Valve Replacement Mechanical versus Biological Prof. Dr. T. Carrel Swiss Cardiovascular Center...
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Transcript of Valve Replacement Mechanical versus Biological Prof. Dr. T. Carrel Swiss Cardiovascular Center...
Valve ReplacementMechanical versus Biological
Prof. Dr. T. CarrelSwiss Cardiovascular Center
University Hospital BerneSwitzerlandNo Disclosure
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
• The Institutional Experience
• The Market (Current Estimations)
• The ESC and ACC/AHA Guidelines
• The Decision-Making Process
• The Literature: Pro and Cons
• The Future
Agenda
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140
100
200
300
400
500
600
700
800
900
AVR bio
AVR mech
TAVI
sAVR total
AVR total
The Institutional Experience
Swiss Cardiovascular Center University Hospital Berne, Switzerland
185
400
768
Ross ≈10/yrDavid ≈20-30/yr
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
(1) Increasing Number of Patients with AVR
(2) Absolute number of mechanical AVR remains stable
(3) Relative number of mechanical AVR decreased
New generation of tissue valves have a lower rate of SVD
Life-style changes (QoL without warfarin)
Changes in Guidelines and Literature regarding cut-off age
The Institutional Experience
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
The Current (surgical) Market
(≈ 200‘000 pts per year)
78-85% 15-22%(43% in 1997) (55% in 1997)
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
The Future (global) Market
(≈ 500‘000 - 1‘000‘000 pts per year)
> 50%
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
The ESC/EACTS Guidelines
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
The AHA/ACC Guidelines
Nishimura RA, AHA/ACC Guidelines Circulation 2015
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
The Decision-Making Process
Objective Criterias
• Durability of the Device
• Need for Anticoagulation
• Risk of Prosthetic Endocarditis
• Life expectancy of the Patient
• Quality of Life
Subjective Criterias
• Patient’s opinion
• Cardiologist’s Recommendation
• Institutional Strategy
• Recommendations through others
(online, relatives, patients)
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
Arguments that may influence valve selection
New anticoagulation strategies
New valve design
pro mechanical valve
Valve-in-valve concept with TAVI
pro tissue valve
The Decision-Making Process
Individual Confort vs Economic Burden
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
The Patient‘s Perspective
„Patients who need heart valve replacement come
with the anticipation of receiving, according to
their conditions, the most appropriate valve
substitute for the rest of their life. They hope to be
operated on only once and to be free of
complications
K. Arom, J Heart Valve Dis 1996;5:505-10
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
The Patient‘s Perspective
“Consensus guidelines have increasingly emphasized
patient preference in preoperative decision making.
Quality-of-life surveys indicate that many patients view the
distant possibility of reoperation as a reasonable trade-off
for freedom from lifelong anticoagulation, reduced quality
of life, and poorer perceived health status associated with
mechanical prosthetic valves“.
Chikwe J et al. JAMA, April 14,
2015
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
The Patient‘s Perspective
Mechanical Valves• Freedom from Reoperation but Anticoagulation
Tissue Valves • Freedom from Anticoagulation but Reoperation
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
The Literature: Historical
Suri R, Circulation 2013;128:1372
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
The Literature: Historical
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
The Literature: Historical
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
The Literature: Historical
• Actuarial: freedom from SVD - assumes all patients are alive
• Actual: death competes to reduce the likelihood of reoperation
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
The Literature: Historical
• Old type of tilting-disk prosthesis
• Biological design no more available
• Results not stratified by age groups
• Perioperative mortality was higher
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
The Literature: Pro and Cons
Circulation 2013;128:1365-1381
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
The Literature: Pro Mechanical
Suri R, Circulation 2013;128:1372
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
Brown M, J Thorac Cardiovasc Surg 2008;135:878-84
Freedom from bleeding Overall survival
The Literature: Pro mechanical
220 pts, matched for age, gender, CABG and valve size
SJM vs CE
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
Chan V et al. Circulation 2011;124 Suppl1:S75-80
The Literature: Pro Mechanical
Reoperation according to age at implantation
3975 pts (3152 AVR) with first time tissue valve
75% redos in pts 40-60 !
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
345 pts > 80 years 58% tissue vs 42% mechanical
Follow-up 40±33 months
Overall survival benefit in pts with mechanical valves
No influence on QoL
Ann Thorac Surg 2008;85:1296-302
The Literature: Pro Mechanical
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
The Future
Avoid Unpredictable SVD
- negative effects of adverse cumulative hemodynamics - ViV-TAVI is less than optimal and expensive
Mitral CE and Aortic Trifecta 3 yrs after AVR+MVR
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
The Future
Hope for a MEC valve w/o AC(Triflo Medical Switzerland)
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
Thrombogenicity of prosthetic heart valves is design-related
• Material factor is NOT a reason for the poorer performance of CARBON valve
The Future
• No inherent difference in material thrombogenicity between mechanical and tissue valves
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
• Projected Dynamic Valve Area (PDVA)
• Digital Particle Imaging Velocimetry (DPIV)
• Parallel Computational Platforms (CFD)
• Platelet-Shear Flow Interactions (PSFI)
a
New Methodologies to Test Mechanical Prostheses
The Future
Biomolecular Link between Fluid Forces
and Platelet Aggregation
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
abrupt closingclose earlier and more smoothly
Closure starts after Onset of Reversed Flow
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
Unadressed Extreme Closing Volume Velocity
- Cavitation
- Micro-bubbles formation (HITS)
- Vortex Formation
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
Physiologic hemodynamic profile
No “jet-like” flow regions
No “hot spots” in the pivoting spaces
Leakage flow velocity 1 m/s
• Warfarin-free
• Not prone to structural failure
The Future A mechanical valve w/o anticoagulation
AATS 2015 – Postgraduate Adults (Mechanical vs Tissue Valves)
Swiss Cardiovascular Center, University Hospital Berne - Switzerland
Pts with Life Expectancy > 10-15 yrs
- MECHANICAL prosthesis w/o AC
All others Pts: TA - or TF-TAVI
The Future: „Predictions“
AVR Surgery must be „re-designed“
- Small incision
- Miniaturized CPB
- Single shot „low volume“ cardioplegia
- Valve device with unlimited durability