Upload
philip-willis
View
215
Download
2
Tags:
Embed Size (px)
Citation preview
Mechanical PVRPearls & Pitfalls
Joseph A. Dearani, MD
Division of Cardiovascular Surgery
AATS Seattle April 2015
©2011 MFMER | slide-2
No disclosures
©2011 MFMER | slide-3
Outline• Background
• Which patients, why to consider
• Old and new literature
• Techniques of PVR
• INR management
• Thrombolysis
• Summary
©2011 MFMER | slide-4
Background• Bioprostheses, homografts – most
common, require re-re-replacement…
• Mechanical valves durable but… require anticoagulation
• The problem…
©2011 MFMER | slide-5
And the competition…
©2011 MFMER | slide-6
©2011 MFMER | slide-7
Who? PVR Population – Mayo >3,000• Conotruncal Anomalies
• native PVR – TOF, PS
• RV - PA conduit
PA-VSD, DORV, Truncus, TGA
• Failed Ross• aortic root + PVR
Note – mechanical PVR at Mayo…2% of all PVR
©2011 MFMER | slide-8
Why?ACHD Reoperation (n=1,040)Sternotomy # 2 3 4 5+
N= 630 298 78 34
Early mortality (%) 2 5 8 0
Resp failure (%) 5 6 6 15
Pacemaker (%) 4 4 4 0
Stroke (%) 1 2 3 0
Renal failure (%) 3 3 5 3
Sternal infect (%) 2 1 6 3Holst et al. Ann Thorac Surg 2011
©2011 MFMER | slide-9
Survival(%)
Years#2 583 415 311 218 139 80#3 268 208 152 108 71 36#4 67 47 31 25 16 7
5+ 31 19 14 8 6 3
P=0.01023
Sternotomy (no.)
45+
Late Survival since Last Sternotomy
Holst et al. Ann Thorac Surg 2011
©2011 MFMER | slide-10
ACHD Reoperations (n=1,040)Valve* Repair Replace
Pulmonary 4 423
Aortic 22 234
Tricuspid 162 144
Mitral 71 114
*85% of all operations were valve-related
*25% of all operations were multi-valveHolst et al. Ann Thorac Surg 2011
©2011 MFMER | slide-11
No anticoagulation6/16 failed
©2011 MFMER | slide-12
No anticoagulation1/4 failed
©2011 MFMER | slide-13
No anticoagulation3/11 failed
©2011 MFMER | slide-14
With anticoagulation1/8 failed with inadequate INR
©2011 MFMER | slide-15
October 1965 August 2008
33 21
Age5 66
33 yr
n= 54
Mechanical PVR
Stulak et al. Ann Thorac Surg 2010
©2011 MFMER | slide-16
# %BAV s/p Ross 12 22
TOF 10 19
Truncus Arteriosus 8 15
Carcinoid 7 13
DORV 6 11
PA/VSD 5 9
TGA 3 6
Other 3 6
Preop Cardiac Diagnoses
©2011 MFMER | slide-17
# %
TV Replacement 15 28
Aortic root replacement 14 26
AV replacement 13 24
TV repair 7 13
MV replacement 5 9
Other 13 24
Operative DataConcomitant Procedures
0 2 4 6 8 100
20
40
60
80
100S
urvi
val (
%)
52 25 11 8 7 792 62 24 11 8 8
p=0.10p=0.10MechanicalTissue
Follow-up (years)
Overall Survival
Stulak et al. Ann Thorac Surg 2010
0 2 4 6 8 100
20
40
60
80
100F
reed
om fr
omre
oper
atio
n (%
)
52 22 11 8 7 792 62 24 11 8 6
p=0.018MechanicalTissue
Follow-up (years)
Freedom from Reoperation
Stulak, Dearani et al. Ann Thorac Surg 2010
©2011 MFMER | slide-20
Follow-upClotting/Bleeding Events – Mechanical PVR
• PE in 1 (INR 1.4) Successful lytic therapy
• 8 late bleeding events Epistaxis in 5 ICH (FH of AVM’s) in 1 Chest wall hematoma in 1 Menorrhagia in 1
©2011 MFMER | slide-21
