Choices in Valve Replacement - Desun Hospital Health Insights


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Desun Hospital Health Insights

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  • Dwight Harken began the modern era of prosthetic valve replacement by insertion of his double cage-ball valve into the aortic orifice below the coronary ostia following excision of the diseased cusps. Some of his patients were still alive after 20 years. Albert Starr, a physician, and Lowell Edwards, an electrical engineer, simplified the caged-ball valve by using a single titanium cage, a silastic ball, and a sewing ring covered with teflon. The Starr-Edwards valve was first implanted in the mitral position in 1960, and leter in the aortic position. It became commercially available in 1965. The sewing ring made it easy to suture silastic ball had a tendency to absorb liquid and become deformed, sometimes jamming central flow obstruction cause high pressure gradients, especially in patients with a narrow aortic root
  • Jerome Kay, a surgeon, and Donald Shiley, and engineer, introduced a low-profile disc valve for use in the mitral position. Some surgeons used it in the aortic position too, because, unlike the caged-ball valve, the disc did not extend into the supravalvular ridge; high valvular gradients were still present; valve was subject to wear and thrombosis Other sliding disc configurations were also developed
  • Juro Wado (Japan) developed a tilting disc valve with teflon hinges and an opening angle of 80 degrees; the tilting disc brought down pressure gradients; the teflon hinges wore out Shiley and Dr. Viking Bjork developed a hingeless low-profile tilting disc valve made of Delrin, and designed with an opening angle of 60 degrees. The Bjork-Shiley disk was used successfully in the aortic and mitral position.
  • Examples of failed valves: - crack in the silastic rubber ball - thrombus on the valve housing - wear on the post’s fabric covering - strut failure of a Bjork-Shiley valve (valve model was recalled, then redesigned as a monostrut to avoid this problem) NOTE: patient with this valve survived the failure
  • Choices in Valve Replacement - Desun Hospital Health Insights

