3rd European Meeting on Adult Congenital Heart Disease                16 - 17 March 2012                  Munich, Germany ...
Pediatric and Adult Congenital Heart Centre4 Valves in the normal Heart                           but………………..             ...
Pediatric and Adult Congenital Heart Centre…………… more than 4 inour patients !!               Gfdfg
Pediatric and Adult Congenital Heart Centre             General Considerations                              Age           ...
Pediatric and Adult Congenital Heart Centre                                                                               ...
Pediatric and Adult Congenital Heart Centre                                  Mitral Valve                  The best valve ...
Pediatric and Adult Congenital Heart Centre                              General Considerations                           ...
Pediatric and Adult Congenital Heart Centre     Mitral Valve                                              Hammermeister et...
Pediatric and Adult Congenital Heart Centre                 General Considerations1,712 Patients with the Biocor™ Porcine ...
Pediatric and Adult Congenital Heart Centre   VALVE REPLACEMENT FOR AGE           MECHANICAL                              ...
Pediatric and Adult Congenital Heart Centre    Aortic Valve                                              Aortic Valve
Pediatric and Adult Congenital Heart Centre    Aortic Valve                                              Hammermeister et ...
Pediatric and Adult Congenital Heart Centre                           Aortic Valve1,712 Patients with the Biocor™ Porcine ...
Pediatric and Adult Congenital Heart Centre                       Aortic ValveStentless bioprostheses provide better Effec...
Pediatric and Adult Congenital Heart CentreVALVE REPLACEMENT FOR AGE    MECHANICAL                                      BI...
Pediatric and Adult Congenital Heart Centre    Aortic Valve                                   “Ascending aorta”           ...
Pediatric and Adult Congenital Heart Centre                                                        Aorto-plastyBentall    ...
Pediatric and Adult Congenital Heart Centre                                       Aortic ValveThere is increasing attentio...
Pediatric and Adult Congenital Heart Centre    Aortic Valve
Pediatric and Adult Congenital Heart CentreTricuspid Valve
Pediatric and Adult Congenital Heart Centre                              Tricuspid valve  Tricuspid valve regurgitation ca...
Pediatric and Adult Congenital Heart Centre                                 Tricuspid valve  Tricuspid valve regurgitation...
Pediatric and Adult Congenital Heart Centre                              Tricuspid valve  Tricuspid valve regurgitation ca...
Pediatric and Adult Congenital Heart Centre                                     Tricuspid valve       Tricuspid valve regu...
Pediatric and Adult Congenital Heart Centre Tricuspid valve
Pediatric and Adult Congenital Heart Centre Tricuspid valve    What to do?                        Edwards MC3
Pediatric and Adult Congenital Heart Centre Tricuspid valve
Pediatric and Adult Congenital Heart CentreTricuspid Valve
Pediatric and Adult Congenital Heart Centre                         Pulmonary Valve              Pulmonary Valve Replaceme...
Pediatric and Adult Congenital Heart Centre                     Pulmonary valveWho are the candidates for surgical        ...
Pediatric and Adult Congenital Heart Centre          Pulmonary valveNot candidates for transcatheter PVI    • Size of pulm...
Pediatric and Adult Congenital Heart Centre                         Pulmonary Valve                    Mechanical or Biolo...
Pediatric and Adult Congenital Heart Centre                     Pulmonary valveThe Authors compared 3 biological valves ty...
Pediatric and Adult Congenital Heart Centre                          Pulmonary valveAnother problem with homograft valves ...
Pediatric and Adult Congenital Heart Centre                              Pulmonary valveThe results for xenografts (porcin...
Pediatric and Adult Congenital Heart Centre                          Pulmonary valveBioprosthetic valves are probably the ...
Pediatric and Adult Congenital Heart Centre                        Pulmonary valveShinkawa and collegues analized the outc...
Pediatric and Adult Congenital Heart Centre                         Pulmonary valveOur current approach, since 2005, is to...
Pediatric and Adult Congenital Heart Centre                          Pulmonary valveAnother criterion to take into conside...
Pediatric and Adult Congenital Heart Centre                    Conclusions                            Age                 ...
Pediatric and Adult Congenital Heart CentreSee you next year in      ITALY
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Valve replacement:choosing the right valve in ACHD

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Valve replacement:choosing the right valve in ACHD

  1. 1. 3rd European Meeting on Adult Congenital Heart Disease 16 - 17 March 2012  Munich, Germany Valve replacement: choosing the right valve for adults with CHD Massimo Chessa Pediatric and Adult Congenital Heart Centre IRCCS- Policlinico San Donato San Donato Milanese – Milano
  2. 2. Pediatric and Adult Congenital Heart Centre4 Valves in the normal Heart but……………….. but………………..
