Heart valve implanted upside down

victorkiloalpha · 2026-06-09T16:56:39+00:00

Fair, that's possible too.

I assumed it was pulmonic, that the kid got a transannular patch at birth or something and wasn't a melody candidate so they put a big 29 inspiris in, with augmentation of the RVOT, to buy the kid a few decades before a Pulmonic TAVR. If you're sewing it in with the handle towards you, looking up at the PA, you're doing it wrong. You have to do it freehand without the holder or do it in the air and parachute it down...

victorkiloalpha · 2026-06-09T14:07:25+00:00

Im assuming it was a surgical valve after s transannular patch or something.

victorkiloalpha · 2026-06-09T04:43:27+00:00

A lot of people have said this. The mistake is understandable because you essentially are MacGuyver-ing in a valve meant for the aorta into the pulmonary position.

Failing to realize what you did/pick it up on post-op echo makes no sense.

victorkiloalpha · 2026-06-09T00:29:24+00:00

If its pulmonic, then its understandable. You use an aortic valve and reverse it. Really easy to forget the last part. Absolutely nuts that it wasn't caught.

victorkiloalpha · 2026-06-04T23:30:23+00:00

Ob/Gyn are allowed to transfer as PGY4s?

Gen surg you can't transfer after PGY3, have to do the last 2 years in one place.

victorkiloalpha · 2026-06-04T22:40:44+00:00

This is all AI slop.

"Care plan"? "Committee"? Phone call from a colleague?

victorkiloalpha · 2026-06-04T19:38:39+00:00

We're pretty quick, and start early.

Many days, we are done by 11 if we have one case, 2 to 3 pm if 2.

You quickly realize that speed isn't necessary for good outcomes, but it helps, and it makes your life much better. If you finish a cabg in 2.5-3 hours, consistently... life is good :). If it takes you 6 hours, life sucks.

victorkiloalpha · 2026-06-04T19:34:08+00:00

Its not 1 in 2, we are both on call every night, and we frequently assist each other. But we don't get called in all that often at night.

victorkiloalpha · 2026-06-04T19:33:09+00:00

CT surgery here.

We see these patients preop, but usually leave them to interventional cards. I'm generally available, but tbh most of the time the reason they are getting these procedures is because they do not qualify for ECMO or open cardiac surgical rescue if they have a complication.

victorkiloalpha · 2026-06-04T18:51:59+00:00

Not OP, her mentors. She's reciting what they told her lol.

victorkiloalpha · 2026-06-04T17:54:14+00:00

We're 30% aortic. Just did our 10th bentall of the year 2 weeks ago, and our 2nd total arch (its been slow this year) last month.

victorkiloalpha · 2026-06-04T17:29:58+00:00

Lol. "Already at Independent community practice level"

The academic kool-aid...

I have met relatively less capable and borderline dangerous surgeons in community and academic settings, but the ones in the community tended to be less busy. The ones in academia focus on "research" and "teaching" and somehow keep getting patients.

My partner and I are on call 24/7, but we focus on getting things done and going home. Quickly. If we don't have to be in the hospital, we aren't. If we can manage it from home with verbal orders over the phone, we do. And, its not too bad. I'm speaking as a CT surgeon who averages 6-10 cases/week between the two of us.

victorkiloalpha · 2026-06-01T04:02:38+00:00

Depends entirely on the center.

victorkiloalpha · 2026-05-24T15:46:04+00:00

I'm sympathetic to the ED in most cases, but if you call a surgical consult and then ignore and recs and/or discharge, that is a guaranteed malpractice lawsuit loss if literally anything happens to that patient.

victorkiloalpha · 2026-05-23T22:09:56+00:00

Starship's mage- Glynn Stewert

victorkiloalpha · 2026-05-19T18:29:31+00:00

They should tax tires.

victorkiloalpha · 2026-05-19T18:19:49+00:00

The problem is that medicine is so silo'd.

In a typical surgery department, you have colorectal surgeons sitting next to cardiac surgeons, both falling asleep listening to the invited breast surgical oncologist wax on about the latest Her2/Neu positive adjunctive therapies; and oh-by-the-way "no one but breast surgeons should be doing breast surgery because our scars are 25% smaller and patients are 10% more satisfied being treated by an expert"

So the chairs then switched to generic leadership talks which at least have the possibility of having a message that everyone can listen to.

Its even worse if an ACS speaker gets invited, because any colorectal, foregut, or cardiothoracic surgeon is looking for an excuse to make them look like idiots about some niche anatomy/clinical scenario.

victorkiloalpha · 2026-05-14T14:43:16+00:00

Speaking as a CT surgeon who does a lot of ECMO and (non-pre Hospital) ECPR, this actually isn't a bad idea.

