[HSF]Closing PFO's/ small ASD-informed consent

Tea Acuff tacuff at swbell.net
Mon Aug 3 22:34:19 EDT 2009 

sounds like a bad time for a discussion....

tea




________________________________
From: Donald Ross <donross at bigpond.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Monday, August 3, 2009 11:18:56 PM
Subject: Re: [HSF]Closing PFO's/ small ASD-informed consent

Prasanna and Roberto, the guy has his chest open undergoing an opcab when the ASD is discovered!
Don
On 04/08/2009, at 5:37 AM, Roberto Battellini wrote:

> 
> the best is to tell the patient that in the future he can have a stroke by not having closed the PFO because of the JAMA paper.
> 
> Roberto and Tea
> 
>> Date: Mon, 3 Aug 2009 12:55:23 -0400
>> Subject: Re: [HSF]Closing PFO's/ small ASD
>> From: msfirst at gmail.com
>> To: OpenHeart-L at lists.hsforum.com
>> CC:
>> 
>> but doctors, he has a hole in his heart that has been linked to strokes and
>> he just had a stroke and you were in there but chose not to close it?
>> 
>> 
>> -michael
>> 
>> 
>> 
>> 
>> On Mon, Aug 3, 2009 at 10:12 AM, <rwmfglycar at aol.com> wrote:
>> 
>>> So he went 65 years without trouble.Probably has a good chance? of living
>>> with his small septal hole for whatever extra years you have given him with
>>> your coronary surgery.
>>> Bob
>>> 
>>> 
>>> -----Original Message-----
>>> From: Roberto Battellini <robertobattellini at hotmail.com>
>>> To: lists HSF <openheart-l at lists.hsforum.com>
>>> Sent: Mon, Aug 3, 2009 3:48 pm
>>> Subject: RE: [HSF]Closing PFO's/ small ASD
>>> 
>>> 
>>> 
>>> 
>>> all you have done is correct: opcab and no ASD closure or Oncab and ASD
>>> closure.
>>> 
>>> Roberto
>>> 
>>>> From: donross at bigpond.com
>>>> To: OpenHeart-L at lists.hsforum.com
>>>> Subject: Re: [HSF]Closing PFO's/ small ASD
>>>> Date: Mon, 3 Aug 2009 22:56:59 +1000
>>>> CC:
>>>> 
>>>> Just to widen the discussion to something perhaps important:
>>>> I did a routine opcab and a small ASD was found on routine TEE.
>>>> There was no bruit or CXR stigmata for ASD
>>>> What should I have done? (Patient 65 male)
>>>> Don
>>>> On 03/08/2009, at 9:18 PM, Ani Anyanwu wrote:
>>>> 
>>>>> 
>>>>>> I agree that increased risk of stroke is difficult to explain.
>>>>>> However, the message that closing an asymptomatic PFO does not add
>>>>>> any benefit to the patient does not seem so trivial to me. >
>>>>>> G
>>>>> 
>>>>> While it may be true that closing an asymptomatic PFO might not be
>>>>> beneficial, as DR Frater says we should not use bad studies to push
>>>>> forward our views, especially when the single most important reason
>>>>> for closing PFOs (prevention of future strokes from paradoxical
>>>>> embolism) was not examined. Without data on long-term stroke rate,
>>>>> the study cannot conclude on whether closing PFOs is beneficial.
>>>>> Presenting beautiful long-term survival rates wont cut it as I doubt
>>>>> there are many surgeons closing these PFOs who feel that this 60
>>>>> second manouver is prolonging patient's lives.
>>>>> 
>>>>> 
>>>>> 
>>>>> To tease out the effect of PFO closure the authors should have
>>>>> limited the study either to patients having mitral or tricuspid
>>>>> surgery (where the atria are opened), or patients having surgery
>>>>> where the left heart is not opened (such as CABG), or having surgery
>>>>> where the left heart is opened but the atria are not (AVR).
>>>>> Combining such heterogenous operations does not make sense. The
>>>>> authors have not even excluded patients having ventricular assist
>>>>> devices who have a definite indication for closing the PFO and also
>>>>> have a much higher incidence of stroke. Thus you end with a bizarre
>>>>> conclusion which suggests
>>> that when you do a mitral you should be
>>>>> sure when closing your left atrium to preserve the communication
>>>>> between both atria. For many, who make incisions deep in the
>>>>> interatrial groove, or in the interatrial septum, the PFO will be
>>>>> closed inadvertently when the atriotomy incisions are closed even if
>>>>> no deliberate attempt was made to do so.
