Βαλβιδοπάθειες. Από ηις τειροσργικές ζηις διαδερμικές θεραπείες

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1 Βαλβιδοπάθειες. Από ηις τειροσργικές ζηις διαδερμικές θεραπείες Ιωάννης Δ. Κανονίδης Καθηγηηής Καρδιολογίας Α.Π.Θ. Γιεσθσνηης Β Καρδιολογικής Κλινικής Α.Π.Θ. Γενικό Νοζοκομείο Θεζζαλονίκης «Ιπποκράηειο»

2 Cardiac Surgery

3 Any surgeon attempting an operation of the heart would lose the respect of his colleagues Theodor Billroth (1883)

4 In 1923 Dr. Elliott Cutler of the Peter Bent Brigham Hospital performed the world s first successful heart valve surgery - a mitral valve repair. The patient was a 12- year-old girl with rheumatic mitral stenosis.

5 In 1925 Henry Souttar operated successfully on a young woman with mitral stenosis. He made an opening in the appendage of the left atrium and inserted a finger into this chamber in order to palpate and explore the damaged mitral valve. The patient survived for several years Souttar s physician colleagues at that time decided the procedure was not justified and he could not continue.

6 Cardiac surgery changed significantly after World War II In 1948 four surgeons working independently of each other carried out successful operations for mitral stenosis due to rheumatic fever. Horace Smithy ( ) of Charlotte, revived an operation due to Dr Dwight Harken of the Peter Bent Brigham Hospital using a punch to remove a portion of the mitral valve. Charles Bailey ( ) at the Hahnemann Hospital, Philadelphia, Dwight Harken in Boston Russell Brock at Guy s Hospital All adopted Souttar s method. All these men started work independently of each other, within a few months. This time Souttar s technique was widely adopted although there were modifications.

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8 First Aortic Valve Replacement Murray, in Toronto considered replacing a diseased valve with a valve taken from a donor animal. Encouraged by results of his experiments with dogs he implanted a valve harvested from a human cadaver into descending thoracic aorta of a 22 Yr. man who had severe AR. This man was a manual worker & was asymptomatic when seen 6 Yrs later First Aortic Valve Repair May Dr. Lillehei repaired an Aortic Valve in a female patient on the heart-lung machine

9 Mechanical prostheses Mitral Valve First implant was done in early 1960 s in USA Aorta First Aortic prosthesis implant performed on a patient in March 1960 in Florida, USA Double Valve Surgery First Double Valve Implant was performed in November 1961 in Pittsburgh, Pennsylvania, USA

10 Πρώηη Γενιά Τεχνηηών Καρδιακών Βαλβίδων Star-Edwards: Κλωβού και ζθαίρας First implanted by Starr and Harken in 1960.

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12 Miles "Lowell" Edwards

13 Ball-and-Cage Valves Opening and closure of the ball-valve

14 Δεύηερη Γενιά Τεχνηηών Καρδιακών Βαλβίδων Star-Edwards: Lillehei-Kaster: 1967 Carpentier-Edwards: 1968 Βιοπρόζθεζη Hancock I: 1969 Βιοπρόζθεζη Jonescn-Shiley: Bjork-Shiley: St. Jude Medical: Βιοπρόζθεζη 1969 BSST 1980 BSCC 70

15 Τρίηη Γενιά Τεχνηηών Καρδιακών Βαλβίδων St. Jude Medical: 1977 Medtronic-Hall: 1977 M-H-1980 Bjork-Shiley Monostrut: 1982 (απεζύρθη) Omniscience: 1978 Duromedics: 1981 Carpentier-Edwards: 1981 Βιοπρόζθεζη Hancock ΙI: 1982 Βιοπρόζθεζη Carbomedics Inc.: 1986 Omnicarbon: 1984

16 Types of Prosthetic Heart Valves I Caged-ball Starr-Edwards Braunwald-Cutter Smeloff-Cromie

17 Types of Prosthetic Heart Valves II Tilting-disk Björk-Shiley Björk-Shiley convexoconcave Medtronic-Hall Lillihei-Kaster Omniscience Sorin

18 Bjork-Shiley Bjork-Shiley Bjork-Shiley in the Mitral position

19 Types of Prosthetic Heart Valves III Bileaflet St. Jude Medical Carbomedics Duromedics

20 St. Jude valve St. Jude valve in the mitral position.

21 Flow Dynamics

22 Mechanical valves Designs and flow patterns of different types of mechanical valves

23 Types of prosthetic valves and thrombogenicity Type of valve Model Thrombogenicity Mechanical Caged ball Starr-Edwards Single tilting disc Bjork-Shiley, Medtronic Hall Bileaflet Bioprosthetic Heterografts St Jude Medical, Sorin Bicarbon, Carbomedics + + Carpentier-Edwards, Tissue Med (Aspire), Hancock II + to + + Homografts +

