病人选择和操作方法机械瓣vs生物瓣主动脉瓣替换西方观点(英文)课件

1、病人选择和操作方法 :机械瓣 vs 生物瓣主动脉瓣替换西方观点Joseph F. Sabik, M.D.The Cleveland Clinic病人选择和操作方法 :机械瓣 vs 生物瓣主动脉瓣替换西“The ideal prosthetic valve would have excellent hemodynamics (similar to a normal human valve in the same position), last a lifetime, be free of structural dysfunction or breakdown, and require no pa

2、rticular medical therapy such as anticoagulation. Needless to say, such a valve is yet to be available.”“The ideal prosthetic valve wo病人选择和操作方法机械瓣vs生物瓣主动脉瓣替换西方观点(英文)课件推荐 “新”的好的瓣膜与“旧”的好的瓣膜结果相似。生物瓣在老年病人中结构性瓣膜毁损率低。在 60 to 65 病人是首选推荐 “新”的好的瓣膜与“旧”的好的瓣膜结果相似。生物瓣在病人选择和操作方法机械瓣vs生物瓣主动脉瓣替换西方观点(英文)课件推荐 新的生物瓣和机械

3、瓣有更好的血流动力学。耐久性和病人死亡率比旧的生物瓣更好单纯根据病人年龄来决定采用什么瓣膜可能不能为个体病人作出正确的决策。推荐 新的生物瓣和机械瓣有更好的血流动力学。耐久性和病人or?or?前瞻性随机研究Edinburgh Heart Valve Trial533 patients; 1975 to 1979Bjork-Shiley vs. porcine (Hancock, Carpentier-Edwards)Bloomfield, et al. New Engl J Med 1991;324:573-9.Oxenham, et al. Heart 2003;89:715-21.Vete

4、rans Affairs Cooperative Study575 patients; 1977 to 1982Bjork-Shiley vs. HancockHammeremister, et al. New Engl J Med 1993;328:1289-96.Hammermeister, et al. J Am Coll Cardiol 2000;36:1152-8.前瞻性随机研究Edinburgh Heart Valve T05101520Years after randomization100806040200Bjork-Shiley%PorcineSource: H生存率 Edi

5、nburgh Heart Valve TrialP=0.3905101520Years after randomizat1008060402000246810121416BioprosthesisMechanicalProsthesisYears after valve replacementMortality%Hammermeister et al., JACC:2000P=0.02死亡率VA Cooperative Study1000246810121416BioprosthesisM1008060402000246810121416MechanicalProsthesisYears af

6、ter valve replacementAll Valve-related Complications%Hammermeister et al., JACC:2000P=0.26Bioprosthesis瓣膜相关性并发症VA Cooperative Study1000246810121416MechanicalYear1008060402000246810121416MechanicalProsthesisYears after valve replacementP=0.0001BioprosthesisBleeding%出血VA Cooperative Study1000246810121

7、416MechanicalYear1008060402000246810121416MechanicalProsthesisYears after valve replacementBleeding%Hammermeister et al., JACC:2000P=0.0001Bioprosthesis瓣膜功能障碍VA Cooperative Study1000246810121416MechanicalYear1008060402000246810121416MechanicalProsthesisYears after valve replacementAll Reoperations %

8、Hammermeister et al., JACC:2000P=0.004Bioprosthesis再次手术VA Cooperative Study1000246810121416MechanicalYear生物瓣 vs. 机械瓣AHA/ACC 标准 采用生物瓣的年龄标准是基于65岁以上病人结构性瓣膜毁损明显下降和出血风险明显升高决定的。生物瓣 vs. 机械瓣AHA/ACC 标准 采用生年龄主要的瓣膜选择标准 65 - 70 岁:生物瓣 65 - 70 岁:机械瓣年龄主要的瓣膜选择标准 65 - 70 岁:生物瓣AHA/ACC 指南避免 华法林风险再次手术个体病人什么是华法林风险？什么是再次

9、手术的风险？AHA/ACC 指南个体病人机械瓣风险机械瓣风险年龄 vs INR 出血的时间75th percentile50th percentile25th percentileWittkowsky, Pharmacotherapy. 2004年龄 vs INR 出血的时间75th percentilDavid et al. 1996.CarboMedicsSt. JudeMedtronic-Hall3.01.00.02.0P = .8FDA: OPCPercent Per Year机械瓣血栓形成David et al. 1996.CarboMedicsSFree of Complicati

10、onsOther DeathsBleedingTEReop/EndoValve Related Deaths100806040200051015Yrs PostopZellner, Ann Thorac Surg: 1999免予并发症率 St. Jude AVRFree of ComplicationsOther Dea生物瓣风险生物瓣风险Survival%Years96765226Survival%Years96765226竞争事件%YearsEvent-freeSurvivalDeath beforeExplantExplant forSVD竞争事件%YearsEvent-freeSurv

11、ivalD结构毁损而取出%Years45556575Age结构毁损而取出%Years45556575Age再次手术死亡率20151050%Mort.CombinedIsolated4.1%5.8%199419961998200020022004再次手术死亡率20%CombinedIsolated4.1%瓣膜演变生物瓣改善血流动力学抗钙化耐久性延长机械瓣抗凝药物治疗瓣膜演变生物瓣1614121086505560657075LE BioAge of ImplantationYearsSource: LE MechEFLE MechEFLE BioEvent-Free Life Expectancy

12、Aortic Valve Replacement16505560657075LE BioAge of ImpRecommendations Valve ChoiceClinical situationPatient preferenceRecommendations Valve ChoiceCClinicalRecommendations Tissue ValveLimited life expectancyOlder AgeCAD-severeLV dysfunction-severeComorbidities-severeIncreased bleeding riskClinicalRec

