SÚČASNÁ SITUÁCIA V CHIRURGICKEJ LIEČBE CHLOPŇOVÝCH VAD
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1 SÚČASNÁ SITUÁCIA V CHIRURGICKEJ LIEČBE CHLOPŇOVÝCH VAD Čanádyová Júlia Kardiocentrum Nemocnice České Budějovice, a.s. 18. sympózium PS Chlopenní a vrozené srdeční vady v dospělosti, Hradec Králove
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3 SÚČASNÉ TRENDY V KARDIOCHIRURGII snaha postupovať menej invazívne s cieľom minimalizovať chirurgickú traumu, bolest i ekonomické náklady držať krok s najnovšími technikami a technologiami Neustály rozvoj intervenčnej kardiologie nás núti byť tiež menej invazívnymi a spolupracovat (hybridné výkony)
4 MINIMÁLNE INVAZÍVNA KARDIOCHIRURGIA Menšie rany lepší kozmetický efekt Kratší čas trvania operácie Bez mimotelového obehu Rýchlejšia rekonvalescencia Hybridný prístup
5 MINIMÁLNE INVAZÍVNA KARDIOCHIRURGIA Menšie rany lepší kozmetický efekt Kratší čas trvania operácie Bez mimotelového obehu Rýchlejšia rekonvalescencia Hybridný prístup
6 MINIMÁLNE INVAZÍVNA KARDIOCHIRURGIA Menšie rany lepší kozmetický efekt Kratší čas trvania operácie Bez mimotelového obehu Hybridný prístup
7 Open heart surgery Minimally invasive surgery
8 MOŽNOSTI MICS Parciálna sternotomia Minitorakotomia pravostranná: 4. medzirebrový priestor - mitrálna,trikuspidálna chlopeň, MAZE, LAST 2. medzirebrový priestor - aortálna chlopeň, aorta ľavostranná: elektrody, TAVI. TMVI Torakoskopia (EndoMAZE, epikardiálne elektrody) Hybridné operácie (hrudná aorta, CABG)
9 PARCIÁLNA STERNOTOMIA Obrátené L do 3. až 5. medzirebrového priestoru štandardná kanylačná i operačná technika Aortálna chlopeň, vzostupná aorta U rizikových pc (COPD, DM) redukcia infekčných komplikácii sterna, nižšie krvné straty, menej revízii pre krvácanie vč. redukcie krvných prevodov Zachovaná stabilita hrudného koša rýchlejšia RHB V kombinácii so Sutureless biochlopňami (Perceval S) skrátenie operácie
10 PRAVOSTRANNÁ MINITORAKOTOMIA CAVE dilatácia asc.aorty Kanylácia AFC a VFC v P třísle a VJ mitrálna, trikuspidálna chlopeň, medzipredsieňové septum FOP, myxomy, MAZE, aortálna chlopeň Sutureless aortálna bio Transaortálna TAVI
11 TORAKOSKOPIA endoskopický MAZE, ľavokomorové elektrody, implantácia AtriClip Rychlá rehabilitace, kontinuita hrudníku, minimum klasických chirurgických komplikací
12 HYBRIDNÉ OPERÁCIE Kombinácia chirurgickej a intervenčnej techniky TAVI (levostranná minitorakotomie) TA off pump mitral valve repair with neochordae implantation Stentgraft pre zostupnú (oblouk) hrudní aortu MIDCAB (bypass on LAD + PCI)
13 MITRÁLNA CHLOPEŇ
14 Andrea Colli, Laura Besola, Eleonora Bizzotto, Fabio Zucchetta, Erica Manzan, Roberto Bellu, Dario Gregori, Demetrio Pittarello, Gino Gerosa, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy
15 Andrea Colli, Laura Besola, Eleonora Bizzotto, Fabio Zucchetta, Erica Manzan, Roberto Bellu, Dario Gregori, Demetrio Pittarello, Gino Gerosa, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy
16 Leaflet involvement PML 28 (87,5%) AML 3 (9,4%) AML and PML 1 (3,1%) Residual MR at discharge 2 (15,6%) Residual MR at 30-days 2+ (18,7%) 3+ (9,4%) 93% MR 2+ at 1 Year Andrea Colli, Laura Besola, Eleonora Bizzotto, Fabio Zucchetta, Erica Manzan, Roberto Bellu, Dario Gregori, Demetrio Pittarello, Gino Gerosa, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy
