Mechanical or Bioprosthetic valve for middle-aged patient Dr.Vijay Dikshit Apollo Hospitals, Hyderabad

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 , ,587

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

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 ?

U.S. Aortic Valve Data : Tissue vs. Mechanical Edwards Lifesciences Estimates

Myths about Mechanical Valves Mechanical valves last lifelong ! Indeed they last beyond life but patient may not !! You’ll 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

Mechanical Prosthesis Cost : Anticoagulant INR Test every days No. of visits to Physicians Thrombolysis Treatment of Hemorrhage Repeated Hospitalization Reoperation

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

Life after a Bioprosthetic Valve Safer No sudden untoward events Less hassles of anticoagulation Elective “Re-do” surgery Better Quality of life, socially acceptable

Mechanical Valves Hufnagel 1952 Ball & Cage 1960 Monoleaflet 1964 Bileaflet 1977 Little progress in design of mechanical valves since 1977

Current bioprosthesis (2 nd and 3 rd generation ) 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) Durability has markedly Increased

Projected Future Risks After Aortic Valve Replacement in a 50-Year-Old Man, Assuming 30-Year Survival Mechanical Valve Bioprosthetic % Operative mortality Risk of death at reoperation (10.8 for 2 nd Reoperation) Valve-related mortality (cumulative for 30 y) Valve-related morbidity (cumulative for 30 y) Total risk of morbidity and mortality over 30 y (59.1 if 2 nd reoperations) Circulation.2008;117:

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%) MVR AVR DVR TVR 2 2 TOTAL( Pt. ) ( Valves ) ( 1644) (742) (2386) Mechanical Tissue Total

Experience of valve surgery at Apollo Hospital Hyderabad (No.of valves)

Experience Of Bioprosthetic Valve BIOCOR360 EPIC 94 PERIMOUNT 171 MAGNA 21 FREESTYLE 76 HANCOCK 06 HP 08 TRONTO SPV 02 PRIMA PLUS 01 MOSAIC 03 Total 742

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

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

Biocor – Lowest Profile valve Low Stent Post Height Minimizes aortic wall protrusion Reduces LV outflow tract obstruction in the mitral position Eases implantability Benefits

Carpentier-Edwards PERIMOUNT Magna Leaflets made of bovine pericardium Good hemodynamics Dependable durability

Freestyle ® Stentless Valve Design Features Minimal Polyester Covering Surgeon’s Flags & Suture Demarcation Line Leaflets Fixed at Zero-Pressure AOA ® Tissue Treatment on Wall and Leaflets Root-Pressure Fixation Full Root Configuration

RE-OPERATION Risk of re-operation % / 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, 1995:60:s 464-9, Munro, Jamieson Ann Thorac Surg 1995:60:S459-63

Webb, J. G. et al. Circulation 2010;121: Transcatheter valve deployed within a surgical prosthesis (SAPIEN THV and Carpentier-Edwards)‏ Percutaneous trans catheter valve-in-valve implantation

New Technologies In Bioprosthetic Valves 3f Aortic Bioprosthesis Stent less Single suture line Medtronics

FUTURE OF TISSUE VALVES The future for heart valve replacement lies in tissue engineering (TEHV) Vesely I Circ.Res.2005;97;

Conclusion Preferred valve in middle age—BIOPROSTHETIC Present generation Bioprosthetic valves are expected to do well for 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