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

Sun Mar 2 10:14:52 EST 2008

Hal -

How do you size them, clearly I do not use as many as you, but the ones I do
put in are in patients with huge annulus (4-6cm) and I am afraid of
downsizing too much.  I am afraid of the ring tearing thru the tissue and
more importantly we have a very senior (and smart) heart
failure/transplant cardiologist here who thinks we create tricuspid stenosis
but downsizing to much (he in fact would prefer that we leave the t-valve
alone altogether)

-michael

On 3/2/08, Prasanna Simha M <prasannasimha at gmail.com> wrote:
>
> I do agree that these sizes are gigantic  and I have rarely used such
> large sizes. I use the former sizer to cover the ATL (the same sizes
> that you can see in the JPEG that I sent earlier)and use that size. In
> the  cases where I have used such a big ring the RV and Tricuspid
> annulus were huge. In fact the septal area extended 4 cms from the
> ends of the sizer. As I said the RV was so huge that probably I could
> swim in it and I am not sure if I could reliably cram the ring inside.
> I have got No TR in the case with a good coaptation line on Control
> Echo done both on table and 24 hours later. In fact I used to not make
> and keep size 40 and 42 earlier but after having to make one in a
> hurry in the past I have kept them ready just in case and I have used
> them occasionaly .
> Prasanna
>
> On Sun, Mar 2, 2008 at 6:36 PM, Ani Anyanwu <anianyanwu at hotmail.com>
> wrote:
> > 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.andresponded 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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> -----------------------------------------> >> > > > -- > Prasanna Simha M>
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> Prasanna Simha M
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