Valvular Heart Disease: No Longer the Realm of the Surgeon?

1. Valvular Heart Disease:No Longer the Realm of the Surgeon? Christopher Young St Thomas’ Hospital, London

2. Outline • History, valve development and failure • Surgical results and demographics • Minimal Access (including robotic) • Lessons to be learnt from surgery • Summary and Conclusions

3. History

5. Heart Valves

6. Bioprosthetic Problem Solving • Early • Calcification • Later valves • Tissue engineering (composite valves / muscle bar) • Zero pressure fixation • Anti-calcification remedies • Blue valves (toluidine blue) • Recent Valves • Sorin Valves (amino acids)

7. Significant Bioprosthetic Failures • Dura Mater – abandoned • Fascia Lata – abandoned • Ionescu-Shiley – abandoned • Autogenics - abandoned

8. Mechanism of Failure • Biological – gradual failure • Mechanical – catastrophic

10. Significant Failures • Mechanical • Bjork-Shiley • Duromedics • Abram’s Valve

11. Product Description Gore Thoracic Excluder Significant Failures – Endovascular Stents ePTFE Deployment Sleeve (attached to stent structure) • Gore Tag Self-expanding Nitinol Stent Structure Flares for wall apposition Radiopaque Band (both ends) ePTFE graft on blood-contact surface Sutureless Graft Attachment Spine Structure for Columnar Support Sealing Cuff (both ends)

12. Stentless Valve

13. Single Layer Stentless

14. Single Layer Stentless

15. 3F Surgical Valve

16. Surgical Results

17. Data from 5th National Adult Cardiac Surgical Database Report

18. Data from 5th National Adult Cardiac Surgical Database Report

19. Data from 5th National Adult Cardiac Surgical Database Report

20. Data from 5th National Adult Cardiac Surgical Database Report

21. Surgical Progress

22. Minimal Access AVR

23. Minimal Access – Aortic Root

24. Minimal Access – Aortic Root

25. Minimal Access – Aortic Root

26. Minimally Invasive Valve Replacement • Percutaneous peripheral cannulation • “Heartport” techniques • Mini-sternotomy • Mini anterior thoracotomy • Surgery under epidural anaesthesia

27. Robotic Aortic Surgery • 5 patients (3M/2F; 35 – 81 years) • 4 calcific AS / 1 AR • Transverse incision 4-5 cm R 3rd IC space • Standard interrupted suture technique • No mortality/complications • Mean hospital stay 8.6±3 days Folliguet et al. EJCTS 28 (2005): 172-173

28. Minimal Access Mitral Repair Port access CPB Endoclamp Multiple small incisions No rib spreading

29. Minimally Invasive vs Conventional Valve Replacement • Overall majority of reported results similar • Death • Length of stay • Complication rates • Minor negative aspects of: • Longer X clamp times • Longer bypass times • Increased early post-operative pain

30. Minimally Invasive vs Conventional Valve Replacement • Some reports of improved outcome with keyhole approach • Lower risk redo operations • Aortic vascular procedures • Lower transfusion requirements • Lower incidence post-operative AF • Lower post-operative pain after day 2

31. Off-Pump Valve Repair • Treatment of functional ischaemic MR • Coapsys device consists of 2 epicardial pads • Pads then connected with flexible chord • Placement TOE guided • MR reduced from grade 2.7±0.8 – 0.4±0.7 Grossi et al Ann Thorac Surg 2005; 80: 1706-11

32. Surgical Problems(Cardiological Problems?)

33. Valveexcision

34. The small annulus A tight squeeze

35. Small annulus • Good exposure from retraction sutures • Position light and table • Enthusiastic excision / decalcification • Do not oversize valve • Consider supra-annular placement • Do NOT use everting mattress sutures • (Root enlargement)

36. The Big Annulus

37. Summary 1 • Valve technology has evolved over 45 years with significant failures along the way (including recently) • Surgical results are excellent with increasing emphasis on minimal access

38. Summary 2 • Increasingly elderly population with more calcific disease • Surgical anatomy/pathology is varied; a “one size fits all” approach will not work • How long will the devices last and how will they fail?

39. Conclusions Proceed carefully! If things go pear-shaped Ring us – as usual, we will always be there to bail you out! This time, however, it may not be enough