24 Ideal valve Good hemodynamic Quiet Require no anticoagulation Last for life time Cheap Easy to implant

25 Mechanical Valves Extremely durable with overall survival rates of 94% at 10 years Primary structural abnormalities are rare Most malfunctions are secondary to perivalvular leak and thrombosis Chronic anticoagulation required in all With adequate anticoagulation, rate of thrombosis is 0.6% to 1.8% per patient-year for bileaflet valves

26 Homografts first aortic valve homograft was used in the descending thoracic aorta for aortic regurgitation In 1962 Alfred Gunning & co-workers in Oxford worked out a reliable method for aortic homograft harvest & preparation. This allowed Ross to perform the first landmark sub-coronary homograft implantation in This success was soon followed by Barrat-Boyce in New Zealand, Mattias Paneth & Mark O Brien at Brompton hospital. Alfred Gunning These were the people who adopted & pioneered homograft aortic replacement at a time when most surgeons preferred the durability & simplicity of Starr Edward valve insertion with a single row of sutures. The homograft insertion was technically more demanding in an era when myocardial preservation was primitive.

27 DEVELOPMENT OF PORCINE BIOPROSTHESIS In 1964 after their succes with homografts, Gunning & Duran diverted their attention to preservation of heteregenous valves. In the same year they performed first human stent mounted porcine valve implantation In 1965 Duran & Carpentier presented their experience of mercurochrome preserved frame mounted heterografts. This was soon followed by reports by Mark O Brien about his experience with formalin preserved pig & calf aortic heterografts. However, long term results were poor because of primitive preservation methods

28 Marion Ionescu ( Leeds) In 1966 Ionescu developed a stent for mounting aortic heterograts. It had Titanium support, 3 legs covered with dacron velour & dacron felt ring was used as a sewing ring. The porcine aortic valve was sutured within the frame.

29 Carpentier next produced a stent made of stainless steel coated with Teflon to minimise thromboembolism & he used mercurial salt for tissue preservation. This stent is the precursor of stent used in modern Carpentier- Edward valve Within 5 yrs of use of stented valves it was realised that stent mounting caused excessive stress on the biological tissue which resulted in accelerated degeneration. This setback caused practice of stent mounting to disappear.

30 1968 -Preservation of tissues with formaldehyde or mercurochrome was proving disappointing, this problem was soon resolved by Carpentier who employed gluteraldehyde preservation for the first time. The chemical treatment of tissues prevents collagen denaturation & reduces antegenicity of foreign tissues

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32 AUTOGRAFTS ROSS OPERATION In 1967 Ross performed the first pulmonary autograft operation for aortic valve replacement. Initially autogenous pulmonary valve was used as a sub- coronary implant & later as a full aortic root replacement. Ross anticipated that autologus pulmonary valve will remain viable & maintain potential for growth in children. Experience have shown this to be true. Whilst Ross persisted with his operation others were reluctant to perform a complex double root replacement for isolated aortic disease which otherwise could be treated with very low morbidity & mortality with a stented valve. is to be true.

33 DEVELOPMENTS IN REPLACEMENT OF MITRAL VALVE Ross attempted to replace mitral valve with a mitral homograft. Though early post-operative hemodynamics were excellent, most patients sustained rupture of chordae tendeniae within a few months of operation. In addition proper placement of papillary muscles inside LV required considerable judgment & skills. Because of these reasons MV homografts replacement has never regained wide spread acceptance.

34 STENTLESS VALVES In 1988 Tyrone David re-explored the use of stentless gluteraldehyde fixed aortic xenograft. Hemodynamic evaluation showed very small gradients & minimal regurgitation in early implants.

35 Stentless Valves Medtronic Freestyle St. Jude Toronto SPV

36 Bioprosthetic Bioprosthetic Valve types: heterografts, homografts advantage: short term anticoagulation limitation: structural failure leaflet calcification & tissue degeneration leading to valvular regurgitation rate of porcine valve degeneration 26% (aortic), 39% (mitral) in 10 yrs

37 Biologic (Tissue) Stented Porcine xenograft Pericardial xenograft Stented bioprostheses Primary mechanical failure at 10 years is 15-20% Preferred in patients over age 70 Subject to progressive calcific degeneration & failure after 6-8 years

38 Types of Bioprosthetic Valves I Porcine (stented) Hancock I Hancock II Hancock MO (modified orifice) Carpentier-Edwards C/E Duraflex Medtronic Intact Bioimplant

39 Types of Bioprosthetic Valves II Pericardial Ionescu-Shiley Carpentier-Edwards pericardial Mitroflow

40 Biological Valves Stentless Porcine xenograft Pericardial xenograft Stentless bioprostheses Absence of stent & sewing cuff allow implantation of larger valve for given annular size->greater EOA Uses the patient s own aortic root as the stent, absorbing the stress induced during the cardiac cycle

