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Prosthetic heart valves
 

Prosthetic heart valves

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prosthetic heart valves

prosthetic heart valves
-Dr. Raajit Chanana

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    Prosthetic heart valves Prosthetic heart valves Presentation Transcript

    • - Dr. Raajit Chanana
    •  Mechanical Bileaflet eg St Jude Medical, Carbomedics Tilting disc/Single disc eg Medtronic Hall Ball cage eg Star EdwardsBioprosthesis /Tissue Stented Porcine –Medtronic Hancock , Carpentier- Edwards Stentless Porcine -St. Jude Medical Toronto SPV , Medtronic Mosaic Pericardial bovine Carpentier-Edwards Perimount
    •  Cadavers –within 24 hours Subcoronary position or the valve and a portion of attached aorta are implanted as a root replacement with reimplantation of coronary arteries into the graft. Advantages superior hemodynamic, low thrombogenicity, avoidance of early endocarditis Disadvantages Higher SVD, prone to calcification, prosthetic AR
    •  Pts own pulmonary valve and adjacent main pulm artery-removed-replace diseased aortic valve with implantation of the coronary arteries into the graft Human pulm or aortic homograft inserted into pulm position
    •  Advantage endocarditis risk low ,durable Disadvantage pulmon homograft stenosis (postop inflammatory reaction) should not be performed in bicuspid aortic vavle and dilated aortic roots Choice-children , adults of life expectancy>20yrs and women who wish to become pregnant
    •  Bileaflet valve are the most commonly implanted mechanical valve Low bulk Flat profile Superior hemodynamic
    • Heart sounds The closure of the mechanical valve accentuates the normal heart sound and the intensity of the sound is proportional to the mass of the closure device in the prosthetic valve Lack of accentuation of the opening or closure sound of the valve suggests an abnormality, such as the presence of thrombus, vegetation or pannus and should be investigated.
    •  Opening is always less intense than closure If there are 2 prosthetic valve all mechanical heart sounds are loud Opening and closing are high frequency sounds and should be differentiated from S3 and S4 Complete absence of an opening sound in a patient with a disk or bileaflet is not unusual such as heavy built or hyperinflated lung
    • Prosthetic aortic valves Systolic ejection murmer-prosthetic valve effective area is less than that of native valve, thus there is a mild inherent aortic stenosis Absenc of SEM low cardiac output hyperinflated lungs Abnormality of prosthetic valveDiastolic murmur-perivalvular leak or valvular regurgitation, thrombus
    • Mitral valveUsually do not produce murmurs.Occasionally low freq rumble in mid diastole in thin persons and due to smaller effective size.A holosystolic murmur-malfunction of valve or perivalvular leak.Any murmur with a mechanical tricuspid valve should prompt an investigation for etiology
    • Type of AORTIC PROSTHESI MITRAL PROSTHESIvalve S S Normal Abnormal Normal Abnormal findings findings findings findingsBileaflet (St. Aortic HighJude cc diastolic OC frequencymedical) S1OC murmur holosystoli Decreased c murmur intensity of Decreased SEM p2 closing s2 DM intensity of click CC closing click
    • Mechanical valve Warfarin should begin 2 days after operation Aortic valve –target INR 2-3 if no risk factors If higher risk for thrombosis eg AF,previous thromboembolism target INR 2.5-3.5 For all valves in the mitral position target INR 2.5-3.5 Low dose aspirin 75-100mg
    • Bioprosthetic valve During first 3 post op months while the sewing ring becomes endothelized there is risk of thrombosis so warfarin is given If no risk factors present then warfarin not given If risk factors –previous embolism,thrombus in the left atrium at operation, remain in AF postoperatively ,need for anticoagulaion persists
    • Aortic valve replacementClass 1 Mechanical prosthesis in patients with a mechanical valve in the mitral or tricuspid position Bioprosthesis in patients of any age who will not take warfarin or who have major medical contraindications to warfarin therapy
    • Class 2a Patient consideration is a reasonable consideration in the selection of valve prosthesis. Mechanical prosthesis is reasonable for AVR in pts <65yrs who do not have contraindication to anticoagulation
    • Cont…. A bioprosthesis is reasonable for AVR in patients <65yr who elect to receive this valve for lifestyle considerations after detiled discussions of the risks of anticoagulantversus the likelyhood that a second AVR may be neede in the future
    • Cont… Bioprosthesis is reasonable for patients >=65yr without risk factors for thromboembolism Homograft is reasonable for patients undergoing repeat AVR with active prosthetic valve endocarditis
    • Class 2b Bioprosthesis might be considered for a woman of child bearing age
    • Mitral valve replacementClass1 Bioprosthesis in patients who will not take warfarin, is incapable of taking warfarin, or has clear contraindication to warfarin therapy
    • Class 2a Mechanical prosthesis reasonable for patients <65yr with longstanding AF Bioprosthesis is reasonable in patients >=65yr
    •  Bioprosthesis reasonable for patients <65yrin sinus rhythym who elect to receive this valve for life style considerations after detailed discussions of the risks of anticoagulation versus the likelyhood that a second MVR replacement may be necessary in future.
    •  Prosthetic endocarditis Prosthetic dehiscence Prosthetic dysfunction - Obstruction: usually thrombotic Regurgitation Hemolysis Structural failure Thromboemboli Hemorrhage with anticoagulant therapy Valve prosthesis–patient mismatch Prosthetic replacement Late mortality, including sudden, unexplained death
    • Mechanical Bioprosthesis Durability more Thrombus +++ + Infection +++ + Dehiscence + +++ Stenosis + ++ Degeneration + +++
    •  Blood pressure wide pulse pressure hypotension Pulses Absent limb pulses Bifid carotid pulse Slow rising low amplitude carotid pulse Elevated jugular venous pulse
    •  Palpation Thrill Bifid apical impulse New right or left ventricular heaves Auscultation Decreased intensity of valve closure sound Loss of previous heard opening sounds New gallops Systolic murmur with mitral prosthesis Any diastolic murmur General Prolonged fever without obvious source Embolic phenomenon
    •  First outpatient postop visit 3-4 week after hospital discharge for baseline assessment of valve function and left ventricular remodelling New regurgitant murmur Development of new or changing cardiovascular symptoms Lack of improvement or deterioration of functional capacity or cardiovascular symptoms after valve replacement
    •  Every 6 month in asymptomatic patients with bioprosthetic valve degeneration and >=mild regurgitation Patients with suspected valve obstruction caused by thrombus or pannus growth Patients with suspected PVE
    •  All patients with PHV need appropriate antibiotics for prophylaxis against infective endocarditis Patients with rheumatic heart disease continue to need antibiotics as prophylaxis against the recurrence of rheumatic carditis Adequate antithrombotic therapy is needed for appropriate patients
    • Several syndromes are peculiar to the postoperativeperiod.• Postperfusion syndrome 3rd or 4th postoperative week. fever, splenomegaly, and atypical lymphocytes;benign and self-limited.• Postpericardiotomy syndrome fever and pleuropericarditis. 2nd and 3rd postoperative week, but can appear as lateas 1 year after surgery self-limited, most patients benefit from takingantiinflammatory drugs• Even though the pericardium is left open at theend of surgery, cardiac tamponade has been known tooccur during the first 6 weeks and needs to be relieved.