TSDA Boot Camp September 13-16, 2018 Introduction to ... · Valvular Aortic Stenosis in Adults...
Transcript of TSDA Boot Camp September 13-16, 2018 Introduction to ... · Valvular Aortic Stenosis in Adults...
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TSDA Boot Camp
September 13-16, 2018
Introduction to
Aortic Valve Surgery
George L. Hicks, Jr., MD
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Aortic Valve Pathology and
Treatment
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Valvular Aortic Stenosis in AdultsAverage Course
(Post mortem data)
Circulation 38 (Suppl. 5) 61, 1968
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Medically Treated Valvular DiseaseAverage Course (Survival)
AI, MI, MS
AS
Rappaport E: Am J Cardiol 35:221, 1975
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Valve Surgery
Represents a
growing public
health problem!
Growth
– over 10 years
– (1992-2001)
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Valve Anatomy
4 Valves
Semilunar
Pulmonic
– Aortic
Atrioventricular
Tricuspid
Mitral
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Aortic Valve
Normal Valve
3 Leaflets
– Right Coronary ]
– Noncoronary ]
– Left Coronary ]
cross-sectional area of
about 3 cm sq
•
••
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Aortic Valve
•
••
Conduction system
Anterior leaflet mitral
valve
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Diagnostic Approach
Clinical findings– Exam
– Murmur
Chest X-Ray
ECG
Imaging– Echocardiography
– Angiography
– MRI
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As ventricular pressure ( ) increases and exceeds atrial pressure ( )– atrioventricular valves close– causing the S1 heart sound
Cardiac Cycle
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Aortic pressure ( ) exceeds Ventricular pressure ( )– the semilunar valves close
causing the S2 heart sound
Cardiac Cycle
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Transesophageal
Echo
LV short axis
Papillary view
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LV short axis mitral view
Transesophageal
Echo
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Four chamber view
Transesophageal
Echo
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Cardiac Catheterization
Right coronaryLeft Coronary
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MRI
The Future
Aortic Regurgitation
Trileaflet Pulmonary Valve
Bileaflet Pulmonary Valve
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Aortic Valve
Stenosis
Regurgitation
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Preoperative Data: AVR
2%
28%
57%
13%
0%
20%
40%
60%
80%
100%
NYHA Class
% o
f P
ati
en
ts
I II III IV
Insufficiency
13%
Stenosis
65%
Valvular Lesion
Mixed
22%
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Aortic Stenosis
Disease of the Elderly
Symptoms begin:
60-80 yrs. of age
Causes:
Scarring
Calcification
Rheumatic fever
Bicuspid valve
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Aortic Stenosis
Pathophysiology
Increased resistance to blood flow from
the left ventricle to the aorta
– Increased work
– Left ventricular hypertrophy
Smaller ventricular cavity
– Increased oxygen demand
Can lead to ischemia
Heart failure
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Aortic StenosisSymptoms
Chest pain (angina) – occurs during exertion– blood supply to the enlarged heart muscle is
inadequate
Heart failure develops– fatigue– shortness of breath during exertion
Syncope– Exertion leads to peripheral arterial vasodilatation– AS limits cardiac output preventing compensation
Sudden Death
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Aortic Stenosis
Diagnosis
Physical Examination– Heart Murmur
Heard over aortic area
2nd right intercostal border
Midsystolic murmur
Radiates down left sternal border
ECG– Left ventricular hypertrophy
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Aortic Stenosis
Chest X-ray
Prominent left ventricle
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Aortic Stenosis
Diagnosis
EchocardiographyCardiac Cath
>45 years
Short Axis
Long Axis
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Aortic Stenosis
Treatment
Asymptomatic– Regular follow-up
Serial Echo
Symptomatic– Aortic valve area less than 1.2 cm2/M2
Severe Aortic Stenosis
–Valve area 1cm2
– Mean Gradient >40 mm Hg (normal LV)
–Max vel> 4.0m/sec2
Medical Therapy– Diuretics
Surgical replacement– before irreversible damage
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Aortic Stenosis
Survival
Symptomatic
Surgery
vs
Medical
NEJM, Carabello 346 (9): 677
February 28, 2002
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Aortic Regurgitation
Increasing volume
and pressure in the
left ventricle
– Result: increased work
ventricles thicken
to compensate
hypertrophy
chambers dilate
Eventually CHF
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Aortic Regurgitation
