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Valvular Heart Disease

Feb 20 | 5:45 AM

Dr. Kamal Sharma: Balloon Mitral Valvotomy (BMV/PTMC) is a better strategy Dr. Anil Jain: Surgical mitral valve repair remains better option in long terms Dr. Tushar Shah: Mitral Commisurotomy (OMC/CMC)is still relevant!

[Music] good morning and thank you very much so it is an interesting topic that today we are going to discuss here and i would like to uh introduce our first speaker for the bout dr kamil sharma who is md dm cardiology dnb cardiology as well as dnp in medicine m ms fscc fsci the degree is known to justice through him he is the chairman and convener of the scientific committee of this cardio he is a senior interventional cardiologist with vast experience of coronary angioplasty strengthening while willow class tp speakers and pediatric interventions a combination of dna dnb and should i say on the verge of ies as well he left administration he had been selected for is also so passionate clinician i would say apart from practicing at sal hospital also in um hospital and uh is also been teaching the subject at visual medical college also been teaching the subject of cardiology as well as medicine has received and worked hard for those 22 gold medals for academic excellence during the medical studies and the world's first vegan no stimulation device in the anthem study was done by him he discovered winking coronary sign for vsr on angiography also known as kamal sharma stein of psr uh principal investigators in the trials like paradigmative atlas tips in canvas more than 200 publication more than thousand citations sorry more than 10 000 citations and audit is excellent teacher by gujarat university and the only cardiologist or i would say one of the rare clinicians or physicians who have cleared the civil services exam in the first attempt is also an author of eight books and a lot many chapters that are uh cannot be counted on the figure tips our next speaker would be dr anil jain the legacy of his is unsurmountable he is the owner director and chief at epic hospital as a ms in general surgery dnb in cardiac surgery more than 28 000 cardiac surgeries in the span of 16 years with total arterial bypass beating heart surgery heart failure surgery congenital heart surgery wall repair wall replacement surgery for atrial fibrillation and surgery for aortic dissection so an eminent surgeon and a very prominent name when you go in the market or third speaker next slide please dr shah who's in uh ms and mch in uh cbs has been practicing thoracic surgery for last three decades he had won several gold medals and awards during his initial surgical training in ahmedabad as well as mumbai one of the youngest recipient of haryong ashram credit olympic research award in 1981 before i was born so interested in lung parenchyma saving surgeries for infective and malignant diseases of lung he started laser assisted pulmonary metastatic tommy lfpm surgeries using 13.8 nanometer diode laser for the first time in asia in 2011 so i would like to welcome all the speakers and i guess we'll start with the red corner by dr commercial master so over to you dr commissioner [Music] sir you are not audible sir unmute all thank you thank you uh zishan for a kind introduction uh pleasure being having hosting you all and again speaking and with my colleagues and dear friends uh dr anil bay and dr tushar bay uh it's incomplete so it's always fun to have you guys for the debate so i'm going to talk about 33 year old female severe rheumatic mitral stenosis wilkins of eight mild mr sebia ph that's the best strategy for him is going to be what that's what i'm going to discuss so this is the case uh dr zeeshan already mentioned that a high gradient of severe critical tight stenosis with severe ph so we have a three cornered fight and you need not guess who's not all the three heroes amongst the three who is not hiding his face is supposed to be the cardiologist because he doesn't have anything to hide so he can be open and he can share so you know who is who why i would suggest and vouch for bmv the reason one is just look at the sts course how the surgeons interpret their own operative risk if we were to look at the cmc omc or even mb repairs or mbr look at the calculations designed by surgeons themselves mortality risks are almost one to one and a half percent re-operation rate five percent morbidity or mortality eleven to twelve percent and short stay is in minority of the patient long stay thanks to being seven to twelve percent of the patient as calculated by sts version four compare this with bmv score less than eight optimal results would be achieved in more than ninety percent success less than three percent complication rate compare this with the complications here which is almost four times and eighty to ninety percent of sustained improvement even during the follow-up of three to seven years reason two why i vouch for bmv is the guidelines look at any guideline even the appropriate use criteria of 2017 or if you look at the esc guidelines all of them they talk in the acc guidelines they talk about in mitral stenosis it has a class one a and one b recommendation even who are not high-risk or who are not candidates for failed previous pbmv even then it's 1b first mentioned in these guidelines for surgery comes at level 2b the mitral valve surgery even when you're planning to do an la appendage exclusion in savior ms who have recurrent emboli while receiving anticoagulation also receives 2b reason 3 is it's an old data published from gb path itself when they looked at the immediate randomization and i'm going to talk about indian patient and hence the indian data this is very old patient of aurora man which talked about comparing the two and it found out that the results were as good or even better with bmv with less complication internationally this is one of the paper which actually changed the guidelines seven-year follow-up mohammed bin paritsa paper published in 1998 which looked at seven-year outcome and there was no early late but mortality or thromboembolism between the three groups but mba was similar as compared to open surgeries residual asd was in only two patients so my surgeon friends may harp upon creating an asd it doesn't last there which actually is a beneficial thing that you can end up actually going through the peer point most of them what about longer duration 12 years this is another data from bulletin long it all published when they looked at 912 patients followed for 12 years overall survival rate of 20 years was 75 this is the longest follow-up data that we can talk about so surgeons can talk about you know valves lasting forever which is actually not the truth which i will again discuss but uh the bmvs do last for quite a