13、ommendations Tissu临床建议-机械瓣华法林 60 岁临床建议-机械瓣华法林病人倾向性性生活质量机械瓣:无结构毁损问题再次手术少抗凝生物瓣:结构毁损和再次手术免予抗凝及抗凝相关出血。病人倾向性性生活质量机械瓣:BioprosthesesMechanicalHomograft10080604020主动脉瓣膜1995-2005%199519971999200520012003Bioprostheses100主动脉瓣膜1995-200100806040200802005 单纯主动脉瓣年龄HumanRepairMechanicalBioprosthesesAge%1003030-3940

14、-4950-5960-69AVR 人群年龄 1980-1995 62 years1996 - 2005 73 years70% 合并冠心病 15 % 病人 60 to 65 years of age.Recommendations Outcomes with病人选择和操作方法机械瓣vs生物瓣主动脉瓣替换西方观点(英文)课件Recommendations Newer tissue and mechanical prostheses afford superior hemodynamics. Durability and patient mortality are superior with ne

15、wer compared with older bioprostheses. Arbitrary cutoffs dictating valve choice based on age may not give appropriate weight to individual patient perspectives.Recommendations Newer tissueor?or?Prospective Randomized TrialsEdinburgh Heart Valve Trial533 patients; 1975 to 1979Bjork-Shiley vs. porcine

16、 (Hancock, Carpentier-Edwards)Bloomfield, et al. New Engl J Med 1991;324:573-9.Oxenham, et al. Heart 2003;89:715-21.Veterans Affairs Cooperative Study575 patients; 1977 to 1982Bjork-Shiley vs. HancockHammeremister, et al. New Engl J Med 1993;328:1289-96.Hammermeister, et al. J Am Coll Cardiol 2000;3

17、6:1152-8.Prospective Randomized TrialsE05101520Years after randomization100806040200Bjork-Shiley%PorcineSource: HSurvival Edinburgh Heart Valve TrialP=0.3905101520Years after randomizat1008060402000246810121416BioprosthesisMechanicalProsthesisYears after valve replacementMortality%Hammermeister et a

18、l., JACC:2000P=0.02MortalityVA Cooperative Study1000246810121416BioprosthesisM1008060402000246810121416MechanicalProsthesisYears after valve replacementAll Valve-related Complications%Hammermeister et al., JACC:2000P=0.26BioprosthesisValve-Related ComplicationsVA Cooperative Study1000246810121416Mec

19、hanicalYear1008060402000246810121416MechanicalProsthesisYears after valve replacementP=0.0001BioprosthesisBleeding%BleedingVA Cooperative Study1000246810121416MechanicalYear1008060402000246810121416MechanicalProsthesisYears after valve replacementBleeding%Hammermeister et al., JACC:2000P=0.0001Biopr

20、osthesisPrimary Valve FailureVA Cooperative Study1000246810121416MechanicalYear1008060402000246810121416MechanicalProsthesisYears after valve replacementAll Reoperations %Hammermeister et al., JACC:2000P=0.004BioprosthesisReoperationVA Cooperative Study1000246810121416MechanicalYearTissue vs. Mechan

21、icalAHA/ACC Criteria The age at which patients may be considered for bioprosthetic valves is based on the major reduction in rate of structural valve deterioration after age 65 and the increased risk of bleeding in this age group. Tissue vs. MechanicalAHA/ACCAgeMajor Criteria for Valve Selection 65

22、- 70 years:Tissue prosthesis 65 - 70 years:Mechanical prosthesisAgeMajor Criteria for Valve SBasis of AHA/ACC GuidelinesAvoid Risks of WarfarinReoperationFor Individual PatientWhat is the risk of warfarin?What is the actual likelihood and risk of reoperation?Basis of AHA/ACC GuidelinesForMechanical

23、Valve RiskMechanical Valve RiskAge vs INR Time of Major Bleeding75th percentile50th percentile25th percentileWittkowsky, Pharmacotherapy. 2004Age vs INR Time of Major BleeDavid et al. 1996.CarboMedicsSt. JudeMedtronic-Hall3.01.00.02.0P = .8FDA: OPCPercent Per YearMech Valve ThrombosisDavid et al. 19

24、96.CarboMedicsSFree of ComplicationsOther DeathsBleedingTEReop/EndoValve Related Deaths100806040200051015Yrs PostopZellner, Ann Thorac Surg: 1999Freedom from Complications St. Jude AVRFree of ComplicationsOther DeaBioprosthetic Valve RiskBioprosthetic Valve RiskSurvival%Years96765226Survival%Years96

25、765226Competing Events%YearsEvent-freeSurvivalDeath beforeExplantExplant forSVDCompeting Events%YearsEvent-frExplant for SVD%Years45556575AgeExplant for SVD%Years45556575AValve Reoperations Mortality20151050%Mort.CombinedIsolated4.1%5.8%199419961998200020022004Valve Reoperations Mortality20Prosthesi

26、s EvolutionBioprosthesisImproved hemodynamicsAnti-calcificationEnhanced durabilityMechanical prosthesesManagement of anticoagulationProsthesis EvolutionBioprosthe1614121086505560657075LE BioAge of ImplantationYearsSource: LE MechEFLE MechEFLE BioEvent-Free Life ExpectancyAortic Valve Replacement16505560657075LE BioAge of ImpRecommendations Valve ChoiceClinical situationPatient preferenceRecommendations Valve ChoiceCClinicalRecommendations Tissue ValveLimited life expectancyOlder AgeCAD-severeLV dysfunction-severeComorbidities-severeIncreased bleed