Valve replacement:choosing the right valve in ACHD

3rd European Meeting on Adult Congenital Heart Disease
16 - 17 March 2012
Munich, Germany

Valve replacement:
choosing the right valve
for adults with CHD

Massimo Chessa
Pediatric and Adult Congenital Heart Centre

IRCCS- Policlinico San Donato
San Donato Milanese – Milano


4 Valves in the normal Heart

but………………..
but………………..


…………… more than 4 in
our patients !!

Gfdfg


General Considerations

Age
Anathomy
Surgeon
Preference

choosing the right valve Surgical History

Patient
Preference
Life’s
Sex expectation


P
AC
3
A
2
Mitral Valve A
A
1
C

•Annulus
•Anterior leaflet
•Chordae Tendineae
•Papillary Muscle


Mitral Valve

The best valve it is its own valve!
Benefits Limitations
• Low operative mortality • Surgeon’s expertise

• Long-term survival • Extent of the disease
– (identical to the general
population)

• Better preservation of
ventricular function

• Decreased need for
anticoagulation therapy « … an operation that can treat the patient for
the rest of his life … »
• Reduced valve-related Prof. A. Carpentier
complications



Mechanical or Biological
Mechanical Prostheses from Biological Prostheses from
1960 1968


Mitral Valve

Hammermeister et al JACC 2000



1,712 Patients with the Biocor™ Porcine Bioprosthesis:
A 20-Year Experience
Actuarial Freedom from Reoperation due to SVD
for the aortic and mitral valve replacement

Hgfdg

Pia S.U. Myken, MD; JTCS 2009


VALVE REPLACEMENT FOR AGE

MECHANICAL BIOLOGICAL

Children 18 – 65 yrs > 65 yrs


Aortic Valve

Aortic Valve


Aortic Valve

Hammermeister et al JACC 2000


Aortic Valve

1,712 Patients with the Biocor™ Porcine Bioprosthesis:
A 20-Year Experience
Actuarial Freedom from Reoperation due to SVD
for the aortic and mitral valve replacement

Hgfdg

Pia S.U. Myken, MD; JTCS 2009


Aortic Valve

Stentless bioprostheses provide better Effective
Orifice Area than stented bioprostheses, which are
relatively stenotic in the small sizes (annulus size 21
mm).

Modern mechanical valves provide better
haemodynamic performance than stented
bioprostheses.


VALVE REPLACEMENT FOR AGE

MECHANICAL BIOLOGICAL

18 – 65 yrs > 65 yrs


Aortic Valve

“Ascending aorta”

Aortic root

Aortic valve


Aorto-plasty

Bentall
Aortic valve + Asc Ao


Aortic Valve
There is increasing attention to

prophylactic replacement of the

moderately dilated ascending aorta at

aortic valve surgery

Moderate ascending aortic dilatation is

common in adult patients with

conotruncal anomalies.


Aortic Valve


Tricuspid Valve


Tricuspid valve
Tricuspid valve regurgitation can be associated with different
anatomical or functional mechanisms.

We can identify selected groups:

1) patients with Ebstein’s anomaly;


Tricuspid valve


2) patients with tricuspid valves damaged by previous operations
(ventricular septal defect closure, complete atrio-ventricular canal repair, etc);


Tricuspid valve


3) patients with a tricuspid valve failing in its capacity as systemic
atrio-ventricular valve (as determined by status post-Senning or Mustard
operation, and congenitally corrected transposition of the great arteries);


Tricuspid valve


4) patients with functional TR related to right ventricular dilation or
dysfunction.

RV dilation/dysfunction is typically associated with chronic volume overloading.

RV volume overloading can be associated with chronic increases of the preload in adult patients
with large atrial septal defects or in long-standing pulmonary valve insufficiency after previous
repair of tetralogy of Fallot or pulmonary stenosis.

The physiologic consequences of chronic RV volume overloading in these patients, can
compromise tricuspid valve function.