long while and this is our own paper published in indian heart journal where we looked at even redo cases following previous mitral commission autonomy so where surgeons have done bmv and omc or omc and cmc even those patients we did and uh end up doing bmvs with fantastic results again you can see wilkins score was favorable in two-thirds 68 of the patient uh in 31 of the patient most of these patients despite having and uh having a bilking score more than eight after undergoing cmc omc actually ended up getting fantastic results this is the reason six which is a new data 2021 what about new science normal sinus rhythm this patient is a normal sinus rhythm af group had less favorable outcome but this patient is in sinus rhythm and hence compared the loop it all published that the patient who do well in on bmv for the rhythm versus say atrial fibrillation the normal sinus rhythm in this meta-analysis of 6000 plus patients actually did much better especially in terms of the valve area it doesn't mean otherwise but you can do bmw and afib as well but if you have normal sinus rhythm it's one of the important reason why you should go ahead and do a bmv of course the lesser complication out of 12 my surgeon friends may hop upon you create mrs and i have to rush no no that's not the case it's very rare that you get an mr in an improper technique or improper valve the survival rates in those patients actually who have mild to moderate mr it's better than compared to those who don't get an mr because the mr reflects probably a better opening of the valve so eight even free survival second pbmv heart failure requiring admission was significantly lower in patients who had significant mr post bmv as compared to those did not this did not mean severe mr but mild to moderate mrs post bmv are actually good in long term survival what about the comparison outcome per se with omc because i have to fight a double corner you have two surgeons punching at my jabs so i need to be debating that way so i'm going to take one of them one one one one by one so pbmv versus omc this is a 60 patient data from rice where they looked at the bolted valve area going up from 0.9 to 2.1 as compared to only two so which is actually i'm not saying superior but surely non-inferior actually probably surgery people are harping on being non-inferior here after three years patients with percutaneous had a higher average valve area and a greater likelihood of nyha functional class as compared to patients who underwent open surgery now there is a problem why the surgeons were wearing a mask why batman and spiderman had to wear a mask because you end up replacing one disease with other this is not what i said this is what denton cooley said that leaving a prosthetic while to a patient is replacing one disease with another and what is that disease it's a disease of prosthetic valve what is that the thrombosis or the bleeding what is the thrombotic risk in life-threatening complication 1.8 to 5 per 7 per year per patient so that is per patient here you have very high risk of a patient coming up with a choke valve and then you will have to actually end up giving a thrombolytic therapy or maybe you'll have to reopen by doing another surgery what about bleeding if the patient is on vka 69 percent of vka versus 31 on even if they end up with prosthetic tissue valves tissue valve patients even on aspirin end up bleeding three month post operatively cumulative incidence of the combined endpoint was nine point two percent weak eleven percent aspirant no difference observed in thromboembolic so vk aspirin should be a similar event rate of ten percent during three years three months after mbr in patients without prior afib other my surgeon friends may harp upon is cost of course balloon mitrals even when you use new balloons is going to be cheaper than having a replacement or open surgery and on top of that maripas maher so that's the card that's the insurance that the government provides you inflate the balloon uh and and the balloon valve is actually better because you go fluoroscopically rather than a blind procedure like a closed mitral chemistry what about duration of hospitalization one to two days omc cnc mbr even if you're a fantastic mini thoracotomy surgeon five days this is the pain scar anesthesia that's all you end up we just go from the groin and remember we are not even puncturing the artery for the sake of procedure it's just the vein the anesthesia of course we just do under local anesthesia as compared to endotracheal intubation and this is how we actually have access not only to what we are doing but also having a fluoroscopic look of inflating the balloon and controlling it and looking out for the procedure very operatively by echocardiography so why replace one disease with the another potential one so the good news is that we have got very few customer complaints because the bad news is that most of the customers end up getting bmv so you will have probably in the time of mitel stenosis may not have more patient complaining about valve thrombosis if they end up with getting more bmvs aligned with the joker's quote with the three uh uh heroes i think the villain also has to come in so who's whoever fights monster should see to it that in the process he does not become a monster when you end up probably treating a disease you should not replace that disease with another disease which is a valve thank you very much over to chair thank you for patient hearing uh thank you very much dr kamal sharma and uh for the blue corner i would like to invite dr anil jainsar for his presentation over to you dr anil genzer [Music] just one second anyone can you see my screen hello can you see my screen yes it's visible sir the presentation is visible yes yes absolutely go ahead uh with all the bashing that uh dr kamal sharma gave i think uh i needed a sip of water so let's go ahead and see you know it's it's very easy for a cardiologist to say that surgeon can do nothing and they are like god there was a time when cardiac surgeons were treated like god now today's cardiologists have come up and started saying we are god we can do anything you want and but they are the judge and the jury themselves and hence they think that whatever they do is the best well you know actually kamal has forgotten to see what his patient is suffering from the patient has nyh class 3 she has got intermittent palpitation which may be a symbol of which may be underlying atrial fibrillation and she has got severe pulmonary hypertension and she's got a wilkinson score eight but there is no clot in la so let's see what happens what is the aim of treating any patient with valvular heart disease our aim is to neutralize the disease and survival and quality of life should be same as the eighth matched population