[HSF] Image of the week - Trans toric approach to the aortic valve
Prasanna Simha M
prasannasimha at gmail.com
Sun Mar 2 14:40:57 EST 2008
42 refers to the equivalent of a 42 Mitral carpentier Edwards ring ie
the central orifice area equals 4.2 cm2. It is my Goretex steel ring.
I have used the area of the ATL for siziing. This large ring was
itself actually "small" and gave quite a lot of annular reduction as
the RV annulus was really huge (One of the "fist goes into the RV"
type of ventricles - my fist not Hals as I am nearly half his size) !!
As I mentioned previously I place a complete ring with bites in the
nodal area on theseptal leaflet of the tricupid valve. Incidentally I
was wondering seeing the extreme annular dilatation abutting the
septal leaflet wether in such cases a complete ring may actually be
better.
Incidentally I made a 3D ring with the nadir near the coronary sinus
to mimick the tricuspid triplanar position in systole (Not sure if it
means much but did give a good competence despite leaflet tethering)
Prasanna
On Sun, Mar 2, 2008 at 2:13 PM, nand kejriwal <nkkejriwal at gmail.com> wrote:
> Prasanna
>
> Did you use a 42 size tricuspid ring? Recently I was going through the
> brochure provided by Edwards. It mentioned that the commonest sizeMC3 ring
> used by Pat McCarty is 26 and 28.
>
> Nand
>
>
>
> On 3/1/08, Prasanna Simha M <prasannasimha at gmail.com> wrote:
> >
> > 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)
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> > > --
> > > Ben Bidstrup FRACS FRCSEd FEBCTS
> > > Consultant Cardiothoracic Surgeon
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> > --
> > Prasanna Simha M
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--
Prasanna Simha M
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