Phillip Rowse, MD, FACS @RowseMD Twitter profile

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Phillip Rowse, MD, FACS

@RowseMD

1 year

Mayo Clinic Cardiothoracic Surgery Residents learning aortic root enlargement techniques, valve sparing root replacement, and myectomy. Our trainees are outstanding!

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Phillip Rowse, MD, FACS

@RowseMD

3 years

Central Venous Pressure Tracing: A-wave: RA contraction (end diastole, P-wave on ekg) C-wave: TV bows into RA (early systole) X-descent: RA relaxation(mid systole, QRS on EKG) V-Wave: RA filling (late systole, T-wave on EKG) Y-descent: early diastolic emptying RA.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Be aggressive with treating sternal wound infections. Here’s a sternum 4 weeks post CABG that ultimately required several washouts and sternal plating followed by pec flaps for closure but we saved the bone.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Classic quote from Will Mayo.

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Phillip Rowse, MD, FACS

@RowseMD

4 years

Aspiring cardiac surgeons should know the views of the mitral valve via TEE. Here’s a refresher.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Systolic anterior motion of the mitral valve in HCM patient.

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Phillip Rowse, MD, FACS

@RowseMD

4 years

There are 5 goals in mitral repair: 1) Preserve leaflet mobility. 2) Restore leaflet coaptation. 3) Reduce posterior leaflet height (“height" refers to the distance from the base of the leaflet at the annulus to the leaflet free margin. 4)Reduce annular dilation. 5) Prevent SAM.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

The quintessential vital sign for bypass graft patency.

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Phillip Rowse, MD, FACS

@RowseMD

4 years

Mitral annular disjunction (MAD) is a distinct separation of the mitral annulus—LA wall continuum & the basal portion of the ventricular myocardium. MAD is detected in systole when the annulus “slides” & detaches from the myocardium by a distance ranging from 1-10mm.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Severe constrictive pericarditis. Starting CVP was 25mmHg, CI was 1.77 L/min/m2 and PAP was 51/20. Following near total pericardiectomy CVP dropped to 10 mmHg, CI improved 3.2 L/min/m2, PAP 34/20. @KrithikaRamapr1

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Phillip Rowse, MD, FACS

@RowseMD

4 years

1. The RA contains: coronary sinus (CS), IVC, septum secundum 2. Appendage: large/broad base 3. Eustachian valve- IVC 4. Thebesian valve- CS 5. Crista terminalis- divides trabeculated RA from smooth RA 6. Sulcus terminalis- points to SA node 7. Pectinate- contractile muscle

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Phillip Rowse, MD, FACS

@RowseMD

2 years

LIMA to LAD…the other graft was in situ RIMA to OM1 via the transverse sinus. Such a beautiful operation.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Transaortic myectomy for obstructive HCM. Incise the septum at the nadir of the RCC, carry incision upward & left toward AMVL. Spongestick can rotate the apical septum into view for 2nd cut. You need to 👀base of papillary muscles when done. #cardiotwitter #MedTwitter #MedEd

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Phillip Rowse, MD, FACS

@RowseMD

3 years

IABP Basics: Electrocardiogram tracing: - Inflates at the middle of the T wave - Deflates on the peak of the R wave. Arterial pressure waveform: - Inflates after AV closure (corresponds to dicrotic notch). - Deflates immediately prior to AV open.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

LIMA-LAD, radial-OM, SVG-PDA, a good alternative to BIMA in a patient with a higher sternal risk profile.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Barlow’s valve with severe anterior leaflet prolapse. Repaired with 3 separate artificial neochordae with pledgeted 4 0 Gortex suture placed at A1, A2, & A3 scallops followed by posterior annuloplasty.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Autologous Great Saphenous Vein- a large capacitance vessel, easy to harvest, readily available but not the best long term conduit. Failure rate @ 1 month ~10-15% Failure rate @ 1 year ~15-20% Failure rate @ 10 years ~ 40-50%

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Apical Variant HCM!

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Off pump pericardiectomy. CVP dropped from 25mmHg to 10-12mmHg. Cardiac output improved to 9 L/min. Always look for progressive MR or TR…fortunately the valves were all ok.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

The beauty of the mitral valve.

