Valvular Heart Valvular Heart Disease:Disease:
No Longer the Realm of the No Longer the Realm of the Surgeon?Surgeon?
Christopher YoungChristopher Young
St Thomas’ Hospital, St Thomas’ Hospital, LondonLondon
OutlineOutline History, valve development and failureHistory, valve development and failure
Surgical results and demographicsSurgical results and demographics
Minimal Access (including robotic)Minimal Access (including robotic)
Lessons to be learnt from surgeryLessons to be learnt from surgery
Summary and ConclusionsSummary and Conclusions
HistoryHistory
Heart ValvesHeart Valves
Bioprosthetic Problem Bioprosthetic Problem SolvingSolving
EarlyEarly CalcificationCalcification
Later valvesLater valves Tissue engineering (composite valves / muscle Tissue engineering (composite valves / muscle
bar)bar) Zero pressure fixationZero pressure fixation Anti-calcification remediesAnti-calcification remedies Blue valves (toluidine blue)Blue valves (toluidine blue)
Recent ValvesRecent Valves Sorin Valves (amino acids)Sorin Valves (amino acids)
Significant Bioprosthetic Significant Bioprosthetic FailuresFailures
Dura Mater – Dura Mater – abandonedabandoned
Fascia Lata – Fascia Lata – abandonedabandoned
Ionescu-Shiley – Ionescu-Shiley – abandonedabandoned
Autogenics - Autogenics - abandonedabandoned
Mechanism of FailureMechanism of Failure
Biological – gradual failureBiological – gradual failure
Mechanical – catastrophicMechanical – catastrophic
Significant FailuresSignificant Failures
MechanicalMechanical
Bjork-ShileyBjork-Shiley
DuromedicsDuromedics
Abram’s ValveAbram’s Valve
Significant Failures – Significant Failures – Endovascular StentsEndovascular Stents
Gore TagGore Tag
Gore Thoracic Excluder
ePTFE Deployment Sleeve(attached to stent structure)
Self-expanding Nitinol Stent Structure
ePTFE graft on blood-contact surface
Radiopaque Band (both ends)
Spine Structure forColumnar Support
Flares for wallapposition
Sealing Cuff (both ends)
Sutureless Graft Attachment
Product DescriptionProduct Description
Stentless ValveStentless Valve
Single Layer StentlessSingle Layer Stentless
Single Layer StentlessSingle Layer Stentless
3F Surgical Valve3F Surgical Valve
Surgical ResultsSurgical Results
Data from 5th National Adult Cardiac Surgical Database Report
Data from 5th National Adult Cardiac Surgical Database Report
Data from 5th National Adult Cardiac Surgical Database Report
Data from 5th National Adult Cardiac Surgical Database Report
Surgical ProgressSurgical Progress
Minimal Access AVRMinimal Access AVR
Minimal Access – Aortic RootMinimal Access – Aortic Root
Minimal Access – Aortic RootMinimal Access – Aortic Root
Minimal Access – Aortic RootMinimal Access – Aortic Root
Minimally Invasive Valve Minimally Invasive Valve ReplacementReplacement
Percutaneous peripheral cannulationPercutaneous peripheral cannulation ““Heartport” techniquesHeartport” techniques Mini-sternotomyMini-sternotomy Mini anterior thoracotomyMini anterior thoracotomy Surgery under epidural anaesthesiaSurgery under epidural anaesthesia
Robotic Aortic SurgeryRobotic Aortic Surgery 5 patients (3M/2F; 35 – 81 years)5 patients (3M/2F; 35 – 81 years) 4 calcific AS / 1 AR4 calcific AS / 1 AR Transverse incision 4-5 cm R 3Transverse incision 4-5 cm R 3rdrd IC IC
spacespace Standard interrupted suture techniqueStandard interrupted suture technique No mortality/complicationsNo mortality/complications Mean hospital stay 8.6Mean hospital stay 8.6±±3 days3 days
Folliguet et al. EJCTS 28 (2005): 172-173
Minimal Access Mitral Minimal Access Mitral RepairRepair
Port access CPB
Endoclamp
Multiple small incisions
No rib spreading
Minimally Invasive vs Minimally Invasive vs Conventional Valve Conventional Valve
ReplacementReplacement Overall majority of reported results Overall majority of reported results
similarsimilar DeathDeath Length of stayLength of stay Complication ratesComplication rates
Minor negative aspects of:Minor negative aspects of: Longer X clamp timesLonger X clamp times Longer bypass timesLonger bypass times Increased early post-operative painIncreased early post-operative pain
Minimally Invasive vs Minimally Invasive vs Conventional Valve Conventional Valve
ReplacementReplacement Some reports of improved outcome Some reports of improved outcome
with keyhole approachwith keyhole approach Lower risk redo operationsLower risk redo operations Aortic vascular proceduresAortic vascular procedures Lower transfusion requirementsLower transfusion requirements Lower incidence post-operative AFLower incidence post-operative AF Lower post-operative pain after day 2Lower post-operative pain after day 2
Off-Pump Valve RepairOff-Pump Valve Repair
Treatment of functional ischaemic MRTreatment of functional ischaemic MR Coapsys device consists of 2 epicardial Coapsys device consists of 2 epicardial
padspads Pads then connected with flexible chordPads then connected with flexible chord Placement TOE guidedPlacement TOE guided MR reduced from grade 2.7MR reduced from grade 2.7±±0.8 – 0.8 –
0.40.4±±0.70.7Grossi et alGrossi et al Ann Thorac Surg 2005; 80: 1706- Ann Thorac Surg 2005; 80: 1706-1111
Surgical ProblemsSurgical Problems
(Cardiological (Cardiological Problems?)Problems?)
ValveValve excisionexcision
The small annulusThe small annulus
A tight squeeze
Small annulusSmall annulus
Good exposure from retraction suturesGood exposure from retraction sutures Position light and tablePosition light and table Enthusiastic excision / decalcificationEnthusiastic excision / decalcification Do not oversize valveDo not oversize valve Consider supra-annular placementConsider supra-annular placement Do NOT use everting mattress suturesDo NOT use everting mattress sutures (Root enlargement)(Root enlargement)
The Big AnnulusThe Big Annulus
Summary 1Summary 1
Valve technology has evolved over Valve technology has evolved over 45 years with significant failures 45 years with significant failures along the way (including recently)along the way (including recently)
Surgical results are excellent with Surgical results are excellent with increasing emphasis on minimal increasing emphasis on minimal accessaccess
Summary 2Summary 2
Increasingly elderly population with Increasingly elderly population with more calcific diseasemore calcific disease
Surgical anatomy/pathology is varied; Surgical anatomy/pathology is varied; a “one size fits all” approach will not a “one size fits all” approach will not workwork
How long will the devices last and how How long will the devices last and how will they fail?will they fail?
ConclusionsConclusions
Proceed carefully!Proceed carefully!
If things go pear-shapedIf things go pear-shaped
Ring us – as usual, we will always be Ring us – as usual, we will always be there to bail you out!there to bail you out!
This time, however, it may not be enoughThis time, however, it may not be enough
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