i'm not talking about five years six years seven years patient should live as long as any other patient person lives of that age and we want to neutralize the disease how can you neutralize the valvular heart disease if you get the patient into a normal atrial and ventricular function there is no rhythm disturbance and perfectly normal long term function is what we are aiming at we are not looking at she's 30 years old 23 years old she's got to live for 80 years you can't talk of six seven years of stuff and say that's okay how can we do this we should get her valuable area more than two centimeter squares and we should try to get her back into a permanent sinus rhythm where there is no episode of palpitation at all and there's all our symptoms metal wall is not a simple thing it's got quality it's got papillary muscle there are two leaflets i think i would like to invite common quantity to the theater and show them how complicated this valve is not something just to be blown up with a balloon where you don't know what's being blown up so if i was a search then what would i do for this patient i would do a commission to compress a complete valve tommy you would ligate the l appendage we will go down to see the sub valve the body split the muscle split the cordy remove whatever pathology is there decalcify the leaflet do a bilateral mass and if this patient has got tricuspid recognition more than moderate or if a t like a speed analysis more than 40 i would also like to repair that mind you this patient got severe for my hypertension and she can have moderate tr and by all the guidelines if there is more than 100 tr when you are addressing vital stigmas atrial uh repel repair is must i have seen more suffering and more misery with trigger speed valve repair than i have seen with primary valvular heart disease so surgical exposure is wonderful there's a lot we do on the table we split the commission split the sub-matter apparatus split the papillary muscle split the cordy we make it absolutely normal and we put a ring and what do we get the end of the day we get a patient who has a valve that has no mitral regurgitation or maximum mild possible reconciliation we would aim for an area of more than two centimeters and a normal sinus rhythm with an l appendage that's ligated so basically all the pathology has been corrected so what if the results mean you know what is the actual survival of the good open metal repair 94.6 percent at 14 years old it's not four years and an 83 percent at 14 years free from the operation and there is this uh particular study by entunes who was one of the leaders in value repair and leaders who promoted valuable heart surgery he says that there are not one but so many patients who have you know more than 20 years of survival without any reoperation without a problem i'm sure all of you have seen a patient of cmc which was done maybe 20 30 years ago and still the patient has a valve area of more than 1.7 or 2 centimeters in this study he said that most of the patients who had pre-operative point a value of 0.99 post-op had areas of 2.88 centimeter square or more and 37 percent and more than 3 centimeter valve area means that's the normal mitral valve that's what the surgeons aim for we don't aim for slip shot or half-hearted jobs where we just blow up a little bit of commission and say oh the patient is okay we look at 98 percent freedom from re-operation 98 percent freedom from mortality we look at 98 percent uh freedom from complications this is what we aim at this is what valve areas we look at more than two point five three centimeters these the valves have been wonderful they have to look like brand new valves when you go and repair it it's not just opening a little bit of commissioner that makes a person okay so let's get that one clear that surgeons do a very nice job a complete job and what if i'm on the table and the valve is not okay i can just go in and replace it not like you know you've got leaking blood into hell into the pericardium where something is punctured or a severe mr and the patient suffers all night and in the morning you come and tell me oh that patient has got severe mr can you do him now and by the time that patient is dead it's not like that we can just go and straight away change the miter valve and put a new valve and prosthetic valves they are wonderful right now you have an actual survival of more than 75 at 15 years and let me tell you new valves are on the block there is a new triangle that's coming which will not need anticoagulation and will last for the patient's life it will be a game changer as it comes by so surgeons have not said the last word yet let me tell you that there's a lot that's happening and there are not one but ample number of trials that show 15 and 20-year data of mitral valve replacement or aotic valve replacement where prosthetic valve patients have done very well and i'm sure kamal in your opd you will be seeing some patients that we operated in 95 96 when i was at u.n method institute of cardiology they're still coming back to you for follow-up so prosthetic valves do well not all of them die with thrombosis or problems that people die some patients die and most of the data everywhere says that definitely repair is better than replacement but replacement itself is not bad so what should we do repair or blow up the valve cancer surgery can utilize the disease but can bmw give a better result let's see what there is to be said now look at this you are said that the wilkinson score is eight what does wilkinson ate mean let me tell you that wilkinson is a very vague scoring victim score is a very big thing it just talks about mobility thickening some calcification something like that there are four criteria and you just make eight out of this but does it look at commissional calcification no it does not look at commission calcification does it look you know it that is the most singularly important thing in a valve does it have commission calcification or not and there is nothing about that in wilkins score about commercial calcification so what are the limitations of you can score all the cardinals jump around oh wilkins for eight let's do it there's many limitations number one it doesn't look at commercial classification it's very observer variable observer may think this valley flight is good the other one may think it's bad and i've always seen even if i show them a report of it the cardiologist will say i'll have a look then he goes and have a look and there is no this one is calcified this one the commissioners are not good something is wrong so let me tell you we are going on a very very you know a score system that is not perfect it has nothing about it it means nothing according to me so if you ask me and again wilkins score does not