valve replacement:choosing the right valve in achd

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………………..


…………… more than 4 in our patients !!

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General Considerations

AgeAge

SexSex

PatientPreference

PatientPreference

Surgeon Preference

Surgeon Preference

Surgical HistorySurgical History

Life’s expectation


choosing the right valve choosing the right valve

AnathomyAnathomy

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Mitral Valve

•Annulus

•Anterior leaflet

•Chordae Tendineae

•Papillary Muscle

AC

PC

A1

A2

A3


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



Mechanical or Biological Mechanical Prostheses from

1960Biological Prostheses from

1968


Hammermeister et al JACC 2000

Mitral 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

MECHANICAL

MECHANICAL

BIOLOGICALBIOLOGICAL

VALVE REPLACEMENT FOR AGE


Children 18 – 65 yrs > 65 yrs


Aortic Valve

Aortic Valve


Hammermeister et al JACC 2000

Aortic Valve


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


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


18 – 65 yrs > 65 yrs


Aortic Valve

““Ascending aorta”““Ascending aorta”

Aortic rootAortic root

Aortic valveAortic valve


Bentall

Aorto-plasty

Aortic valve + Asc Ao


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


Aortic Valve

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Tricuspid Valve


Tricuspid valveTricuspid valve regurgitation can be associated

with different anatomical or functional mechanisms.

We can identify selected groups:

1) patients with Ebstein’s anomaly;





2) patients with tricuspid valves damaged by previous operations (ventricular septal defect closure, complete atrio-ventricular canal repair, etc);


Tricuspid valveTricuspid valve regurgitation can be associated with different anatomical or functional

mechanisms.


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);





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.


Tricuspid valve

http://icr-heart.com/


Tricuspid valve

What to do?

Edwards MC3 Edwards MCEdwards MC3 3


Tricuspid valve


Tricuspid Valve


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


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:


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

http://ht.edwards.com/sci/edwards/sitecollectionimages/edwards/newsroom/mod-640840_sapien_angle.jpg


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


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)


Pulmonary valveAnother problem with homograft valves is their availability

Considering all these limitations, many authors now agree that homograft valves are far from ideal.


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.


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


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


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


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


Conclusions

AgeAge

SexSex

PatientPreference

PatientPreference

Surgeon Preference

Surgeon Preference

Surgical HistorySurgical History



choosing the right valve choosing the right valve

AnathomyAnathomy


See you next year in ITALY

valve replacement:choosing the right valve in achd

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