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Phillip Rowse, MD, FACS

@RowseMD

4 years

Resection of a large atypical Myxoma from the left atrium. Removing the endocardium with the stalk followed by patch reconstruction is key to prevent recurrence and stenosis of the right pulmonary veins.

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Phillip Rowse, MD, FACS

@RowseMD

3 years

Air embolism while on pump. Rare but can be fatal. Quick action is required: 1. STOP the pump and clamp aortic and venous lines. De-air circuit 2. Trendelenberg 3. Connect arterial line to SVC cannula / start RCP for 2 min 4. Root vent on 5. 100% O2 6. Cool 7. Steroids, pressors

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Bileaflet mechanical aortic valves: here’s a 25 mm On X v.s. 23 mm St Jude. I use both valves. ⚠️Be careful using an On X in a small root with low set coronaries…might consider a lower profile St. Jude in such a scenario.

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Phillip Rowse, MD, FACS

@RowseMD

3 years

Aortic Stenosis vs. Obstructive HCM Key Facts: 1. AS (fixed obstruction) has NO change in pulse pressure or gradient after PVC. 2. HCM (dynamic obstruction) will have ^ LV pressure and decrease pulse pressure after PVC. Following myectomy LV and Ao pressures will equalize

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Phillip Rowse, MD, FACS

@RowseMD

4 years

After complete pericardiectomy you can expect to observe: 1) CVP should drop by half. 2) UOP should increase. 3) Patients often become tachycardic. Watch out for worsening TR / MR. Perform annuloplasty liberally if +2 regurgitation occurs post pericardiectomy as it will worsen.

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Phillip Rowse, MD, FACS

@RowseMD

3 years

A view that should never get old for mitral surgeons. Know your surroundings!

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Phillip Rowse, MD, FACS

@RowseMD

1 year

Myocardial bridge: systolic compression of an intramyocardial coronary ➡️ dynamic compression and angina. Division of the bridge relieves symptoms in 2/3 of patients. Endothelial dysfunction likely responsible for those with persistent symptoms if division was adequate.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Bicuspid aortic valve 🔹1% of pop. 🔹AD w incomplete penetrance 🔹Screen AV/Ao in 1st-deg relative 🔹LCC-RCC fusion 70-85% 🔹L coronary dominance common 🔹TTE sensitivity 80-90% 🔹Cystic medial degeneration 🔹>1/3 BAV develop complication -valve dz, aortopathies

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Inflammation to the mitral leaflets caused by a MitraClip.

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Phillip Rowse, MD, FACS

@RowseMD

4 years

The R. fibrous trigone of MV lies at the base of the NCC of AV. The L. fibrous trigone is at the base of the LCC. Manouguian root enlargement crosses AV annulus & extends squarely in middle of AMVL = no MR. If Nicks is extended onto AMVL you may distort coaptation= Watch for MR!

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Phillip Rowse, MD, FACS

@RowseMD

3 years

Prosthetic patient mismatch occurs when indexed EOA = <0.65 cm2/m2. No PPM = 0.85 cm2/m2. Indexed EOA = EOA / BSA To avoid PPM: 1)calculate the patient’s BSA 2)multiply BSA by 0.85 3)the result is the minimum prosthetic EOA required to avoid PPM. Use chart below.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Measuring the LV-to-aortic pressure gradient (with needle manometry) at rest and with PVC should be done before and after septal myectomy to ensure abolishment of gradient.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

To the CT Resident: A median sternotomy means a median sternotomy….a few years ago, this septuagenarian was distraught about the size and location of his incision. Pride yourself on being focused & attentive to detail.

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Phillip Rowse, MD, FACS

@RowseMD

1 year

Full metal jacket at age 50…very sad & disappointing

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Phillip Rowse, MD, FACS

@RowseMD

8 months

One of the most important slides for all CT Fellows to study!!!