have anything about contraindication can you believe a score that there is no contraindication anybody according to this 16 scoring bus the risk is low or the risk is high go ahead and do a bmv you don't know what the leaflet is like you don't know what the commissions are like just a little bit leaflet thickness little bit the subwell fibrosis then just go and do a bmw will concern is eight i am happy wilkinson is nine i am happy two observers if you sent for an echo both will give you different results and will concern so that does not mean anything let me tell you more than that does wilkinson identify the highest subsets no you just look at wilkinson go and do a bmv no it's not like that acc aha and esc all have defined certain high risk criteria they say whether the anatomy is good or bad there are certain contraindications to bmb and in that they have mentioned atrial fibrillation and severe pulmonary hypertension this patient has severe problem hypertension intermittent palpitation which definitely stands for uh atrial fibrillation in the developing means her left atrial appendage is already hypertrophy and she can get into trouble now what is a successful bmw have you ever heard what is a successful bmw a successful bmv is where the valve area becomes double or there is a 50 percent improved from the previous bank valve area you know when a cardiologist comes and said well fully means from 0.8 he has made it 1.6 and i would like to ask the audience how many have you seen valve areas post bmv that cross 2 centimeters in my life till now i have not seen one valve that has come with an area of more than two centimeters one point five is excellent result we will write excellent mild to moderate mr bmw are 1.5 this is very good but does everybody in the audience think 1.5 is good and suppose if the area is 0.6 and this is from their journal i picked up double the valve area or 50 percent gain from pre bmv area now what is 50 gain if it is pointed and you make it 1.2 it is still vitals stenosis so it this is a very subjective thing send me these equals i'll have a look and tell you what the valve area is so it's that a good bmw they're scared of mr so they'll inflate the valve a little come and come out that's how it goes that's not the way you treat a patient and this is totally subjective let me point out this paper to dr kamal sharma i think you should start looking at commissional area ratio and leaflet displacement these are better guidance than wilkins score for a bmv because this looks at commissional calcification which is more important also you should have a better look at the submittal valve apparatus that you move carefully you may open the valve up there but if the submatter is bad the patient still does not make it that's very important people say commissioner commissioner dummy outdated look patients have data of 20 years 30 years 40 years this data is up to 30 years but there is 45.9 percent survival in 30 years which is excellent this particular paper from 19 says omc remains the best alternative for treatment of treatment of all cases of metal stenosis independent of degree of liability in our experience the median long-term results are significantly better than those usually reported in three bmc series and these are our big pioneers this is from shiv kumar chaudhary delhi where they have seen an average mean area of two point six centimeters plus minus point six centimeters and their long-term follow-up shows excellent survival and good uh results you know many times you wonder why should bmv not be as good as omc i'm sure none of you have gone and read your books of rheumatic heart disease and its pathology after finishing mbbs rheumatic heart disease is such that if there is turbulence if the flow is not good then recalcification can happen the main reason spencer at all have reported the main reason for better result is reduction in turbulent blood flow created by a widely patented and competent mitral valve delicious progressive valve fibrosis and generally objects the need for future valve replacement so surgeons can obviate the need to need for future valve replacement because we do a complete job not an incomplete job like our cardiologist does and you have open metal data of 18 years 20 years years and years we have data that is excellent see a little bit two minutes just two minutes bmv uh some data is presented to us but go and look in general data what is it like bmw survival 69 percent and freedom from 71 actual survival 56 percent at 10 years this is the type of data i came across when i went on the internet so what do you want you want a patient who lives happily who's got the disease neutralized who does not suffer from atrial fibrillation pulmonary hypertension and multitude of complications i have seen patients who had a bmv after five years they seek a balloon challenge now we go ahead and do we do a metal ball replacement and when that patient comes to us that patient is severe permanently hypertension atrial fibrillation trigger speed regurgitation and a multitude of complications and then the patient doesn't do well and they say the surgeon messed up the case so i think a stitch in time saves nine when the patient comes do a good job open the valve completely make the patient normal and let her live don't do something like a bt bmc that is just for sure you've just blown up the valve a little don't know what really happened to the complete pathology in the valve and let the patient suffer for five six years then say this work well for four five years that's enough now we can just go for an mdr no no no when you do a procedure for 30 years the patient should do well thank you very much dr kamal sharma i don't want to say more than this i'm not here to criticize the procedure i know it's a good procedure but i think you need to go go back to the drawing board and look up to everything and try to do something better than and so don't think we are villains we are very good people and we give a good long term survival and patients will live we want them to live thank you so much thank you and we have no doubt on your competency as a surgeon what happens is that whenever we refer a patient for an mb repair uh advise that mbr is indicated and what happens if they end up putting a process into the patient's heart we are more than 12. important what is good for the patient is important on a scientific problem [Music] hello yeah please share what's going to show me full screen yeah i'm safe by the time he shares i think we can uh i can rebut at least one thing what anil said you know 50 and you get away it's not like that you know somebody can argue but that doesn't mean there are not people who not get 99 is defined as passing of the bmv if you don't do 50 of the area your procedure is unsuccessful