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

Sun Mar 2 16:37:46 EST 2008

Michael

Not to be disrespectful but I think your heart failure cardiologist needs some education. We do around 200 tricuspid rings a year. Our early series is published in the annals 2006 and there we downsized and most patients ended up with a 26 or 28. We now true size based on the area of the anterior/posterior leaflet and 28 is still the most frequent true size and 26 and 30 very frequent. Like Hal said we see many where 24 would have been the true size but those end up 26. Stenosis never occurs (all patients have echo) - so far we have never seen a patient having echocardiographically relevant stenosis after tricuspid valve repair. 

The issue of tissue tearing out if the annulus is reduced greatly is overcome quickly with experience. Provided the sutures are through the true annulus the ring holds. May be worth doing it on an arrested, rather than beating, heart in patients where this is a worry. We have also not seen recurrent TR through a dehisced ring. 

Also for clarity of nomenclature, downsizing refers to the size of the chosen ring relative to the size of the anterior/posterior leaflets - it does not matter how dilated the annulus is. With a ring the annulus should be reduced to the true size, else you would still have coaptation problems and tendency to TR. No matter how enormous the annulus looks - even if 7cm across - you should not be afraid to bring it down to 26 mm if that is indeed the size of the anterior/posterior leaflet. Downsizing means you a choosing a size less than the size  determined by sizing of the leaflet.

I suspect part of your cardiologists view is biased by having to biopsy transplant patients where you have placed a ring at time of transplant - it can be very difficult to get the bioptome across the valve and that is probably what gives the impression the valve is stenotic.

Ani

> Date: Sun, 2 Mar 2008 10:14:52 -0500> From: msfirst 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: > > 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)> > > >> > >_______________________________________________> > > > >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>> > -----------------------------------------> > > _________________________________________________________________> > > Free games, great prizes - get gaming at Gamesbox.> > >> > http://www.searchgamesbox.com_______________________________________________> > >> > >> > > 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> -----------------------------------------
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