterior and anterior leaflet resection? Is the small ventricle with its
wn set of prosthesis ventricle "reverse mismatch" (prothesis too large for
entricle) problems including the LVOT problem an exemption to this general
ule?
tea
---- Original Message ----
rom: "rwmfglycar at aol.com" <rwmfglycar at aol.com>
o: OpenHeart-L at lists.hsforum.com
ent: Sunday, January 20, 2008 4:30:57 PM
ubject: Re: [HSF] Access to AV groove area post bypass Bioprosthesis choice
Thank you Michael.
ctually it was Morris Levy, Walt's resident who did the study. The whole
urpose of the exercise at that time was to improve operative mortality of
itral valve replacement, which certainly happened in Walt's cases. The sceptics
aid "Walt finally learned how to replace a mitral valve without killing the
atient". Kirklin and Rastelli published a dog study alleging that there was no
ifference in ventricular function between animals after mitral replacement
ith or without total excision of the native valve. Examination of the data
hows that there were indeed changes in the ventricles of the animals whose
atural valves had been excised, which Gianni Rastelli and John Kirklin had
issed (both now dead, but knowing them I believe they would acknowlege the
rror).
ll of my experience, all our lab and clinical observations , all of the work
one by many others on the subject tells me that we ignore the relationship
etween annular-papillay connection at our patient's peril. We had this debate
efore and I am repeating myself but let me make a couple of points.
will state with confidence that 1) acute consequences of interruption of
nnular-papillary connection have been clearly and securely shown.
) in patients with mitral insuffriciency ventricular function in the first few
ears is superior if the annular -paillary connection is preserved.
) in patients with mitral stenosis comparison of patients with the native valve
xcised and those with at least partial preservation of the native valve has
een much less dramatic and harder to determine.
) in my longterm follow up of rheumatic stenosis patients , there was a small
roup who had had thier valves excised as part of the replacement. 10-15years
ater their ventricular function appeared to have changed little.
My suspicion is that two factors may explain the difference between the
entricular response of patients who have their stenotic or insufficient native
alves excised:
) the ventricles at the start are completely different
) I have noticed in the presence of rheumatic stenosis that there can be
isible endocardial fibrosis behind the posterior leaflet.
ould this prevent ventricular dilatation after loss of ann-pap connection?
inally I agree completely with Prasanna that any size 27 mitral bioprosthesis
an be used without resulting in maintenance of pulmonary hypertension.
iuseppe's description of the case shows a very late stage of disease with fixed
ulmonary vascular resistance, and a right ventricle with a certainty of
ontinuing in failure. Correction of the tricuspid insufficiency in these cases
ommonly fails to improve the right sided consequences of pulmonary vascular
hange or the cardiac output, whatever is done on the left side. It was my
ractice to reconnect the papillary muscles to the annulus with goretex chordae.
have no proof that this made a difference in my cases.
ob.
.Crittenden at va.gov>
o: OpenHeart-L at lists.hsforum.com
ent: Sun, 20 Jan 2008 12:48 pm
ubject: 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
egant animal experiments that demonstrated improved/preserved LV function in
imals post MVR when the subvalvular apparatus was preserved.
3) A long term article...
tral Valve Replacement With and Without Chordal Preservation in a Rheumatic
pulation: Serial Echocardiographic Assessment of Left
ntricular Size and Function
jwal K. Chowdhury, MCh, et al Ann Thor Surg 2005; 79:1926
n my opinion, the wide acceptance of the concept of preserving the subvalvular
paratus in mitral valve replacements led to the (re)consideration of mitral
lve repair as a better alternative to valve replacement for those surgeons who
re not yet convinced by Carpentier, Frater et. al.
ust my two cents...
----Original Message-----
om: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-bounces at lists.hsforum.com]
n Behalf Of Ani Anyanwu
nt: Sunday, January 20, 2008 10:33 AM
: openheart-l at lists.hsforum.com
bject: 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
OT operative survival) with this approach? The essence of the technique is not
reduce operative mortality (studies showing this are likely demonstrating
me form of bias) but to reduce late mortality from progressive LV dilatation.
your student in his thesis found an operative survival benefit from chord
aring there is likely an alternative explanation.
