Percutanoeus mitral and Aortic valve repairs. Who will be doing these in the future? Cardiac surgeons or Interventionalists?
Percutanoeus mitral and Aortic valve repairs.
- Thread starter copacetic
- Start date
I think evryone knows the answer to this.
- Joined
- Apr 12, 2003
- Messages
- 3,335
- Reaction score
- 22
Why would the surgeons do them? It'll be the interventionalists. Percutaneous pulmonary valves as well esp. in the congenital heart disease realm.
- Joined
- Aug 30, 2007
- Messages
- 2,059
- Reaction score
- 10
Dude, I had a 40 something year old with corrected ToF. I was following him, and one day he had a new diastolic murmur. His pulmonic valve was flapping in the wind. Very cool. Well, not for him.
- Joined
- Apr 12, 2003
- Messages
- 3,335
- Reaction score
- 22
If it was a transannular patch repair it's been flappin' in the wind for a long time. Or was he able to be repaired with just a VSD patch?
- Joined
- Aug 30, 2007
- Messages
- 2,059
- Reaction score
- 10
Im not sure, but I think it was transannular, the pulmonic root (if thats even the right term) was also dilated. Unfortunately I dont really know how things turned out, our CT guys decided to send him out. Wimps.
Question - in surgery, do/did they create some sort of a ductus arteriousus type conduit outside the heart even thought they close the VSD? One of the attendings insisted that they did. I didnt know what he was talking about.
- Joined
- Apr 12, 2003
- Messages
- 3,335
- Reaction score
- 22
If there was inadequate pulmonary blood flow post-natally then they would have palliated with some type of systemic to pulmonary shunt; most likely a modified Blalock-(Thomas)-Taussig shunt until they did the intracardiac repair at which time they'd take down the shunt, patch the VSD, and place the transannular patch across the stenotic infundibular and valvular area. Over time aneurysmal dilation of the patch area is common. There is usually a combination of pulmonary stenosis and (usually free [with the TA patch]) insufficiency. Post stenotic dilation of the pulmonary trunk is common. Throughout childhhood and adulthood stenosis of the branch PAs (ESP. The left) is common as well (LPA ballooning/stenting is one of the most common things done inour cath lab. And we do all ages)
Last edited:
- Joined
- May 15, 2008
- Messages
- 5,089
- Reaction score
- 55
Interventional cards will (and does) definitely do the percutaneous valve replacements. I wouldn't be totally shocked if CT surgery tried to get in on this too, though I'm not sure.
- Joined
- Aug 30, 2007
- Messages
- 2,059
- Reaction score
- 10
gotcha. I kinda figured that if theyre going to take the trouble of repairing the intracardiac defects and the RV outflow, they wouldnt need to create a shunt. Pretty cool.
- Joined
- Aug 30, 2007
- Messages
- 2,059
- Reaction score
- 10
Yeah, CT has already cornered the market on interventional pulmonology (stents, rigid bronchs, yag lasers...)
- Joined
- Apr 12, 2003
- Messages
- 3,335
- Reaction score
- 22
HJ: If you get a chance you should take a look at some congenital cineangiograms. Look for some repaired Tets. They might be fun for you to look at.
from my understanding cardiac surgeons never particpated in the early trials and development of percutaneous techniques. most of the field pretty much wrote PCI off, and innovation in CT lagged. Nowadays however, most CT training programs incorporate hybrid techniques that involve both CT and interventional techniques. also, alot of the guys in practice are learning interventional techniques.
Moreover, with all the latest interventional techniqes, CT surgeons are participating. PCI mitral, and Aortic valve repairs, as well as aortic stenting are being pioneered hand in hand with interventionalists.
Now Im not saying that CT surgeons will ever replace interventionalists in any way shape or form, but what i am suggesting is that CT surgeons will be doing interventionalist procedures as well. In an era of cost cutting, hospitals are gonna want people who can 'do it all' so to speak. Interventional and CT. There will of course be alot of interventionalists around, and they will be doing most of the interventions, but i suspect that CT surgeons will become greatly involved in further PCI innovation, and implementation.
Do any of you have thoughts on this? and please lets try to keep focused and logical with our arguments.
- Joined
- May 29, 2003
- Messages
- 190
- Reaction score
- 2
I have not personally seen any CT surgeons getting training in percutaneous techniques - this is just not in the scope of cardiac surgery. There has been surgical involvement in some of the "percutaneous" AVR trials, as in the transapical approach... which is obviously not purely percutaneous. CT surgeons already spend 7+ years in training learning difficult procedures, there's really not additional time to spend 1+ year becoming facile in percutaneous techniques, which is the bare minimum of what would be required. Cardiologists and CT surgeons will continue to work closely together in deciding what the best options are for a patient, and possibly as hybrid OR/Cath labs develop, but I don't think CT surgeons will be doing percutaneous work.
- Joined
- May 15, 2008
- Messages
- 5,089
- Reaction score
- 55
I kind of agree with myostatin. Coordination with CT surgery is really important, though, including in cardiology training programs. I'm glad we get along well w/our cardiac surgery colleagues @my hospital. I don't ever see them getting involved w/stents, ASD and PFO closure, etc. via the percutaneous approach, and I guess to do even perc. valve replacement they'd basically have to learn most of the cath lab techniques used to get access, etc. just like doing coronary stents...so probably not worth their while. I think the CT surgeons are too busy learning traditional and "minimally invasive" surgery stuff, and don't have time to also learn percutaneous techniques to any significant degree.
- Joined
- Apr 12, 2003
- Messages
- 3,335
- Reaction score
- 22
[YOUTUBE]http://www.youtube.com/watch?v=WjyeS1FQDPo[/YOUTUBE]
Mostly for HJ: I loaded up a cine of a long ago repaired Tet-AV Canal. I thought you might find it interesting, but I didn't want to start a new thread for it. You can see the dilated pulmonary trunk, free PR, and stenotic origin of the LPA. There's post-stenotic dilation of the distal segments.
In re the OP: I'll 3rd what D99 and Myo said: the skills involved in cath (both adult and congenital of all ages) is very specialized. Skills in the cath lab are hard earned with lots of practice over a one year fellowship. A CT surgeon would most likely never have the time nor inclination to learn interventional techniques. It's not like a general surgeon knowing how to do endoscopy. Agree with hybrid work as well, though I don't know, personally what the adult hybrid procedures are (anyone care to educate). In the congenital world there are hybrid stage 1 Norwoods for single Vs (but nobody knows yet if they are aqctually better than completely open procedures) and at our facility our interventionalist has done hybrid (open chest), perventricular VSD device closures in defects that aren't in areas amenable to surgical reach (ex. apical) in small hearts. A question for Myo (again, one born of ignorance) why "hybrid" for perc. AVR? Our interventionalist will do trans-thoracic access if needed (not often needed though). Is there some issue with apical access?
Last edited:
- Joined
- Aug 30, 2007
- Messages
- 2,059
- Reaction score
- 10
thanks J-Rad! very cool.
- Joined
- Jun 16, 2006
- Messages
- 63
- Reaction score
- 0
Perc AVR (ie the PARTNER trial) requires CTS involvement, not so much for the perc femoral portion, but for those pts with less than adequate diameter of the femoral or iliac arteries. These are the pts that require thoracotomy approaches and apical insertion of the AV by CTS. Also CTS is on hand for potential badness.
But generally speaking, interventional cards handles most of this crap.
But generally speaking, interventional cards handles most of this crap.
