[HSF] TVR with liver failure

Sun Mar 2 15:46:24 EST 2008

I agree with Ani. We have a moderate experience with caridac operations in pts with cirrhosis as we have a large liver transplant service. In the past we have done the cardiac procedure first. Our experience in Childs C pts is a 25 to 30% mortality, mostly from liver failure post op. Sounds high but compare that to a 100% mortality without the cardiac procedure and transplant. We have recently been in discussions with our liver transplant guys and they are up for simultaneous procedures. That is- they list them for transplant, as soon as they get a call for an organ we mobilize the troops and do their cardiac procedure (valve, cabg) followed in the same sitting with the liver transplant. They tell me that there are several places that do this but I have not seen it. Hopefully in the next several months we will be able to give some feedback to the group on how it works.
I would almost never use a mechanical valve in the tricuspid position as they all clot. I am prejudiced to the porcine valves in the tricuspid position as the force of opening is less and theoretically you should have less risk of thrombosis which even occurs with tissue valves in the tricuspid position. This is presumably due to the slower flow through the tricuspid.

Tom Martin
U of Florida
Gainesville

-----Original Message-----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Sun, 2 Mar 2008 11:52 am
Subject: RE: [HSF] TVR with liver failure

> 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?
> > -m
But what does it matter? This patient already has cirrhosis. The aim of surgery 
here is not to improve liver dysfunction (which has been assumed to be 
irreversible if listed for a transplant) but to make the liver transplant safer 
from the cardiac perspective and to protect the new liver from high venous 
pressure.

If a tissue valve you can consider balloon dilatation.

Suggest to the liver surgeons that you do a combined procedure - you will 
rereplace the valve at time of liver transplant. That way both operations become 
survivable. I bet you they will run a mile. That way you see how committed they 
are to this patient rather than seeking an excuse not to do the transplant. If 
you operate now, I bet you will find the patient die on your hands of liver 
failure and be told post-operatively by liver team (who you were doing a favor) 
that the patient is too sick to transplant.

Ani

> Date: Sun, 2 Mar 2008 10:56:34 -0500> From: msfirst at gmail.com> To: 
OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] TVR with liver failure> CC: > 
> 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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