Mechanical versus bioprosthetic valve. Intern: Supervisor: VS

Transcription

1 Mechanical versus bioprosthetic valve Intern: Supervisor: VS

2 Patient basic data ID: N Name: Age: 64 years old Sex: male Occupation: Admission date:

3 Chief complaint Exertional dyspnea for six months

4 Present illness He ever received mitral valve valvuloplasty at NTUH 12 years ago. Six months ago he felt dyspnea while walking 50 meters. Sometimes he had dyspnea when climbing stairs. He became weakness and fatigue progressively. Body weight loss about 7kg was noted these periods. He had no cough, hemoptysis, fever, abdominal discomfort, or chest pain. No orthopnea, PND, or palpitation was noted.

5 Past Hx: chronic hepatitis, HBV(+) peptic ulcer four months ago Social Hx: cigarette smoking: half pack per day for 40 years alcohol: occasion betel nuts chewing:(+), quit for a long time Medication: furosemide 40mg, QD ramipril 2.5mg, QD Digoxin 0.25mg, QD Warfarin 1mg, QD

6 Physical examination BP: 122/83 mmhg, BT:36.9 C, HR: 84bpm, RR: 20 /min. Cons : clear Conj : not pale Sclera: mild icteric Neck : supple, no lymphadenopathy, external jugular vein engorgement:(+) Chest: symmetric expansion, percussion: resonance, breathing sound: basal rales were heard.

7 Physical examination Heart: PMI: lateral to left mid-clavicular line 1.5cm, at 5th intercostal space, irregular heart beats, high-pitched pansystolic murmur, grade3/6 was noted at apex area, low-pitched diastolic murmurs, grade 2/6 was noted at tricuspid area. S3(-), S4(-), LV heave(+) Abdomen: soft, no tenderness. percussion: tympany, liver span: 7cm at right midclavicular line, palpable while inspiration. bowel sound: normoactive. Spleen: not palpable. Extremities: freely movable, no edema, no cyanosis

8 Lab data Blood GOT/AST 37 IU/L Blood GPT/ALT 29 IU/L Blood BUN 17 mg/dl Blood U A 6.1 mg/dl Blood CRE 0.6 mg/dl Blood TCH 141 mg/dl Blood TG 52 mg/dl Blood GLU-AC 88 mg/dl Blood Na 138 mmol/l Blood K 3.90 mmol/l Blood Cl 103 mmol/l Blood Ca 2.17 mmol/l Blood HDL-C 62 mg/dl Blood WBC 2.52 *10^3/ul Blood RBC 3.90 *10^6/ul Blood Hb 12.8 g/dl Blood Ht 37.3 % Blood PL 84 *10^3/ul Blood BT (Ivy) 7.0 min Blood PT 11.9 sec Blood Control 10.0 sec Blood INR 1.20 Blood APTT 34.0 sec Blood Control 28.5 sec

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11 Cardiac echo dilated LA, RA and LV. MV thickening with mild MS and moderately severe MR were also found. LVEF was 58%. Catheter mild stenosis at LAD-D diffuse hypokinesis of LV with borderline global LV performance mod-severe MR severe MS mod pulmonary HTN, cardiac output: l/min

12 From America society of echocardiography

13 Under the tentaitve diagnosis of mitral valve disorder, severe MS and mod-severe MR, congestive heart failure, NYHA Fc II-III. CVS was consulted for mitral valve replacement. Bioprosthetic valve was considered.

14 PICO Patient: 64 y/o male with severe MS, modsevere MR Intervention: mitral valve replacement with bioprosthetic valve Comparison: with mechanical valve Outcome: mortality

15 Search method Database: pubmed Key word: mechanical, bioprosthetic valve, mortality Twenty year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses. Heart Jul;89(7): Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial. J Am Coll Cardiol Oct;36(4):

16 Method: 541 pts with valve replacement in were randomly assigned to receive mechanical Bjork-Shiley valve or porcine valve. 267 pts received Bjork- Shiley prosthesis, 211 pts received porcine bioprosthesis.

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19 Survival without a major event Survival with original prosthesis intact

20 Method: between , 572 men undergoing single AVR(394) or MVR(181) are randomized in the OR to receive either the Bjork-Shiley mechanical valve or Hancock porcine valve.

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22 Death from any cause Valve related complication

23 Bleeding Valve failure

24 Conclusion Long term survival: no difference Survival with an intact valve: mechanical > bioprosthetic Valve failure: bioprosthetic > mechanical Bleeding: mechanical > bioprosthetic

25 From ACC/AHA practice guideline

26 Reference Twenty year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses. Heart Jul;89(7): Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial. J Am Coll Cardiol Oct;36(4): ACC/AHA 2006 Practice guidelines for the management of patients with valvular heart disease: executive summary. J Am Coll Cardiol Aug;48(3):

27 Thank you for listening

28 Comments Dr. : papers, basic data,, 20, expected survival years 20, mortality rate,, failure rate

29 Comments Dr. : 65, 5 10,,, failure rate,, redo,

30 Comments Dr. :,