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

[Ani Anyanwu]

Prasanna
 
42 seems gigantic - how do you determine the size of your tricuspid ring? In our experience we rarely size a tricuspid larger than a 32 and like Hal the majority sizes are 26 and 28. Indeed the largest available sizes for both the Carpentier ring and MC3 ring is 36mm.
 
Ani
 



> Date: Sun, 2 Mar 2008 14:40:57 +0530> From: prasannasimha at gmail.com> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Image of the week - Trans toric approach to the aortic valve> CC: > > 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)> > > > >_______________________________________________> > > > >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> > > _______________________________________________> > > 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> > > -----------------------------------------> > >> > _______________________________________________> > 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> _______________________________________________> 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> -----------------------------------------
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