Universitätsherzzentrum      Thüringen      Klinik für Herz- und Thoraxchirurgie  Hemodynamic Comparison between TwoSupraa...
Background I                       Universitätsherzzentrum                                                   Thüringen    ...
Background II                     Universitätsherzzentrum                                                 Thüringen       ...
Stented Tissue Valves are „Hemodynamically Challenged“   Universitätsherzzentrum                                          ...
Mitroflow: Taking on the Challenge…       Universitätsherzzentrum                                          Thüringen      ...
Improved Hemodynamics by Design                                                        Universitätsherzzentrum            ...
Porcine Bioprostheses            Universitätsherzzentrum                                             Thüringen            ...
SJM Epic and Epic Supra   Universitätsherzzentrum                          Thüringen                          Klinik für H...
In vitro comparison                            Universitätsherzzentrum                                                    ...
Hemodynamic Expectations                 Universitätsherzzentrum                                                Thüringen ...
Hemodynamic Expectations                    Universitätsherzzentrum                                                   Thür...
How are „Hemodynamics“ assessed?                      Universitätsherzzentrum                                             ...
Effect of anatomy on EOA                           Universitätsherzzentrum                                                ...
Hemodynamic Assessment Summary                 Universitätsherzzentrum                                                 Thü...
Valves and Sizers – Labeled „23“            Universitätsherzzentrum                                            Thüringen  ...
Valves Comparison by Outer Diameter                  Universitätsherzzentrum                                              ...
Valve Size Selection based on Manufacturer         Suggested Sizing Strategy                                             U...
Valve Comparison by Selected Size          Universitätsherzzentrum                                           Thüringen    ...
Hypothesis                        Universitätsherzzentrum                                                  Thüringen      ...
Patients and Methods                          Universitätsherzzentrum                                                     ...
Demographic Data                    Universitätsherzzentrum                                          Thüringen            ...
Size Distribution of Implanted Valves         Universitätsherzzentrum                                              Thüring...
Pressure gradients by size label for Mitroflow   Universitätsherzzentrum                                                 T...
Pressure gradients by size label for Epic Supra   Universitätsherzzentrum                                                 ...
Valve comparison by Size Label 21   Universitätsherzzentrum                                    Thüringen                  ...
Valve comparison by Size Label 23   Universitätsherzzentrum                                    Thüringen                  ...
Valve Size Selection based on Manufacturer         Suggested Sizing Strategy                                             U...
Comparison by Selected Size     Universitätsherzzentrum                                Thüringen                          ...
Conclusions                         Universitätsherzzentrum                                                    Thüringen  ...
UniversitätsherzzentrumThüringenKlinik für Herz- und ThoraxchirurgieThank you for your Attention
The Surgeon as Patient              Universitätsherzzentrum                                               Thüringen       ...
Determinants of Pressure Gradient   Universitätsherzzentrum                                     Thüringen                 ...
UniversitätsherzzentrumThüringenKlinik für Herz- und Thoraxchirurgie
Controversy about PPM              Universitätsherzzentrum                                                 Thüringen      ...
UniversitätsherzzentrumThüringenKlinik für Herz- und Thoraxchirurgie
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Cairo 09.03.2012

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  • Geometric expressions of prosthesis size include internal orifice area and external diameter. It would seem logical that the valve with the greatest internal opening area in relation to ist outer diameter should allow the best hemodynamic performmance. The problem is neither of these 2 parameters is reflected by the label size provided by the manufacturer.
  • The FlexFit stent reduces leaflet stress The outflow edge of the Epic valveis covered with a pericardial shield, providing a tissue-to-tissue interface to help prevent the riskof abrasion. Three separate porcine leafletsare matched to optimize leafletcoaptation and reduce stress
  • Alvot is the area of the LVOT just before the valve, VTI lvot is the velocity-time integral of pulsed doppler velocity at the LVOT level, VTI transvalvular is calculated from continuous wave doppler velocity through teh prosthesis. Caveats: Varies from moment to moment with patient activity, cardiac output and blood pressure. Varies with the anatomy of the LVOT and aortic root. pitfalls in its calculation. failure to incorporate the effects of pressure recovery.
