What you need to know about the post-op management of...

What you need to know about the post-op management of

valvular heart disease

What you need to know about the post-op management of

valvular heart disease

Steven F BollingProfessor of Cardiac Surgery

University of Michigan

Top 10 Post OP Valve MythsTop 10 Post OP Valve Myths

Steven F BollingProfessor of Cardiac Surgery

University of Michigan

All valve patients are the same

post operatively

All valve patients are the same

post operatively

Myth # 10Myth # 10

OH, come on…AS MRMS AR

pressure + volume overload,Individualize !!

OH, come on…AS MRMS AR

pressure + volume overload,Individualize !!

Myth # 10Myth # 10

Assymptomatic, severevalve disease exists

Assymptomatic, severevalve disease exists

Myth # 9Myth # 9

Madaric et al. Am Heart J 2007;154:180MadaricMadaric et al. Am Heart J 2007;154:180et al. Am Heart J 2007;154:180

n =19LVEF > 60%NYHA class I

Severe MR without symptoms does not exist !Severe MR without symptoms does not exist !

Buckberg et al. Congestive heart failure: Treat the disease, not the symptom—Return to normalcy J. Thorac. Cardiovasc. Surg. 2001;121: 628-637.

Risk of Late Death following myocardial infarction

Survival vs. ESVI

If If ““severesevere”” -- and they are asymptomatic and they are asymptomatic …… they are dead !they are dead !

ACC/AHA indications :ACC/AHA indications :Mitral valve repair, wait until:

Symptoms …. BADor if “no” symptoms, wait until:

A Fib, Pul HtnIncrease LV sizeFall in EF%

….also BAD !

Mitral valve repair, wait untilMitral valve repair, wait until::Symptoms Symptoms ……. . BADBAD

or if or if ““nono”” symptoms, wait untilsymptoms, wait until::A Fib, A Fib, PulPul HtnHtnIncrease LV sizeIncrease LV sizeFall in EF% Fall in EF%

……..also BAD !also BAD !

ALL in CHF !

Neuro hormone, anti-diuresis,Not instantly better

PAp elevated – long term

ALL in CHF !

Neuro hormone, anti-diuresis,Not instantly better

PAp elevated – long term

Myth # 9Myth # 9

Just crank up the EPI !!

Just crank up the EPI !!

Myth # 8Myth # 8

Changes in myocardial receptors in heart failure.

Vanoli E , Adamson P B Eur Heart J Suppl 2006;8:C51-C57

CHF : Beta receptors – down regulated

Crank it up! = side effects

Phosphodiasterase inhibitor, Milrinone,

Vasopressin,Nitric Oxide,

Viagra

Crank it up! = side effects

Phosphodiasterase inhibitor, Milrinone,

Vasopressin,Nitric Oxide,

Viagra

Myth # 8Myth # 8

Ischemic MR goes awayafter CABG

Ischemic MR goes awayafter CABG

Myth # 7Myth # 7

MR after CABGMR after CABG

Adler et al: Am J Adler et al: Am J CardiolCardiol 58:195, 198658:195, 1986

•• 2004 patients: Isolated CABG2004 patients: Isolated CABG•• 22--year survival inversely related to Degree of MRyear survival inversely related to Degree of MR

Sheikh, Sheikh, KissloKisslo, et al: Circulation 84:594, 1991, et al: Circulation 84:594, 1991

MR p CABG : DonMR p CABG : Don’’t leave it !t leave it !it doesnit doesn’’t go away!t go away!

TR goes away by itselfTR goes away by itself

Myth # 6Myth # 6

Tricuspid InsufficiencyDuran (Circ 112:2005)

Tricuspid InsufficiencyDuran (Circ 112:2005)

At MVr, > 50% with TR TV annulus size - predicted recurence !

Up to 80% with large annulus

At MVr, > 50% with TR TV annulus size - predicted recurence !

Up to 80% with large annulus

Tricuspid InsufficiencyDreyfus (ATS 79:2005)

Tricuspid InsufficiencyDreyfus (ATS 79:2005)

311 pts for MVr, ½ TVr, ½ did not :> 40 mm or 2/3 mitral

30 d mort was = , but….

2 % vs 48 % return of 3-4+ TR @ 2 yrs

311 pts for MVr, ½ TVr, ½ did not :> 40 mm or 2/3 mitral

30 d mort was = , but….