>>>>> 
>>>>> 
>>>>> 
>>>>> Personally, I would not open an atrium to close an incidental PFO
>>>>> except in an LVAD patient. I would also not go on pump to do a CABG,
>>>>> just so I can close a PFO. I agree with Dr Salerno that if a problem
>>>>> emerges it could be closed with a device. However, with the atrium
>>>>> wide open for mitral or tricuspid surgery I struggle to see how some
>>>>> more prolene in the heart can make a difference to a left atrium
>>>>> already riddled with suture line and foreign material.
>>>>> 
>>>>> 
>>>>> 
>>>>> 
>>>>> 
>>>>> Ani
>>>>> 
>>>>> 
>>>>> 
>>>>> 
>>>>> 
>>>>> 
>>>>>> Date: Mon, 3 Aug 2009 09:05:53 +0200
>>>>>> From: grescigno at mac.com
>>>>>> To: OpenHeart-L at lists.hsforum.com
>>>>>> Subject: Re: [HSF]Closing PFO's
>>>>>> CC:
>>>>>> 
>>>>>> I agree that increased risk of stroke is difficult to explain.
>>>>>> However, the message that closing an asymptomatic PFO does not add
>>>>>> any benefit to the patient does not seem so trivial to me. I always
>>>>>> keep in mind this: "what is useless may be harmful".
>>>>>> 
>>>>>> G
>>>>>> 
>>>>>> 
>>>>>> 
>>>>>> 
>>>>>> 
>>>>>> On Monday, 03 August, 2009, at 03:35AM, "Prasanna Simha M"
>>> <prasannasimha at gmail.com
>>>>>>> wrote:
>>>>>>> Actually I was going to post that in etrads we actually make PFO's
>>>>>>> by
>>>>>>> stabbing the IAS (they close down in a couple of months) and
>>>>>>> valved patches
>>>>>>> for near eisenmengers. The vice vesa is also true. They said a
>>>>>>> higher stroke
>>>>>>> rate for PFO closure - could have been due to Afib per se which
>>>>>>> seems to be
>>>>>>> a pretty common arrhythmia post op in the west ..
>>>>>>> The only "possibel" reason for increased stroke could have been
>>>>>>> creation of
>>>>>>> a cul de sac due to the closure suture but
>>> that also seems far
>>>>>>> stretched.
>>>>>>> Seems to be a statsitical exercise. Of course 1 in 20 attempts
>>>>>>> witha p =0.05
>>>>>>> will reject the null hypothesis.
>>>>>>> Prasanna
>>>>>>> 
>>>>>>> On Mon, Aug 3, 2009 at 6:03 AM, Ani Anyanwu
>>>>>>> <anianyanwu at hotmail.com> wrote:
>>>>>>> 
>>>>>>>> 
>>>>>>>> I think there is even less evidence for closing an isolated PFO
>>>>>>>> than
>>>>>>>> closing one incidentally at cardiac surgery. Was a closure of PFO
>>>>>>>> not
>>>>>>>> central to Ariel Sharon's incapacitation or did the rumor mills
>>>>>>>> get that
>>>>>>>> wrong?
>>>>>>>> 
>>>>>>>> 
>>>>>>>> 
>>>>>>>> That said i think this paper is another example of researchers
>>>>>>>> using large
>>>>>>>> numbers to push a result without the backing of a priori
>>>>>>>> hypothesis or
>>>>>>>> biological plausibilty. What would be the plausible explantation
>>>>>>>> why closing
>>>>>>>> a PFO causes higher strokes? Substantial proportion of PFO
>>>>>>>> closures are, for
>>>>>>>> example, in patients having mitral or tricuspid surgery. Assuming
>>>>>>>> either
>>>>>>>> atrium is already open, why would placing a simple or running
>>>>>>>> suture on a
>>>>>>>> PFO cause a stroke? Indeed some surgeons to perform a mitral repair
>>>>>>>> routinely transgress and repair the interatrial septum.
>>>>>>>> Personally, I think
>>>>>>>> this is statistics gone crazy - of course the JAMA editors would
>>>>>>>> not know
>>>>>>>> that as to them closing a PFO sounds like some big procedure,
>>>>>>>> like placing a
>>>>>>>> percutaneous device is, but any surgeon who actually does this
>>>>>>>> operation
>>>>>>>> will realize how silly the results sound and would seek other
>>>>>>>> (statistical
>>>>>>>> or clinical) explanations before advising that surgeons refrain
>>>>>>>> from closing
>>>>>>>> PFOs.