17 Andrea Colli, Laura Besola, Eleonora Bizzotto, Fabio Zucchetta, Erica Manzan, Roberto Bellu, Dario Gregori, Demetrio Pittarello, Gino Gerosa, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy
18 Andrea Colli, Laura Besola, Eleonora Bizzotto, Fabio Zucchetta, Erica Manzan, Roberto Bellu, Dario Gregori, Demetrio Pittarello, Gino Gerosa, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy
19 AORTÁLNA CHLOPEŇ
20 TAVI INDIKÁCIE VO SVETLE GUIDELINES ESC/EACTS
21 TAVI DNES Hľadanie alternatívnych prístupov (Tao-TAVI, TS-TAVI) Posun implantácii k menej rizikovým a mladším pacientom Rozšírenie indikácii pre t.č.off-label použitie Valve-in-valve do bioprotéz či ringov TAVI pri AVR
22 Perceval S Sutureless biological valve (Sorin Group, Saluggia, Italy) 3f Enable aortic bioprosthesis (Medtronic, Minneapolis, MN) INTUITY Valve System (Edwards Lifesciences Corporation, Irvine, CA) based on years of tissue valve technology based on the Carpentier-Edwards based on the ATS 3f Aortic PERIMOUNT Magna Ease Bioprosthesis and a self-expanding Nitinol frame
23 PREČO SUTURELESS CHLOPNE? kombinujú výhody klasickej náhrady a TAVI kompletná excízia natívnej chlopne, paravalv. insuf. minimálne invazívny prístup (parc. sternotomia, torakotomia) rešpektovanie individuálnych anatomických pomerov rýchle, netraumatické zavedenie pod kontrolou zraku skrátenie ECC a Cx času pri sternotomii rýchlejšia learning curve
24 > 65 years Nutnosť intervencie na mitrálnej chlopni??? <19 mm or > 25 mm
25 SUTURELESS CHLOPNE A INTERVENCIA NA MITRÁLNEJ CHLOPNI OUT OFF LABEL APPROACH?? Obecne KI pre riziko interferencie 2 chlopní na úrovni aortomitrálnej kontinuity, možnosť narušenia 3D štruktúry koreňa Ao a LVOT Nutnosť rešpektovať niektoré technické okolnosti Minimálna dĺžka ao-mi fibroznej kontinuity pre pacientov s mechanickou Mi chlopňou pred TAVI je 9 mm, pre sutureless chlopne bude pravdepodobne ešte menšia Zavedenie sutureless chlopne do Ao pozície až po výkonu na mitrálnej a/alebo trikuspidálnej chlopni Výber vhodnej protézy event prstenca (semirigidný anuloplast. prstenec, zachovanie flexibility v anter. časti, minimalizácia rizika interferencie
26 Sutureless AVR in the setting of concomitant mitral valve surgery is a feasible, reproducible and safe procedure
27 ZÁVERY MICS je realitou, ktorá prináša výhody predovšetkým v niektorých podskupinách pacientov (COPD, DM, obezita, vysoký vek, REDO ) MICS nie je kompromisom čo do kvality operácie, ale je to riešenie porovnateľné so zavedenými spôsobmi liečby MICS ako súčasť hybridných výkonov rozširuje spektrum možností v rizikových skupinách pacientov
28 ĎAKUJEM ZA POZORNOSŤ
29 ANATOMICKE TYPY MITRÁLNEJ CHLOPNE TYP A TYP B TYP C izolovany centrálny prolaps P2 bez tetheringu predného cípu prolaps zadného cípu rozširujúci sa i laterálne do P1/P3 alebo s mnohočetnými prolabujúcimi častmi zadného cípu prolaps predného cípu, prolaps oboch cípov a/alebo kalcifikacia cípov anulu
30 MV anatomy (Type A) presented isolated central posterior leaflet (P2) prolapse and without anterior leaflet tethering. Patients with acceptable MV anatomy (Type B) showed a posterior leaflet prolapse extending laterally into the P1 or P3 segments, or showed multiple posterior prolapsing segments. Patients with a challenging MV anatomy (Type C) had an anterior leaflet prolapse, a bileaflet prolapse or leaflet/annular calcifications.
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