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

[Prasanna Simha M]

5 Green and 5 white sutures  so 10. Since youThe white are not seen
well as they are enface.
One can be seen well at the base of the strut.
I have seen at least two reports showing no paravalavar rleaks post
op. What could be the mechanism of such a destructive paravalavar leak
in the absence of an overt history of endocarditis ?
 Prasanna

On Sat, Mar 1, 2008 at 4:14 AM, Ben Bidstrup
<benjamin.bidstrup at bigpond.com> wrote:
>
>  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)
>  >_______________________________________________
>  >OpenHeart-L mailing list
>  >
>  >Send postings to:
>  >  OpenHeart-L at lists.hsforum.com
>  >
>  >To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>  >http://mmp.cjp.com/mailman/listinfo/openheart-l
>  >
>  >All messages transmitted by the OpenHeart-L are subject to the policies and
>  >disclaimers posted at:
>  >http://www.hsforum.com/listdisclaim
>  >-----------------------------------------
>
>
>  --
>  Ben Bidstrup FRACS FRCSEd FEBCTS
>  Consultant Cardiothoracic Surgeon
>  _______________________________________________
>  OpenHeart-L mailing list
>
>  Send postings to:
>   OpenHeart-L at lists.hsforum.com
>
>  To UNSUBSCRIBE, to CHANGE email address, or to view archives:
>  http://mmp.cjp.com/mailman/listinfo/openheart-l
>
>  All messages transmitted by the OpenHeart-L are subject to the policies and
>  disclaimers posted at:
>  http://www.hsforum.com/listdisclaim
>  -----------------------------------------
>



-- 
Prasanna Simha M