[HSF] Image of the week -Autopericardial valve
Tea Acuff
tacuff at swbell.net
Sun Aug 16 13:26:18 EDT 2009
This is your first autologous replacement?
Tea
Sent from my iPhone
On Aug 16, 2009, at 10:19 AM, Prasanna Simha M <prasannasimha at gmail.com> wrote:
This patient had calcific MS + MR and was non repairable. You can see
the fixed orifice which gives rise to stenosis + regurgitation.I did
ring them to fix the annulus and also it allows an easier implantation
technique. As a subset they are non repairable valves if you can call
an N=1 a subset !! I would probably use it for all non repairable
valves which would include calcified valves and valves where a repair
is not possible or failed intraop. It is yet too early to tell
anything bu that would be a goal.The patient had undergone a closed
mitral valvotomy over 14 years ago in another hospital in another
state.
Prasanna
On Sun, Aug 16, 2009 at 8:18 PM, Tea Acuff<tacuff at swbell.net> wrote:
Did these patients have recurrent MS or MR as their indication? Were their LVs small? Do you ring these patients if you "repair" them? Are these patients as patients, not as procedures, a special subset?
Tea
Sent from my iPhone
On Aug 15, 2009, at 11:57 AM, Prasanna Simha M <prasannasimha at gmail.com> wrote:
I sutured them to the anterior papillary muscle based on the length of
the sutured sides of the frustrum cone.So the two seams form the
"strut chordae"
The adhesions were due to a previous CMV and not due to rheumatic
bread and butter pericardiits(The pericardium was thin and pliant)
I am worried to do this without ring stabilization and thought it
worth placing a ring.
The Protamine - capping of briefly treated pericardium was mentioned
in a study in a few articles and additional ionic binding was also
mentioned and this was shown in subcut implantation tests to retard
calcification and is the easiest to get in an OR.So I elected to do
it.
I will be following these cases closely and now with extensive spread
of mobile phones in India follow up has actually become easier for
me.(Today I got a birthday phone call from one of my repairs that i
have operated 10 years back.- all my patients phone me on their
birthdays)
Prasanna
On Sat, Aug 15, 2009 at 10:10 PM, <Rwmfglycar at aol.com> wrote:
Dear Prasanna,
Congratulations for your effort.
I gather that your design is similar to Radu Deac's with a large anterior
leaflet and the posterior leaflet functioning more or less as a shelf. Ovil
(Israel , South Africa and Canada) had something very similar. I found in
animal work that they could develop a crease where interscallop clefts would
be in the natural valve. Where is the seam?
Do you suture the distal ends to the inside of the large anterior parts of
the left and right papillary muscles?
When I used untreated autogenous pericardium for mitral repair a couple of
generations ago, I thought that prior rheumatic adhesions were a risk
factor for an aggressive harmful host healing response.
Do you know whether the design works better with a fixed or a potentially
dynamic ring?
I have never tried the treatment combination that you used so I cannot
comment. It is a moot point whether you need aldehyde capping after 10 minutes
of aldehyde treatment. What evidence do you have for each of the
components? I do not know but I suspect the protamine and heparin has similarities to
the Shelhigh "NoReact" treatment which seemed not to prevent tissue
change in valve devices implanted in young people. One issue is how quickly
the treatment reacts with the residual uncapped aldsehydes. We had some
evidence that half an hour of glut exposure turned autogenous tissue into the
equivalent of bovine tissue with standard multiday aldehyde exposure. We
never tested our aldehyde capping propylene glycol Rx for less than 24 hours.
You do not need to justify your use of an experimental device in patients
from the hinterland. I know what you are faced with. Just be realistic that
your prognostications for the future cannot be better than hopes and
promissory notes.
I recently had followups on 8 female Quattro patients aged 14 to 28 at
their original operations who have survived more than 10 years without further
valve surgery. Six of them appear to have had 7 or 8 succesful
pregnancies. They have done well but more than half have thickened anterior leaflets
and some change in valve function. This suggests that the healing response
is slowly destroying the valves rather than calcification which was the
original concern. for patients in this age group
One very sad one is the 14 year old. She came from Mozambique and
probably should not have been in the trial. She was lost for ten years and then
was heard from again. She was Class 1 doing very well and pregnant. The
pregnancy was succesful but not too long postpartum she developed what seemed
like a tear at the base of the anterior leaflet and became extremely
symptomatic. The family could not raise the money for transport to South Africa
and further efforts at telephone contact have failed completely. We now
presume she must be dead.
Bob
In a message dated 8/15/2009 3:04:12 P.M. South Africa Standard Time,
prasannasimha at gmail.com writes:
Yes. We harvested the valve intraop and started treating it during
cannulation and during tricuspid ring implantation and after excising
the valve and taking sutures after sizing and determining the size it
took around 5 minutes to suture the valve (to construct it) during
which cardioplegia was being administered.
The cost of bioprosthetic valves have been excessive and I felt that
if I amsending these patients to the hinterland I might as well offer
a method that will preserve annulopappilary continuity, good valve
area and a low cost option. If you look at the literature of
autopericardial mitral valves they have excellent results with results
up to 70 months being reported by Deac. The results of Duran in the
aortic and mitral positions have also been excellent considering the
fact that these patients where young patients. I have had candid
conversations with some of our cardiologists who say practically they
see a 20 % complication rate per year and that is what we have to
fight against. This method on practical terms is very cheap even if I
were to implant a commercial ring so I thought it would be worth it.
It is actually not so difficult as you would think it is.The only
thing is you need to do a lot of 3D visualization of the valve which
anyone who is prepared to repair valves should be able to do.In fact I
would consider it easier to do than a regular repair.
Prasanna
2009/8/15 erdinç naseri <enaseri at hotmail.com.tr>:
Prasanna,
Dıd you tailored this valve intraoperatively?
What was the reason not to use a manufactured prosthetic valve?
Finally congradulations , what you have accomplished is unimaginable
for me?
erdinc
From: prasannasimha at gmail.com
Date: Fri, 14 Aug 2009 22:06:30 +0530
To: OpenHeart-L at lists.hsforum.com
CC:
Subject: [HSF] Image of the week -Autopericardial valve
I am sending the image of an autopericardial valve that I made and
implanted this week.Pateint received a tricuspid repair +
autopericardial mitral valve + eMAZE. I ma sorry, I did not take
intraop photos (which I wish I did)
The case was a 58 year old lady (says she is 46 but age at marriage +
time to birth of first sone + age of eldest son adds to 58 !!) with
calcific MS, sever TR severe pulmonary hypertension and atrial
fibrillation.
I have tried to reduce a video to fit into the email constraints so it
hasnt come out that well but would give you an idea. The valve looked
like a "natural valve"
The valve is stentless ie attached to the papillary muscles and is
tabilized at the annulus with my indigenous ring.
Prasanna
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Prasanna Simha M
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