Edward Evans MD FACC Desoto Heart Clinic Disclosures

2. Edward Evans MD FACCDesoto Heart ClinicDisclosures • Medtronic: speaker • St. Jude Medical: speaker

3. Valvular Surgery

4. 1858 - Improved bottle stopper conceptual impetus for the first successful ball and cage design

5. 1960s - Commercially Available Valves • Caged-ball valves were improved and became commercially available 1960: Harken implanted a double-cage ball valve into aortic annulus 1960: first implant of the Starr-Edwards valve - mitral position (first sold in 1965)

6. Prosthetic Heart ValveManagement

7. Prosthetic Heart ValveManagement • Post-operative surveillance • Prevention of infection • Prevention of thrombosis • Management of complications

8. Surveillance • Initial post-op visit: • H&P, CXR, EKG –class 1 • 2D echo – class 1if unsatisfactory…other studies • Labs: CBC, INR

9. Surveillance • Later visits: (patients without complications) • Routine follow-up yearly. Earlier if clinical change—Class I • Routine serial echo—Class IIb • Echo if change in exam • New regurgitation—echo every 3-6 months.

10. Prevention of Infection • Class I • Class I • Class I • 2% risk of infection at 14 days with no prophylaxis. • Dental procedures • Invasive Respiratory procedures with incision or biopsy • Surgery involving infected skin or musculoskeletal tissue

11. Prevention of Infection30-60 min before procedure • Amoxicillin 2g PO/Ampicillin 2g IV/IM • Cephalexin 2g PO • Azithromycin 500mg PO • Clindamycin 600mg PO or IV • Cefaxolin or Ceftriaxone 1g IV/IM

12. Anticoagulation • Mechanical valves: • Risk of thromboembolic event • Untreated: up to 8% per year • Treated: less than 2% per year • Mitral greater risk than aortic • Higher risk early post-operatively • Bioprosthetic valves: • 0.7% per year risk

13. Anticoagulation • All valves require anticoagulation • Duration • Agent(s) • Valve type and position • Patient risk factors • Atrial fibrillation • Previous thromboembolic event • Hypercoagulable state • Low EF < 30% • Contraindications

14. Anticoagulatioin • Aspirin 75-100mg daily • All patients – class 1 • Use alone with bioprosthetic AVR and MVR with no risk factors • Coumadin (INR 2.0-3.0) • Mechanical AVR bileaflet, no risk factors • Bioprosthetic • First 3 months – class 2a • Long term with risk factors.

15. Anticoagulation • Coumadin (INR 2.5-3.5) • All others • Starr-Edwards run higher >3.0

16. Anticoagulation • Events while at target: • INR 2-3: increase to 2.5 to 3.5 • INR 2.5-3.5: increase to 3.5 to 4.5 • Short term interruption: • Bileaflet AVR no risk factors: No bridge • Bridge all others with UFH • LMWH is class 2b • FFP in emergencies • No vitamin K

17. Complications • Structural valve deterioration • Non-structural Valve Dysfunction • Thrombosis and Embolism • Valvularendocarditis • Hemolysis

18. Structural Valve Dysfunction

19. Structural Valve DysfunctionMechanical • Primary failures rare now. Led to discontinuation of certain valves • Now mainly valve ring-tissue interface • Mechanisms: • Valve dehiscence • Perivalvular regurgitation • Tissue in growth (pannus) and thrombosis

20. Structural Valve DysfunctionBioprosthetic • Incidence 20-30% at 10 years, 50% at 15 years • Tissue degeneration • Secondary calcification • Stenosis increasing after 6 years • More likely with MVR, youth, pregnancy, and chronic renal failure • Perforation • Perivalvular regurgitation

21. Nonstructural Valve Dysfunction • Clinically significant obstruction in the setting of normal prosthetic function • Patient prosthetic mismatch • Occurs mostly in older women • Thrombus and Pannus

22. MODERATE SEVERE MILD/NONE (non significant) 0.85 0.65 Indexed EOA (cm2/m2)

23. Combined Impact of PPM and LV Dysfunction on Short-term Mortality Short-TermMortality (%) 67% P<0.001 16% P<0.001 7% P=0.05 23% P<0.001 5% P=0.08 3% LVEF < 40% LVEF 40%

24. Thrombosis and Embolism • Incidence 0.6% to 2.3% per patient year • Anticoagulated mechanical rate same as unanticoagulatedbioprosthetic • Mitral position greater risk than aortic • Tricuspid greatest risk • Intrinsic thrombogenicity of valve materials, flow turbulence and stagnation, shear stresses, risk factors

25. Valve thrombosis • Echo, TEE, Fluoroscopy, MRI/CT • Thrombolysis • 70-90% effective • Mortality 4-12% acutely • Better for right sided valves • Duration < 24hours • Surgery • Class 2a for large clot, NYHA 3-4 • Class 1 small clot, failure or contraindications to lysis

26. Embolism • Mechanical valves • No anticoagulation: 4% per year • Aspirin: 2% per year • Coumadin (therapeutic) 1% per year • Mitral valves twice the risk of aortic valves

27. Prosthetic valve endocarditis • Yearly risk 0.5% despite prophylaxis • Highest risk MVR • No difference mechanical and bioprosthetic • Risk greatest in first 6 months • Usually involves the valve ring • Substantial mortality

28. Prosthetic Valve Endocarditis • Medical • Hospitalize at CV surgery center • Delay antibiotics until organism identified • TEE • Prolonged antibiotics with ID guidance • Surgery • Heart failure, abscess, dehiscence, relapsing infection, failed antibiotic

30. Macroangiopathic hemolytic anemia • Anemia post operatively • Microcytic • Increased LDH • Decreased haptoglobin • NO suspicion of ITP/TTP • Schistocytes • May lead to heart failure • Transfusion dependent anemia • Potential need for re-do valve surgery

31. Summary • Prosthetic valves are not a cure for valvular disease • Associated with large number of potential medical management issues • Careful post-operative valvular surveillance is important

32. Questions?