and that is what i showed that even by that marking 90 of the people are passing that means 35 percent mark lucky to class 90 people are passing so 90 of bmvs get area more than double that is what it meant don't try to twist that we always end up getting only half double the area most of the times you as i showed you you can get area as high as 2.2 2.1 and i showed you papers on that we can come to that i think uh i don't want to argue on that point all there are two things which before i start my presentation open it up one is kamal has given a topic which is overlapping between anil and me so there is bound to be some discussion which will be common to both and secondly i want to remind all of you that everything has been said before but since nobody was listening it has to be repeated again this is what andrew regedia said omv and cmv are very much alive extremely relevant and modern to consider them old fashioned is wrongly banishing the huge patient population of patients of mitosis either to incomplete treatment and that is bmv or unnecessary mitral replacement there is a great place of omv and cmv in this scenario of course i do admit dmv is a procedure of choice isolated uncomplicated mitral stenosis with very favorable morphology like nicely plant non-calcific wall minimal survival crowding consistent sinus rhythm not intermittent and no don't laugh at your trumpets go ahead come on do a blv but remember what i'm saying the profile that you have given me is incomplete there is no mention of rhythm no mention about any clothes and there is no mention of brightest football disease this is exactly what cardiologists do they ignore rhythm and eclipse strike as people just see wilkinsons and blast they are likely these patients are likely to be in as having severe pulmonary hypertension and therefore they have categorization plots and tricuspid disease which has not been mentioned in the profile that you have given me muscles and rheumatic pathology affects everything unfortunately bmv just separates the leaflets body and papillary muscles are not touched and they form a formidable part of pathology this slide shows the progression of a normal one to calcific wall stenosis called the quality normal quality and then shortening of body and then crowding and papillary muscles getting attached to the cusp tell me how balloon can do anything to this congested body and capillary muscles attached to the miter cuts it has to be opened up mechanically at open miter valve automatically use cardiopulmonary bypass left atrium is open miter wall pathology is studied systematically valve is open at customal cordless and papillary muscles that is if mild to mounted casual classification dust can be shaved off chromos can be removed left atrium can be plicated in presence of giant giant atrium which we all know biatrial base can be done left material appendage can be excluded and tricuspid valve is repaired if there is moderate to severe regurgitation so you treat the patient completely do not treat just the test which bmv does this is the technique of mitral valve automate these are operative pictures and through electric fuse commissures for two neutrals whose semesters are separated these seven structures are cut and division of the papillary muscles with procedure system so that miter wall is competent and yet fully opened what does bmw do it simply spreads the fuse commissions it does not adequately treat the vulva crowding which may form an important part of pathology and it ignores clots atrial fibrillation and triglyceride institution what are the indications of open miter valve from absolute indication presence of thrombus atrial fibrillation survivor crowding calcification failed bmv stenosis after bnb resources after cmv significant outer stenosis and mitral stenosis which can be opened up very easily moderate to severe attractive speed relation and large atrium mild metal mitral regurgitation these are the place times where open miter one bottom will be ideal dr sampat kumar's paper has already been referred by anil this is a landmark paper which established open mitral volvotomy as a technique which is not relegated to the past what are the advantages i mentioned again but it is import important to iterate direct inspection of the wifi methodology there is no procedure neither bmv nor cruise nitrous you see the valve completely and do whatever is necessary will just see an image its image and then intensification of imagination but not real picture is seen by any cardiologist there is careful deploy deployment of tension deposits some valve structures are separated and rest of the things i have already mentioned if valve is bad in contrast to what was found on echo one can be replaced 30 percent of patients with isolated mitosis have atrial fibrillation stroke and peripheral embolizations are ever present threats atrial fibrillation reduces cardiac output tachycardiomyopathy is end-stage disease and there is chronic fatigue and cardiac failure this is the place where the appendage gets plotted and then the clot spreads into the left atrial body incidence of arterial thrombus 25 of patients with mitosis of actual numbers and routine transact esophageal electrocardiography will detect many more it is a major cause of morbidity and mitral stenosis what can you do on bmv with these clothes i am told that you give anticoagulation for three weeks and then you can do bmv now here is what uh cardiology journal journal of heart wall disease says effective resolution and organization of lateral materials from bi needs optimal six months in order to opt for bmv patients are asked to wait and suffer symptoms and take long-term anticoagulation with its possible complications some patients may embolize in spite of intervention during this waiting time some patients go into severe symptoms low output state needing icu care while waiting for bmv right here we have omg which is next day procedure quick definitive and removes all plots completely so don't ask your patients with atrial fibrillation to wait for a long time and then assist with bnb offer them quick and effective solution right away this is how we convert atrial fibrillation into sinus rhythm all the lesions left atrial lesions are shown and left atrial appendage is also excluded you can see in the figure and this is right at real maze complete mess gives you 70 to 80 of the patients from atrial fibrillation into sinus rhythm nothing can be done like this in a bmv left atrial appendage is excluded sometimes in exclusion of left atrial appendage is a hot topic in cardiology so many devices and procedures have been described but they ignore the same fact while doing the mv why not exclude left atrial appendage we can do it at the same time when we are doing open miter while