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Phillip Rowse, MD, FACS

@RowseMD

3 years

Do you know the waves on venous pressure tracing? A rapid Y descent is seen in constrictive pericarditis due to impaired RV filling in LATE diastole. Early diastolic filling occurs briefly. After pericardiectomy: CVP should drop by 1/2, and UOP should ^

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Explanting an infected Sapien valve…I prefer an endarterectomy spatula (free it from the aortic sinuses) and two Schnidt clamps (bend the cage inward) and pull it out. What do you do?

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Phillip Rowse, MD, FACS

@RowseMD

2 years

To the thoracic surgery resident: Age categories exist with Primary MR YOUNG➡️ Myxomatous degen OLD➡️ Fibroelastic deficiency

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Quadricuspid aortic valve: 🔹estimated frequency <0.006% 🔹many eventually require surgery (regurgitation > stenosis). 🔹~1/3 have Ao/root dilatation 🔹~1/3 have other structural anomalies 🔹Progressive cusp fibrosis leads to regurgitation.

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Phillip Rowse, MD, FACS

@RowseMD

3 years

Trans-septal exposure of the mitral valve provides good access/visibility particularly in redo scenarios (retraction through an interatrial groove incision often limited by adhesions). Be careful not to incise too close to the anterior limbus of FO, can injure anterior MV annulus

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Phillip Rowse, MD, FACS

@RowseMD

2 years

What’s the diagnosis?

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Phillip Rowse, MD, FACS

@RowseMD

4 years

The aortomitral angle (AMA) is formed by the intersection of the mitral annulus and the aortic annulus at the intervalvular fibrosa. A narrow AMA (<120 degrees) is a risk for systolic anterior motion following MV repair.

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Phillip Rowse, MD, FACS

@RowseMD

3 years

Smoking cessation 4-6 weeks before cardiac surgery can contribute to a lower postoperative morbidity rate and a lower risk of chest infections.

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Phillip Rowse, MD, FACS

@RowseMD

1 year

What’s the diagnosis

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Phillip Rowse, MD, FACS

@RowseMD

4 years

Every day in cardiac surgery is like a “Game 7.” You must bring focus, passion, grit, knowledge, humility, and a never give up attitude. Do you have what it takes?

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Phillip Rowse, MD, FACS

@RowseMD

3 years

A classic teaching by a surgeon whom I feel blessed to have been trained by and to have as a colleague.

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Phillip Rowse, MD, FACS

@RowseMD

1 year

Anomalous pap muscle insertion onto the body of the AMVL in HCM can cause severe crowding and contribute to LVOT obstruction. I favor resection of the anomalous pap muscle (preserve any chords to leaflet) and perform extended myectomy.

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Phillip Rowse, MD, FACS

@RowseMD

4 years

Brockenbrough-Braunwald-Morrow sign: a decrease in arterial pulse pressure (PP) after a PVC...followed by a sharp increase in peak LV systolic pressure. Expect to see this sign in patients with dynamic obstructive HCM and not in valvular aortic stenosis.

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Phillip Rowse, MD, FACS

@RowseMD

3 years

Surgical MV repair is AT LEAST a class 2a indication for ALL patients with Severe MR provided a >95% likelihood of successful repair with mortality < 1%.

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Phillip Rowse, MD, FACS

@RowseMD

4 years

Risks of SAM & MV repair: 1. Posterior leaflet height >1.5 cm 2. Basal septum >15 mm 3. Distance between leaflet coaptation and the septum <25 mm 4. Aorto-mitral angle <120° 5. Small hyperdynamic LV 6. Undersized ring: coaptation bulges Ant. 7. Ant. to Post. height ratio ≤1.3

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Phillip Rowse, MD, FACS

@RowseMD

4 years

Cardiac surgeons should know/expect that EF can drop after mitral valve repair. It has to do with an understanding of the following: 1. Forward stroke volume 2. Regurgitant volume 3. End-diastolic volume Don’t forget the following formulas 1. EDV = SV / EF 2. EF = SV / EDV

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Phillip Rowse, MD, FACS

@RowseMD

3 years

What’s a safe way to remove an aortic valve prosthesis? I like to use a 15 blade and cut the valve out leaving a portion of the sewing ring still attached. Then debridement the remaining sewing ring, annulus, and remove pledgets.

