[HSF] Image of the week - Trans toric approach to the aortic valve

[Ben Bidstrup]

Prasanna,
Am I correct in seeing / stating the valve was sewn in with 5 sutures?

>30 year old male had AVR done 3 years ago by a colleague. At that time
>Echo was normal. 3 months back patient started becoming breathless. No
>fever  and worsenedprogressively over a month and then came to us.. No
>fever etc. Counts normal and Echo showed a major valve dehiscence and
>a rocking valve.There was 1+ MR and severe TR.
>It was decided to do an AVR +TV Plasty and the MR was acute and
>thought to be due to annular dilatation.
>Redo AVR done after TV ring placement (42 No). The approach was via
>the adheren t RA over the aorta after incising the aorta and extending
>it into the Torus aorticus of the Right Atrium.This allowed excellent
>exposure and a 25 mm Chitra vavle was placed. Closure was done with
>closure of the aortic torus and the aortic wall en mass and the RA was
>closed thereafter there was a problem weaning so an epicardial showed
>significant MR so an MVR was done.
>Patient was weaned off but was not doing well despite increasing
>supports with normal functioning valves and LV wall acceleration was 5
>cms/ sec and so was judged weanable (> 4 cms/sec) and was shifted to
>the ICU with maxi Inotropes after putting an IABPThe patient continued
>to do poorly immediately on shifting and since his radial showed a
>better curve than the femoral (actually he was receiving transaortic
>NTG) so I started Pitressin with a dramatic change in events and
>stoppage of all other inotropes in1/2 an hour and he continued to do
>well. and the Pitressin was weaned off after a few hours. I rechecked
>his drugs (He was in the medical ICU on Inotropes, raised liver
>parameters (Childs A) , renal failure and had a Eurscore prediction of
>58 %Mortality) and found that the cardiology residents had restarted
>ACE Inhibitors that I had asked to discontinue 24 hours prior to
>surgery. He was vasoplegic.and responded to Pitressin. He contined to
>receive Intraortic NTG which did not cause  problems after Pitressin
>was started and weaned.
>I did a Hepatic artery Doppler estimation (Last few daysdid a bit of
>reading and trials on imagin and Doppler interrogation of the Hepatic
>artery - not as difficult as I thought !!) and there is a demonstrable
>increase in hepatic artery flow velocity (both systolic and diastolic
>) with Intraortic NTG and a decrease on stopping it and waiting for 5
>minutes).
>On NTG Peak Systolic (S) 71 cms/sec Diastolic (D)  48 Off NTG 63 and
>35. 12 Hours Later On NTG 74 (S) and 42 (D) and Off NTG 61S and 35 D.
>I  am not sure of the significance of one data set but it did seem
>useful and reproducible in the patient (Improvement on restarting
>NTG). On putting the IABP on you could clearly see diastolic
>augmentation of hepatic arterial flow too !!
>Currently off Inotropes , IABP removed (actually did not help much
>anyway) and extubated.
>
>Prasanna
>
>
>--
>Prasanna Simha M
>
>Content-Type: image/jpeg; name="transtoric redoaortic valve eml.jpg"
>X-Attachment-Id: f_fd8ro0tk0
>Content-Disposition: attachment; 
>filename="transtoric redoaortic valve eml.jpg"
>
>Attachment converted: Absolute Genius:transtoric 
>redoaorti#CFA8DD.jpg (JPEG/«IC») (00CFA8DD)
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-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon