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

Thu Jan 24 18:41:48 EST 2008

Oh that caveat anyway applies !!
Prasanna

On Jan 24, 2008 9:38 AM, Tea Acuff <tacuff at swbell.net> wrote:

> Assuming it is god like repair. If it is an imperfect man made repair, it
> depends.
>
> tea
>
>
> ----- Original Message ----
> From: Prasanna Simha M <prasannasimha at gmail.com>
> To: OpenHeart-L at lists.hsforum.com
> Sent: Wednesday, January 23, 2008 10:53:12 AM
> Subject: Re: [HSF] Access to AV groove area post bypass Bioprosthesis
> choice
>
> 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
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> --
> Prasanna Simha M
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-- 
Prasanna Simha M