[HSF] mitral repair unclamping the aorta
Nasser F Abou'Seada
nfaabouseada at gmail.com
Sun Sep 6 20:04:34 EDT 2009
Any references to these "numbers" ?
NFA
-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of gustavo abuin
Sent: Sunday, September 06, 2009 5:40 PM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] mitral repair unclamping the aorta
Hal,
Of course, the left lateral approach has an 8% of supraventricular
disturbances, the Giraudon approachs to the 35%.
gustavo
----- Original Message -----
From: <Hgrmd at aol.com>
To: <OpenHeart-L at lists.hsforum.com>
Sent: Sunday, September 06, 2009 7:08 PM
Subject: Re: [HSF] mitral repair unclamping the aorta
> Gustavo,
> Thanks for the anatomic clarification. Regardless, and I think you
> would agree, the transseptal incision is bad for the conduction system.
> That's
> why I avoid it unless I'm repairing a mitral valve in the presence of a
> stented aortic prosthesis.
>
> Hal
>
>
> In a message dated 9/6/2009 5:19:38 P.M. Eastern Daylight Time,
> gabuin at intramed.net writes:
>
> The sinus node artery is not the culprit of the atrioventricular
> disturbances following Giraudone`s incision.
> The sinus node artery does not supply the sinus node, but transmit
> information regarding blood pressure and heart rate than a vital
> nourishment
> for the structure.
> The atiroventricular disturbances of this approach are because some small
> atrial arteries that supply the septal wall and the atrioventricular
> node
> (not the sinus node) are often damaged. The bundles of atrial tissue that
> communicates the sinus node with the atrioventricular node (I don`t say
> "internodal tracts") are damaged too, irrespective of the section or not
> of
> the sinus node artery.
> An example of one of the vessels often damaged is Kugel`s artery.
> This arery supplies the atrioventricular node and the roof of the left
> atrium and the interatrial septum.
> I send a photo to explain my point. The anatomical preparation is viewed
> from the base of the heart, generating some traction between the aorta
> and
> the interatrial bundle.
> The ascending aorta and the origin of the two coronaries are seen. The
> interatrial bundle and the two (right and left) atrial appendages (LAA
> and
> RAA) are well seen too.
> Look at SAN(sinus node artery) and Kugel artery.
> gustavo.
>
>
>
>
>
>
>
>
>
>
>
>
>
> ----- Original Message -----
> From: <Rwmfglycar at aol.com>
> To: <OpenHeart-L at lists.hsforum.com>
> Sent: Sunday, September 06, 2009 12:37 PM
> Subject: Re: [HSF] mitral repair unclamping the aorta
>
>
>> That is the theoretical culprit. As you know the artery's origin is
>> variable and the incision may not touch it at all. In beating heart
> surgey
>> if
>> the incision went into the dome we always could see when we had cut
> it.
>> When
>> I tried to correlate the rhythm post bypass with cutting or not cutting
> I
>> found I had not recorded this fact consistently so the study was
> useless.
>> My objection to the Giraudon incision is that it is so close to the
>> ascending aorta it is difficult to fix if a suture site bleeds; hence my
>> advice to
>> cross into the dome halfway between SVC and Aorticroot.
>> Bob
>>
>>
>> In a message dated 9/6/2009 5:24:16 P.M. South Africa Standard Time,
>> hgrmd at aol.com writes:
>>
>> Bob,
>> Yes, the problem with Giraurdone's incision is nodal rhythm. As you
>> know,
>> the SA node artery is usually transected, and this is often cited as
> the
>> culprit (Cox).
>>
>
>> Hal
>> Sent from my Verizon Wireless BlackBerry
>>
>> -----Original Message-----
>> From: Rwmfglycar at aol.com
>>
>> Date: Sun, 6 Sep 2009 11:03:34
>> To: <OpenHeart-L at lists.hsforum.com>
>> Subject: Re: [HSF] mitral repair unclamping the aorta
>>
>>
>> Hal we studied our own patients when we started using vertical
>> transseptal
>>
>> incisions; temporary nodal rhythmwas seen. By discharge the preop
>> rhythm
>> had returned. There is a literature on this. Preoperative sinus node
>> dysfunction has been present when postoperative sinus node dysfunction
> is
>> identified as a problem.
