valve replacement:choosing the right valve in achd
TRANSCRIPT
Valve replacement:
choosing the right valve
for adults with CHD
3rd European Meeting on Adult Congenital Heart Disease16 - 17 March 2012 Munich, Germany
Massimo ChessaPediatric and Adult Congenital
Heart Centre
IRCCS- Policlinico San Donato San Donato Milanese – Milano
Pediatric and Adult Congenital Heart Centre
4 Valves in the normal Heart
but………………..
but………………..
Pediatric and Adult Congenital Heart Centre
…………… more than 4 in our patients !!
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Pediatric and Adult Congenital Heart Centre
General Considerations
AgeAge
SexSex
PatientPreference
PatientPreference
Surgeon Preference
Surgeon Preference
Surgical HistorySurgical History
Life’s expectation
Life’s expectation
choosing the right valve choosing the right valve
AnathomyAnathomy
Pediatric and Adult Congenital Heart Centre
Mitral Valve
•Annulus
•Anterior leaflet
•Chordae Tendineae
•Papillary Muscle
AC
PC
A1
A2
A3
Pediatric and Adult Congenital Heart Centre
The best valve it is its own valve!
Mitral Valve
Benefits• Low operative mortality
• Long-term survival– (identical to the
general population)
• Better preservation of ventricular function
• Decreased need for anticoagulation therapy
• Reduced valve-related complications
Limitations• Surgeon’s expertise
• Extent of the disease
« … an operation that can treat the patient for the rest of
his life … »Prof. A. Carpentier
Pediatric and Adult Congenital Heart Centre
General Considerations
Mechanical or Biological Mechanical Prostheses from
1960Biological Prostheses from
1968
Pediatric and Adult Congenital Heart Centre
Hammermeister et al JACC 2000
Mitral Valve
Pediatric and Adult Congenital Heart Centre
General Considerations
1,712 Patients with the Biocor™ Porcine Bioprosthesis:
A 20-Year Experience
Pia S.U. Myken, MD; JTCS 2009
Actuarial Freedom from Reoperation due to SVD for the aortic and mitral valve replacement
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MECHANICAL
MECHANICAL
BIOLOGICALBIOLOGICAL
VALVE REPLACEMENT FOR AGE
Pediatric and Adult Congenital Heart Centre
Children 18 – 65 yrs > 65 yrs
Pediatric and Adult Congenital Heart Centre
Aortic Valve
Aortic Valve
Pediatric and Adult Congenital Heart Centre
Hammermeister et al JACC 2000
Aortic Valve
Pediatric and Adult Congenital Heart Centre
Aortic Valve
1,712 Patients with the Biocor™ Porcine Bioprosthesis:
A 20-Year Experience
Pia S.U. Myken, MD; JTCS 2009
Actuarial Freedom from Reoperation due to SVD for the aortic and mitral valve replacement
Hgfdg
Pediatric and Adult Congenital Heart Centre
Stentless bioprostheses provide better Effective Orifice Area than stented bioprostheses, which are relatively stenotic in the small sizes (annulus size 21 mm).
Modern mechanical valves provide better haemodynamic performance than stented bioprostheses.
Aortic Valve
MECHANICALMECHANICAL BIOLOGICALBIOLOGICAL
VALVE REPLACEMENT FOR AGE
Pediatric and Adult Congenital Heart Centre
18 – 65 yrs > 65 yrs
Pediatric and Adult Congenital Heart Centre
Aortic Valve
““Ascending aorta”““Ascending aorta”
Aortic rootAortic root
Aortic valveAortic valve
Pediatric and Adult Congenital Heart Centre
Bentall
Aorto-plasty
Aortic valve + Asc Ao
Pediatric and Adult Congenital Heart Centre
Aortic Valve
Moderate ascending aortic
dilatation is common in adult
patients with conotruncal
anomalies.
There is increasing attention
to prophylactic replacement of
the moderately dilated
ascending aorta at aortic valve
surgery
Pediatric and Adult Congenital Heart Centre
Aortic Valve
Pediatric and Adult Congenital Heart Centre
Tricuspid Valve
Pediatric and Adult Congenital Heart Centre
Tricuspid valveTricuspid valve regurgitation can be associated
with different anatomical or functional mechanisms.
We can identify selected groups:
1) patients with Ebstein’s anomaly;
Pediatric and Adult Congenital Heart Centre
Tricuspid valveTricuspid valve regurgitation can be associated
with different anatomical or functional mechanisms.
We can identify selected groups:
2) patients with tricuspid valves damaged by previous operations (ventricular septal defect closure, complete atrio-ventricular canal repair, etc);
Pediatric and Adult Congenital Heart Centre
Tricuspid valveTricuspid valve regurgitation can be associated with different anatomical or functional
mechanisms.
We can identify selected groups:
3) patients with a tricuspid valve failing in its capacity as systemic atrio-ventricular valve (as determined by status post-Senning or Mustard operation, and congenitally corrected transposition of the great arteries);
Pediatric and Adult Congenital Heart Centre
Tricuspid valveTricuspid valve regurgitation can be associated
with different anatomical or functional mechanisms.
We can identify selected groups:
4) patients with functional TR related to right ventricular dilation or dysfunction.