bottom there is a comparison between dmv and omv omg gives better long term hemodynamics and lower rate of risk noses bmv is a power yes i agree dmv is a procedure of choice only in selected patients due to its less invasive nature immediate this again was quoted by immediate and long-term results of balloon and surgical closed miter will automate randomized comparative trans what remember this 40 of all patients with rhd have ms and mr together most of them have symptomatic severe mitral stresses but significant mitral regurgitation for most patients with pre-existing moderate patterns regurgitation bmd is out of question it's contraindication so how much how many few patients left patients 40 percent patients with mitral regurgitation are out 25 percent of atrial fibrillation are out from bmv 40 to 25 percent operations with plots on trans forensic eco they are out for bmd so just imagine how much is left for bnb michael commissioner told me a technique outdated here is a paper which has studied for over 25 35 years but this meta meta analysis says it's a systematic study of effectiveness of bmv versus closed and open surgical micro albertoni it's a very very painstaking study over from 1974 to 2010 all clinical control trials were compared abstracts for major cardiology and cardiac surgery meetings were studied references also were studied and even corresponded with authors of all relevant research very landmark article and what does it say sorry no difference in mortality yes we admit in vmware there is mortality of 4.13 in surgery that is 3.24 fine we accept survival after bmv was significantly lower compared with omv on long term list surgery has the inherent superiority over bmv in providing the potential for additional surgical techniques which may improve late survival and destination rate inherent superiority or over bmv 30 to 50 this is very very important listen to us 30 fifty percent of bmv patients develop mitral regurgitation and four percent need immediate surgery but let's not forget mitral regurgitation begets mitral regurgitation if you leave mild mitral regurgitation oh that's mind mitral regurgitation after three or four or five years it will be severe mitral vegetation did not show any significant differences in terms of operative and late mortality and complication incidence of late new onset mr and late reintervention but significantly higher efficiency balloon surgery remains the treatment of choice for rheumatic mitral stenosis here is another paper study of 314 patients 32 patients had 32 percent of the patients had moderate to severe tricuspid regurgitation and the third point is absolutely important i have highlighted try to speed regurgitation did not improve in 88 percent of patients study don't say that this is functional tricuspid to get vegetation we have open balloon we have opened the wall with balloon tricuspid regulation will resolve no in 88 it doesn't really result tr functional or organic must be treated to avoid long-term disease of secretion dysfunction of the right ventricle so 30 to another group 32 are out for out from bmv it just takes 10 to 15 minutes to repair a symptom free life for wrong use leaving moderate to severe tr untreated at the first instance when you do baby is a crime however tempting and easy bmv appears based on into inverted commas wilkinson score reduced functional capacity heart failure massive federal edema scientists hepatic dysfunction and metabolic consequences are too well known because of cvtr and it definitely pointed out to this long-term effects of progressive tr are grave leave the patient miserable an attempt to correct surgically will have mortality more than 50 this is how the tricuspid valve is repaired in just 10 15 minutes a ring is established and that's it and a long good life is given to the patient incidence prognosis implications mechanism and management this again is a very very important article in cardiology journal it says one third of the patients with mitral stenosis at least moderate triggers to regurgitation and all moderate trackers for regurgitation need treatment bmv turns a blind eye to significant tr they just don't look at it this is what it happens you live tr moderate tr and over a period of three or four years it becomes severe and patients survival decreases to 50 percent and if it is severe it the survival decreases to 40 percent so the myth of functional tricuspid regurgitation let us all together admit that there is nothing like functional tricuspid regurgitation if the track speed annulus is more than 35 or 40 millimeter and every day day in and day out with dmv 50 of the patients will have this priyar which is tricuspid annulus which will be 35 40 millimeter and they all will come back after five years with gross tier and ascites results of repeat surgery are extremely bad and prophylactically attached regarding repair is also now indicated if the patient has dilated tricuspid annulus there is no significant tr but dilated annulus needs repair cannot be done in bmv giant left atrium is common in other countries though literature says it is just 0.6 and in our country it is much more than that eight centimeter or more entrepreneurial diameter of left atrium measured in this axis and consequences what are the consequences of uh giant left atrium decreased cardiac output in spite of correcting mitral stimulus so we can have discussion now yes just a second let me let me complete in defense of closed microsomi this is the procedure and these are the articles proving recent articles proving the effectiveness of closed miter one automate cmd represents a satisfactory technique in terms of lower cost high efficiency simplicity and reproducibility when compared with balloon cmv offers a satisfactory technique it can be done in pregnancy and we have done even at bedside this procedure can be done at website omv and cmv omb is far better but like bmv cmv also has limitations in long-term results bmv and cmv we conclude with the immediate and long-term results of bmv and cmvs same but cmg results in better long-term survival and fewer well-related complications as compared to balloon mitral velocity and dmv and when they are more or less same but late results are better with ofp do not this is my message to all of cardiologists do not just look at the balloonable mitral stenosis as dictated by wilkinson's score look at the patient's presentation do not do half-hearted treatment at the first instance this is her only chance of a good life complete treatment that one go gives the best short and long-term results untreated pathology spoils patients medical history bmv but dmv has an excellent role in selected patients rheumatic mitral disease is a progressive disease this are the pictures of two grandmothers the first one left side