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

Wed Jan 23 22:23:12 EST 2008

They are explained about the survival risks between repair and replacement.
They (especially children's parents and young ladies) are told about the
risks versus benefits. The cardiologists who refer repairs to me already
discuss it with them in advance and patients do accept it.It is important to
tell them that mechanical implants have their risks of their
own.Patientsseem to understand that repairing the valve that God gave
them is better
than that of an imperfect man made valve.
Prasanna

On Jan 23, 2008 10:10 PM, erdinç naseri <enaseri at hotmail.com.tr> wrote:

>
> Prasanna,
> Do you encounter any social manipulation( by patient and  family) while
> deciding on valve repair. How is the attitude of the patient and family
>  regarding the possibilities of repair failure there .
> erdinc> Date: Mon, 21 Jan 2008 20:21:47 +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: > > 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 hing
>  e 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 ha
>  ve 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 fro
>  m 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 cont
>  ractiltiy 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