>>>>>>>> 
>>>>>>>> 
>>>>>>>> 
>>>>>>>> While the authors concluded that "the finding that repair may
>>>>>>>> increase
>>>>>>>> postoperative stroke risk should discourage routine surgical
>>>>>>>> closure..."
>>>>>>>> they did not at all discuss in their paper any potential
>>>>>>>> mechanism for such
>>>>>>>> an e
>>> ffect. This is a great flaw in that paper as one of the key
>>>>>>>> requirements
>>>>>>>> for epidemiological association is that there should be a
>>>>>>>> biologicaly
>>>>>>>> plausible mechanism for the observed effect. Otherwise we might
>>>>>>>> as well
>>>>>>>> tomorrow study anything, such as for example the effect of
>>>>>>>> delayed plane
>>>>>>>> flights out of JFK airport and on perioperative mortality aftr
>>>>>>>> CABG - if
>>>>>>>> you observe enough planes and repeat the experiment often enough,
>>>>>>>> you will
>>>>>>>> sooner or later find an effect that more patients died when
>>>>>>>> planes were
>>>>>>>> delayed at JFK...then you can also publish that in JAMA.
>>>>>>>> 
>>>>>>>> 
>>>>>>>> 
>>>>>>>> 
>>>>>>>> 
>>>>>>>> Ani
>>>>>>>> 
>>>>>>>>> From: TSalerno at med.miami.edu
>>>>>>>>> To: OpenHeart-L at lists.hsforum.com
>>>>>>>>> Date: Sun, 2 Aug 2009 19:35:31 -0400
>>>>>>>>> Subject: Re: [HSF]Closing PFO's
>>>>>>>>> CC: OpenHeart-L at lists.hsforum.com
>>>>>>>>> 
>>>>>>>>> If in isolation
>>>>>>>>> 
>>>>>>>>> 
>>>>>>>>> Tx
>>>>>>>>> 
>>>>>>>>> Sent from my iPhone
>>>>>>>>> 
>>>>>>>>> On Aug 2, 2009, at 7:34 PM, "Michael Firstenberg" <
>>> msfirst at gmail.com
>>>>>>>>>> 
>>>>>>>>> wrote:
>>>>>>>>> 
>>>>>>>>>> ?
>>>>>>>>>> 
>>>>>>>>>> -michael/iPhone
>>>>>>>>>> 
>>>>>>>>>> On Aug 2, 2009, at 6:55 PM, "Salerno, Tomas" <
>>> TSalerno at med.miami.edu
>>>>>>>>>>> 
>>>>>>>>>> wrote:
>>>>>>>>>> 
>>>>>>>>>>> Pfo is closed percutaneously
>>>>>>>>>>> 
>>>>>>>>>>> Ts
>>>>>>>>>>> 
>>>>>>>>>>> Sent from my iPhone
>>>>>>>>>>> 
>>>>>>>>>>> On Aug 2, 2009, at 6:06 PM, "Michael Firstenberg" <
>>> msfirst at gmail.com
>>>>>>>>>>>> 
>>>>>>>>>>> wrote:
>>>>>>>>>>> 
>>>>>>>>>>>> can you describe you 2 stage cannula technique?
>>>>>>>>>>>> Do you just make a small additional hole in the RA, suck out
>>>>>>>>>>>> the
>>>>>>>>>>>> extra
>>>>>>>>>>>> blood and look for the PFO and close?
>>>>>>>>>>>> 
>>>>>>>>>>>> -m
>>>>>>>>>>>> 
>>>>>>>>>>>> 
>>>>>>>>>>>> On Aug 2, 2009, at 4:45 PM, Roberto Battellini wrote:
>>>>>>>>>>>> 
>>>>>>>>>>>>> 
>>>>>>>>>>>>> Tomorrow I have a AVR with PFO, with some left to right shunt.
>>>>>>>>>>>>> 
>>>>>>>>>>>>> I am going to close it, think the old lady is already spo
>>> ken
>>>>>>>>>>>>> by
>>>>>>>>>>>>> cardiologists abot paradoxal embolies, etc.
>>>>>>>>>>>>> 
>>>>>>>>>>>>> I do it with 2 stage cannula, do not need 2 cannlas.