underwent open mitral volvo to me in 1984 she was the first open heart operation of gujarat and in 1934 she underwent metal wall replacement she is doing very well there is another grandmother who underwent close michael valvertoni by us 37 years ago 1985 and everything is good with them there are no even needing hospitalization friends let me assure you that if you offer these two uh these procedures in selected patients bmw will be out of out of consideration in more than 30 to 40 of the issues thank you very much kamal and all friends jignesh lada calfish and prasanth for giving me an opportunity to talk something which i used to talk in 1985. thank you so much so i would like to ask our moderators to give a quick bite of what do they think of these presentations and then we can move on to the question and answer so there are some questions in the chat box as well so dr sunil dr kiran please give us your point of views yeah but not so basically if we are running out of time but still i have some question and the comments to make here like one thing uh mrb gets mr that is not for dramatic diseases mr biggest mr is for dielectric cardiomyopathy where if there is mr then it causes a heart enlargement and again secondary for rheumatic what we see is even if people develop mr during the procedure unless it is not tolerated or there is no tear if it is due to tear then yes it is not all later otherwise many of these mild to moderate is well tolerated even if severe if the left hip is very large they do tolerate and over a period of time it actually disappears like the pneumatic pathology is like that ultimately there is a commercial fusion and that is bound to happen after a bme so there is commercial separation thereafter over a period of time we have few patients who develop a severe mr during process uh didn't require surgery uh immediately because the law is large and somehow they got this blood was adjusted and over a period of six months it became multimodal so this mr bigger smr is for dcmp that will not be valid for um this uh dramatic diseases second is for af as kusarza said af is out no af is not out we do not consider if the passant is af it's not like we do not consider bmd uh or many air passenger bmd can be considered it is not a contraindication anywhere the third it is not a contact indication anyway shall i respond yes come on let them finish all the questions yeah i think let's have all questions in a go and then we all get two minutes each to rebut i think that's all we should do then third is about like none of us are here cosmetology so how it appears on table after mbr like everything is open now this is open this is open that doesn't matter if the outcomes are not different that is what it is none of us are cosmetologists so it appears too good on table with mbr and may not be good because you are only opening the commission that doesn't matter if the long-term desserts are okay so this is third thing and uh another is about the maize so particularly these patients are young patients whenever dramatic patients need body intervention if you're even after me if the passion is in air you have to give anticoagulation so that doesn't make it that is not required even if you are doing a repair so for af passenger if you are doing mess during repair then also passion need to be on anticoagulation and the embolism is because the embolism disk remains uh even after mesh processor and converts into chinese genome and third uh another thing about mortality so most of the papers quoted here are from uh centers some from india many from abroad but the real life data if you see older i think some 20 years old data from ames uh delhi by dr sampath umar so what he has one is the passions many of patients at ms delhi come from bihar up and so many uh remote places and the actual mortality at one year was 30 percent that is too high after wall replacement so valve repair can be an option but many a places wall repair is not being done once they open it it becomes like the valve is too bad and it is replaced so it doesn't uh in a indian scenario where the anticoagulation uh the compliance to treatment is not very good and the mortality we cannot accept a mortality of 30 percent in the real life scenario yeah doctor brian kasina he's a cardiothoracic surgeon uh doing a lot of repairs please go ahead i'm sorry i just wanted to make a few point that there has been a lovely discussion i have been traveling the missing bits and pieces of it but the thing is what we wanted to highlight is the anatomy with the anatomy of the mitral valve we need to understand and analyze the anatomy very well once we understand the anatomy and the morphology of the diseased valve it becomes very easy to choose between whether we want to do a bmp or a cmc or a vital repair or omc they're all complimentary procedures complimenting each other at various times then i would beg to say that they are all brothers and sisters everything has a place and i think that morphology would define what needs to be done thank you so much yes uh dr kiran good morning the panelists just i want to uh comment that uh as we have discussed i think the patient's uh condition of the wall and the timing more for subjecting patient for bmv or omc or cmc or mbi uh one thing i want to ask to our surgeon panel that at what at which point you consider that this omc is is successful and then long-term outcome is good so patient may not need uh surgery maybe near 10 years or something 10 to 15 years at least so just i want to know that so because we have to tell that okay this is no no you are now omc is done and then mostly you will not require mvr maybe in uh coming 15 to 10 to 15 years so just i want to know the end point after surgery when you can say that now this is successful omc and then the patient is now having a good long-term outcome good question i think i'll just add one point [Music] [Music] secondly secondly during the procedure and after the procedure and it is the ultimate cardiologist or table tells you that you have done a good job so it is a very controlled nicely controlled with finger itself yes sir and so we also see on echo if the area is not open completely we again do another inflation by going up by hans formula so that's the answer to anil is fifty percent no nothing better than digital palpation [Music] a complete job like ring and omc and some valve division and everything we do and repeat echo and if the valve area is more than two centimeters there is no gradient there is no what do you say no mitral regulation is considered as a successful repair and that is the benchmark and we have to we usually get that if you've done a good job there's no problem and with that sort of repair 15 20 30 years is not a problem if the patient is put on penicillin