  • This fig is an illustration of the influence of different anatomy on the relationship between GOA (green) and EOA (red) by echocardiography. A, if a tissue valve leaves a rest stenosis, the vena contracta moves distally to the GOA. As a consequence, the EOA will be smaller than the GOA. B, ideal placement of the same tissue valve in a smaller annulus would place the vena contracta at the site of the GOA , and EOA would then equal GOA.
  • Despite this controversy i think most of the audience wuold agree with me that this notion ..Bigger valves are better seems logical.
  • Another factor that makes comparison of different biological valves difficult is discripancies between external diameters of valves with the same label size as well as diameter difference in their sizers.
  • Geometric expressions of prosthesis size include internal orifice area and external diameter. It would seem logical that the valve with the greatest internal opening area in relation to ist outer diameter should allow the best hemodynamic performmance. The problem is neither of these 2 parameters is reflected by the label size provided by the manufacturer.
  • The outer diameter of a label size 23 Perimount is 31 mm, while that of a same label size Mitroflow is 26 mm This may be explained by the design advantage of the Mitroflow
  • Cairo 09.03.2012

    1. 1. Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie Hemodynamic Comparison between TwoSupraannular Biological Aortic Prosthesis. The Importance of Sizing Strategies. Mahmud Diab , Gloria Faerber, Jack Peter, Wolfgang Bothe, Susan Lemke, Martin Breuer, Torsten DoenstDepartment of Cardiothoracic Surgery, University of Jena, Jena, Germany
    2. 2. Background I Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie• Aortic Valve Replacement (AVR) is a common cardiac procedure with approximately 200 000 implantations each year worldwide.• There is a dramatic shift toward use of bioprosthetic valves.• Today, according to the STS Database, 80% of patients receive biological valves.
    3. 3. Background II Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie• Despite evolutionary improvement in prosthetic heart valve design, hemodynamic performance of prostheses does not yet match that of native valves.• Significant residual gradients may prevent regression of LV hypertrophy and are postulated to influence long-term survival after AVR; a phenomenon having been described as patient- prosthesis mismatch.
    4. 4. Stented Tissue Valves are „Hemodynamically Challenged“ Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie Passable for blood stream Space needed for implantation
    5. 5. Mitroflow: Taking on the Challenge… Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie Passable for blood stream Space needed for implantation
    6. 6. Improved Hemodynamics by Design Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie Internal orifice area Internal orifice area Site of Stitches in Sewing Ring Pericard on the inside Pericard on the outside
    7. 7. Porcine Bioprostheses Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie• The Epic is a stented bioprosthesis made from porcine aortic cusps.
    8. 8. SJM Epic and Epic Supra Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie
    9. 9. In vitro comparison Universitätsherzzentrum Thüringen Klinik für Herz- und ThoraxchirurgieMitroflow Peri-in Supra Porc-intact Epic Supra Supra
    10. 10. Hemodynamic Expectations Universitätsherzzentrum Thüringen Klinik für Herz- und ThoraxchirurgieThe Mitroflow should be hemodynamically superior to the Epic Supra,
    11. 11. Hemodynamic Expectations Universitätsherzzentrum Thüringen Klinik für Herz- und ThoraxchirurgieThe Mitroflow should be hemodynamically superior to the Epic Supra, i.e., Mitroflow should have lower postoperative pressure gradients and therefore larger effective orifice areas (EOA)
    12. 12. How are „Hemodynamics“ assessed? Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie• Pressure gradient : modified Bernoulli equation: ΔP= 4  V2• Effective orifice area (EOA) from continuity equation: EOA  =  (Alvot × VTIlvot) / VTItransvalvular
    13. 13. Effect of anatomy on EOA Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie EffectiveOrifice AreaGeometricOrifice Area Large aortic root Small aortic root
    14. 14. Hemodynamic Assessment Summary Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie• EOA reflects hemodynamic relevance for the patient.• EOA is influenced by patient anatomy (LVOTA)• EOA cannot be used to compare different prostheses.