  3. 3. Pediatric and Adult Congenital Heart Centre…………… more than 4 inour patients !! Gfdfg
  4. 4. Pediatric and Adult Congenital Heart Centre General Considerations Age Anathomy SurgeonPreference choosing the right valve Surgical History PatientPreference Life’s Sex expectation
  5. 5. Pediatric and Adult Congenital Heart Centre P AC 3 A 2Mitral Valve A A 1 C •Annulus •Anterior leaflet •Chordae Tendineae •Papillary Muscle
  6. 6. Pediatric and Adult Congenital Heart Centre Mitral Valve The best valve it is its own valve! Benefits Limitations• Low operative mortality • Surgeon’s expertise• Long-term survival • Extent of the disease – (identical to the general population)• Better preservation of ventricular function• Decreased need for anticoagulation therapy « … an operation that can treat the patient for the rest of his life … »• Reduced valve-related Prof. A. Carpentier complications
  7. 7. Pediatric and Adult Congenital Heart Centre General Considerations Mechanical or BiologicalMechanical Prostheses from Biological Prostheses from 1960 1968
  8. 8. Pediatric and Adult Congenital Heart Centre Mitral Valve Hammermeister et al JACC 2000
  9. 9. Pediatric and Adult Congenital Heart Centre General Considerations1,712 Patients with the Biocor™ Porcine Bioprosthesis: A 20-Year Experience Actuarial Freedom from Reoperation due to SVD for the aortic and mitral valve replacement Hgfdg Pia S.U. Myken, MD; JTCS 2009
  10. 10. Pediatric and Adult Congenital Heart Centre VALVE REPLACEMENT FOR AGE MECHANICAL BIOLOGICALChildren 18 – 65 yrs > 65 yrs
  11. 11. Pediatric and Adult Congenital Heart Centre Aortic Valve Aortic Valve
  12. 12. Pediatric and Adult Congenital Heart Centre Aortic Valve Hammermeister et al JACC 2000
  13. 13. Pediatric and Adult Congenital Heart Centre Aortic Valve1,712 Patients with the Biocor™ Porcine Bioprosthesis: A 20-Year Experience Actuarial Freedom from Reoperation due to SVD for the aortic and mitral valve replacement Hgfdg Pia S.U. Myken, MD; JTCS 2009
  14. 14. Pediatric and Adult Congenital Heart Centre Aortic ValveStentless bioprostheses provide better EffectiveOrifice Area than stented bioprostheses, which arerelatively stenotic in the small sizes (annulus size 21mm).Modern mechanical valves provide betterhaemodynamic performance than stentedbioprostheses.
  15. 15. Pediatric and Adult Congenital Heart CentreVALVE REPLACEMENT FOR AGE MECHANICAL BIOLOGICAL 18 – 65 yrs > 65 yrs
  16. 16. Pediatric and Adult Congenital Heart Centre Aortic Valve “Ascending aorta” Aortic root Aortic valve
  17. 17. Pediatric and Adult Congenital Heart Centre Aorto-plastyBentall Aortic valve + Asc Ao
  18. 18. Pediatric and Adult Congenital Heart Centre Aortic ValveThere is increasing attention toprophylactic replacement of themoderately dilated ascending aorta ataortic valve surgery Moderate ascending aortic dilatation is common in adult patients with conotruncal anomalies.
  19. 19. Pediatric and Adult Congenital Heart Centre Aortic Valve
  20. 20. Pediatric and Adult Congenital Heart CentreTricuspid Valve
  21. 21. Pediatric and Adult Congenital Heart Centre Tricuspid valve Tricuspid valve regurgitation can be associated with different anatomical or functional mechanisms.We can identify selected groups: 1) patients with Ebstein’s anomaly;
  22. 22. Pediatric and Adult Congenital Heart Centre Tricuspid valve Tricuspid valve regurgitation can be associated with different anatomical or functional mechanisms.We can identify selected groups: 2) patients with tricuspid valves damaged by previous operations (ventricular septal defect closure, complete atrio-ventricular canal repair, etc);
  23. 23. Pediatric and Adult Congenital Heart Centre Tricuspid valve Tricuspid valve regurgitation can be associated with different anatomical or functional mechanisms.We can identify selected groups: 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);
  24. 24. Pediatric and Adult Congenital Heart Centre Tricuspid valve Tricuspid valve regurgitation can be associated with different anatomical or functional mechanisms. We can identify selected groups: 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 patientswith large atrial septal defects or in long-standing pulmonary valve insufficiency after previousrepair of tetralogy of Fallot or pulmonary stenosis.The physiologic consequences of chronic RV volume overloading in these patients, cancompromise tricuspid valve function.
