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Heart Valve selection

Heart Valve selection. Weerachai Nawarawong M.D. Inter-hospital conference March 19, 2011. Mechanical valve advantage. Children Patients <40 yrs High reoperation risk Small annular size Atrial fibrillation Pregnancy desired Patients > 70 yrs High thromboembolism risk

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Heart Valve selection

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  1. Heart Valve selection Weerachai Nawarawong M.D. Inter-hospital conference March 19, 2011

  2. Mechanical valve advantage • Children • Patients <40 yrs • High reoperation risk • Small annular size • Atrial fibrillation • Pregnancy desired • Patients > 70 yrs • High thromboembolism risk • High hemorrhage risk Tissue valve advantage Akins CW: Ann Thorac Surg 1991,52:161-172

  3. Which valve ?

  4. If one can choose the valve prosthesis one would choose: • “One valve for life”

  5. Myths about Mechanical Valves • You’ll Never Need Another Operation • You can Live without Restrictions • Risks of TE/ACH are Minimal • Coumadin is Not a Problem

  6. Ideal valve • Good hemodynamic • Quiet • Require no anticoagulation • Last for life time • Cheap • Easy to implant

  7. Valve Prosthesis • Mechanical • types: caged-ball, tilting-disk, bi-leaflet • advantage: durability • limitation: thrombogenicity • Bioprosthetic • types: heterografts, homografts • advantage: short term anticoagulation • limitation: structural failure • leaflet calcification & tissue degeneration leading to valvular regurgitation • Rate of porcine valve degeneration 26% (aortic), 39% (mitral) in 10 yrs

  8. Homografts • 1956 - first aortic valve homograft was used in the descending thoracic aorta for aortic regurgitation • 1962 - first sub-coronary use • High incidence of post-op failure * (years) 5 10 15 20 survival rate (%) 85 66 53 38 re-operation (%) 22 62 85 95 * Circulation 1991; 84(suppl 3):III81-III88

  9. Durability and hemodynamic Bleeding and thromboembolism

  10. Thromboembolism and Bleeding

  11. Wall Street Journal 8//16//07 • Warfarin “is the second-most-likely drug, after insulin, to send Americans to the emergency room”. • By one estimate, it accounts for 43,000 ER visits a year in the U.S.

  12. Incidence of major embolismafter mechanical valve replacement • Absence of antithrombotic therapy • 4% per year • plus 1.8% per year risk of valve thrombosis • Antiplatelet therapy • 2.2% per year • plus 1.6% per year risk of valve thrombosis • Wafarin therapy • 1% per year • 0.8% per year with an aortic valve • 1.3% per year with a mitral valve • plus 0.2% per year risk of valve thrombosis • Incidence of major bleeding in patients treated with warfarin • 1.4 per 100 patient-years. (Circulation. 1994;89:635-641.)

  13. IncidenceRatesofValveThrombosisandMajorandTotalEmbolismsWith CoumadinTherapy: EffectofValvePosition IncidenceRatesper 100 Patient-Years (95% ConfidenceIntervals) ValvePositionValveMajorTotal ThrombosisEmbolismEmbolism* Aortic 0.1 (0.1-0.2) 0.8 (0.7-0.9) 1.1 (1.0-1.3) Mitral 0.5 (0.3-0.7) 1.3 (1.1-1.5) 2.7 (2.3-3.0) Both 0.4 (0.2-0.7) 1.4 (1.0-1.9) 2.1 (1.6-2.7) (Circulation. 1994;89:635-641.)

  14. Typesofprostheticvalvesandthrombogenicity TypeofvalveModelThrombogenicity Mechanical CagedballStarr­Edwards + + + + SingletiltingdiscBjork­Shiley, MedtronicHall + + + BileafletStJudeMedical, SorinBicarbon, Carbomedics + + Bioprosthetic HeterograftsCarpentier­Edwards, TissueMed (Aspire), + to + + HancockII Homografts +

  15. Zellner et al “Long term experience With the St.Jude Medical Valve Prosthesis” South Carolina,USA AVR 418 pts, mean age 54.8yrs Re-operation inc. 1.0%/pt/y

  16. Hemodynamic advantages

  17. Gradient Comparison of mean pressure gradients for     commonly implanted prosthetic valves.

  18. EOA Comparison of EOAs for commonly implanted     prosthetic valves.

  19. Circulation 2009;119;1034-1048

  20. Circulation 2009;119;1034-1048

  21. Late Overall Survival and Freedom From Cardiovascular Death Non significant PPM Moderate PPM Severe PPM J. Am. Coll. Cardiol. 2009;53;39-47

  22. There are trends in the United States and Europe toward the increasing use of tissue rather than mechanical valves and toward the use of bioprostheses in progressively younger patients • Dagenais F, Cartier P, Voisine P, Desaulniers D, Perron J, Maillot R, Raymond G, Métras J, Doyle D, Mathieu P. Which biologic valve should we select for the 45- to 65-year-old age group requiring aortic valve replacement? J Thorac Cardiovasc Surg. 2005;129:1041–1049.

