AW: [HSF] Calcified Homograft

Wed Mar 19 16:23:15 EDT 2008

> Firstly, is this patient an operative candidate? To me the answer is yes. Thus the suggestions for solutions for non

>operative patients need to be put to the bottom of the list. We have discussed earlier the issues re redos. Seems like

>many of  today's surgeons shy away from them. 

Ben

This is so very true - I was at the UK meeting last week and listened to presentations about transpical AVI, transfemoral AVI and also stenting of arch aneurysms with extra-anatomic bypass. The common theme I saw in all these cases is that surgeons are increasingly using (easier but less or questionably effective) novel procedures that should (at the current time) be reserved for research studies or inoperable cases as a means to avoid doing a difficult operation. I stood up and asked one presenter what he considered a too high operative risk for conventional AVR and he said 15% - hardly a definition of inoperable. Another presenter was stenting Marfan arch aneurysms because patients were 'too old or high risk' for an arch replacement yet half his patients were below 68. What is more interesting is how soon these patients are converted to conventional surgery if they have procedural complications suggesting that they were never inoperable in the first place.

We are more and more falling guilty of what we accuse the cardiologists of - opting for an easier but less effective (long-term) solution in order to avoid the high immediate procedural risk or to avoid having to do a tough operation.

Using experimental procedures as an alternative to conventional surgery is okay in the context of trying to advance science and practice, but provided this is with informed consent of the patient and necessary ethics/IRB approval. However, these procedures must not be used in the non-research setting as an alternative to conventional surgery simply because the surgeon is keen to avoid a tough operation or does not want to take the risk. 

There is nothing unusual about the case presented - hundreds, if not thousands, have been done worldwide with good results. The coronary ostia are almost always soft and supple and the calcified homograft can be disconnected from these ostia, from the LV and from the distal aorta. The rest can be chiselled away piecemeal just enough that is necessary to allow placement of new conduit. It is hard work and as you say needs patience and planning but that is no justification to resort to experimental options in such a young patient - the other option Tea suggests, referral to a surgeon who has interest or track record in doing such cases, should in my opinion be much higher on the list than 'solutions' such as AVI and apicoaortic conduit.

Ani

> Date: Wed, 19 Mar 2008 23:31:45 +1000> To: OpenHeart-L at lists.hsforum.com> From: benjamin.bidstrup at bigpond.com> Subject: Re: AW: [HSF] Calcified Homograft> CC: > > > Firstly, is this patient an operative candidate? To me the answer is > yes. Thus the suggestions for solutions for non operative patients > need to be put to the bottom of the list.> We have discussed earlier the issues re redos. Seems like many of > today's surgeons shy away from them. Esp CABG. For many years these > were a regular occurrence and did not add much to our operating time > or concerns.> I have worked in several centres where multiple redos were frequent - > replacement of degenerate tissue valves and homografts.> This case will need some patience and planning. Does the CT have a > good 3D reconstruction?> With patience, even a heavily calcified root can be dissected free. > You are likely to be left with the top of the LV, 2 coronaries and > the distal aorta. A valve conduit is suitable here. May need some > bovine pericardium to help in joining the conduit to the LV if there > is residual damage from the earlier endocarditis.> > If the coronary orifices are damaged in the dissection, then a Cabrol > or CABG procedure will be needed.> > Go for an anatomical reconstruction. Be patient - first case and only > case for the day. Have a good night's sleep prior.> > > > >Z,> > I have done three apico-aortic conduits for patients who otherwise would> >not have been operative candidates. I use the coring device from the> >HeartMate LVAD which works fine. Additionally, if you use the > >Medtronic apical> >conduit I'm pretty sure it comes with a coring device. Make the > >hole relatively> >small and dilate it to the size you need with Hagar dilators. Each of these> >cases has been relatively easy, certainly in comparison to doing a> >traditional redo. All are doing very well.> >> >> > > > Ed> >> >Edward P. Raines, M.D., J.D.> >BryanLGH Cardiothoracic Surgery> >BryanLGH Medical Center East> >1600 South 48th Str.> >Lincoln, Nebraska 68506> >Office: 402-481-8430> >Cell: 402-730-9242> >Fax: 402-481-8429> >> >> >> >In a message dated 3/19/2008 7:34:13 A.M. Central Daylight Time, > >zzhoumd at pol.net writes:> >> >> >I went to see Dr. Brown (who has the largest series of this kind case) a few> > months ago for apical conduit case which is a little nerve racking. Make> >sure that you have level one infuser available. The problem is no good device> >for making the hole on the LV.> >> >I do not know how well a mechanic valve will perform in such conduit.> >> >Z Zhou> >> >> >> >Sent via BlackBerry by AT&T> >> >-----Original Message-----> >From: Hgrmd at aol.com> >> >Date: Wed, 19 Mar 2008 06:20:08 > >To:OpenHeart-L at lists.hsforum.com> >Subject: Re: AW: [HSF] Calcified Homograft> >> >> >Roberto,> >I would vote for an anatomic solution at this woman's young age. Though I> >don't have an extensive experience (fortunately) with these types of cases,> >I distinctly remember doing a failing homograft a few years ago. It was> >one > >of the hardest cases I can recall. The old graft had to be hacked out with> >Mayo scissors. If the coronary ostia are also heavily calcified and not> >suturable, then grafting the RCA, CX, and LAD may be necessary. I would> >not be in> >favor of an AVI since the patient is so young. Another option would be the> >aortic valve bypass, which is the LV apical-descending aorta conduit. In > >fact, I plan to do my first such case next month with Jim Gammie proctoring> >the> >case.> >> >Hal> >> >> >> >**************Create a Home Theater Like the Pros. Watch the video on AOL> >Home. > >(http://home.aol.com/diy/home-improvement-eric-stromer?video=15?ncid=aolhom000> >30000000001)> >_______________________________________________> >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> >-----------------------------------------> >> >> >> >> >> >**************Create a Home Theater Like the Pros. Watch the video on AOL> >Home. > >(http://home.aol.com/diy/home-improvement-eric-stromer?video=15?ncid=aolhom00030000000001)> >_______________________________________________> >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> -----------------------------------------
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