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

[Hgrmd at aol.com]

Michael,
  I've never ever seen tricuspid stenosis on a postop echo.  I  suspect the 
tricuspid is much like the mitral.  Patient size mismatch is  generally not an 
issue.  Don't feel alone about your program's relative  neglect of the 
tricuspid.  I was shocked to see that Chitwood's program had  a concomitant tricuspid 
repair rate of less than 5%.  It is a fact that  even moderate TR, like MR, 
adversely affects the 10 year survival.  If you  do it warm, beating heart 
after the clamp is released, there is virtually no  down side to repairing TR 
other than the cost of the prosthesis.  As I've  said many times before, going 
back in and fixing newly developed TR has enabled  me to wean patients from the 
pump without a balloon.  I'm convinced I've  avoided more than a few bad 
outcomes by my current policy.  
  I size them by placing the sizer over the unfurled anterior  leaflet.  
Generally I will undersize by 1 to 2.  If you think about  it, particularly in 
secondary MR cases from myopathic ventricles, why should  only the left AV valve 
dilate?  Those cases, in particular, deserve a ring  if the systolic diameter 
is 40 mm or more, regardless of the amount of current  TR.  Also, any case 
with a preop echo showing moderate or worse TR need to  be repaired, regardless 
of the intraop findings.  I'm sure our good friend,  Dr. Frater, would agree.
 
Hal



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