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Slide 2 Edward Evans MD FACC Desoto Heart Clinic Disclosures Medtronic:speaker St. Jude Medical:speaker Slide 3 Valvular Surgery YearSurgeonDescription 1960Dwight Harken1 st successful aortic valve replacement (AVR). A caged ball valve was used 1960Starr and Edwards 1 st successful mitral valve replacement (MVR) using caged-ball valve of their own design. 1960-67Approx. 2000 Starr-Edwards valves implanted 1962HeimbeckerToronto. 1 st clinical implant of an aortic hemograft valve. 1962Daniel Ross1 st successful aortic valve homograft implant 1964Duran and Gunning Aortic valve replacement with xenograft porcine aorti valve (formaldehyde-fixed xenografts->tissue degradation and calcification). 1971CarpentierXenograft valves fixed with glutaraldehyde and mounted on a stent to produce a bioprosthesis Slide 4 4 1858 - Improved bottle stopper conceptual impetus for the first successful ball and cage design Slide 5 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) Slide 6 Prosthetic Heart Valve Management Slide 7 Post-operative surveillance Prevention of infection Prevention of thrombosis Management of complications Slide 8 Surveillance Initial post-op visit: H&P, CXR, EKG class 1 2D echo class 1 if unsatisfactoryother studies Labs: CBC, INR Slide 9 Surveillance Later visits: (patients without complications) Routine follow-up yearly. Earlier if clinical changeClass I Routine serial echoClass IIb Echo if change in exam New regurgitationecho every 3-6 months. Slide 10 Prevention of Infection 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 Slide 11 Prevention of Infection 30-60 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 Slide 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 Slide 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 Slide 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. Slide 15 Anticoagulation Coumadin (INR 2.5-3.5) All others Starr-Edwards run higher >3.0 Slide 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 Slide 17 Complications Structural valve deterioration Non-structural Valve Dysfunction Thrombosis and Embolism Valvular endocarditis Hemolysis Slide 18 Structural Valve Dysfunction Slide 19 Structural Valve Dysfunction Mechanical 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 Slide 20 Structural Valve Dysfunction Bioprosthetic 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 Slide 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 Slide 22 SEVERE MODERATE MILD/NONE (non significant) 0.65 0.85 Indexed EOA (cm 2 /m 2 ) Slide 23 LVEF 40% 3% 5% P=0.0 8 23% P