RV dilation/dysfunction is typically associated with chronic volume overloading.
RV volume overloading can be associated with chronic increases of the preload in adult patients with large atrial septal defects or in long-standing pulmonary valve insufficiency after previous repair of tetralogy of Fallot or pulmonary stenosis.
The physiologic consequences of chronic RV volume overloading in these patients, can compromise tricuspid valve function.
Pediatric and Adult Congenital Heart Centre
Tricuspid valve
What to do?
Edwards MC3 Edwards MCEdwards MC3 3
Pediatric and Adult Congenital Heart Centre
Tricuspid valve
Pediatric and Adult Congenital Heart Centre
Tricuspid Valve
Pediatric and Adult Congenital Heart Centre
Pulmonary Valve
Pulmonary Valve Replacement (PVR) is the reoperation most frequently performed today
The type of valve to be inserted into the RVOT is still debated.
Surgery or Percutaneous
Pediatric and Adult Congenital Heart Centre
Pulmonary valve
Who are the candidates for surgical PVI ?
Those that are not good candidates for
transcatheter PVIGiamberti et al. Ann Thorac Surg 2009; 88: 1284-90:
Pediatric and Adult Congenital Heart Centre
Pulmonary valve
Not candidates for transcatheter PVI
• Size of pulmonary annulus
• Morphology of RVOT o RV-PA conduit
• Associated cardiac malformation•RV aneurism
•TV regurgitation•Arrhythmias
Pediatric and Adult Congenital Heart Centre
Pulmonary Valve
At present time, options include mechanical as well as several biological valves (including homografts, xenografts, prosthetic valved conduits, and bioprosthetic valves)
Bioprosthetic valves perform well hemodynamically, but are prone to structural degeneration that results in multiple reoperations.
Mechanical valves lead to a persistent need for anticoagulation therapy, and despite some positive reports in the literature, have generally been associated with pulmonary thromboembolic complications
Mechanical or Biological
Pediatric and Adult Congenital Heart Centre
Pulmonary valve
The Authors compared 3 biological valves types (stented xenograft valve, bovine pericardial valve, and pulmonary homograft)
The late dysfunction was more likely with homograft valves than either porcine or bovine pericardial valves. At 6 years, the freedom from explantation of the homograft was 35%
Fiore CA, Rodefeld M, Turrentine M, et al (2008)
Pediatric and Adult Congenital Heart Centre
Pulmonary valveAnother problem with homograft valves is their availability
Considering all these limitations, many authors now agree that homograft valves are far from ideal.
Pediatric and Adult Congenital Heart Centre
Pulmonary valve
The results for xenografts (porcine pulmonary-valve conduits, stentless porcine aortic-root bioprostheses, and bovine jugular valved vein conduits) remain controversial at this time.
In any case, an extensive dissection of the pulmonary arteries, as with the homograft valves, is needed to avoid kinking due to the excessive length of the prosthesis. Extreme care must be taken during implantation, as any twisting, kinking, or external compression can easily lead to early failure
Goffin YA, J Heart Valve Dis 2000,9: 207-14
The same considerations can be taken for the prosthetic valved conduits, such as Hancock or Edwards conduits.
Pediatric and Adult Congenital Heart Centre
Pulmonary valve
Bioprosthetic valves are probably the most widely used for pulmonary valve replacement, because they are readily available and do not need permanent anticoagulation therapy.
The bioprosthesis valves are very easy to implant and permits the avoidance of extensive dissection of the pulmonary arteries, which is particularly favourable in patients submitted multiple operations
Pediatric and Adult Congenital Heart Centre
Pulmonary valve
Shinkawa and collegues analized the outcome and performance of bovine pericardial valves in pulmonary position.
Freedom from pulmonary valve reoperation was 100%, 97.7%, and 97.7% at 1, 3 and 5 years, respectively
Shinkawa T, Ann Thorac Surg 2010; 90: 1295-1300
Pediatric and Adult Congenital Heart Centre
Pulmonary valve
Our current approach, since 2005, is to reconstruct the RVOT with a bioprosthetic porcine valve.
No reoperations or valve revisions were necessary.
Our experience is a short-term study, and obviously, a larger follow-up is needed to determine the rate of structural valve deterioration and the function of this porcine bioprosthetic valve in the pulmonary position.
Giamberti A, et al. Submitted
Pediatric and Adult Congenital Heart Centre
Pulmonary valve
Another criterion to take into consideration in the RVOT reconstruction, should be the facilitation of future interventional procedures, such as percutaneous pulmonary- valve implantation
Until now, homograft valves or prosthetic valved conduits seemed to be the ideal candidates but many recent reports appeared in the literature show possible the percutaneous approach even in bioprosthesis valves.
MacDonald ST, Eur Heart J2011; Jan 27
Pediatric and Adult Congenital Heart Centre
Conclusions
AgeAge
SexSex
PatientPreference
PatientPreference
Surgeon Preference
Surgeon Preference
Surgical HistorySurgical History
Life’s expectation
Life’s expectation
choosing the right valve choosing the right valve
AnathomyAnathomy
Pediatric and Adult Congenital Heart Centre
See you next year in ITALY