    15. 15. Valves and Sizers – Labeled „23“ Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie Doenst et al. JTCVS 2011
    16. 16. Valves Comparison by Outer Diameter Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie Internal orifice area Internal orifice area 28 mm 29 mm SJM Epic Supra 23 Mitroflow 25
    17. 17. Valve Size Selection based on Manufacturer Suggested Sizing Strategy Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie
    18. 18. Valve Comparison by Selected Size Universitätsherzzentrum Thüringen Klinik für Herz- und ThoraxchirurgieEpic Supra 23 Sorin Mitroflow 21 23mm 17.3mm 23 29
    19. 19. Hypothesis Universitätsherzzentrum Thüringen Klinik für Herz- und ThoraxchirurgieThe hemodynamic design advantage of the Mitroflow is lost due to a defensive sizing strategy compared to the Epic Supra.
    20. 20. Patients and Methods Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie• Between Januar 2007 and November 2011, we performed 1067 Aortic valve replacements.• We retrospectively reviewed discharge echos (performed by the same examiner) from all patients having received a Mitroflow (n=161) or an Epic Supra (n=92) aortic prosthesis as the only valve procedure.• The decision to implant the given prosthesis was made by the operating surgeon.• All patients received supraannular valve placement.
    21. 21. Demographic Data Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie Mitroflow Epic Supra (n=161) (n=92)Age 74 ± 9.75 74.30 ± 8.36Female 60% 40%EF 60.1% ± 13.33 59.4 ± 13.53ASmoderate 8% 8.7%severe 64% 45.7%
    22. 22. Size Distribution of Implanted Valves Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie Mitroflow Epic Supra
    23. 23. Pressure gradients by size label for Mitroflow Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie
    24. 24. Pressure gradients by size label for Epic Supra Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie
    25. 25. Valve comparison by Size Label 21 Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie P <0.05 P <0.05
    26. 26. Valve comparison by Size Label 23 Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie P <0.05 P <0.05
    27. 27. Valve Size Selection based on Manufacturer Suggested Sizing Strategy Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie
    28. 28. Comparison by Selected Size Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie n.s n.s
    29. 29. Conclusions Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie• The hemodynamic design advantage of the Mitroflow is lost due to a “defensive” sizing strategy.• The results underscore the importance of sizing strategy and surgical technique and supports the provision and the intensive use of replica sizers with the new generation valves.
    30. 30. UniversitätsherzzentrumThüringenKlinik für Herz- und ThoraxchirurgieThank you for your Attention
    31. 31. The Surgeon as Patient Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie • 27 cardiac surgeons in the US needed aortic valve replacement.• Question: How many times did they choose a tissue valve?
    32. 32. Determinants of Pressure Gradient Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie• Valve opening area o• Subvalvular dimension (outflow tract)• Supravalvular dimension• Angle LV outflow tract/aorta
    33. 33. UniversitätsherzzentrumThüringenKlinik für Herz- und Thoraxchirurgie
    34. 34. Controversy about PPM Universitätsherzzentrum Thüringen Klinik für Herz- und Thoraxchirurgie PPM Relevant PPM Not RelevantPibarot et al 2001 Moon et al 2006Rao et al 2000 Ryomoto et al 2008Ennker et al 2005 Florath et al 2008Borger et al 2005 Mascherbauer et al 2008Lopez et al 2008 Nozohoor et al 2008Kohsaka et al 2008 Sakamoto et al 2007Pibarot et al 2007 Kapetanakis et al 2008Moon et al. 2009* Rinas et al 2007Mohthy et al. 2009* Moon et al. 2009* Mohthy et al. 2009* Jamieson et al. 2010
    35. 35. UniversitätsherzzentrumThüringenKlinik für Herz- und Thoraxchirurgie

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