Valvular Heart Valvular Heart Disease:Disease:

No Longer the Realm of the No Longer the Realm of the Surgeon?Surgeon?

Christopher YoungChristopher Young

St Thomas’ Hospital, St Thomas’ Hospital, LondonLondon

OutlineOutline History, valve development and failureHistory, valve development and failure

Surgical results and demographicsSurgical results and demographics

Minimal Access (including robotic)Minimal Access (including robotic)

Lessons to be learnt from surgeryLessons to be learnt from surgery

Summary and ConclusionsSummary and Conclusions

HistoryHistory

Heart ValvesHeart Valves

Bioprosthetic Problem Bioprosthetic Problem SolvingSolving

EarlyEarly CalcificationCalcification

Later valvesLater valves Tissue engineering (composite valves / muscle Tissue engineering (composite valves / muscle

bar)bar) Zero pressure fixationZero pressure fixation Anti-calcification remediesAnti-calcification remedies Blue valves (toluidine blue)Blue valves (toluidine blue)

Recent ValvesRecent Valves Sorin Valves (amino acids)Sorin Valves (amino acids)

Significant Bioprosthetic Significant Bioprosthetic FailuresFailures

Dura Mater – Dura Mater – abandonedabandoned

Fascia Lata – Fascia Lata – abandonedabandoned

Ionescu-Shiley – Ionescu-Shiley – abandonedabandoned

Autogenics - Autogenics - abandonedabandoned

Mechanism of FailureMechanism of Failure

Biological – gradual failureBiological – gradual failure

Mechanical – catastrophicMechanical – catastrophic

Significant FailuresSignificant Failures

MechanicalMechanical

Bjork-ShileyBjork-Shiley

DuromedicsDuromedics

Abram’s ValveAbram’s Valve

Significant Failures – Significant Failures – Endovascular StentsEndovascular Stents

Gore TagGore Tag

Gore Thoracic Excluder

ePTFE Deployment Sleeve(attached to stent structure)

Self-expanding Nitinol Stent Structure

ePTFE graft on blood-contact surface

Radiopaque Band (both ends)

Spine Structure forColumnar Support

Flares for wallapposition

Sealing Cuff (both ends)

Sutureless Graft Attachment

Product DescriptionProduct Description

Stentless ValveStentless Valve

Single Layer StentlessSingle Layer Stentless

Single Layer StentlessSingle Layer Stentless

3F Surgical Valve3F Surgical Valve

Surgical ResultsSurgical Results

Data from 5th National Adult Cardiac Surgical Database Report

Data from 5th National Adult Cardiac Surgical Database Report

Data from 5th National Adult Cardiac Surgical Database Report

Data from 5th National Adult Cardiac Surgical Database Report

Surgical ProgressSurgical Progress

Minimal Access AVRMinimal Access AVR

Minimal Access – Aortic RootMinimal Access – Aortic Root

Minimal Access – Aortic RootMinimal Access – Aortic Root

Minimal Access – Aortic RootMinimal Access – Aortic Root

Minimally Invasive Valve Minimally Invasive Valve ReplacementReplacement

Percutaneous peripheral cannulationPercutaneous peripheral cannulation ““Heartport” techniquesHeartport” techniques Mini-sternotomyMini-sternotomy Mini anterior thoracotomyMini anterior thoracotomy Surgery under epidural anaesthesiaSurgery under epidural anaesthesia

Robotic Aortic SurgeryRobotic Aortic Surgery 5 patients (3M/2F; 35 – 81 years)5 patients (3M/2F; 35 – 81 years) 4 calcific AS / 1 AR4 calcific AS / 1 AR Transverse incision 4-5 cm R 3Transverse incision 4-5 cm R 3rdrd IC IC

spacespace Standard interrupted suture techniqueStandard interrupted suture technique No mortality/complicationsNo mortality/complications Mean hospital stay 8.6Mean hospital stay 8.6±±3 days3 days

Folliguet et al. EJCTS 28 (2005): 172-173

Minimal Access Mitral Minimal Access Mitral RepairRepair

Port access CPB

Endoclamp

Multiple small incisions

No rib spreading

Minimally Invasive vs Minimally Invasive vs Conventional Valve Conventional Valve

ReplacementReplacement Overall majority of reported results Overall majority of reported results

similarsimilar DeathDeath Length of stayLength of stay Complication ratesComplication rates

Minor negative aspects of:Minor negative aspects of: Longer X clamp timesLonger X clamp times Longer bypass timesLonger bypass times Increased early post-operative painIncreased early post-operative pain

Minimally Invasive vs Minimally Invasive vs Conventional Valve Conventional Valve

ReplacementReplacement Some reports of improved outcome Some reports of improved outcome

with keyhole approachwith keyhole approach Lower risk redo operationsLower risk redo operations Aortic vascular proceduresAortic vascular procedures Lower transfusion requirementsLower transfusion requirements Lower incidence post-operative AFLower incidence post-operative AF Lower post-operative pain after day 2Lower post-operative pain after day 2

Off-Pump Valve RepairOff-Pump Valve Repair

Treatment of functional ischaemic MRTreatment of functional ischaemic MR Coapsys device consists of 2 epicardial Coapsys device consists of 2 epicardial

padspads Pads then connected with flexible chordPads then connected with flexible chord Placement TOE guidedPlacement TOE guided MR reduced from grade 2.7MR reduced from grade 2.7±±0.8 – 0.8 –

0.40.4±±0.70.7Grossi et alGrossi et al Ann Thorac Surg 2005; 80: 1706- Ann Thorac Surg 2005; 80: 1706-1111

Surgical ProblemsSurgical Problems

(Cardiological (Cardiological Problems?)Problems?)

ValveValve excisionexcision

The small annulusThe small annulus

A tight squeeze

Small annulusSmall annulus

Good exposure from retraction suturesGood exposure from retraction sutures Position light and tablePosition light and table Enthusiastic excision / decalcificationEnthusiastic excision / decalcification Do not oversize valveDo not oversize valve Consider supra-annular placementConsider supra-annular placement Do NOT use everting mattress suturesDo NOT use everting mattress sutures (Root enlargement)(Root enlargement)

The Big AnnulusThe Big Annulus

Summary 1Summary 1

Valve technology has evolved over Valve technology has evolved over 45 years with significant failures 45 years with significant failures along the way (including recently)along the way (including recently)

Surgical results are excellent with Surgical results are excellent with increasing emphasis on minimal increasing emphasis on minimal accessaccess

Summary 2Summary 2

Increasingly elderly population with Increasingly elderly population with more calcific diseasemore calcific disease

Surgical anatomy/pathology is varied; Surgical anatomy/pathology is varied; a “one size fits all” approach will not a “one size fits all” approach will not workwork

How long will the devices last and how How long will the devices last and how will they fail?will they fail?

ConclusionsConclusions

Proceed carefully!Proceed carefully!

If things go pear-shapedIf things go pear-shaped

Ring us – as usual, we will always be Ring us – as usual, we will always be there to bail you out!there to bail you out!

This time, however, it may not be enoughThis time, however, it may not be enough