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Valvular Heart Disease: No Longer the Realm of the Surgeon?

Valvular Heart Disease: No Longer the Realm of the Surgeon?. Christopher Young St Thomas’ Hospital, London. Outline. History, valve development and failure Surgical results and demographics Minimal Access (including robotic) Lessons to be learnt from surgery Summary and Conclusions.

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Valvular Heart Disease: No Longer the Realm of the Surgeon?

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  1. Valvular Heart Disease:No Longer the Realm of the Surgeon? Christopher Young St Thomas’ Hospital, London

  2. Outline • History, valve development and failure • Surgical results and demographics • Minimal Access (including robotic) • Lessons to be learnt from surgery • Summary and Conclusions

  3. History

  4. Heart Valves

  5. Bioprosthetic Problem Solving • Early • Calcification • Later valves • Tissue engineering (composite valves / muscle bar) • Zero pressure fixation • Anti-calcification remedies • Blue valves (toluidine blue) • Recent Valves • Sorin Valves (amino acids)

  6. Significant Bioprosthetic Failures • Dura Mater – abandoned • Fascia Lata – abandoned • Ionescu-Shiley – abandoned • Autogenics - abandoned

  7. Mechanism of Failure • Biological – gradual failure • Mechanical – catastrophic

  8. Significant Failures • Mechanical • Bjork-Shiley • Duromedics • Abram’s Valve

  9. Product Description Gore Thoracic Excluder Significant Failures – Endovascular Stents ePTFE Deployment Sleeve (attached to stent structure) • Gore Tag Self-expanding Nitinol Stent Structure Flares for wall apposition Radiopaque Band (both ends) ePTFE graft on blood-contact surface Sutureless Graft Attachment Spine Structure for Columnar Support Sealing Cuff (both ends)

  10. Stentless Valve

  11. Single Layer Stentless

  12. Single Layer Stentless

  13. 3F Surgical Valve

  14. Surgical Results

  15. Data from 5th National Adult Cardiac Surgical Database Report

  16. Data from 5th National Adult Cardiac Surgical Database Report

  17. Data from 5th National Adult Cardiac Surgical Database Report

  18. Data from 5th National Adult Cardiac Surgical Database Report

  19. Surgical Progress

  20. Minimal Access AVR

  21. Minimal Access – Aortic Root

  22. Minimal Access – Aortic Root

  23. Minimal Access – Aortic Root

  24. Minimally Invasive Valve Replacement • Percutaneous peripheral cannulation • “Heartport” techniques • Mini-sternotomy • Mini anterior thoracotomy • Surgery under epidural anaesthesia

  25. Robotic Aortic Surgery • 5 patients (3M/2F; 35 – 81 years) • 4 calcific AS / 1 AR • Transverse incision 4-5 cm R 3rd IC space • Standard interrupted suture technique • No mortality/complications • Mean hospital stay 8.6±3 days Folliguet et al. EJCTS 28 (2005): 172-173

  26. Minimal Access Mitral Repair Port access CPB Endoclamp Multiple small incisions No rib spreading

  27. Minimally Invasive vs Conventional Valve Replacement • Overall majority of reported results similar • Death • Length of stay • Complication rates • Minor negative aspects of: • Longer X clamp times • Longer bypass times • Increased early post-operative pain

  28. Minimally Invasive vs Conventional Valve Replacement • Some reports of improved outcome with keyhole approach • Lower risk redo operations • Aortic vascular procedures • Lower transfusion requirements • Lower incidence post-operative AF • Lower post-operative pain after day 2

  29. Off-Pump Valve Repair • Treatment of functional ischaemic MR • Coapsys device consists of 2 epicardial pads • Pads then connected with flexible chord • Placement TOE guided • MR reduced from grade 2.7±0.8 – 0.4±0.7 Grossi et al Ann Thorac Surg 2005; 80: 1706-11

  30. Surgical Problems(Cardiological Problems?)

  31. Valveexcision

  32. The small annulus A tight squeeze

  33. Small annulus • Good exposure from retraction sutures • Position light and table • Enthusiastic excision / decalcification • Do not oversize valve • Consider supra-annular placement • Do NOT use everting mattress sutures • (Root enlargement)

  34. The Big Annulus

  35. Summary 1 • Valve technology has evolved over 45 years with significant failures along the way (including recently) • Surgical results are excellent with increasing emphasis on minimal access

  36. Summary 2 • Increasingly elderly population with more calcific disease • Surgical anatomy/pathology is varied; a “one size fits all” approach will not work • How long will the devices last and how will they fail?

  37. Conclusions Proceed carefully! If things go pear-shaped Ring us – as usual, we will always be there to bail you out! This time, however, it may not be enough

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