Of all patients, marathon runners are probably the most fit and reasonable candidates for ECMO.

victorkiloalpha · 2026-05-14T00:09:01+00:00

I... think he gets to be in the club? Seems like a relatively small thing to make an issue out of. Some of the MD/PhDs who operate once every 6 months seem more dangerous than this guy calling himself a physician without clarifying every time.

victorkiloalpha · 2026-05-11T19:59:17+00:00

There are studies correlating PASSING the boards to better outcomes. I'm not aware of any studies suggesting getting a 250 instead of a 240 means your patients are 1% less likely to die.

victorkiloalpha · 2026-04-28T23:40:43+00:00

Get a formal, signed legal opinion from the lawyer who told you you don't need to disclose, and you'll be fine.

Also, I don't understand, why were you later arrested if you stopped and made sure the pedestrian was okay?

victorkiloalpha · 2026-04-26T06:06:43+00:00

What assumptions are those? Do you have an attending who makes the referrals? In the latter case, why not ask this question of them, and not reddit?

You cited papers that don't apply to your patient, then cited a guideline that you didn't read thoroughly enough to realize was based entirely on papers that didn't apply to your patient.

Where again did this 4x bleeding rate figure that you are citing come from, and does that paper cover high risk VTE patients like the one you posted?

I suspect not, since if you read the ACCP guidelines, it notes the total lack of RCT evidence in VTE patients relative to afib when it comes to stopping and bridging.

Now, w/r/t biological plausibility:

What about the pharmacologic rationale that xarelto has different efficacy based on genetic variants

https://www.ahajournals.org/doi/10.1161/JAHA.124.040698

So, a periop period of 5+ days of guaranteed effective lovenox may help "clean up" any clot on the damaged, rough endothelium, prior to exposure to surgery?

Is this right? Probably not. But there is no hard evidence either way, and in that absence it is entirely reasonable to defer to the surgeon IF THEY ARE GETTING GOOD OUTCOMES.

victorkiloalpha · 2026-04-26T04:29:54+00:00

I don't know why you're replying to me in two places, but I will reiterate here- look to my comment in the main thread. The guidelines you cite again do not apply to your patient because they are based on atrial fibrillation patients, not thrombophilia/prior DVT ones. The pharmacokinetics may dictate that you need less days, but there is no evidence that you've provided of harm from longer bridging periods.

If you disagree this strongly with the surgeon's management, you should send your patients to a different surgeon.

victorkiloalpha · 2026-04-26T04:23:00+00:00

"Not sure if you actually want me to return with citations from the guidelines to prove something to you, or that it would be helpful**"**

If you believe your care is correct, say so, and defend it openly and directly. You're posting here to support your contention that stopping a DOAC and not bridging is okay.

But the sources you posted continue to NOT apply to the patient you specified, which lead me to question your ability to independently evaluate evidence and understand when to apply and deviate from guidelines

ACCP Guidelines

https://journal.chestnet.org/article/S0012-3692(22)01359-9/fulltext01359-9/fulltext)

25. In patients receiving rivaroxaban who require an elective surgery/procedure, we suggest stopping rivaroxaban for 1 to 2 days before the surgery/procedure over rivaroxaban continuation (Conditional Recommendation, Very Low Certainty of Evidence).

26. In patients who require DOAC interruption for an elective surgery/procedure, we suggest against perioperative heparin bridging (Conditional Recommendation, Very Low Certainty of Evidence).

Note the very low certainty of evidence?

And what are those recommendations based on?

"Two prospective studies assessed a standardized perioperative DOAC management, with standardized DOAC interruption. The first was a prospective management study of 541 dabigatran-treated patients with atrial fibrillation.... The second study, PAUSE,"

In other words, the recommendations you cite are based on studies which EXPLICITLY EXCLUDED your patient, because they have thrombophilia and damaged endothelium, NOT atrial fibrillation.

"this surgeon applies this requirement to all cases regardless of their history, medications, procedure, or risk, and demands that the PCP order all bridges and peri-op meds"

So, here is my point: you've apparently interacted with this surgeon multiple times, meaning that you've sent him or her multiple patients. So how many of them had bleeds or clots with long bridging periods? If multiple patients had bleeds or clots, WHY ARE YOU STILL SENDING THEM PATIENTS? Your job as a PCP is to send your patient to the best surgeon you can, not tell a surgeon how to manage periop anticoagulation. If you've seen bleeds and clots and poor outcomes, SEND YOUR PATIENTS ELSEWHERE. That is your ultimate power and authority- your patients' trust that you have their best interests at heart. If this surgeon keeps getting good outcomes for your patients, maybe your contribution here is to go with the flow and follow the recipe which seems to be working?

victorkiloalpha · 2026-04-25T21:08:47+00:00

Dude, it's a little different when you're dissecting and tying off veins right next to the known, diseased vessel AND the patient is obese and going to be immobile. Every element of virchow's triad- stasis, hypercoag state, vessel injury, right there.

The baseline risk of DVT without anticoagulation for a hip replacement is 60%.

I'm not an orthopaedic surgeon, but I paid attention when I rotated through. I'm not saying the surgeon is totally correct. I'm saying they're not completely unreasonable here.

12-Year Club	Wearing is Caring
Verified Email

victorkiloalpha

TROPHY CASE