[HSF] Calcified Homograft - Found word(s) cum in the Text body

[Tea Acuff]

I agree with the basic recommendation to re-reconstruct the root. This is in theory only as I have not done a case like this. When I am seeing a once or twice in a career case, I would see if surgeons are around with with more than theory under their belt. If you want to make a career of this type of case, that is different. We can't send all the virgins to one guy.

I know you weren't looking for a funny story, but i am still laughing at this one from today. A cardiologist was telling me about an elderly patient with a poor LV and Cab twice with ugly targets and associated morbidities. While I was on the phone with this cardiologist I was with a surgeon who did a 9 hour case yesterday, a redo this redo that etc, and who was a good friend of the cardiologist also. I said, "I think we should send this case to Dr. X (who was in the room), while laughing and mentioning the redo, redo patient under my breath. The cardiologist quickly quipped, "Oh, you mean the Do-do doctor." (For the non English language reader, this is a scatological pun.)

tea



----- Original Message ----
From: Demertzis Stefanos <Stefanos.Demertzis at cardiocentro.org>
To: OpenHeart-L at lists.hsforum.com
Sent: Tuesday, March 18, 2008 1:05:18 PM
Subject: R: [SPAM] - [HSF] Calcified Homograft - Found word(s) cum in the Text body

Hi George!

Boy, this is a tough case.... My best bet would still be a composite graft replacement of the whole aortic root and the ascending aorta. I would cannulate the right axillary artery, so if the aorta shoud be unclampable to be able to proceed to circulatory arrest with antegrade cerebral perfusion. If the dissection around the coronary ostia is too messy, there is always the option of some variation of the Cabrol approach. The composite graft can be attached deeply "under" the homograft's proximal suture line, even at the level of the insertion of anterior mitral leaflet. At this age I would go for an "anatomical solution" and not for a potentially irreversible one (such as the Sapien valve or the apico-aortic conduit)despite the fear of infection. The composite graft record even in cases of destructive endocarditis with multiple abscesses around the root is good, provided the debridment is carried out extensively. I can feel the pain of the decision
 though...

ALl the best & good luck!


PD Dr. med. S. Demertzis
Cardiocentro Ticino

www.cardiocentro.org



-----Messaggio originale-----
Da: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-bounces at lists.hsforum.com] Per conto di G T Stavridis
Inviato: martedì, 18. marzo 2008 13:51
A: OpenHeart-L at lists.hsforum.com
Oggetto: [SPAM] - [HSF] Calcified Homograft - Found word(s) cum in the Text body


Dear Forum,

32 year old female with previous AVR (Subcoronary Homograft) and MVPlasty with a pericardial band in 1995, subsequently, in 1996, underwnt Redo AVR (new Homograft as a root inclusion) and MVRepair with 
C-E Ring and sliding plasty because of  fungal endocarditis  of the original Homograft. She remained for almost 8 years on antifungal therapy. Gradually over the years she developed modearte symptoms NYHA II. Now her ECHO has worsened with the following findings:
LA=71mm(was 60), EDD/ESD 58/42  E`F~~50% RVEF=40%  TDI=5m/sec, AVA 0.8cm2 AVpgrad 65mmHg  3/4 MReg  and MVA 1.4cm2, PHYT.
The coronary angiography appears normal, with severe calcification of the ARoot and the prox 2/3 of the AsAo. The CT chest in addition shows circumferential calcification of the involved Aorta. Realizing the technical difficulties of this Redo-Redo case as far as the prox Ao is concerned, would you consider for the AVR (despite her young age) the solution of the apical valved conduit, the transapical SAPIEN or the implantation of a mechanical prosthesis at the level of midAscAo-(Hufnagel)  in addition to MVR!!!. Of course one can embark on the difficult approach of Redoing the AValve..is it easy to endarterectomize the homografted aorta in order to create a suturable area ?? is the type of calcification worse than the native porcelain aorta?? ANY OTHER IDEAS!! Thanks in advance

G T Stavridis MD FETCS
Onassis Cardiac Surgery Ctr.
AThens GREECE 
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