[HSF] TVR with liver failure

[Michael Firstenberg]

I also use tissue valves in the tricuspid position (and put on perm
epicardial wires!).  I recently saw a patient with a mechanical MVR/TVR who
needed a perm pacer for a junctional rate in the 30's.

I thought showing our liver transplant surgeon what real pain is..... doing
a liver transplant on a patient who requires coumadin to keep the INR in the
3-4 range!
(I may never get another consult from the solid organ transplant team
again..... wait, is that a bad thing?)

I agree - but is there anyway to tell how much of her liver is from the TS?
My understanding is that these patients do not get cirrhosis?

Should I insist on a biopsy?

of course, according to the STS risk database this case has about a 2-5%
mortality (redo valve)

-m


On 3/2/08, Hgrmd at aol.com <Hgrmd at aol.com> wrote:
>
> 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
>
>
>
> **************Ideas to please picky eaters. Watch video on AOL Living.
> (
> http://living.aol.com/video/how-to-please-your-picky-eater/rachel-campos-duffy/
> 2050827?NCID=aolcmp00300000002598)
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