    1. 1. C H O I C E O F H E A R T V A L V E S Criteria for patient selection Presented by Public Awareness Program
    2. 2. Four Predictors of Performance of a valve <ul><li>Durability </li></ul><ul><li>Hemodynamics </li></ul><ul><li>Implantability </li></ul><ul><li>Thromboresistance </li></ul>
    3. 3. 1960’s - Commercially Available Mechanical Heart Valves <ul><li>Caged-ball valves were improved and became commercially available . </li></ul><ul><ul><li>1960: Harken implanted a double-cage ball valve into aortic annulus </li></ul></ul><ul><ul><li>1960: first implant of the Starr-Edwards valve - mitral position (first sold in 1965) </li></ul></ul>
    4. 4. 1960’s <ul><li>Disc & Cage designs introduced </li></ul><ul><ul><li>1964: Kay-Shiley </li></ul></ul><ul><ul><li>Beall </li></ul></ul><ul><ul><li>Starr-Edwards </li></ul></ul><ul><ul><li>Cooley-Cutter </li></ul></ul>
    5. 5. 1960’s <ul><li>Low profile, tilting disc valves introduced </li></ul><ul><li>Late 60’s: Wado developed a tilting disc valve reducing pressure gradients </li></ul><ul><li>1969: Bjork-Shiley disk enhanced wear resistance </li></ul>
    6. 6. 1960’s <ul><li>Valve replacement became widely accepted, but mortality and complication rates were high </li></ul><ul><li>Product failures common due to: </li></ul><ul><ul><li>Metal fatigue in mechanical valves. </li></ul></ul><ul><ul><li>Limited thromboresistance knowledge. </li></ul></ul><ul><ul><li>Biomaterials standards not established. </li></ul></ul>
    7. 7. Early Product Failures
    8. 8. 1977 <ul><li>Introduction of the SJM bileaflet mechanical heart valve. </li></ul><ul><ul><li>Largest opening angle </li></ul></ul><ul><ul><li>Lowest pressure gradients </li></ul></ul><ul><ul><li>Minimal turbulence and lower thrombogenicity . </li></ul></ul>
    9. 9. Tissue Valve History <ul><li>Early generation tissue valves </li></ul><ul><ul><li>Intact porcine valves </li></ul></ul><ul><ul><ul><li>Septal muscle bar may reduce blood flow </li></ul></ul></ul><ul><ul><li>High pressure tissue fixation </li></ul></ul><ul><ul><ul><li>Flattened tissue structure </li></ul></ul></ul><ul><ul><li>No anti-calcification treatments </li></ul></ul><ul><ul><ul><li>May have led to early degeneration of tissue </li></ul></ul></ul>
    10. 10. Tissue Valve History <ul><li>Next generation tissue valves </li></ul><ul><ul><li>Intact porcine valves </li></ul></ul><ul><ul><ul><li>Reduction of muscle shelf bar </li></ul></ul></ul><ul><ul><li>Composite valves </li></ul></ul><ul><ul><ul><li>Porcine tissue </li></ul></ul></ul><ul><ul><ul><ul><li>Three separate leaflets </li></ul></ul></ul></ul><ul><ul><ul><li>Pericardial tissue </li></ul></ul></ul><ul><ul><li>Low pressure tissue fixation </li></ul></ul><ul><ul><ul><li>Maintained tissue structure </li></ul></ul></ul><ul><ul><li>Introduction of anti-calcification treatments </li></ul></ul><ul><ul><ul><li>May prolong life of tissue valve </li></ul></ul></ul>
    11. 11. What kinds of heart valves are available? Bioprosthetic Valves Mechanical Valves How do you choose between these valves?
    12. 12. Two Main Sources of Bioprosthesis Bov ine Pericardium <ul><li>Tissue Source: </li></ul><ul><li>Valves removed from pigs. </li></ul><ul><li>Tissue Source: </li></ul><ul><li>Valves prepared from bovine pericardium. </li></ul>Porcine
    13. 13. What kinds of heart valves are available? Bioprosthetic Valves <ul><li>Valve Characteristics </li></ul><ul><li>Gray = good </li></ul><ul><li>Blue = acceptable </li></ul><ul><li>Red = poor </li></ul><ul><li>Non obstructive </li></ul><ul><li>Closure is prompt </li></ul><ul><li>Non-thrombogenic </li></ul><ul><li>Chemically inert </li></ul><ul><li>Noise Free </li></ul><ul><li>Infection resistance </li></ul><ul><li>Life of Implant </li></ul>Valves from human or animal tissue and sterilized for use How do you choose between these valves?
    14. 14. What kinds of heart valves are available? Mechanical Valves <ul><li>Valve Characteristics </li></ul><ul><li>Gray = good </li></ul><ul><li>Blue = acceptable </li></ul><ul><li>Red = poor </li></ul><ul><li>Closes quickly </li></ul><ul><li>Durable </li></ul><ul><li>Non-obstructive </li></ul><ul><li>Chemically Inert </li></ul><ul><li>Infection Resistant </li></ul><ul><li>Noisy </li></ul><ul><li>Non thrombogenic </li></ul>Valves made from Metal materials How do you choose between these valves?
    15. 15. Current Trends in Valve Implants Tissue valves have become more accepted in the U.S. due to concerns about quality of life and improved durability. Mechanical valves, however, still compose a large part of valve implants, particularly in younger patients. U.S. Implant Trends Mechanical vs Tissue Valve Implants Mechanical 45% Tissue 55%
    16. 16. Indian Scenario
    17. 17. Valvular Heart Disease <ul><li>There are estimated 5 million patients in India suffering from Heart Valve Disease </li></ul><ul><li>New patients added every year 50,000 </li></ul><ul><li>Total no. of Heart Valve Surgeries </li></ul><ul><li>performed all over India in year </li></ul><ul><li>2007 12,234 </li></ul><ul><li>2009 18,587 </li></ul>
    18. 18. St. Jude Medical Tissue valve usage
    19. 19. Myths about Mechanical Valves <ul><li>Mechanical valves last lifelong ! </li></ul><ul><li>Indeed they last beyond life but patient may not !! </li></ul><ul><li>You’ll Not Need Another Operation ! </li></ul><ul><li>Risks of T hromboembolism is minimal on anti –coagulants ! </li></ul><ul><li>Coumadin therapy is simple </li></ul><ul><li>Re-operation is very risky </li></ul><ul><li>Mechanical valves are less expensive </li></ul>
    20. 20. Mechanical Prosthesis Cost Analysis : Anticoagulantion therapy INR Test every 15-30 days No. of visits to Physicians Thrombolysis Treatment of Hemorrhage/Struck Valve Repeated Hospitalization
    21. 21. <ul><li>Cost Analysis : </li></ul><ul><li>WARFARIN 5mg (Anticoagulant </li></ul><ul><li>Therapy): Rs 150 </li></ul><ul><li>PT / INR : Rs 150 </li></ul><ul><li>Professional Services: Rs 200 </li></ul><ul><li>Misc. : Rs 800 – Rs 1000 </li></ul>Total: Rs 1,300 to Rs 1,500 per month Mechanical Prosthesis
    22. 22. Choice of Valve The Patient Age Gender Compliance Concomitant Illness Lifestyle Cost Medical services
    23. 23. Choice of Valve Indian Scenario : Rheumatic Heart Disease Children & Young Males & Females Rural & Remote Illiteracy & Poverty Ignorance
    24. 24. Choice of Valve in Children Mechanical Prosthesis Advantages
    25. 25. BIOPROSTHESIS Advantages in Young <ul><li>No Anticoagulation No Excessive Bleeding </li></ul><ul><ul><li> </li></ul></ul><ul><li>No INR Testing Free Mobility, active life </li></ul><ul><li>Noiseless Better Sociability </li></ul>
    26. 26. BIOPROSTHESIS Advantages in Females <ul><li>No Anticoagulation </li></ul><ul><li>No excessive bleeding </li></ul><ul><li> </li></ul><ul><li>No embryopathy </li></ul>
    27. 27. BIOPROSTHESIS Advantages in Middle Age <ul><li>No Anticoagulation </li></ul><ul><li>No Dietary Modifications </li></ul><ul><li>No Lifestyle Modification </li></ul>
    28. 28. BIOPROSTHESIS Advantages in the Elderly <ul><li>No anticoagulation </li></ul><ul><li>No Thromboembolic episodes </li></ul><ul><li>Anticoagulation associated bleeding </li></ul><ul><li>No regular follow up </li></ul><ul><li>No PT/INR testing </li></ul>
    29. 29. Life with a Bioprosthetic Valve <ul><li>Safer </li></ul><ul><li>No sudden emergency events </li></ul><ul><li>Less hassles of anticoagulation </li></ul><ul><li>Elective “Re-do” surgery </li></ul><ul><li>Better Quality of life, socially acceptable </li></ul>
    30. 30. If I Need A Valve Surgery VALVE REPAIR Follow Up Leave it to the Cardiologist
    31. 31. If Valve Needs to be Replaced TISSUE VALVE ( Young female, old life exp<20 yrs) No major Follow Up Re do after 10-15 yrs
    32. 32. If tissue valve cannot be used MECHANICAL VALVE ( young patient, poor, not ready for re op) Regular Follow Up Required Compromised lifestyle Lifetime anticoagulation required
    33. 33. Decisions to make Is Lifestyle Important?
    34. 34. Thank You!