Mechanical PVR Pearls &...
Transcript of Mechanical PVR Pearls &...
Mechanical PVR
Pearls & Pitfalls
Joseph A. Dearani, MD
Division of Cardiovascular Surgery
AATS Seattle April 2015
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No disclosures
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Outline
• Background
• Which patients, why to consider
• Old and new literature
• Techniques of PVR
• INR management
• Thrombolysis
• Summary
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Background• Bioprostheses, homografts – most
common, require re-re-replacement…
• Mechanical valves durable but… require anticoagulation
• The problem…
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And the competition…
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Who? PVR Population – Mayo >3,000
• Conotruncal Anomalies
• native PVR – TOF, PS
• RV - PA conduit
PA-VSD, DORV, Truncus, TGA
• Failed Ross
• aortic root + PVR
Note – mechanical PVR at Mayo…2% of all PVR
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Why?ACHD Reoperation (n=1,040)
Sternotomy # 2 3 4 5+
N= 630 298 78 34
Early mortality (%) 2 5 8 0
Resp failure (%) 5 6 6 15
Pacemaker (%) 4 4 4 0
Stroke (%) 1 2 3 0
Renal failure (%) 3 3 5 3
Sternal infect (%) 2 1 6 3Holst et al. Ann Thorac Surg 2011
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Survival(%)
Years
#2 583 415 311 218 139 80
#3 268 208 152 108 71 36
#4 67 47 31 25 16 7
5+ 31 19 14 8 6 3
P=0.0102
3
Sternotomy (no.)
4
5+
Late Survival since Last Sternotomy
Holst et al. Ann Thorac Surg 2011
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ACHD Reoperations (n=1,040)
Valve* Repair Replace
Pulmonary 4 423
Aortic 22 234
Tricuspid 162 144
Mitral 71 114
*85% of all operations were valve-related
*25% of all operations were multi-valveHolst et al. Ann Thorac Surg 2011
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No anticoagulation
6/16 failed
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No anticoagulation
1/4 failed
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No anticoagulation
3/11 failed
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With anticoagulation
1/8 failed with inadequate INR
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October 1965 August 2008
33 21
Age5 66
33 yr
n= 54
Mechanical PVR
Stulak et al. Ann Thorac Surg 2010
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# %
BAV s/p Ross 12 22
TOF 10 19
Truncus Arteriosus 8 15
Carcinoid 7 13
DORV 6 11
PA/VSD 5 9
TGA 3 6
Other 3 6
Preop Cardiac Diagnoses
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# %
TV Replacement 15 28
Aortic root replacement 14 26
AV replacement 13 24
TV repair 7 13
MV replacement 5 9
Other 13 24
Operative DataConcomitant Procedures
0
20
40
60
80
100
0 2 4 6 8 10
Surv
ival (%
)
52 25 11 8 7 792 62 24 11 8 8
p=0.10Mechanical
Tissue
Follow-up (years)
Overall Survival
Stulak et al. Ann Thorac Surg 2010
0
20
40
60
80
100
0 2 4 6 8 10
Fre
edom
fro
mre
op
era
tio
n (
%)
52 22 11 8 7 792 62 24 11 8 6
p=0.018Mechanical
Tissue
Follow-up (years)
Freedom from Reoperation
Stulak, Dearani et al. Ann Thorac Surg 2010
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Follow-upClotting/Bleeding Events – Mechanical PVR
• PE in 1 (INR 1.4)
Successful lytic therapy
• 8 late bleeding events
Epistaxis in 5
ICH (FH of AVM’s) in 1
Chest wall hematoma in 1
Menorrhagia in 1
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Other new literature…
• N=121 mechanical PVR
• 70% male, mean age 23 yr
• Tetralogy of Fallot 90%
• Mean follow-up 7 years
• No early, late mortality
Dehaki et al. Thorac Cardiovasc Surg 2014
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Other new literature – cont.
• PVR malfunction 8.3%
• 9 thrombosis; 8 thrombolysis, 1 reop
• Mean time 1.7 yr
• Freedom from…at 1, 5, 10 years
• Reop 100, 99, 98%
• Thrombosis 100, 93, 91%
• Bleeding (epistaxis) 98%
Dehaki et al. Thorac Cardiovasc Surg 2014
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• 19 observational studies; N=299 (adult & peds)
• Mean follow-up 73 months
• Nonstructural deterioration 1.5%
• Thrombosis 2.2%
• Reoperation 0.9%
• Thrombolysis 0.5%
Mechanical PVR - Meta-Analysis
Dunne et al. Ann Thorac Surg 2015
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Valve OutcomesWarfarin
%
No Warfarin
%
Non-structural
dysfunction
0.2 1.5
Thrombosis 0.6 2.2
Surgical
reintervention
0.4 0.9
Thrombolysis 0.2 0.5
Severe bleeding 0.1 0.4
Dunne et al. Ann Thorac Surg 2015
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Bioprosthetic failure
3 yr % 5 yr % 10 yr %
Homograft 12 40 25 - 60
Pericardial 11 - 26 22
Contegra 20 - 27
Medtronic
Freestyle
7 - 16
Hancock II 4 - 17 50
Melody 2 - 10Dunne et al. Ann Thorac Surg 2015
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Technique Native RVOT and PA
• Annulus vs proximal PA; tilt toward confluence
• Patch may not be necessary with dilated PA
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Intimal Peels in Right-sided Conduits
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PA
RV
Bovine Pericardial Conduit Roof
No intimal peels
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Prosthesis Selection
Anticoagulation for Valves Advances
• Low intensity AC for bileaflet
aortic prostheses
• Patient INR self-testing
• Novel anticoagulants on the way
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Point-of-Care INR
Instruments
Time In Range
0
25
50
75
100
Usual Care Self-TestingLafata JE. J Gen Intern Med 2000
89%
6% 5%
% T
ime i
n R
an
ge
Low
Therapeutic
High
Reduction in AE Rate
0
5
10
15
Usual Care Self Testing
Thromboembolic
Hemorrhage
Horstkotte D. J Heart Valve Dis 2004
3.6%
0.9%
11%
4.5%
Perc
en
t p
er
pt-
yr
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“Thrombolysis is the
recommended initial treatment for
thrombosed right-sided
mechanical valves.”
JS Alpert JACC 2003
When it happens…
Thrombolysis• Urokinase, Streptokinase, rt-PA
• Lytic agent + heparin
• Temporary pacing with HR
• Kao et al. Tex Heart Inst J 2009
• Lengyel et al. J Heart Valve Dis 2005
• Alpert J Am Coll Cardiol 2003
• Manteiga et al. J Thorac Cardiovasc Surg 1998
• Keuleers et al. Am J Cardiol 2011
• Kogon et al. J Thorac Cardiovasc Surg 2004
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Anticoagulation for PVR Mayo Clinic Practice
• Aspirin (81 mg/day) + warfarin
• Isolated PVR INR 2.5 – 3.0
• AVR + PVR INR 3.0 – 3.5
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•Excellent durability
•Low risk – thrombosis, valve failure
•Consider in selected patients
• Multiple prior operations
• Receiving AC for other reasons, e.g., AVR
• Premature bioprosthetic degeneration
• INR self-testing essential
Summary – Mechanical PVR
Questions & Discussion