Mechanical or Bioprosthetic valve for middle-aged patient

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Mechanical or Bioprosthetic valve for middle-aged
patient
Dr.Vijay Dikshit Apollo Hospitals, Hyderabad
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1952-1962
1963-1966
1967-1969
1969-1977
1977-1984
1985-1990
1990-1992
1993-1999
1999-2000
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Valvular Heart Disease

• There are estimated 5 million patients in India
  suffering from Heart Valve Disease
• New patients added every year
  50,000
• Total no. of Heart Valve Surgeries
• performed all over India in year
• 
  2007 12,234
• 
  2009 18,587

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Choice for middle age patientsControversial

• USA Life expectancy M 75 F 78
• Middle age (55-65 yrs)
• India Life expectancy M 63 F 64
• Middle age ? ?
• Life expectancy with Valvular heart disease in
  India Class III- IV Limited Life Span

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Why Do I Prefer Tissue Valve ?

• Hemodynamics Central flow without hindrance
• Freedom from disc Impingement or sudden
  mechanical Dysfunction
• Anti Coagulation- Less stringent
• Noise free
• Durability A concern ?

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Indian Data of Heart valve Repalcement
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U.S. Aortic Valve Data Tissue vs. Mechanical
Edwards Lifesciences Estimates
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Myths about Mechanical Valves

• Mechanical valves last lifelong !
• Indeed they last beyond life but patient
  may not !!
• Youll Not Need Another Operation !
• Risks of Thromboembolism is minimal on anti
  coagulants !
• Coumadin therapy is simple
• Re-operation is very risky
• Mechanical valves are less expensive

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Mechanical Prosthesis
Cost Anticoagulant INR Test every
15-60 days No. of visits to
Physicians Thrombolysis Treatment of
Hemorrhage Repeated Hospitalization
Reoperation
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Perils of Life Long Anticoagulation

• Patient compliance
• Dose standardisation
• PT INR results variation
• Hemorrhage /Valve Thrombosis
• Cerebral / Visceral bleed with advancing age
• Dose regulations in variety of clinical situation
• Drug interaction with Anticoagulants

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Life after a Bioprosthetic Valve

• Safer
• No sudden untoward events
• Less hassles of anticoagulation
• Elective Re-do surgery
• Better Quality of life, socially acceptable

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Mechanical Valves
Hufnagel 1952
Ball Cage 1960
Monoleaflet 1964
Bileaflet 1977
Little progress in design of mechanical valves
since 1977
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Current bioprosthesis (2nd and 3rd generation )
Durability has markedly Increased

• Low or Zero pressure fixation
• (Edward Perimount,Medtronic Mosaic Porcine
  Valve)
• Anti mineralization techniques( Mitigate
  calcification)
• a. Polysorbate 80 (Tween 80)
  Ethanol(XenoLogiX) (Carpentier-Edwards SAV
  Perimount)
• b. Sodium dodecyl sulphate
• (Hancock II Porcine Bioprosthesis)

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Projected Future Risks After Aortic Valve
Replacement in a 50-Year-Old Man, Assuming
30-Year Survival Mechanical Valve
Bioprosthetic Operative
mortality 1.5
1.5
Risk of death at reoperation 2.1
5.8

(10.8 for 2nd Reoperation) V
alve-related mortality (cumulative for 30 y)
27 29 Valve-related
morbidity (cumulative for 30 y) 78
12 Total risk of morbidity and 108.6
48.3 mortality over 30
y (59.1 if 2 nd

reoperations)
Circulation .2008117253-256
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Our Experience(July1991 Oct 2010)

• Total No. of Cardiac Surgical procedures 14,256
• No. of valve repair 184
• No. of Heart Valve Replacements 2,230 (15.6)

Total
Tissue
Mechanical

• MVR 804 358 1162
• AVR 662 252 914
• DVR 89 63 152
• TVR 2 2
• TOTAL(Pt.) 1555 675 2230
• (Valves) (1644)
  (742) (2386)

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Experience of valve surgery at Apollo Hospital
Hyderabad
(No .of valves)
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Experience Of Bioprosthetic Valve
BIOCOR 360 EPIC 94 PERIMOUNT
171 MAGNA 21 FREESTYLE 76 HANCOCK
06 HP 08 TRONTO SPV 02 PRIMA PLUS 01
MOSAIC 03 Total 742
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Experience with Mechanical valves

• Medtronic hall 458
• St.Jude 392
• TTK Chitra 408
• On X 85
• Starr Edward 188
• ATS 5
• Edward Meera 16
• St.Vincents 15
• Omniscience 2
• Carbomedics 16
• Others 23

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Surgical Results of Bioprosthetic Valve

• Total number of Pts
  675
• Mortality (30 days)
  16 (2.3)
• Cause
• Low cardiac output 12
• Infection
  3
• CVA
  1
• New atrial fibrillation
  8
• Complete heart block
  2
• Prolonged ventilation
  17

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Biocor Lowest Profile valve
Benefits

• Low Stent Post Height
• Minimizes aortic wall protrusion
• Reduces LV outflow tract obstruction in the
  mitral position
• Eases implantability

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Carpentier-Edwards PERIMOUNT Magna

• Leaflets made of bovine pericardium
• Good hemodynamics
• Dependable durability

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Freestyle Stentless Valve
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RE-OPERATION

• Risk of re-operation 0.5 - 1.8 /
  patient - year
• Freedom from re-operation 88 - Mechanical
  valves
• at 10 years
  76 - Bioprosthesis
• Mortality
• 15.3 - Bioprosthesis
• 28.6 - Mechanical valves
• Reason
• Bioprosthesis - elective operation
• Mechanical urgent- may be in catastrophic
  circumstances

Tyers, Ann Thorac Surg, 199560s 464-9, Munro,
Jamieson Ann Thorac Surg 199560S459-63
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Percutaneous trans catheter valve-in-valve
implantation
Webb, J. G. et al. Circulation 20101211848-1857
Transcatheter valve deployed within a surgical
prosthesis (SAPIEN THV and Carpentier-Edwards)?
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New Technologies In Bioprosthetic Valves
3f Aortic Bioprosthesis
Stent less Single suture line Medtronics
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FUTURE OF TISSUE VALVES

• The future for heart valve replacement lies in
  tissue engineering (TEHV)

Vesely I Circ.Res.200597743-755
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Conclusion

• Preferred valve in middle ageBIOPROSTHETIC
• Present generation Bioprosthetic valves are
  expected to do well for 15-20 yrs possibly
  beyond
• Unpredictable long term outcomes of mechanical
  valve makes it of inferior choice
• With better Quality of life low risk of repeat
  surgery, Tissue-valves deserve a second look
  for younger patients
• Evolving percutaneous Valve-in-Valve tecchnology
  makes tissue valve even more attractive choice