>>>>>>>>>>>>> 
>>>>>>>>>>>>> Roberto
>>>>>>>>>>>>> 
>>>>>>>>>>>>>> From: msfirst at gmail.com
>>>>>>>>>>>>>> To: OpenHeart-L at lists.hsforum.com
>>>>>>>>>>>>>> Subject: Re: [HSF]Closing PFO's
>>>>>>>>>>>>>> Date: Sun, 2 Aug 2009 16:36:21 -0400
>>>>>>>>>>>>>> CC:
>>>>>>>>>>>>>> 
>>>>>>>>>>>>>> While there may be no survival advantage and closing them
>>>>>>>>>>>>>> intra-
>>>>>>>>>>>>>> operatively is a debatable procedure in terms of peri-
>>>>>>>>>>>>>> operative
>>>>>>>>>>>>>> risk -
>>>>>>>>>>>>>> I think closing them can save a patient a lot of headache,
>>>>>>>>>>>>>> literally
>>>>>>>>>>>>>> and figuratively, later in life. For example, a couple of
>>>>>>>>>>>>>> weeks
>>>>>>>>>>>>>> ago I
>>>>>>>>>>>>>> did a CABG in a 30 year/old disaster patient (imagine the
>>>>>>>>>>>>>> 30 yr
>>>>>>>>>>>>>> old
>>>>>>>>>>>>>> who would need a cabg). He had a PFO which I closed. He is
>>>>>>>>>>>>>> clearly
>>>>>>>>>>>>>> going to have issues later in life stemming from his severe
>>>>>>>>>>>>>> peripheral
>>>>>>>>>>>>>> vascular disease and his diabetes, and etc - now he does
>>>>>>>>>>>>>> not have
>>>>>>>>>>>>>> to
>>>>>>>>>>>>>> worry about the PFO being blamed for every little headache,
>>>>>>>>>>>>>> potential
>>>>>>>>>>>>>> migrane, tia, stroke, neurologically this that or the other
>>>>>>>>>>>>>> or
>>>>>>>>>>>>>> whatever else is being blame on these things these days. If I
>>>>>>>>>>>>>> saved
>>>>>>>>>>>>>> him an unnecessary tee or 2 (let alone a perc procedure to
>>>>>>>>>>>>>> close
>>>>>>>>>>>>>> this)
>>>>>>>>>>>>>> that I hope that I have helped him.
>>>>>>>>>>>>>> 
>>>>>>>>>>>>>> I am not sure I understand this article - implying we
>>>>>>>>>>>>>> should leave
>>>>>>>>>>>>>> them alone?
>>>>>>>>>>>>>> 
>>>>>>>>>>>>>> -michael
>>>>>>>>>>>>>> 
>>>>>>>>>>>>>> 
>>>>>>>>>>>>>> 
>>>>>>>>>>>>>> On Jul 31, 2009, at 4:57 PM, Edward Bender wrote:
>>>>>>>>>>>>>> 
>>>>>>>>>>>>>>> For Prasanna:
>>>>>>>>>>>>>>> Prevalence and repair of intraoperatively diagnosed patent
>>>> 
>>>>>>>>>>>>>> foramen
>>>>>>>>>>>>>>> ovale and association with perioperative outcomes and long-
>>>>>>>>>>>>>>> term
>>>>>>>>>>>>>>> survival.
>>>>>>>>>>>>>>> 
>>>>>>>>>>>>>>> Krasuski RA, Hart SA, Allen D, Qureshi A, Pettersson G,
>>>>>>>>>>>>>>> Houghtaling
>>>>>>>>>>>>>>> PL, Batizy LH, Blackstone E.
>>>>>>>>>>>>>>> Department of Cardiovascular Medicine, J2-4, Cleveland
>>>>>>>>>>>>>>> Clinic,
>>>>>>>>>>>>>>> 9500
>>>>>>>>>>>>>>> Euclid Ave, Cleveland, OH 44195, USA. krasusr at ccf.org
>>>>>>>>>>>>>>> CONTEXT: A recent survey suggested that cardiothoracic
>>>>>>>>>>>>>>> surgeons
>>>>>>>>>>>>>>> may
>>>>>>>>>>>>>>> alter planned procedures to repair incidentally discovered
>>>>>>>>>>>>>>> patent
>>>>>>>>>>>>>>> foramen ovale (PFO). How frequently this occurs and the
>>>>>>>>>>>>>>> impact on
>>>>>>>>>>>>>>> outcomes remain unknown. OBJECTIVE: To measure the
>>>>>>>>>>>>>>> frequency of
>>>>>>>>>>>>>>> incidentally discovered PFO closure during cardiothoracic
>>>>>>>>>>>>>>> surgery
>>>>>>>>>>>>>>> and determine its perioperative and long-term impact.