ni
> Date: Sun, 20 Jan 2008 20:45:06 +0530> From: prasannasimha at gmail.com> To:
enHeart-L at lists.hsforum.com> Subject: Re: [HSF] Access to AV groove area post
pass Bioprosthesis choice> CC: > > On the other side there are various series
so showing a survival benefit> and anyway it does seem to negate the incidence
post MVR ventricular> rupture.> I can say I am a strong believer because we
d done a study as a part of> one of my colleagues study for his MCH Thesis and
saw an obvious and> dramatic survival albeit we were using at that time
odoo cardioplegia.> Maybe the effect may be minimized with superior
rdioplegic techniques> etc but I am not sure that they can totally be
nored.> 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
srupe> > the> annulopapillary contnuity . In fact I may make an inflammatory
mment> > that it is> unethical not to preserve annulopappillary continuity in
dern> > day mitral> valve surgery> > >> Prasanna> > Yes Prasanna, I would say
at is a rather inflammatory comment! As you> > know this chordal sparing
siness was largely an invention of Dr David in> > the 1980s. There is however
aper (in press) from David's group> > questioning the validity of this
chnique. David et al looked at all MVRs> > done over 15 years in their
stitution and found no difference in patients> > who had chordal sparing
hese procedures largely done by David who is an> > ardent believer like you)
no chordal preservation (these largely done by> > his colleagues). Of course
e would have expected chordal sparing to do> > better for two reasons -
cause the chords were spared and because they> > were operated by one of the
st talented surgeons of the era...yet the data> > showed no difference.> >> >
i> >> >> >> > > Date: Sun, 20 Jan 2008 19:35:01 +0530> From:
asannasimha at gmail.com>> > To: OpenHeart-L at lists.hsforum.com> Subject: Re:
SF] Access to AV groove> > area post bypass Bioprosthesis choice> CC: > > Two
ings, I do not think a> > 27 size valve is stenotic in an average> patient
pecially the one with> > your weight and height - there must be some> other
oblem.> There is also> > no need to "excise" leaflets or more precisely
srupe the> annulopapillary> > contnuity . If you really need to do that then
ere are> alternatives like> > creating artificial neochordae and bivalving the
L. I> can say that I> > virtually do all cases with annulopappillary
ntinuity> preservation in all> > mitrals (and have my fair share of calcified
trals> with small LV's . In> > fact I may make an inflammatory comment that it
> unethical not to> > preserve annulopappillary continuity in modern day
tral> valve surgery> > since we can always construct neochordae (these can be>
ccessfully be done> > with Ticron too - not necessarily Goretex)> I do not
ow the EOA for 27> > Epic can anyone give me the data). The patients> BSA by
bois formula is> > 1.659 m2.> What was done for her Afib ?> Prasanna> > > On
n 20, 2008> > 7:14 PM, Macbook <grescigno at mac.com> wrote:> > > Dear Hal,> >> >
gree> > 100% with you. However I recently operated on a very sick 76> >
ar-old> > woman who had undergone a previous open heart mitral> >
mmissurotomy for> > mitral stenosis. She had 80 mmHg systolic PAP and> > a
vere tricuspid> > regurg (of course), giant left and right atria and> >
ntinuous AFib. I put> > a 27 Epic prosthesis (the european equivalent> > of
ocor) and a n° 30 MC3> > tricuspid ring. BTW I had to resect both> > leaflet
order to obtain this> > valve size. She needed NO to be> > weaned from
chanical ventilation;> > subsequently she was transferred> > to the ward but
e continued to show> > some degree of right heart> > failure (I should admit
at she was not> > managed in a perfect way and> > I did not follow the patient
rictly and> > personally as was probably> > needed....) After 20 days she was>
etransferred to our ICU and> > reintubated for severe hypercapnia (100> >
Hg!). All the subsequent> > attempts to wean were unsuccessful and the> >
tient eventually died> > from pneumonia. A collegue of mine said that the> >
ic valve was the> > possible cause because of its small orifice area (the> >
dy was 165 cm> > and 60 Kgms). Honestly I am not sure about his conclusion> >
t I> > should say that next time I will put a mechanical SJM (she was> >> >
ready anticoagulated). I will appreciate your toughts and those of> > all> >
e members about the orifice areas of Biocor/Epic prostheses and> > the> >
ssibility to create a patient/prosthesis mismatch in mitral> > position.>> > >
ank you> >> >> > Giuseppe> >> >> > Il giorno 20/gen/08, alle ore 13:14,> >
rmd at aol.com ha scritto:> >> > > Dear Yadav,> > > It's nice to hear a new> >
ice on HSF. I understand your concern> > > about> > > lifting the heart to> >
spect the CX graft in the presence of a mitral> > > bioprosthesis.> >
cellent suggestions have been given by Drs. Asai> > > and Flege. In> > >> >
dition, I would suggest that you use the smallest, lowest> > > profile> >
oprosthesis> > > available in order to lessen the likelihood of trauma to> >
e> > > lateral wall> > > from the struts of the valve. That is why I've> >
ne to using the> > > St. Jude> > > Biocor. The height of the Edwards> >
rcine valve is 13mm, while> > > the Biocor is 9> > > mm. This also reduces> >
e likelihood of important left> > > ventricular outflow> > > tract> >
struction in small, hyperdynamic hearts. One valve I> > > would> >
ecifically> > > avoid is the Edwards Perimount. Years ago, I lost 2> >
tients from> > > LV wall> > > rupture while using that valve. The reason> > is
s high profile as> > > well as> > > extremely sharp struts.> > >> > >> > Hal>
> > >> > >> > > **************Start the year off right. Easy ways to> > stay
shape.> > >> > http://body.aol.com/fitness/winter-exercise?NCID=aolcmp00300000002489>
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