[HSF] restrictive tethering due to extreme RV dilatation

[Nasser F. Abou'Seada]

I would query why the patient was a "subject" of balloon valvotomy first
place, in Lutembacher Syndrome ?? ..... ASD would need to be closed anyway
..."? planning to use an occluding device????" ...
Poor Prasanna .... you have to deal with other's experimental mistakes
....... I know all that must be getting on your nerves ....
I'd not have done any better than what did Prasanna do .... also considering
an Alfeiri-type stitch if the valve showed significant residual
regurgitation. Still, .. replacement with a bioprosthesis would be my last
card if all options fail.

Well Done Prasanna .... any photos ?

NFA

On Jan 30, 2008 12:50 PM, Prasanna Simha M <prasannasimha at gmail.com> wrote:

> I had a case today - Lutembacher which had undergone a balloon valvotomy 2
> months back resulting in severe mitral regurgitation. Patient  was sick ,
> severe TR , JVP to the skull and even face and scalp edematous , hepatic
> and
> renal dysfunction and severe 9suprasystemic pulmonary hypertension. (when
> they come they come in a bunch !!) .
> On table I found a linear tear in the AMl that I reapproximated with
> interrupted sutures and did an OMV.
> I closed the ASD with  a large Goretex patch to augment the LA volume
> which
> was very small. The problem was the extremely large RV (huge) and the TV
> annulus was stretched extremely and was 14 cms !! and thugh the leaflets
> were not large they were tethered down by sheer traction from the dilated
> RV.I placed a complete 42 indigenous ring which gave a fair coaptation
> though there was some mildcentral leak which was probably due to the
> restriction due to RVdilatation as there was actually sufficient leaflet
> "down under". I accepted this as closure of the ASD would decrease RV
> volume
> in the long run and probably would help in further optimizing coaptation.
> I came off with Grade 1 TR and trivial MR. (Incidentally used targeted
> perfusion for this too and patient is being extubated now with good urine
> and liver function so far hasn't worsened.) CVP is low and I hope he does
> well.
> My question is  - if I had failed to get coaptation and there was
> signifiant
> TR (say Grade 2 or3) what options would the members use . I was
> considering
> down  sizing further or using a clover leaf Alfieri stitch on the 42 ring.
> Any suggestions. Seeing the traction due to papillary muscle displacement
> I
> doubt further down sizing would have got a better result and I was already
> pretty "cramming up" the annulus - as it is (it was huge and (though I am
> small statured,) my whole fist could easily oscillate freely in the
> tricuspid valve orifice . Any other suggestions or ideas in managing such
> a
> pathology?
> Prasanna Simha M
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