Rheumatic Fever– Historical cause
myxomatous degeneration
aortic aneurysms & dissection
bicuspid valve
infective endocarditis
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Aortic Regurgitation
Symptoms
Mild– Asymptomatic heart murmur
Severe– Palpitations
LVH
– Congestive heart failure Shortness of breath
Fatigue
Angina
– Reduce SBP during ventricular diastole
– Wide pulse pressure
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Aortic Regurgitation
Physical exam– Murmur
Heard with diaphragm
Midsystolic
ECG:– LVH
Chest X-ray– cardiomegaly
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Aortic Regurgitation Echo
Cardiac Cath– 20% of people with aortic regurgitation also have
coronary artery disease
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Aortic Regurgitation
Treatment Mild
– Medical management Digoxin, Diuretics
Calcium channel blocker
Ace
Moderate to severe:– Surgery
Cardiac Cath– 20% of people with aortic regurgitation also have
coronary artery disease
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Aortic Valve Replacement
Possible ProsthesesMechanicals valves
Homografts
Engineered Tissue Valves
-Stented (porcine or bovine)
-Stentless (porcine)
Pulmonary Autograft
Aortic Remodeling
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Mechanical Valve
Products
SJM Regent™
valve (bileaflet)
Carbomedics
Standard bileaflet
valve
Medtronic –
Hall™ tilting
disc valve
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Tissue Valve Products
Stented Valve
Edwards Lifesciences
Carpentier - Edwards
Perimount™ valve
Stentless
Valve
St. Jude Medical
Toronto SPV®
valve
Homograft
LifeNet
Homograft
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Stentless Aortic Valves
Modeled afternative aortic valve
Eliminates residualstenosis causedby stents
Near-normalhemodynamics
Normalizes LVmass and performance
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Toronto SPV® Valve Freestyle® Valve
Stentless Porcine Valves
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Sutureless Aortic Valves
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Percutaneous Aortic Valves
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Stented Aortic Valves
Obstructive to flow
Decreased effectiveorifice areas
Increased transvalvularpressure gradients
Residual leftventricular hypertrophy
Calcification atstent/tissue interfaces
Rigid, non-compliantwith aorta
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Aortic Root Reconstruction
Aortic Root Replacement
Coronary Reimplantation
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Aortic Root Remodeling
Aortic valve preservation
Remodeling of root geometry
Coronary Reimplantation
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Echo
Stentless Freestyle Natural Valve
Bioprosthesis
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DurabilityAnticoagulation
Valve Surgery Trends
Lim JTCVS 02 485 patients
composite TE Risk 7% per pt yr
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Mechanical Valves
Thromboembolic event rate
– 1-4%/pt-year
Anticoagulant related hemorrhage rate
– 2-5%/pt-year
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Risk Factors for
Thromboembolism
Mechanical valve implant
Atrial Fibrillation
Increased LV cavity size/LV dysfunction
Regional Wall Motion Abnormality
Depressed Ejection Fraction
Previous Thromboembolism
Hypercoagulability
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St. Jude Medical, Training and Education
Anticoagulants - Coumarins
Development/clinical use began in the 1920s
Used for long-term anticoagulation therapy
– Oral anticoagulant
– Produces a functional deficiency of Vitamin K
several clotting factors on Vitamin K
– Takes 36 hours to achieve a therapeutic blood
level which will last 4 - 5 days
Blood levels can vary
– patients must be checked regularly
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Minimally Invasive
Aortic Valve
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Aortic Valve
Freedom from Valve Dysfunction
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Aortic Valve Complications
Thromboembolism
Anti-coagulant related
hemorrhage
Valve
dysfunction/structural
failure
Para-valvular leak
Re-operation
Endocarditis
Hemolysis
Death
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Aortic ValveSurvival
Early (hospital) death - 3-6%
Time-related survival
· 5 years - 75%
· 10 years - 60%
· 15 years - 40%
Mode of death
· Early due to CHF, hemorrhage, infection, CVA
· Sudden - 20%
· Device related - 20%
CTSNet, Residents Section
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Aortic Valve
Risk Factors for Survival after AVR· Advanced age· Functional status (NHYA class)· Depressed LV function (aortic incompetence)· Coronary artery disease· Presence of endocarditis· Aneurysm of ascending aorta· Mismatch of prosthesis and body size