[HSF] Rt thoracotomy MVR

Thu Mar 13 22:37:14 EDT 2008

Tea 

I think you are right in your analysis (of my view point), but just to clarify to others on my earlier contribution regarding right thoracotomy for mitral surgery.

1) My comments do not necessarily represent my personal views or practice but are my summation of reality and data  i may well do things different or believe different from what i say. 

2) Anything *is* possible through a right thoracotomy - even a heart transplant - provided it is big enough. That is not the manner in which thoracotomy for mitral surgery is marketed in the present day. It is sold as a mini-invasive procedure. I have seen several patients who had previous mini-mitral or aortic surgery via the right thorax where the thoracotomy scar is longer than the sternotomy scar. 

3) Whatever we mat claim, there is a limit to what is surgically possible via minithoracotomy compared to a median sternotomy. This limit varies from surgeon to surgeon. While some surgeons maybe able to repair an AV canal defect via a minithoracotomy others will only be comfortable placing an annuloplasty ring or replacment prosthesis.

4) Robotic surgery is a very different entity from right thoracotomy surgery. That the robotic ports are in the right thorax is incidental and a matter of convenience. I certainly agree that with a robot most things will be achievable - indeed it is likely that with a robot one can achieve some things with better ease and accuracy than via sternotomy because of superior vision, better instrumentation, and more degrees of freedom. 
5) While it may be true that some surgeons can perform ANY mitral procedure via the left or right chest, this is the exception rather than the rule. Only a few here even seem to be familiar with the left thoracotomy route. We can talk the talk all we like but the reality is that few surgeons are capable of performing even routine mitral procedures seamlessly via a left or right thoracotomy. Again I would caution on a team that is not used to this approach applying it in a complicated scenario. If list members recall, the last case I argued against use of a right thoracotomy (the reop TVR) ended up disatrous. In an unusual or complicated case, the median sternotomy is, in most scenarios, the safest and most controlled route.

6) Stating all mitrals can be done via any single incision (including sternotomy) is akin to our previous discussions like all CABG can be done off-pump, all CABG without aortic touch and all valve operations with a beating heart. Possible in a few hands but impossible in most hands.

7) While it is possible, I doubt most surgeons here would truly elect for the thoracotomy approach if they were treating this patient. I might be the only one speaking out but I think we are making this procedure much more complicated than it need be.

Ani

> Date: Wed, 12 Mar 2008 21:50:38 -0700> From: tacuff at swbell.net> Subject: Re: [HSF] Rt thoracotomy MVR> To: OpenHeart-L at lists.hsforum.com> CC: > > Interesting theory, Ani. Your ideas follow a pattern. We can talk about that later, but for now you suggest the following.> > Results are determined by approach. So far, perhaps, no problem. This however leads to standardization of approach for sake of the operation. Perhaps, not a problem, but I can think of collaries that show the error of such thought.> > comments?> > tea> > > > ----- Original Message ----> From: Ani Anyanwu <anianyanwu at hotmail.com>> To: openheart-l at lists.hsforum.com> Sent: Wednesday, March 12, 2008 6:27:35 PM> Subject: RE: [HSF] Rt thoracotomy MVR> > Hal> > This is most certainly fact. I am out of the country right now and have only limited internet access so am not able to get you exact references. However if you do a pubmed search on either of those authors and also search on Colvin, Cosgrove and Cohn (mini mitral via via non=endoscopic approach) you will get the exact figures and find replacement rates between 7 and 15 %. Indeed in Vanermans's initial series his replacement rate was 30%. There is no doubt that the limited access and tactile control limits what can be done via any mini-incision. Indeed I heard Chitwood give a lecture just this week and he still does the odd replacement via thoracotomy. It depends on what one's priorities are - if it is to use a side or mini incision for all cases then there will be some avoidable replacements. If it is to repair all cases then (as you will testify) the surgeon will agree that in some cases a sternotomy may be the preferable option. > > Obviously these data are historical as they include initial experience, and having overcome the learning curve these gurus can likely repair almost everything via mini access but the same definitely does not apply to the occasional 'side surgeon'.> > Ani> > > > > From: Hgrmd at aol.com> Date: Wed, 12 Mar 2008 06:19:16 -0400> Subject: Re: [HSF] Rt thoracotomy MVR> To: OpenHeart-L at lists.hsforum.com> CC: > > Dear Ani,> That's a pretty provocative statement you made about Vanermen, Chitwood, > and Mohr. Not that I'm doubting you, but could you please provide references > demonstrating what you stated? I realize your boss advertises a nearly > "100%" repair rate on his website. He is also quite vocal in his opposition to > any approach other than full sternotomy. The problem is the public doesn't > want a full sternal split for the average mitral repair.> > Hal> > > > **************It's Tax Time! Get tips, forms, and advice on AOL Money & > Finance. (http://money.aol.com/tax?NCID=aolprf00030000000001)> _______________________________________________> 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> -----------------------------------------> _________________________________________________________________> Who's friends with who and co-starred in what?> http://www.searchgamesbox.com/celebrityseparation.shtml_______________________________________________> 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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