Download Aortic Valve Aetiology

ALLOGRAFT
VALVE
SURGERY
P.Skillington CANBERRA April 2003
Aortic Valve Replacement
•Aetiology of Valvular Disease
•Pathology encountered
•Operations Available: focus on Allograft
•Operative Techniques
•Results
Aortic Valve - Aetiology
•Congenital: bicuspid, monocuspid
age – 0-70 (peak 35-50)
•Degenerative: tricuspid
age - >60 (peak 70-80)
•Rheumatic: Post rheumatic fever,
uncommon in Australia
age – all ages
AVR: Choice of Prosthesis
•Durability of Prosthesis
•Necessity for Warfarintemporary or permanent
•Risk of Thrombo-embolism &
Bleeding
•Re-operation rate & difficulty
Patient Related Factors
•Haemodynamic Performance:
flow dynamics
functional state achieved
•Biocompatibility
•Effect of various disease states
eg: Marfans,other connective
tissue diseases
•Possible future pregnancy
•Valve noise
AVR : Mechanical vs. Tissue
Valve
• Excellent Durability
95% at 10yrs.
90% at 20yrs
Low rate of re-operation.
• Easy to insert
• Warfarin, blood tests
• Thrombo-embolism
1-2%/pt/yr
• Bleeding risk 2%/pt/yr
• Non Cardiac Surgery
hazardous
• Do not need warfarin
• Low risk of thromboembolism and bleeding :
0-1%
• Noiseless
• Durability variable:ie
higher rate of re-operation
• Insertion may be more
difficult
• Other surgery safe
Tissue Valve Durability
• Porcine,Pericardial:
40yrs:– 8-10 yrs
70yrs:- 12-15yrs
• Aortic Allograft:
20yrs:- 10yrs
40-70yrs:- 15yrs
• Ross Procedure: On average,will
last 40-50yrs (variable)
Re-operation rate:- 1%/pt/yr
Stentless Porcine Valve
AVR in elderly
Better Haemodynamic function
Larger orifice area
Better resolution of Left Ventricular
Hypertrophy
Aortic Allograft Insertion
•Human cadaveric Ao. v
•Cryopreserved
•AVR
•Root Replacement vs
Subcoronary
Aortic Homograft (Allograft)
Durability
•Better than Xenografts
lifespan (vs 10 yrs )
eg 50yr old: expect 15yr
Other Advantages
•Endocarditis with aortic root abcess
•Warfarin not required
•Not on shelf
•Re-operation difficult
Disadvantages
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
O’Brien et al,2001
Aortic Homograft Durability vs Age: Freedom from Re-op
Summary – Allograft AVR
•Best age range: 30 – 65 yrs
•Durability in that age range: 15yrs avge
•Indications: Endocarditis
Not suitable for Ross Proc.
•Results: 78 pts over 12 yrs (1990-2002)
Early Mortality: 0
Late re-operation: 3
Ross Procedure
Advantages
•Viable aortic valve
•Improved Durability cf other tissue valves
•No Warfarin absence T/E, ARH
Disadvantages
•Longer operation
•Follow up of pulmonary valve
Ross Procedure
Indications
•Age 20-60yrs, requiring AVR
Contra-indications
•Bicuspid pulmonary valve(echo)
•Marfans Syndrome
•Other connective tissue disease
•Active rheumatic heart disease
•Triple vessel CAD/ Mitral v. dis.
R.arthritis/ SLE
Patient Demographics (Ross P.)