>>>>>>>>>>>>>>> DESIGN,
>>>>>>>>>>>>>>> SETTING, AND PATIENTS: We reviewed the intraoperative
>>>>>>>>>>>>>>> transesophageal echocardiograms of 13,092 patients without
>>>>>>>>>>>>>>> prior
>>>>>>>>>>>>>>> diagnosis of PFO or atrial septal defect undergoing
>>>>>>>>>>>>>>> surgery at
>>>>>>>>>>>>>>> the
>>>>>>>>>>>>>>> Cleveland Clinic, Cleveland, Ohio, from 1995 through 2006.
>>>>>>>>>>>>>>> Postoperative outcomes were prospectively collected until
>>>>>>>>>>>>>>> discharge.
>>>>>>>>>>>>>>> MAIN OUTCOME MEASURES: All-cause hospital mortality and
>>>>>>>>>>>>>>> stroke
>>>>>>>>>>>>>>> were
>>>>>>>>>>>>>>> predetermined primary outcomes; length of hospital stay,
>>>>>>>>>>>>>>> length
>>>>>>>>>>>>>>> of
>>>>>>>>>>>>>>> intensive care unit stay, and time on cardiopulmonary
>>>>>>>>>>>>>>> bypass were
>>>>>>>>>>>>>>> secondary outcomes. RESULTS: Intraoperative PFO was
>>>>>>>>>>>>>>> diagnosed in
>>>>>>>>>>>>>>> 2277 patients in the study population (17%), and risk
>>>>>>>>>>>>>>> factors for
>>>>>>>>>>>>>>> stroke were similar in patients wit
>>> h and without PFO. After
>>>>>>>>>>>>>>> propensity matching was performed with the comparator
>>>>>>>>>>>>>>> groups,
>>>>>>>>>>>>>>> patients with PFO demonstrated similar rates of in-
>>>>>>>>>>>>>>> hospital death
>>>>>>>>>>>>>>> (3.4% vs 2.6%, P = .11) and postoperative stroke (2.3% vs
>>>>>>>>>>>>>>> 2.3%, P
>>>>>>>>>>>>>>> = .
>>>>>>>>>>>>>>> 84). Surgical closure was performed in 639 PFO patients
>>>>>>>>>>>>>>> (28%),
>>>>>>>>>>>>>>> and
>>>>>>>>>>>>>>> surgeons were more likely to close defects in patients who
>>>>>>>>>>>>>>> were
>>>>>>>>>>>>>>> younger (mean [SD] age, 61.1 [14] vs 64.4 [13] years; P < .
>>>>>>>>>>>>>>> 001),
>>>>>>>>>>>>>>> were undergoing mitral or tricuspid valve surgery (51% vs
>>>>>>>>>>>>>>> 32%, P
>>>>>>>>>>>>>>> < .
>>>>>>>>>>>>>>> 001), or had history of transient ischemic attack or
>>>>>>>>>>>>>>> stroke (16%
>>>>>>>>>>>>>>> vs
>>>>>>>>>>>>>>> 10%, P < .001). Patients with repaired PFO demonstrated a
>>>>>>>>>>>>>>> 2.47-
>>>>>>>>>>>>>>> times
>>>>>>>>>>>>>>> greater odds (95% confidence interval, 1.02-6.00) of
>>>>>>>>>>>>>>> having a
>>>>>>>>>>>>>>> postoperative stroke compared with those with unrepaired PFO
>>>>>>>>>>>>>>> (2.8%
>>>>>>>>>>>>>>> vs 1.2%, P = .04). Long-term analysis demonstrated that PFO
>>>>>>>>>>>>>>> repair
>>>>>>>>>>>>>>> was associated with no survival difference (P = .12).
>>>>>>>>>>>>>>> CONCLUSIONS:
>>>>>>>>>>>>>>> Incidental PFO is common in patients undergoing
>>>>>>>>>>>>>>> cardiothoracic
>>>>>>>>>>>>>>> surgery but is not associated with increased perioperative
>>>>>>>>>>>>>>> morbidity
>>>>>>>>>>>>>>> or mortality. Surgical closure appears unrelated to long-
>>>>>>>>>>>>>>> term
>>>>>>>>>>>>>>> survival and may increase postoperative stroke risk.
