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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 !