>> I presue it is sinus node dysfunction you are referring to , not heart
>> block
>> Bob
>>
>>
>>
>> In a message dated 9/6/2009 3:35:53 P.M. South Africa Standard Time,
>> hgrmd at aol.com writes:
>>
>> Theofilo,
>> I generally try to avoid the transseptal approach, particularly if
>> the
>> patient is NSR, because I believe there is a higher incidence of heart
>> block
>> and subsequent need for pacemaker.
>> In addition, a standard incision avoids the danger of a friable LA
>> dome.
>>
>> Hal
>>
>> Sent from my Verizon Wireless BlackBerry
>>
>> -----Original Message-----
>> From: "THEOFILO GAUZE" <tgauze at cardiol.br>
>>
>> Date: Sun, 6 Sep 2009 10:27:10
>> To: OpenHeart-L at lists.hsforum.com<OpenHeart-L at lists.hsforum.com>
>> Subject: Re: [HSF] mitral repair unclamping the aorta
>>
>>
>>
>> Gustavo,
>> You problaby know that the bleeding was coming from the left atriotomy
>> close to the atriun/aortic junction. I had this problem when I began
>> beating
>> mitrals approach. For me what worked well was either a kind of semi
>> circle
>> incision on the interatrial septun running away from the aortic
> junction
>> on
>> the upper portion of it (sligtlly towards SVC) - or - cardioplegic
>> reconstruction of the incision when aortic valve was involved and the
>> heart
>> arrested. "The roof of the left atriun is nobody's friend" - wise
>> words
>> from Toby
>> Cosgrove at Cleveland Clinic teaching us about transseptal aproach
>> towards
>> mitral valve in minimally invasive surgery. Just some thoughts.
>> Theo Gauze
>>
>>> -----Mensagem Original-----
>>> De: gustavo abuin <gabuin at intramed.net>
>>> Para: OpenHeart-L at lists.hsforum.com
>>> Data: 06/09/2009 07:56
>>> Assunto: [HSF] mitral repair unclamping the aorta
>>>
>>> Dear members.
>>> The HSF have had a great influence on my surgical strategies and I
>> start
>> to
>>> operate some mitral procedures without clamp the aorta without any
>> concern.
>>> This week I operated a 72 y/o lady (EF 21%, Aortic stenosis, mitral
>>> insufficiency (annular dilatation) and tricuspid insufficiency.
>>> I decided to perform the surgery as follows:
>>> Access to the left and right atrium via a right atriotomy,
>>> interatrial
>>> septum and roof of the left atrium.
>>> Mitral annuloplasty without clamp, closure of the left atrium and
>>> interatrial septum.
>>> Aortic clamp and aortic valve replacement.
>>> Release of the aortic clamp and tricuspid valve annuloplasty.
>>> I was surprised because the good exposure of the scenario.
>>> 45 minutes of aortic clamp time, 140 of extracoporeal circulation.
>>> Off
>> pum
>>> with 10mics of dopamine and large doses of nitroglycerin.
>>> I was happy and surprised about the easy of the procedure since a red
>> (very
>>> red) flood was coming from the left atrium- aortic junction.
>>> I have to re-clamp the aorta, transect the aorta, repair the stuff
> etc.
>>> The patient is doing well (fortunately) and she will be at her home
>>> tomorrow.
>>> I ask to any of the members of the forum :
>>> What are the tips to expose the mitral valve with this approach but
>>> generating minimal tension of the tissues.
>>> Can the procedure be performed via a left lateral approach for the
>> mitral
>>> valve? Is the exposure good without clamp the aorta with this
> approach?
>>> Is possible to do the procedure via the right atrium and the
>> interatrial
>>> septum with no incision of the left atrial roof, as it is when is
>> decided to
>>> clamp the aorta?
>>> Another tips?
>>> Next week I have another patient with similiar pahtology and I will
> try
>> the
>>> same approach (I hope a more perfect approach)
>>> gustavo.
>>>
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