2 % vs 48 % return of 3-4+ TR @ 2 yrs

TR is benignTR is benign

Myth # 5Myth # 5

Tricuspid InsufficiencyBernal (JTCVS 130:2005)Tricuspid InsufficiencyBernal (JTCVS 130:2005)

Patients who left with post-op TR, when returned for redo

30 day mortality was 35% ! …and most don’t come back!

They just die!

Patients who left with post-op TR, when returned for redo

30 day mortality was 35% ! …and most don’t come back!

They just die!

When you leave TR, they do poorly…When you leave TR, they do poorly…

Anyone can do post op valve care

Anyone can do post op valve care

Myth # 4Myth # 4

MultidisciplinaryProtocol driven, Specialty care

MultidisciplinaryProtocol driven, Specialty care

Myth # 4Myth # 4

Good post-op care can make up for a

mediocre operation

Good post-op care can make up for a

mediocre operation

Post op Post op

Anyone can do valve operations Anyone can do

valve operations

Myth # 3Myth # 3

Predictors of Mitral RepairPredictors of Mitral RepairPredictors of Mitral Repair

STS ACSD 2005 - 2007:

Mitral cases/yr - 5.3 (0.3 – 166)

Mean repair rate - 41% (0 – 100 %)

STS ACSD 2005 STS ACSD 2005 -- 20072007::

Mitral cases/yr Mitral cases/yr -- 5.3 (0.3 5.3 (0.3 –– 166)166)

Mean repair rate Mean repair rate -- 41% (0 41% (0 –– 100 %)100 %)

MVR Volume effectMVR Volume effectMVR Volume effect

Predictors of Mitral RepairPredictors of Mitral Repair

Mitral volume Mitral volume vsvs repair rate relationshiprepair rate relationship

Predictors of Mitral RepairPredictors of Mitral RepairPredictors of Mitral RepairRisk Adjusted Odds Ratio for Mitral Repair (95% CI)

Positive: (vs median)

Mitral Volume: 30 1.42 (1.18 - 1.71)Mitral Volume: 60 2.16 (1.44 - 3.24)Mitral Volume: 100 3.78 (1.87 - 7.64)Mitral Volume: 150 7.61 (2.60 - 22.26)Mitral Volume: 160 8.76 (2.78 – 27.58)

Risk Adjusted Odds Ratio for Mitral Repair (95% CI)Risk Adjusted Odds Ratio for Mitral Repair (95% CI)

Positive: (Positive: (vsvs median)median)

Mitral Volume: 30 Mitral Volume: 30 1.42 1.42 (1.18 (1.18 -- 1.71)1.71)Mitral Volume: 60 Mitral Volume: 60 2.16 2.16 (1.44 (1.44 -- 3.24)3.24)Mitral Volume: 100 Mitral Volume: 100 3.78 3.78 (1.87 (1.87 -- 7.64)7.64)Mitral Volume: 150 Mitral Volume: 150 7.61 7.61 (2.60 (2.60 -- 22.26)22.26)Mitral Volume: 160 Mitral Volume: 160 8.768.76 (2.78 (2.78 –– 27.58)27.58)

Coumadin is benignCoumadin is benign

Myth # 2Myth # 2

Benign ?Benign ?

2% to 5% per pt / yearrisk of hemorrhage or TELinear event rate !

(Akins, Ann Thorac Surg 1995)

2% to 5% per pt / yearrisk of hemorrhage or TELinear event rate !

(Akins, Ann Thorac Surg 1995)

10 All valve dz same post op9. Assx severe valve disease exists 8. Crank up the EPI !7. MR goes away after CABG6. TR goes away by itself5. TR is benign4. Anyone can care for post op valves3. Anyone can do valve surgery2. Coumadin is benign

……..and the #1 myth

10 All valve dz same post op9. Assx severe valve disease exists 8. Crank up the EPI !7. MR goes away after CABG6. TR goes away by itself5. TR is benign4. Anyone can care for post op valves3. Anyone can do valve surgery2. Coumadin is benign

……..and the #1 myth

Myths Myths

That there is even the slightest chance that OSU

can beatMICHIGAN

this year

That there is even the slightest chance that OSU

can beatMICHIGAN

this year

Myth #1Myth #1

Valve MythsValve Myths

Go BLUE !Go BLUE !