[HSF] Isolated Severe TR in a redo

Sat Aug 1 20:17:21 EDT 2009

Judgement call.Very often they do better without a leaking valve than with
one.The key is often the comorbidities.
Prasanna

On Sat, Aug 1, 2009 at 11:43 AM, Donald Ross <donross at bigpond.com> wrote:

> Does that mean you would not operate on this very late case?
> Don
>
> On 01/08/2009, at 11:48 AM, Prasanna Simha M wrote:
>
>  Why does right heart surgery have a higher mortality - simply because of
>> two
>> reasons - we are sent  the cases late - (who will operate on isolated TR
>> is
>> a common commnet) forgetting that just like MR can cause the LV to
>> deteriorate the TR can cause the RV to deteriorate and RV function is far
>> more difficult to determine than LV function in the declining phase.
>> The second cause is that while LV dysfunction hits the lungs and causes
>> erlier symptoms the V failure causes whole body fialure which can be
>> insiduous till late RV dysfunction has set in. Of course you need 4-5
>> litres
>> to accumulate before you get even mild pedal edema and 10 -15 litres when
>> you have ascites  and other over features. This leads to major body
>> upheavals when  we disturb the balance by going in for surery which is a
>> point correction.
>> I have had a cardiologist who sends me non resolving TR early and those
>> patients have done well with patients saying they have had striking
>> improvements in quality of life that they did not relaize they had subtely
>> lost compared to those who send them late .
>> Prasanna
>>
>> On Sat, Aug 1, 2009 at 6:18 AM, Donald Ross <donross at bigpond.com> wrote:
>>
>>  I  would be cautious also having had some bad experiences after isolated
>>> TR
>>> surgery.
>>> I remember trying to ascertain the reasons on the HSF without a
>>> satisfactory conclusion.
>>> There are many variables of course and if you have seen good results in
>>> similar situations then one has acknowledge that.
>>>
>>> Don
>>>
>>> On 01/08/2009, at 5:01 AM, Ani Anyanwu wrote:
>>>
>>>
>>>  Can I just ask what we are going in to do here and why? What do we tell
>>>> her she will gain from having surgery?
>>>>
>>>>
>>>>
>>>> This lady has had severe TR for 10 years.
>>>>
>>>>
>>>>
>>>> She is 75 years old.
>>>>
>>>>
>>>>
>>>> She is truly 75 given that she has been setback so much by a UTI to
>>>> require hospitalization.
>>>>
>>>>
>>>>
>>>> Although on one had Michael says if not fixed she will "continue to be
>>>> miserable" on the other hand he says she is relatively healthy and
>>>> functional - which is it?
>>>>
>>>>
>>>>
>>>> Have we excluded liver fibrosis?
>>>>
>>>>
>>>>
>>>> Finally, there is no such thing as minimally invasive reoperative
>>>> tricuspid valve surgery...particularly in a 75 year old. Her body may
>>>> well
>>>> find this surgery more invasive than her prior double valve replacement,
>>>> even if done with aid of Hal's or Ed's robot.
>>>>
>>>>
>>>>
>>>> There is a distinct possibility that surgery worsen or shorten her life
>>>> compared to what she has now, so a recommendation to have surgery should
>>>> be
>>>> made only if there is tangible and realistic expectation of significant
>>>> benefit. The indications for surgery were probably clearer 10 years ago
>>>> than
>>>> they are now...
>>>>
>>>>
>>>>
>>>> Ani
>>>>
>>>>
>>>>
>>>>
>>>>
>>>>
>>>>
>>>>
>>>>
>>>>
>>>>
>>>>
>>>>
>>>>
>>>>
>>>>
>>>>
>>>> From: prasannasimha at gmail.com
>>>>
>>>>> Date: Fri, 31 Jul 2009 22:39:20 +0530
>>>>> Subject: Re: [HSF] Isolated Severe TR in a redo
>>>>> To: OpenHeart-L at lists.hsforum.com
>>>>> CC:
>>>>>
>>>>> Go in after endocarditis is ruled out or is treated.Dont go in too
>>>>> quickly
>>>>> and find out RV function first.
>>>>> Prasanna
>>>>>
>>>>> On Fri, Jul 31, 2009 at 9:07 PM, Michael Firstenberg <
>>>>> msfirst at gmail.com
>>>>>
>>>>>> wrote:
>>>>>>
>>>>>
>>>>> I was recently asked to see a very pleasant and relatively healthy and
>>>>>
>>>>>> functional 75 year/old lady.
>>>>>> She had a mechanical AVR and MVR replacement many years ago for
>>>>>> rheumatic
>>>>>> disease.
>>>>>> An echo from 10 years/old reports severe TR.
>>>>>> She is admitted now with probably urosepsis for which an echo was
>>>>>> obtained.
>>>>>> She does had a little "something" on her mitral and a trace
>>>>>> paravalvular
>>>>>> leak and a small PFO
>>>>>> No one is very excited about her having endocarditis
>>>>>> But by question is if it is worth going after her tricuspid
>>>>>> - obviously know rush and let her get completely cleared of her any
>>>>>> and
>>>>>> all
>>>>>> infections
>>>>>> (like 6 wks of abx just in case and repeat TEE)
>>>>>>
>>>>>> The right atrium is "severely enlarged" - I dont have exact numbers
>>>>>> and
>>>>>> her
>>>>>> RV was not well visualized.
>>>>>> She also has a history of pulmonary hypertension - but again, only by
>>>>>> history
>>>>>>
>>>>>> The clinical inidcations are severel bilateral leg swelling and
>>>>>> probably
>>>>>> some component of heart failure secondary to low forward flow (and
>>>>>> some
>>>>>> minor renal insuffiency).
>>>>>>
>>>>>> My thought is that if not fixed, she is going to continue to be
>>>>>> miserable
>>>>>> and only worse..... even though this has been going on for at least 10
>>>>>> years.
>>>>>>
>>>>>> I would probably just put in a tissue valve (the leaftets appear
>>>>>> trashed
>>>>>> by
>>>>>> the same process that destroyed her aortic and mitral)
>>>>>>
>>>>>> -michael
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>>>>>
>>>>> --
>>>>> Prasanna Simha M
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>> --
>> Prasanna Simha M
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-- 
Prasanna Simha M