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Phillip Rowse, MD, FACS

@RowseMD

3 years

Central cannulation over a wire with use of Epiaortic ultrasound & TEE is my preferred technique to confirm true lumen access for Type A Dissection. What’s yours?

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Phillip Rowse, MD, FACS

@RowseMD

3 years

We noted moderate central AI on pre-bypass TEE prior to CABG x2 in a 49 F. We decided to repair the valve by closing the subcommissural triangles using Teflon pledgets. Post-bypass TEE showed only mild AI.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Type A dissection with the entry tear in the lesser curvature of the aortic arch (zone 2). We performed an aggressive hemi-arch removing all the lesser curve (sparing the island of arch vessels) using DHCA and RCP...how would you manage it?

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Phillip Rowse, MD, FACS

@RowseMD

3 years

Acute papillary muscle rupture is a surgical emergency. Acute severe MR is poorly tolerated. Cardiogenic shock with escalating drips and lactate will follow. The posteromedial papillary muscle is the culprit in 3/4 cases. IABP reduces afterload as you prepare for surgery.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Just a couple Mayo Clinic Cardiothoracic Surgeons at AATS. #AATS2022 @MayoClinicCVS

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Phillip Rowse, MD, FACS

@RowseMD

4 years

Bicuspid AV (BAV) and aortopathy. When do you replace the root/ascending aorta with or without concomitant surgical BAV disease? I look at: Size >45 mm with concomitant need AVR. Growth >3mm/yr. Family history of dissection. Size 50-55mm without concomitant need of CVS.

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Phillip Rowse, MD, FACS

@RowseMD

4 years

Atypical Myxoma - Handle with care! These tumors crumble easily. A 4 0 prolene is a good handle during resection. Resect the LA attachment site (prevent recurrence) and have a low threshold to reconstruct/close the LA with a patch to prevent narrowing the pulmonary veins.

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Phillip Rowse, MD, FACS

@RowseMD

3 years

What congenital anomaly would you suspect if you do not see an innnominate vein after sternotomy for planned AVR for severe AI? Why is this important?

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Phillip Rowse, MD, FACS

@RowseMD

1 year

Extended trans-aortic septal myectomy. The “depth”of myectomy is less of the focus (7-8 mm, the width of a #10 blade is enough), as compared to the “length” of the myectomy (need to extend apically enough to see the base of the papillary muscles).

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Phillip Rowse, MD, FACS

@RowseMD

4 years

We have a tremendous group of cardiothoracic surgical trainees at Mayo. Saturday pig lab fun.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Post-infarction posterobasal VSD… we went through the infarcted Inferior LV…another option is through the right atrium to spare ventriculotomy and improve exposure but will likely require TVR with that approach.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Debridement of moderate MAC and explanation of a 20 yr old posterior annuloplasty band means careful placement of valve sutures and sizing.

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Phillip Rowse, MD, FACS

@RowseMD

4 years

Cerebral perfusion pressure (CPP) is the net gradient causing cerebral blood flow. CPP = MAP - CVP (70mmHg). The next time you retract the heart for open MV repair, calculate the CPP. Drain the SVC if needed. Be safe. Protect the brain. Good luck!

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Phillip Rowse, MD, FACS

@RowseMD

4 years

Knowing the segmental LV anatomy on TEE is essential. Take a look at the image below for a refresher if needed.

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Phillip Rowse, MD, FACS

@RowseMD

4 years

A patient WALKS into your office with severe MR (regurgitant volume of 60 mL). If their EF is 60%, how big is their left ventricle (i.e end-diastolic volume)? Think volumetrically! If they walk their SV is at least 60 mL. Total SV is 120 mL. EDV= SV/EF. Thus EDV is 200.

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Phillip Rowse, MD, FACS

@RowseMD

2 years

⬇️risk of thromboembolism following SAVR with a bioprosthesis is, perhaps, the most common misconception in the selection of a heart valve substitute The rate of thromboembolic complications following SAVR is 0.5% to 1% per year with either biological or mechanical.