>>>>>>>>>>>>>>> 
>>>>>>>>>>>>>>> On Jul 31, 2009, at 12:38 PM, Prasanna Simha M wrote:
>>>>>>>>>>>>>>> 
>>>>>>>>>>>>>>>> I agree .No stopping the heart just go on percut bypass.
>>>>>>>>>>>>>>>> In and
>>>>>>>>>>>>>>>> out
>>>>>>>>>>>>>>>> with
>>>>>>>>>>>>>>>> minimal dissection.
>>>>>>>>>>>>>>>> What is this "enpassant PFO closure study ' ?
>>>>>>>>>>>>>>>> 
>>>>>>>>>>>>>>>> Prasanna
>>> 
>>>>>>>>>>>>>>>> 
>>>>>>>>>>>>>>>> On Fri, Jul 31, 2009 at 10:58 PM, Edward Bender
>>>>>>>>>>>>>>>> <ebender001 at me.com>
>>>>>>>>>>>>>>>> wrote:
>>>>>>>>>>>>>>>> 
>>>>>>>>>>>>>>>>> If no other cardiac problems (CAD, etc) do her tricuspid
>>>>>>>>>>>>>>>>> once
>>>>>>>>>>>>>>>>> sepsis
>>>>>>>>>>>>>>>>> cleared. These are wonderful cases to do minimally
>>>>>>>>>>>>>>>>> invasively
>>>>>>>>>>>>>>>>> warm
>>>>>>>>>>>>>>>>> beating.
>>>>>>>>>>>>>>>>> She will thank you. Close PFO also (the recent en
>>>>>>>>>>>>>>>>> passant PFO
>>>>>>>>>>>>>>>>> closure by
>>>>>>>>>>>>>>>>> surgeons study does not apply here).
>>>>>>>>>>>>>>>>> Ed bender, MD
>>>>>>>>>>>>>>>>> 
>>>>>>>>>>>>>>>>> 
>>>>>>>>>>>>>>>>> On Friday, July 31, 2009, at 10:37AM, "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
>>>>>>>>>>>>>>>>>> _______________________________________________
>>>>>>>>>>>>>>>>>> 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.hs
>>> forum.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
>>>>>>>>>>>>>>>>> -----------------------------------------
>>>>>>>>>>>>>>>>> 
>>>>>>>>>>>>>>>> 
>>>>>>>>>>>>>>>> 
>>>>>>>>>>>>>>>> 
>>>>>>>>>>>>>>>> --
>>>>>>>>>>>>>>>> Prasanna Simha M
>>>>>>>>>>>>>>>> _______________________________________________
>>>>>>>>>>>>>>>> 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 anddisclaimers 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
>>>>>>>>>>>>>> -----------------------------------------
>>>>>>>>>>>>> _______________________________________________
>>>>>>>>>>>>> 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
>>>>>>>>>>>> -----------------------------------------
>>>>>>>>>>> _______________________________________________
>>>>>>>>>>> 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
>>>>>>>>>> -----------------------------------------
>>>>>>>>> _______________________________________________
>>>>>>>>> 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
>>>>>>>>> -----------------------------------------
>>>>>>>> 
>>>>>>>> _________________________________________________________________
>>>>>>>> Windows Live Messenger: Thanks for 10 great yearsnjoy free
>>>>>>>> winks and
>>>>>>>> emoticons.
>>>>>>>> 
>>>>>>>> 
>>> http://clk.atdmt.com/UKM/go/157562755/direct/01/_______________________________________________
>>>>>>>> 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
>>>>>>>> -----------------------------------------
>>>>>>>> 
>>>>>>> 
>>>>>>> 
>>>>>>> 
>>>>>>> --
>>>>>>> Prasanna Simha M
>>>>>>> _______________________________________________
>>>>>>> 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
>>>>>> -----------------------------------------
>>>>> 
>>>>> _________________________________________________________________
>>>>> Windows Live Messenger: Thanks for 10 great yearsnjoy free winks
>>>>> and emoticons.
>>>>> 
>>> http://clk.atdmt.com/UKM/go/157562755/direct/01/_______________________________________________
>>>>> 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
>>>> -----------------------------------------
>>> ________________________________________
>>> _______
>>> 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
>>> -----------------------------------------
>>> 
>> _______________________________________________
>> 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
> -----------------------------------------

_______________________________________________
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 anddisclaimers posted at:
http://www.hsforum.com/listdisclaim
-----------------------------------------

More information about the OpenHeart-L mailing list