[HSF] AATS

Sat May 17 22:54:53 EDT 2008

Hey Hal - I did more than attack results of CCF and Barnes - there were at least 20 other papers I went through! I was trying to bring more understanding to the interpretation of the literature - using mitral repair as an example - rather than discuss the results of mitral repair but I suppose everyone took a different message from it and what stood out the most had to be the challenging of CCF literature which is regarded by most as sacred gospel. 

As regards MICS, we have changed our views substantially and do not oppose it - provided at the end you have a high repair rate, a valve that does not leak, a valve with good coaptation and with low morbidity/mortality, it does not matter that much how it was achieved (sternotomy, thoracotomy, subxiphiod, tansvenous, transvaginal (maybe oneday) etc). Our criticism is that what we see increasingly is surgeons adapting mitral operations to minimally invasive surgery (the goal being to perform any operation, whether the best for the patient or not, via a small hole rather than focus on the best operation for the valve); this is in contrast to adapting the minimally invasive approach to mitral surgery (as you and others have done thereby applying the least invasive technique - sometimes sternotomy - to achieve the best repair result). Like I said to you we are starting MIS for selected cases and one of our team is going to spend few weeks in Leipzig next month.

One other paper I found interesting was one presented by Hayward on behalf of the Melbourne group (Buxton's) on 8 year outcomes of a two arm randomized trial between radial artery and RITA and RA and SVG. All were equivalent at this time point. What I found most interesting was not this result, which is not unexpected at 8 years, but the patency of their saphenous vein grafts (90% at one-year). Of course it was brought up how come in Melbourne they achieve such excellent vein graft patency compared to 70% patency seen in most recent US studies. The answer was that it is likely down to the way the vein is treated. All veins are harvested meticulously by an attending surgeon, all harvested open with a strict non-touch technique, all treated exactly the same way as an arterial conduit - injected with blood and papaverine solution etc, all patients get milrinone for 24h as a conduit dilator...this compares to the commercially driven brutalization of veins by endoscopes that is prevalent in North America. Agree endoscopic harvest can be atraumatic to the vein but that has to be the exception rather than the rule. Little wonder if one walks by the cath-lab it is not unusual to see grafts implanted a few months before that are severely diseased. Last year we had a lady operated by a colleague where four of five grafts all blocked in six months - she was 47 and of course only open graft was LIMA and all the endoscopically harvested veins were blocked - all for the sake of a small scar on the leg, avoiding risk of leg infection, enriching industry and not taking the effort and time to do the more tedious operation (multiple arterial grafting). If I have a CABG I don't want vein unless I don't have arterial conduit or an emergency - and if so i want it taken open, never an endoscope.

Ani

> From: Hgrmd at aol.com> Date: Sat, 17 May 2008 09:26:43 -0400> Subject: Re: [HSF] New case- CAD + Leriche> To: OpenHeart-L at lists.hsforum.com> CC: > > Prasanna,> Honestly, I spent a good bit of the conference networking. However, there > were a few key papers that made an impression. We've already referred to > the presentations by David Adams and Ani. David proposed a classification > system for degenerative mitral disease with fibroelastic deficiency on one end > and Barlow's on the other end of the spectrum. "FED +" is isolated excess > tissue in the area of the prolapse, i.e., the rest of the valve appears to be > FED. "Form fruste" is intermediate between FED + and Barlow's. I don't know > if this classification system will ever catch on, but I think it actually > exists. It has important implications in the strategy for repairing degenerative > valves. The FED valves have no excess tissue. They are the ones in which > resection is a mistake. Try doing a sliding leaflet plasty on an FED valve. > It won't work. In contrast, the Barlow's valve should frequently require > resection so as to not have more tissue than can be accomodated by the valve > orifice without producing SAM. > David also spent time denigrating the results of minimally invasive valve > surgery from Vanderbilt in this month's edition of Annals. Unfortunately, I > think it's part of his condemnation of minimally invasive approaches in > general. Anyway, this paper showed less than a 50% repair rate. For anterior > leaflet repair, the rate was around 21%. For ischemic MR, the rate was 11%. > Actually, I think Dave should have looked at the historic open repair rate for > the main surgeon in that paper, because I know for a fact that this particular > surgeon doesn't do much repair work anyway. Whether Dave likes it or not, > minimally invasive mitral repair is here to stay. I've now got people > traveling considerable distances to get a small incision repair.> Ani's presentation was also incendiary in that he attacked the results of > ischemic MR repair from CCF and Barnes. He rightly pointed out that their > crappy results were most likely due to the use of flexible bands rather than > rigid rings for such valves. The Barnes results are in this month's Annals > with Crabtree as the first author.> Califiore presented a paper in which he advocated an aggressive stance > towards concomitant tricuspid repair. He basically said to repair any tricuspid > that had mild or worse TR at the time of surgery. He didn't mention > repairing nonleaking dilated tricuspids (>40mm systolic diameter), regardless of the > degree of TR, which I think is the correct approach. Unfortunately, his > repairs were done using the DeVega. At one year followup, over 50% of his > tricuspids had moderate or worse TR. The discussion of his paper was memorable > for me, because I discussed it after Dr. DeVega discussed it. Of course, > DeVega supported Califiore's technique and said some sort of humorous nonsense how > we surgeons shouldn't be influenced by the "Lords of the Rings". I told > Califiore that I applauded his aggressive stance for the "forgotten valve", but > that I respectfully disagreed with using the DeVega. I pointed out that > Tirone David had a recent publication demonstrating the poor durability of > DeVega's as compared to rings. I also pointed out that the presence of moderate or > worse TR at one year was not satisfactory in my eyes. I asked him if he > planned to track these valves by echo beyond one year, and if he planned to use > rings in the future. He replied that he thought his results were > satisfactory (!!!), but that he was now using rings on the most severe cases.> There was a presentation on the Wolf minimaze that showed that it only > reliably works for PAF. Ganglionectomy, in addition to PVI, doesn't apparently > improve the results. To me, the Wolf is essentially dead. It is a > dangerous, very painful procedure accomplishing what can generally be done through a > catheter based approach (other than stapling of the LAA).> > Hal > > > > **************Wondering what's for Dinner Tonight? Get new twists on family > favorites at AOL Food. > (http://food.aol.com/dinner-tonight?NCID=aolfod00030000000001)> _______________________________________________> 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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