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Phillip Rowse, MD, FACS

@RowseMD

4 years

Intra-operative aortic dissection will have these classic signs: promptly establish true lumen flow and cool. 1. Sudden increase in arterial line pressure. 2. Drop in systemic pressure. 3. Decreased venous return to the pump. 4. Dissection flap on TEE. 5. Discolored aorta.

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Phillip Rowse, MD, FACS

@RowseMD

9 months

Severe mitral annular calcification. How do you manage this when performing MVR? Debridement with or without patch? Suture around the calcium bar? Suture into the leaflet? Suture to left atrium? Whatever you can to get a good valve in with no perileak.

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Phillip Rowse, MD, FACS

@RowseMD

1 year

I use flow probes with every CABG and here’s why…. Here is a recent SVG-rPDA with questionable flow (16mL) and pulsatility index (8.0). We revised the distal anastomosis and had dramatic improvement in flow (56mL) and pulsatility index (2.7).

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Phillip Rowse, MD, FACS

@RowseMD

4 years

Effort builds skill and makes skill productive. Talent is how quickly your skills improve when you invest effort. Achievement is what happens when you take your acquired skills and use them. Angela Duckworth suggests EFFORT counts twice in the equation....and I agree.

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Phillip Rowse, MD, FACS

@RowseMD

4 years

IABP have 2 basic features: increased diastolic aortic pressure (augment coronary flow) and decreased end-diastolic aortic pressure prior to systole (reduces afterload on the heart thereby decreasing myocardial work and O2 demand). Avoid in severe PAD and AI

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Phillip Rowse, MD, FACS

@RowseMD

9 months

It is not uncommon to see a partial or complete LBBB after myectomy. Watch out for a pre-existing RBBB as this carries increased risk of requiring PPM after myectomy. The asterisks indicates the initial site of myectomy (nadir of the RCC…it is then carried CCW to the AMVL).

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Phillip Rowse, MD, FACS

@RowseMD

3 years

Post-myectomy direct needle manometey with no residual LVOT gradient following a PVC.

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Phillip Rowse, MD, FACS

@RowseMD

9 months

When should you advise surgical myectomy for HCM? 1. Effort induced symptoms are unresponsive to medical Rx (beta blockers, calcium channel blockers, disopyramide). 2. Patient is intolerant to medicine (meds make them feel worse).

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Phillip Rowse, MD, FACS

@RowseMD

2 years

Flail middle (P2) scallop….an excellent candidate for robotic mitral repair!

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Phillip Rowse, MD, FACS

@RowseMD

1 year

Myectomy surgery reminds me of Janis Joplin… “Take another little piece of my heart…”

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Phillip Rowse, MD, FACS

@RowseMD

4 years

Severe MR with significant posterior mitral annular calcification and left coronary dominance = BE CAREFUL! Place your annular sutures through the posterior leaflet tissue (imbricating the leaflet) with pledgets on ventricular side.

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Phillip Rowse, MD, FACS

@RowseMD

4 years

Aortic annular dilation can cause AR due to sagging of the cusps and a lack of central apposition. Closure of the subcommissural triangles using 4 0 Ethibond with a Teflon pledget can improve AR. Be careful, valve orifice decreases as sutures are placed LOWER along commissure.

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Phillip Rowse, MD, FACS

@RowseMD

3 years

A quick way to calculate cerebral perfusion pressure is: MAP - CVP. Normal cerebral perfusion pressure (CPP) is ~70mmHg. This is important when doing MV operations. If CVP elevates due to LA retraction CPP will go down! Always pay attention to CVP and place an SVC cannula.

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Phillip Rowse, MD, FACS

@RowseMD

4 years

Redo-sternotomy can be treacherous particularly with patent coronary grafts. Thank goodness for expert radiologist and imaging techniques that enhance the surgeon’s ability to predict graft location. Plan ahead, take your time, be prepared. Good Luck!

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Phillip Rowse, MD, FACS

@RowseMD

4 years

Occasionally you may need to place the RIMA to the LAD. Careful skeletonized technique can enable it to reach the mid-LAD. Pass the RIMA high along the innominate vein and cover it with thymic fat for protection. Alternatively, you can pass it through transverse sinus.

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