[HSF] TVR with liver failure

[Hgrmd at aol.com]

Michael,
  I probably wouldn't operate since the patient has advanced primary  liver 
disease.  If it was secondary to tricuspid disease, that might be a  different 
story.  However, I'd have to eyeball her before I could  definitely tell you 
not to operate.  If you do offer surgery, the bleeding  will be predictably 
horrendous.  First, I would do a maze.  The  patient would definitely benefit 
from eventually getting off Coumadin.  Do the tricuspid part with the heart warm 
and beating.  Do a  replacement with a bioprosthesis.  I would favor an 
Edwards  Perimount.  You may ask why, since I invariably castigate the hell out of  
that valve for its propensity to savage the lateral wall with its sharp  
struts.  However, in the tricuspid position, I wouldn't be worried about AV  
rupture, as long as the RV was ample.  Don't use a mechanical.  They  have a higher 
thrombosis rate, even with Coumadin.
 
Hal



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