  25. 25. Pediatric and Adult Congenital Heart Centre Tricuspid valve
  26. 26. Pediatric and Adult Congenital Heart Centre Tricuspid valve What to do? Edwards MC3
  27. 27. Pediatric and Adult Congenital Heart Centre Tricuspid valve
  28. 28. Pediatric and Adult Congenital Heart CentreTricuspid Valve
  29. 29. Pediatric and Adult Congenital Heart Centre Pulmonary Valve Pulmonary Valve Replacement (PVR) is the reoperation most frequently performed todayThe type of valve to be inserted into the RVOT is still debated. Surgery or Percutaneous
  30. 30. Pediatric and Adult Congenital Heart Centre Pulmonary valveWho are the candidates for surgical PVI ?Those that are not good candidates for transcatheter PVI Giamberti et al. Ann Thorac Surg 2009; 88: 1284-90:
  31. 31. Pediatric and Adult Congenital Heart Centre Pulmonary valveNot candidates for transcatheter PVI • Size of pulmonary annulus • Morphology of RVOT o RV-PA conduit • Associated cardiac malformation •RV aneurism •TV regurgitation •Arrhythmias
  32. 32. Pediatric and Adult Congenital Heart Centre Pulmonary Valve Mechanical or BiologicalAt present time, options include mechanical as well as severalbiological valves (including homografts, xenografts, prosthetic valvedconduits, and bioprosthetic valves)Bioprosthetic valves perform well hemodynamically, but are proneto structural degeneration that results in multiple reoperations.Mechanical valves lead to a persistent need for anticoagulationtherapy, and despite some positive reports in the literature, havegenerally been associated with pulmonary thromboemboliccomplications
  33. 33. Pediatric and Adult Congenital Heart Centre Pulmonary valveThe Authors compared 3 biological valves types (stentedxenograft valve, bovine pericardial valve, and pulmonaryhomograft)The late dysfunction was more likely with homograft valvesthan 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)
  34. 34. Pediatric and Adult Congenital Heart Centre Pulmonary valveAnother problem with homograft valves is their availabilityConsidering all these limitations, many authors now agree thathomograft valves are far from ideal.
  35. 35. Pediatric and Adult Congenital Heart Centre Pulmonary valveThe results for xenografts (porcine pulmonary-valve conduits, stentless porcineaortic-root bioprostheses, and bovine jugular valved vein conduits) remaincontroversial at this time.In any case, an extensive dissection of the pulmonary arteries, as withthe homograft valves, is needed to avoid kinking due to the excessivelength of the prosthesis. Extreme care must be taken duringimplantation, as any twisting, kinking, or external compression caneasily lead to early failure Goffin YA, J Heart Valve Dis 2000,9: 207-14The same considerations can be taken for the prosthetic valvedconduits, such as Hancock or Edwards conduits.
  36. 36. Pediatric and Adult Congenital Heart Centre Pulmonary valveBioprosthetic valves are probably the most widely used for pulmonaryvalve replacement, because they are readily available and do not needpermanent anticoagulation therapy.The bioprosthesis valves are very easy to implant andpermits the avoidance of extensive dissection of thepulmonary arteries, which is particularly favourable inpatients submitted multiple operations
  37. 37. Pediatric and Adult Congenital Heart Centre Pulmonary valveShinkawa and collegues analized the outcome and performance ofbovine pericardial valves in pulmonary position.Freedom from pulmonary valve reoperation was 100%, 97.7%, and97.7% at 1, 3 and 5 years, respectively Shinkawa T, Ann Thorac Surg 2010; 90: 1295-1300
  38. 38. Pediatric and Adult Congenital Heart Centre Pulmonary valveOur current approach, since 2005, is to reconstruct the RVOT with abioprosthetic 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 deteriorationand the function of this porcine bioprosthetic valve in the pulmonaryposition. Giamberti A, et al. Submitted
  39. 39. Pediatric and Adult Congenital Heart Centre Pulmonary valveAnother criterion to take into consideration in the RVOTreconstruction, should be the facilitation of future interventionalprocedures, such as percutaneous pulmonary- valve implantationUntil now, homograft valves or prosthetic valved conduits seemed tobe the ideal candidates but many recent reports appeared in theliterature show possible the percutaneous approach even inbioprosthesis valves. MacDonald ST, Eur Heart J2011; Jan 27
  40. 40. Pediatric and Adult Congenital Heart Centre Conclusions Age Anathomy SurgeonPreference choosing the right valve Surgical History PatientPreference Life’s Sex expectation
  41. 41. Pediatric and Adult Congenital Heart CentreSee you next year in ITALY

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