  23. Reasons for increasing use of Bioprosthesis • Newer generation bioprosthesis • more durable and better. • Better fixation technique • Better anticalcification technique • Better long term result in newer generation valve • The risks of reoperation have continued to decrease • Patients undergoing AVR today are older population • Young patients are often reluctant to accept warfarin therapy and the activity constraints associated with anticoagulants. • There are survival benefit for patients receiving bioprostheses, in age > 65 years .

  24. Durability

  25. Two historic randomized clinical trials compared outcomes after valve replacement with a first-generation porcine heterograft and the original Bjork-Shiley tilting-disc mechanical valve: • The Edinburgh Heart Valve Trial, conducted between 1975 and 1979 with an average follow-up of 12 years, • The Veteran Affairs (VA) Cooperative Study on Valvular Heart Disease, conducted between 1979 and 1982 with an average follow-up of 15 years.

  26. The Edinburgh trial • a small survival advantage associated with a mechanical valve in the aortic but not in the mitral position; • both trials showed • increased bleeding associated with mechanical valves • increased reoperation with tissue valves; • structural failure of tissue valves and overall thromboembolic complications were greater after mitral than after aortic valve replacement.

  27. A meta-analysis of 32 articles evaluated mortality from 15 mechanical and 23 biological valve series including 17,439 patients and 101, 819 patient-years of follow-up. • no difference in riskcorrected mortality between mechanical and bioprosthetic aortic valves regardless of patient age • choice between a tissue and mechanical valve should not be based on age alone. • Lund O, Bland M. Risk-corrected impact of mechanical versus bioprosthetic valves on long-term mortality after aortic valve replacement. J Thorac Cardiovasc Surg. 2006;132:20 –26.

  28. Retrospective study comparing mechanical and tissue aortic valve replacement in 3062 patients with combined follow-up of 22 182 patientyears • age but not valve type was predictive of valve-related mortality. • reoperation was higher after tissue aortic valve replacement only for patients ≤60 years of age, • combined valverelated morbidity was higher after mechanical valve replacement for all patients 40 years of age. • Chan V, Jamieson WRE, Germann E, Chan F, Miyagishima RT, Burr LH, Janusz MT, Ling H, Fradet GJ. Performance of bioprostheses and mechanical prostheses assessed by composite of valve-related complications to 15 years after aortic valve replacement. J Thorac Cardiovasc Surg. 2006;131:1267–1273.

  29. Hypothetical model for the structural deterioration of bioprosthetic valves

  30. Advances in tissue fixation and anticalcification treatment have resulted in current-generation bioprostheses that have superior durability

  31. Freedom from structural valve deterioration • Carpentier-Edwards pericardial aortic valve (age 65) • 94% at 10 years • 77% at 15 years • 10% chance that a 65-year-old patient would require reoperation before 80 years of age. • Third-generation bioprostheses may be even more durable, with • 92.8% at 12 years (mean age of 54 years) • In addition, advances in myocardial protection and cardiac surgical techniques have led to lower risks at reoperation, making the prospect of redo valve surgery less dangerous. • Banbury MK, Cosgrove DM III, White JA, Blackstone EH, Frater RWM, Okies JE. Age and valve size effect on the long-term durability of the Carpentier-Edwards aortic pericardial bioprosthesis. Ann Thorac Surg. 2001;72:753–757. • Bach DS, Metras J, Doty JR, Yun KL, Dumesnil JG, Kon ND. Freedom from structural valve deterioration among patients 60 years of age and younger undergoing Freestyle aortic valve replacement. J Heart Valve Dis. In press.

  32. Freedom from structural valve deterioration after 15 years • 2ndgeneration Hancock II aortic valve • 81.5% ( age 65 years) • 1stgeneration Hancock bioprosthesis. • 57.4% (age 69 years ) • David TE, Ivanov J, Armstrong S, Feindel CM, Cohen G. Late results of heart valve replacement with the Hancock II bioprosthesis. J Thorac Cardiovasc Surg. 2001;121: 268–278. • Cohn LH, Collins JJ Jr, Rizzo RJ, Adams DH, Couper GS, Aranki SF. Twenty-year follow-up of the Hancock modified orifice porcine aortic valve. Ann Thorac Surg. 1998; 66(suppl):S30 –S34.

  33. Hancock Valve Durability Data

  34. ACC/AHA VHD Guidelines: 2008

  35. ACC/AHA VHD Guidelines: 2008

  36. M.O’Brien et al “The Homograft Aortic Valve:29 yrs” J. Heart V. Dis 2001;10:334-345 1,022 patients mean age 47yrs: Actuarial Survival

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