41 Biologic Valves Continued Homografts Harvested from cadaveric human hearts Advantages: resistance to infection, lack of need for anticoagulation, excellent hemodynamic profile (in smaller aortic root sizes) More difficult surgical procedure limits its use Autograft Ross Procedure

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44 Mitral valve repair CARPENTIER CLASSIFICATION

45 Τεχνικές Διόρθωσης Μιτροειδούς Βαλβίδας Δακτύλιος α) Tοποθέηηζη δακηςλίος (Carpentier, Duran, Cosgrove) β) Δακηςλιοπλαζηική Γλωχίνες Μεπική εκηομή και ζςππαθή ή μόνο πλαζηική μεηάθεζη σοπδών επί πήξεωρ αςηών, ζμίκπςνζη σοπδών ή θηλοειδών μςών επί επιμηκύνζεωρ αςηών. Κινηηοποίηζη γλωσίνων καηόπιν εκηομήρ σοπδών ηηρ βάζηρ ή δεςηεπεςόνηων. Yποβαλβιδικός μηχανισμός Κινηηοποίηζη ηος ςποβαλβιδικού μησανιζμού καηόπιν διαίπεζηρ ηων θηλοειδών μςών μέσπι ηη βάζη αςηών, απομάκπςνζη αζβεζηίος.

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47 Aortic valve repair Aortic valve repair is a surgical procedure used to correct some aortic valve disorders as an alternative to aortic valve replacement. Aortic valve repair is performed less often and is more technically difficult than mitral valve repair. There are two surgical techniques of aortic-valve repair: The Reimplantation-Technique (David-Procedure) The Remodeling-Technique (Yacoub-Procedure)

48 Minimally invasive Cardiac Surgery Endoscopic or robotic heart surgery. Hugo Vanerman (Belgium). In minimally invasive valve surgery, long-handled tools are inserted into the chest through four or more small incisions. While watching a video monitor, the surgeon manipulates the tools and conducts the surgery. In some cases, robotic arms may be used to manipulate the tools for the surgeon. Only some hospitals can offer minimally invasive valve surgery. Cardiac surgeons are not unanimous about the relative merits of sternotomy versus the minimally invasive approach. The minimally invasive approach can produce a less prominent scar, is beneficial for very obese patients, and may allow the patient to return to their normal activity sooner than a sternotomy.

49 VALVES AND INTERVENTIONAL CARDIOLOGY

50 Balloon Valvuloplasty Valvuloplasty is the widening of a stenotic valve using a balloon catheter. Types include: Aortic valvuloplasty in repair of a stenotic aortic valve Mitral valvuloplasty in the correction of an uncomplicated mitral valve Pulmonary valvuloplasty

51 Percutaneous mitral valvuloplasty 1.Single large balloon 2.Double balloon 3.Multi Track System (P. Bonhoeffer) 4.Innoue balloon

52 Inn-oue balloon Valvuloplasty of the Mitral Valve." The balloon is sub-divided into 3 segments and is dilated in 3 stages. 1st the distal portion (lying in the left ventricle) is inflated and pulled against the valve cusps. 2nd the proximal portion is dilated, in order to fix the centre segment at the valve orifice. Finally, the central section is inflated, This should take no longer than 30 seconds since full inflation obstructs the valve and causes congestion, leading to circulatory arrest and flash pulmonary edema.

53 Aortic balloon valvuloplasty 1.Anterograde approach (transeptal) 2.Retrograde approach

54 Percutaneous valve replacement 1.Bonhoeffer: pulmonary (2000) 2.Al. Cribier: aortic (2002)

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56 The SAPIEN valve Lifesciences. made by Edwards The CoreValve system made by Medtronic

57 Percutaneous aortic valve replacement Implants the valve using a catheter, without open heart surgery. It is used in more than 50 countries in patients who are at extreme or high risk to undergo open heart surgery In high-risk patients with severe aortic stenosis, transcatheter and surgical procedures for aortic-valve replacement had similar rates of survival at 1 year, although there were important differences in risks associated with the procedure. [2] The transcatheter procedure was associated with a higher risk of stroke than the surgical replacement (5.5% vs. 2.4% after 30 days; 8.3% vs. 4.3% after 1 year). [3]

58 Mitral Valve Clip

59 Feldman (2005)

60 What about the futur?

61 Thank you!

62 Prosthetic Valves are classified as tissue or mechanical Tissue: Actual valve or one made of biologic tissue from an animal (bioprosthesis or heterograft) or human (homograft or autograft) source Mechanical Made of nonbiologic material (pyrolitic carbon, polymeric silicone substances, or titanium) Blood flow characteristics, hemodynamics, durability, and thromboembolic tendency vary depending on the type and size of the prosthesis and characteristics of the patient