Time Frame
No. of Patients
: October 1992 to February 2003
: 172
1. Age:
Range 16-62
2. :Gender
M = 122 (70.9%)
3. Valve Lesion: Aortic Stenosis:
AS/AR(Mixed):
Aortic Regurg:
4. Aortic Valve Aetiology:
Congenital:
158 (92%)
Other:
14 (8%)
5. Re-operation:
19 (11%)
(Mean 39.3)
F = 50 (29.1%)
68 (40%)
51 (29%)
53 (31%)
Microsoft Excel Spreadsheet – May 2002
Age
Prev Type of
Pre-Op Valve
Valve Aortic Valve Cardiac
at Op Hosp Sex Surg Prev Surg NYHA Aetiology Lesion Gradient
Cath
LVEDD
29
1
2
1
4
2
7
3
0
0
6.7
23
1
1
1
1
3
1
1
60
1
4.1
22
1
2
0
0
3
1
2
7.2
40
1
1
0
0
3
1
3
1
6.1
27
1
2
0
0
2
1
2
70
1
6
24
3
2
0
0
2
1
2
35
0
6.3
24
3
1
0
0
3
1
2
46
0
4.3
32
3
2
0
0
1
1
3
5
0
6.6
19
1
1
0
0
2
1
1
40
0
4.6
32
3
2
0
0
2
1
2
75
0
5.6
53
1
2
0
0
3
1
1
90
1
4.6
25
1
1
0
0
3
1
1
56
0
4.2
40
1
2
0
0
3
1
1
45
1
4.3
34
3
2
0
0
1
1
1
0
7
17
1
2
1
1
2
1
2
55
1
7
22
1
1
1
1
3
1
1
50
0
4.7
31
2
2
0
0
1
1
3
18
0
6.4
33
1
2
0
0
2
1
3
14
0
6
54
2
2
0
0
2
1
2
56
0
5.8
25
1
2
0
0
2
1
2
40
0
5
33
1
2
0
0
1
1
3
1
6.6
MORTALITY & MORBIDITY
1. Early Mortality (in hosp. Or within 30 days) 1 (0.6%)
Myocardial Infarct
2. Early Morbidity
- Re-Exploration
9
(a) Bleeding
7 (4.1%)
(b) Graft RCA.
1 ( c ) Low C.O. 1
- Retinal Embolus
1
- CHB >>>
Pacemaker
1
- Renal Impairment
4
- AMI
2
- Inotropes
3
- IABP
1
- Respiratory Failure (Re-Intubation) 1
- Pericardial Effusion
1
- Arrhythmia
Ventricular
2
Atrial (AF)
20
-Sternal Infection
1
N=172
Late Results
•
•
•
•
•
•
(n = 172)
Late Death (non-cardiac)
2
1.2%
Follow up 98.6% complete
735 patient years
Thrombo-embolism 1 Cumulative Inc.
Bleeding(ARH)
0
Endocarditis
0
Re-operation
6
Late AR>mild
0
* 5yr freedom from re-operation = 96.2%
0.1%
0.0%
0.0%
0.8%
0.0%
Ross (inclusion cylinder) Actuarial Survival: 155
patients
5yrs = 98%
7yrs = 95%
155
4
127
101
83
54
37
19
7
(n=155)
5yrs = 99%
7yrs = 99%
155
127
101
83
54
37
19
7
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
*10yr survival 58%
Pregnancy after the Ross
Procedure
•Seven women have under gone 11
successful pregnancies
•No maternal cardiac complications
•No problems with the passengers
•Favourable in contrast with mechanical
valves
Durability Aortic Valve
Prostheses
PulmonaryPulmonary
Regurgitation
regurgitation
100
80
60
Percent
40
20
nil or trivial
mild
0
1 wk
moderate
1 yr
2-3 yr
time post-op
4-5 yr
severe
6-7 yr
8-9 yr
Survival After Valve Replacement
AVR - Choice Prosthesis-Effect
of Age
•
•
•
•
15-60 yrs
Ross, Mechanical, Allograft
60-70 yrs
Mechanical, Allograft,
Porcine/Pericardial
• >70 yrs
• Stentless Porcine,Stented
Pericardial, Mechanical
Results Pulmonary Allograft
Insertion for Tetralogy, other
Congenital Cardiac
•45 patients over 12 year period
•zero mortality, minimal complications
•Beating heart surgery
•Do not require warfarin
•Quality of life very good
Conclusion
•300 patients have had cardiac allograft valve
replacement: Ross Procedure
177
Aortic Allograft
78
Pulmonary Allograft 45
•Safe surgery: one(1) early death
•Excellent quality of life without anticoagulants : young people
Standard Post-op Management
Early BP(sys, mean) ; filling pressures (R+L)
C. Output – depends on temperature
Low CO (>37 C) Pericardial Tamponade
signs of tamponade : low bp,high cvp,low
urine output (usually prior bleeding)
Improve CO optimal filling (+ve balance 1-2 l)
vasodilators (GTN, prop., nipride)
inotropes (milrinone, NOT adr,dop)
noradrenaline
IABP
rate(80-90),rhythm
ANTICOAGULATION
•AVR mechanical : INR, Time to reach 2.0
pacing wire removal day 3-4 if not required
porcine / pericardial : warfarin 6 weeks
Ross / Allograft : aspirin 3months
•MVR mechanical INR 3.0 ,if chr.AF, clexane
after 3-4 days
porcine / pericardial Warfarin at least 3
months, often permanent
•MV Repair Warfarin 3 months
Special Situations
•Mitral valve surgery /PHT : pul vaso-dil ,extub, sw
ganz, LA line ,b. gases, pht crisis
•AVR for AS and severe LVH
•AVR thin walled aorta – sys BP
•Ross : Sw Ganz removal
•Patients with poor LV sys function :early IABP
•TVR : pacing , cvp only for Repl.
