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Prosthetic heart valves


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prosthetic heart valves
-Dr. Raajit Chanana

Published in: Health & Medicine

Prosthetic heart valves

  1. 1. - Dr. Raajit Chanana
  2. 2.  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
  3. 3.  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
  4. 4.  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
  5. 5.  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
  6. 6.  Bileaflet valve are the most commonly implanted mechanical valve Low bulk Flat profile Superior hemodynamic
  7. 7. 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.
  8. 8.  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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. Class 2b Bioprosthesis might be considered for a woman of child bearing age
  19. 19. Mitral valve replacementClass1 Bioprosthesis in patients who will not take warfarin, is incapable of taking warfarin, or has clear contraindication to warfarin therapy
  20. 20. Class 2a Mechanical prosthesis reasonable for patients <65yr with longstanding AF Bioprosthesis is reasonable in patients >=65yr
  21. 21.  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.
  22. 22.  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
  23. 23. Mechanical Bioprosthesis Durability more Thrombus +++ + Infection +++ + Dehiscence + +++ Stenosis + ++ Degeneration + +++
  24. 24.  Blood pressure wide pulse pressure hypotension Pulses Absent limb pulses Bifid carotid pulse Slow rising low amplitude carotid pulse Elevated jugular venous pulse
  25. 25.  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
  26. 26.  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
  27. 27.  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
  28. 28.  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
  29. 29. 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.