Other new literature…
• N=121 mechanical PVR
• 70% male, mean age 23 yr
• Tetralogy of Fallot 90%
• Mean follow-up 7 years
• No early, late mortality
Dehaki et al. Thorac Cardiovasc Surg 2014
©2011 MFMER | slide-22
Other new literature – cont.• PVR malfunction 8.3%
• 9 thrombosis; 8 thrombolysis, 1 reop
• Mean time 1.7 yr
• Freedom from…at 1, 5, 10 years
• Reop 100, 99, 98%
• Thrombosis 100, 93, 91%
• Bleeding (epistaxis) 98%
Dehaki et al. Thorac Cardiovasc Surg 2014
©2011 MFMER | slide-23
• 19 observational studies; N=299 (adult & peds)
• Mean follow-up 73 months
• Nonstructural deterioration 1.5%
• Thrombosis 2.2%
• Reoperation 0.9%
• Thrombolysis 0.5%
Mechanical PVR - Meta-Analysis
Dunne et al. Ann Thorac Surg 2015
©2011 MFMER | slide-24
Valve OutcomesWarfarin
%No Warfarin
%Non-structural dysfunction
0.2 1.5
Thrombosis 0.6 2.2Surgical reintervention
0.4 0.9
Thrombolysis 0.2 0.5Severe bleeding 0.1 0.4
Dunne et al. Ann Thorac Surg 2015
©2011 MFMER | slide-25
Bioprosthetic failure3 yr % 5 yr % 10 yr %
Homograft 12 40 25 - 60
Pericardial 11 - 26 22
Contegra 20 - 27
Medtronic Freestyle
7 - 16
Hancock II 4 - 17 50
Melody 2 - 10Dunne et al. Ann Thorac Surg 2015
©2011 MFMER | slide-26
Technique Native RVOT and PA
• Annulus vs proximal PA; tilt toward confluence• Patch may not be necessary with dilated PA
©2011 MFMER | slide-27
Intimal Peels in Right-sided Conduits
©2011 MFMER | slide-28
PA
RV
Bovine Pericardial Conduit RoofNo intimal peels
©2011 MFMER | slide-29
Prosthesis Selection
Anticoagulation for Valves Advances
• Low intensity AC for bileaflet
aortic prostheses
• Patient INR self-testing
• Novel anticoagulants on the way
©2011 MFMER | slide-31
Point-of-Care INR Instruments
Time In Range
Usual Care Self-Testing0
25
50
75
100
Lafata JE. J Gen Intern Med 2000
89%
6% 5%
% T
ime
in R
ang
e
Low
Therapeutic
High
Reduction in AE Rate
Usual Care Self Testing0
5
10
15Thromboembolic
Hemorrhage
Horstkotte D. J Heart Valve Dis 2004
3.6%
0.9%
11%
4.5%
Per
cen
t p
er p
t-yr
©2011 MFMER | slide-34
“Thrombolysis is the
recommended initial treatment for
thrombosed right-sided
mechanical valves.” JS Alpert JACC 2003
When it happens…
Thrombolysis• Urokinase, Streptokinase, rt-PA
• Lytic agent + heparin
• Temporary pacing with HR• Kao et al. Tex Heart Inst J 2009• Lengyel et al. J Heart Valve Dis 2005• Alpert J Am Coll Cardiol 2003• Manteiga et al. J Thorac Cardiovasc Surg 1998• Keuleers et al. Am J Cardiol 2011• Kogon et al. J Thorac Cardiovasc Surg 2004
©2011 MFMER | slide-36
Anticoagulation for PVR Mayo Clinic Practice
• Aspirin (81 mg/day) + warfarin
• Isolated PVR INR 2.5 – 3.0
• AVR + PVR INR 3.0 – 3.5
©2011 MFMER | slide-37
•Excellent durability
•Low risk – thrombosis, valve failure
•Consider in selected patients• Multiple prior operations
• Receiving AC for other reasons, e.g., AVR
• Premature bioprosthetic degeneration
• INR self-testing essential
Summary – Mechanical PVR
Questions & Discussion