Anton Moritz. Department of Cardiothoracic Surgery University of Frankfurt
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1 Anton Moritz Department of Cardiothoracic Surgery University of Frankfurt
2 Long Term Survival after Valve Replacement
3 Autograft Long term survival after Ross or AVR mechanical compared to normal life expectancy Mechanical protheses Martin Andreas et al. Eur J Cardiothorac Surg 2014;46: The Author Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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5 Scharfschwerdt M Ann Th Surg 2007
6 Re OP s autograft n= 100 Mean follow up period 13 a 4 re OP s in 1147 ptyrs (0.35%/yr) Re OP s RVOT 7 patients intervention on homograft (7,7%) 0.8%/yr dgthg 2011, Stuttgart Seebacher et al.
7 RVOT after Ross RVOT after Congenital Surgery Brown JW Ann Th Surg 2008 Homografts show good durability but develop gradients. Bioprosthetic replacement an option? 45% 19% Survival free of reop n=1065 Dearani JA, Ann Th Surg 2003
8 Proximal RVOT strictures developed Perikardsleeve solves the proximal but aggravates the distal problem
9 Freedom from neopulmonary valve failure after 5 years: 97% in homografts versus 73% in bioprosthesis logrank test: p< Hazard Ratio: 6.1 (95% CI ) Homograft Bioprosthesis Time (years) Number at risk Group: Homograft Group: Bioprosthesis Incidence rate: 1:80 pat. year in homografts versus 1:14 pat.year in xenografts. p<0, Text durch klicken bearbeiten 9
10 4/193
11 Aorta conjoined leaflet non coronary leaflet left ventricle
12
13 Durchmesser Aorta ascendens mm Gesamtkollektiv Bikuspid Trikuspid Insuffizienz Kombiniert Stenose Aortenraffung Entlassungsuntersuchung Letzte Follow up Untersuchung
14 Das
15
16
17 Autografts at Reoperation
18 Long Term Complications 18 Reoperations on AG, but only 6 valve replacements 9 embolic events related to a-fib (0,54% / pt yr) 9 events of endocarditis (0,54% / pt yr) No ACH related bleeding or valve thrombosis
19 Valve-related complications Event Mechanical valve (n = 173) Ross procedure (n = 159) P-value Stroke 5.8% (1.02%/pt yr) 0.6% (0.06%) <0.01 TIA 1.7% (0.25%) 0% (0%) 0.07 Valve thrombosis 0.6% (0.08%) /1,35% 0% (0%) / 0.06% 0.30 Endocarditis 5.2% (0.76%) 3.8% (0.38%) 0.32 Bleeding 10.4% (1.95%) 0.6% (0.06%) <0.01 Reintervention 5.8% (0.85%) 12.6% (1.27%) 0.05
20 Long Term Survival Sievers H. Ross vs mech randomisiert Mortality 10 vs 40% Bleeding 0 vs 25% Reoperation 15 vs 5% Miskovic et al EACTS 2014 Seebacher Vienna 13 a
21 Summary When respecting certain technical principles the Ross procedure provides excellent and stable hemodynamics in the long term. Valve related complications are reduced to reoperations and which are due to conceptual problems in majority. Degenerations are rare AG provides a durable biologic valve. RVOT replacement is a possible long term problem but might be cured percutaneousely in the future. Normal long term survival appears to be the major asset of this technically demanding procedure. Projekt / Datum / Name
22 Reop oder AI III Böhm JO. AnnThSurg 2009 Reoperationen
23 interventricular septum in cm Regression of left ventricular hypertrophy 2.5 Mean gradient in mmhg 2 Interventricular Septum implant 1 year 10 years
24 Mortality Long term n=2 (10%) n=8 (40%) Valve related n= 1 n= 5 bleeding n=0 n=5 (25%) thromboembolism n=1 n=1 Reoperation n=3 (15%) n=1 (5%)
25 Wrap N= ASC.events yrs to event FU no 33 Effect 9 of Wrap ,3 Vicryl_Mesh ,6 6.9 Vypro_Mesh David Total Dilatation or Reoperation
26 Statistik nur für Bioprothesen PK_Event = entweder Reintervention oder PS>50mmHg oder PI>II Häufigkeit Prozent direkte Naht nein 43 74,1 ja(reop oder sign Dysf) 15 25,9 Gesamtsumme ,0 Plus Pach/Sleeve nein 34 89,5 ja(reop oder sign Dysf) 4 10,5 Gesamtsumme ,0 Reintervention an der Bioprothese in Pulmonalklappenposition Häufigkeit Prozent direkte Naht nein 45 77,6 ja 13 22,4 Gesamtsumme ,0 Plus Pach/Sleeve nein 36 94,7 ja 2 5,3 Gesamtsumme ,0
27 100 Survival Logrank test : P = 0,15 Location Wien Frankfurt Time Number at risk Group: Wien Group: Frankfurt
28 Projekt / Datum / Name RVOT Reinterventions
29 Projekt / Datum / Name Reoperations Aorta
30 All Reinterventions 60% event free at 18 years Projekt / Datum / Name
31 Optimized Reinterventions 89% event free at 18 yrs With current knowledge avoidable reinterventions excluded: RVOT strictures, pseudoaneurysms and aortic dilatations Projekt / Datum / Name
32 Outcome Reintervention Total Homograft Xenograft Signific. (n=205) (n=113) (n= 92) Time to redo (y) 6.4 years 9.6 years 4.5 years p=0.003 (± SD) (± 4.8) (± 4.8) (±3.9) Reintervention n.s. Reoperation Perc. Procedure p=0.005 Balloon dilatation in 10, Melody implantation in 4 Re-reintervention n.s. Balloon dilatation in 2, Melody implantation in 4 Main Finding Stricture p=0.03 Degeneration Endocarditis Text durch klicken bearbeiten 32
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34 Event at the neopulmonary valve in Bioprosthesis Reintervention or PS (>50mmHG) without pericardial sleeve Event no Event plus pericardial sleeve % 20% 40% 60% 80% 100% Text durch klicken bearbeiten 34
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36 100 Reoperation of the Pulmonary Autograft Logrank test : P = 0,12 Location Wien Frankfurt Time Number at risk Group: Wien Group: Frankfurt
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