profile access for the l appendage closure just my counter was that a lot of trials have shown that it is not inferior to anticoagulation including our watchman devices you know we have got fantastic devices but still you don't have to choose them ahead of anticoagulation so just for the sake of ligating an appendage at least you should not be going an open heart to record to pay for this come on i cannot i can't know that if all the devices are going to stop anticoagulation after ligating the appendage if the patient is af yes or no i have a question for you why do you not do a bmv to a person who has got a clot in life we do and we have published our case reports is when a patient comes with mitral valve disease and his normal sinus rhythm does not have a clot should he not be undergoing bmv was the question fibrillation he patiently got severe permanent that's the assumption palpitation can be sinus tachycardia palpitation can be simply because of the exertion disease it's nowhere mentioned af you for that you may do an halter and document an area then i don't mind if the echo is okay for sure give me the alter report give me the track speed val report you will not put that there and for the tricuspid the btv balloon tricuspid volvo plasti is even easier safer method you actually never have a tv repair required never reported if it's organic if it's organic tr you always have associated ts the tr regresses when the ph regresses which regresses in ninety percent of the patients when you release your beliefs reference from american journal of cardiology which says 88 percent of the tr does not regress if the trigger speed annulus is more than 3.5 there is but that's not the case which is not here rather than just looking at the pressures and the jet area when you're looking to define organic the annulus is not dilated even if you have severe tr it is functional no it doesn't work like myth for most of the patients yes and coming back to dr sunil's question mrb gets mr this is a very well documented fact in all textbooks of cardiac surgery you take a take kirklin you take spencer you take victims everybody says michael triggers dramatic mitral regurgitation binary is a progressive reason how yes i agree initially after bm yes you are right initially after bmv if there is little increase in mr with fibrosis it might decrease but after three to four months if there is mr it is bound to progress to severe mitral regulation needing intervention repair or replacement secondly dr sunil raised the question of af is not a contraindication for bmd yes it is not but can you convert it to sinus rhythm conversion of scientists let me complete conversion to sinus rhythm obvious so many complications of atrial fibrillation which are well known to you more known to you than to us sinus rhythm there is worse rhythm in the body is actual fibrillation conversion to sinus rhythm gives an excellent life which bmv just cannot whether you use anticoagulation or not if the ls size remains large you would still give anticoagulation in a very low dose but most of these patients more than 70 questions 70 percent of the patients have five years sinus rhythm what more do you want third question trigger speed regulation worsens faster yes if there is af the tr versus faster than the patient in sinusoidal if you have not corrected the uh tr and there is af all of you have seen patients we all know we all know that if you have to do a redo bmv the incidence of complication stay procedural outcome stroke rate which in our own paper published in indian heart journal shows that the mortality eventuality rate was lesser than the first mbr so even if i was to get a re-stenosis at 12 years i'm okay in my case series we did two third of the cases where surgeons had done cnc or omc so sir i respect both of you surgeons you are fantastic surgeons your patients don't require a second surgery but i have done surgeries or bmps for the cases where two-thirds were seen omc out of 70 people no no no no talk of data and good that is my data that i'm talking it's published it's published on indian heart journal what i'm saying is about this particular case what should we do yeah so this case would be there long term result one bmv i do my event rate is less than three percent cmc omc rates mvr rates of complication i've shown you by sts score is almost including morbidity and mortality more than 10 four times that of bmv if you're arguing for long term outcome i can go ahead and take this patient for a second dmv based on our own paper which again says that we can still do a successful procedure without having complication of equal to even the first mbr or omc or cnc so you know what i want to say dr kamal started who's wearing a mask see the surgeons are without masks our outpatients are seen by the cardiologist echo is done the physicians see cardiologists wear this mask of an echocardiography and they hide behind that echo machine they do their echoes you know just just say oh this area this is 1.8 if the cardiologist has done it and if i have done you know oh no there is more than moderate mr there is microstenosis it's like that you're behind hiding i i want to ask i have seen innumerable vital bmv reports and the value is 1.5 1.6 1.4 good result continue and you know what happens after four years five years this mission come back with severe tr severe ph a very bad valve it cannot be opened anymore and will need mbr and these patients have a higher mortality so i think doing a good job primarily when the patient comes first time to do a complete opening and wilkins score that's useless i've read entire data in the past 10 15 years and will continue for nothing it means nothing at all no cardiographic assessment it's not a clinical assessment dmv no no even echocard it's not an anatomical assessment it is nothing about so you have even naga yoshi's data which also talks about another scoring which is very much on the same line just for the sake and i think we had a fantastic debate we need to end the session we are running late and we have another surgeon and it's always a pleasure to have you both nobody is hiding behind mask we call each other's superman batman and superman rather than patients calling us the jokers so better to be called that the whole idea was to promote science and thank you very much to have all of you thank you chairpersons thank you moderators thank you both the speakers and my debaters

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dr. Kamal Sharma

Dr. Kamal Sharma

Chief of Interventional Cardiology, SAL Hospital | Author | Researcher | Innovator

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dr. Kamal Sharma

Dr. Kamal Sharma

Chief of Interventional Cardiology, SAL Hospi...

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