Tricuspid valve


Tricuspid valve
What to do?

Edwards MC3


Pulmonary Valve

Pulmonary Valve Replacement (PVR)
is the reoperation most frequently performed today

The type of valve to be inserted into the RVOT is still debated.

Surgery or Percutaneous


Pulmonary valve

Who are the candidates for surgical
PVI ?

Those that are not good candidates
for transcatheter PVI

Giamberti et al. Ann Thorac Surg 2009; 88: 1284-90:


Pulmonary valve
Not candidates for transcatheter PVI

• Size of pulmonary annulus
• Morphology of RVOT
o RV-PA conduit
• Associated cardiac malformation
•RV aneurism
•TV regurgitation
•Arrhythmias


Pulmonary Valve

Mechanical or Biological

At present time, options include mechanical as well as several
biological valves (including homografts, xenografts, prosthetic valved
conduits, and bioprosthetic valves)

Bioprosthetic valves perform well hemodynamically, but are prone
to structural degeneration that results in multiple reoperations.

Mechanical valves lead to a persistent need for anticoagulation
therapy, and despite some positive reports in the literature, have
generally been associated with pulmonary thromboembolic
complications


Pulmonary valve

The Authors compared 3 biological valves types (stented
xenograft valve, bovine pericardial valve, and pulmonary
homograft)

The late dysfunction was more likely with homograft valves
than either porcine or bovine pericardial valves. At 6 years,
the freedom from explantation of the homograft was 35%

Fiore CA, Rodefeld M, Turrentine M, et al (2008)


Pulmonary valve

Another problem with homograft valves is their availability

Considering all these limitations, many authors now agree that
homograft valves are far from ideal.


Pulmonary valve

The results for xenografts (porcine pulmonary-valve conduits, stentless porcine
aortic-root bioprostheses, and bovine jugular valved vein conduits) remain
controversial at this time.

In any case, an extensive dissection of the pulmonary arteries, as with
the homograft valves, is needed to avoid kinking due to the excessive
length of the prosthesis. Extreme care must be taken during
implantation, as any twisting, kinking, or external compression can
easily lead to early failure
Goffin YA, J Heart Valve Dis 2000,9: 207-14

The same considerations can be taken for the prosthetic valved
conduits, such as Hancock or Edwards conduits.


Pulmonary valve

Bioprosthetic valves are probably the most widely used for pulmonary
valve replacement, because they are readily available and do not need
permanent anticoagulation therapy.

The bioprosthesis valves are very easy to implant and
permits the avoidance of extensive dissection of the
pulmonary arteries, which is particularly favourable in
patients submitted multiple operations


Pulmonary valve

Shinkawa and collegues analized the outcome and performance of
bovine pericardial valves in pulmonary position.

Freedom from pulmonary valve reoperation was 100%, 97.7%, and
97.7% at 1, 3 and 5 years, respectively

Shinkawa T, Ann Thorac Surg 2010; 90: 1295-1300


Pulmonary valve

Our current approach, since 2005, is to reconstruct the RVOT with a
bioprosthetic porcine valve.

No reoperations or valve revisions were necessary.

Our experience is a short-term study, and obviously, a larger follow-
up is needed to determine the rate of structural valve deterioration
and the function of this porcine bioprosthetic valve in the pulmonary
position.

Giamberti A, et al. Submitted


Pulmonary valve

Another criterion to take into consideration in the RVOT
reconstruction, should be the facilitation of future interventional
procedures, such as percutaneous pulmonary- valve implantation

Until now, homograft valves or prosthetic valved conduits seemed to
be the ideal candidates but many recent reports appeared in the
literature show possible the percutaneous approach even in
bioprosthesis valves.

MacDonald ST, Eur Heart J2011; Jan 27


Conclusions

Age
Anathomy
Surgeon
Preference

choosing the right valve Surgical History

Patient
Preference
Life’s
Sex expectation


See you next year in
ITALY

Valve replacement:choosing the right valve in ACHD

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