[HSF] Mitral ring redux

Sun May 4 21:43:30 EDT 2008

I don't know exactly. Probably 5-10 a year more often the former. As you may know I think we could learn about the ventricle if we would study it more especially with CMR. There is a real block in the thinking of everyone from heart failure cardiologists, EP doctors, to community surgeons doing their 100-150 CAB a year like myself. I think we will have to wait on the Stitch trial to start hammering people to do the right thing which includes evaluating the patient from the long term perspective rather than the "urgent" severe CAD with poor EF. Patients with and without hyper enhancement (scar or acute injury) and with and without LV dilation, I think and have cases as protypes, will behave differently to acute and delayed surgery. I don't have long term data to these points and they are observational only at this point. There is also a wide spectrum of disease depending on who is engaging the patient as per our recent discussion on Michael's case. I am
 confident and have some indirect insight that the Stitch trial will show SVR is better therapy, however. As you know there is recent paper showing the long term (couple of years) results of MR annuloplasty for CHF is dependenat on "remodeling" of the LV. If the surgeon "remodels" the LV at the time of annuloplasty, the patient has a head start in the right direction.

tea

----- Original Message ----
From: "Douville, Chuck" <ecdouville at orclinic.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Sunday, May 4, 2008 6:19:37 PM
Subject: RE: [HSF] Mitral ring redux

Tea may I ask you, as your opinions are well thought out, how much SVR you are doing, and perhaps how much others are doing. Cases per year?  I took a course at STS a couple of years ago at STS but have not done one since. Anyone else in this camp on the forum?

________________________________

From: openheart-l-bounces at lists.hsforum.com on behalf of Tea Acuff
Sent: Sun 5/4/2008 3:52 PM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Mitral ring redux

I would like to raise the issue as to why this patient has a dilated myopathic ventricle. With a LV dimension of 7 cm he must have a large ESV and EDV but the exact numbers would be reassuring for consideration prior to intervention. It is very doubtful that his MR is causative or even contributory at this point. Most likely he has a substantial ant/septal infarction which likely can be "cured" or stabilized with SVR. This may or may not even require direct surgical annular narrowing. Undoubtedly this clinically based on population studies occurs over and over and is largely missed as this thread would suggest. A cardiac MR would be very helpful to make this diagnosis, but as Ani would argue the odds are (in such population) that SVR would help the majority of the patients with this description and should be ruled out before deciding on alternative therapy. It may be quite difficult to make a clear intra op decision without opening the LV because of
frequent lack of full thickness scarring and the primary endocardial pattern of scarring. If you are not aggressively inclined to do SVR on this population, you will very likely  not make the correct assessment intra op.

tea

----- Original Message ----
From: Mitch Lirtzman <drmitch at cox.net>
To: OpenHeart-L at lists.hsforum.com
Sent: Saturday, May 3, 2008 9:26:14 AM
Subject: Re: [HSF] Mitral ring redux

Being well aware of Bolling's work, I opted not to get into a pissing match
with my colleague.

Nonetheless, he does have a left bundle, about 0.16- 0.18. By echo and on
the V-gram, his anterior wall moves, albeit sluggishly.

MitchAt 10:02 PM 5/2/2008, you wrote:
>There is no thing as a pop of valve MR in current thinking. Stephen Bolling
>has proven that well. Wether there will be a sruvival advantage in low EF MR
>is a different question altogether.Incidentally has his QRS widened ?
>Prasanna
>Prasanna
>
>On Sat, May 3, 2008 at 8:18 AM, Mitch Lirtzman <drmitch at cox.net> wrote:
>
> > Please help clarify a point I made concerning mitral repair.
> >
> > I have a 50yo male smoker with no history of drugs, EtOH, industrial
> > exposure, etc, and rather severe CAD. The LAD is previously stented and
> > occluded at it's origin. Fills rt-to lt. The Cx has a proximal 90% lesion.
> > RCA normal. EF is 20%. LVEDD~ 7cm. TEE shows moderate MR with a central jet
> > to mid-atrium. Septum and lateral walls still move. Previously refused by
> > another surgeon. They putzed around with him at the local Charity hospital
> > til he went into VT...and sent him to me. Still has occasional chest pains
> > in ICU.
> >
> >
> > Frankly, the guy has no chance without surgery and at high risk with it.
> > I've done bunches of low-EF patients with quite satisfactory results. The
> > question is that I plan to put a "quick" ring on his mitral as has been my
> > practise for several years. You all know the possible scenario in six
> months
> > with CHF and worsening MR, if the MR is not corrected. The cardiologist
> > feels that his LV won't be able to take the added strain without that
> > "pop-off valve".
> >
> > Thanks in advance for your comments and advice in advance.
> > Mitch
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>
>--
>Prasanna Simha M
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