•PVR : Usually no PA catheter
Stentless Tissue Valves
• Examples include:
stentless porcine valve
Aortic Allograft (homograft)
Ross Proc. (pul.autograft)
• Features:
Better haemodynamic funct.
Improved resolution of left
ventricular hypertrophy
Haemodynamic Function
Residual aortic valve gradient(mmHg)
•
•
•
•
•
Ross (pulmonary autograft)
Stentless Porcine
Aortic Allograft
Mechanical
Stented Porcine/Pericardial
*gradients at rest
2-4
5
6
10-20
12-25
MITRAL VALVE - Aetiology
•Myxoid Degeneration – 75% Repair
•Rheumatic – 95% Replacement
•Ischaemic – 50% Repair, 50%
Replace
•Other – Endocarditis, SLE, Chordal
Rupture
Actuarial
Survival
5yr. 97.5%
5yr.Cardiac Related 98.7%
% Survival
101
100
99
% Survival
98
55yr.
97
96
0
1
2
3
4
5
Years
132
No.Patients
107
86
65
41
22
AVR - Mortality
•Depends on age ,cor.dis.,LV function
<70
1%
70-80
2%
>80
3-5%
Conclusions
•Early Mortality for AVR very low – all ages
•Tissue Valves favoured where
possible,especially in the elderly,to avoid
warfarin related problems & T- embolism
•If Tissue Valve used, Stentless valve is
better haemodynamically
•In the elderly, patient will usually outlive
their valve
•In younger patients, Ross Proc. is safe,
good quality of life, low risk re-operation
ALREADY SHOWN
• Low Operative Mortality and
Morbidity
• Resolution LVH
• Normalization LV Size and Function
AIMS
• Late Valve Related Events
• Aortic Valve Function and Need For
Re-Operation
AORTIC VALVE FAILURE
• A.R.
Re-operation
• Moderate Aortic Regurgitation or Greater
Factors Analyzed
• Age
• Sex
• Aortic Valve Lesion : AS/AR/Mixed
• Aortic Annulus Diameter
• Aortic Annulus Reduction
• Method Implantation of Autograft
TORONTO SPV
CLINICAL SERIES
June 1994 – May 2001
90 Patients
Mean Age 75.5 years (61-87)
Sex :
Male
Female
53.3% (48)
46.7% (42)
Results Stentless Valve Insertion
Early Mortality
Hospital
Re-operation
<30 days Total
(%/pt/yr)
Ross Proc. 143
0
1
1(0.7%)
0.9
TSPV
90
1
1
2(2.2%)
0
Aortic Allo.
35
0
0
0
1.5
Aortic Allograft :- Indications
• Endocarditis :
Lowest risk of recurrent
infection
Exclusion of abcess cavities
• Women of child bearing age
• <60 yrs:-Unsuitable for Ross
Procedure
• 60-70yrs:-Unsuitable for Mechanical
device
Cardiac Surgery
•Modern Surgical specialty
•1953: Development of the heart/lung
machine (cardiopulmonary bypass)
allowed intracardiac procedures to be
performed on the empty heart
•Later improvements (cardioplegia) led
to Asystolic arrest– flaccid or still heart
•1960: Cardiac Valve Replacement
•1968: Coronary Artery Bypass Surgery