病人選擇和操作方法機械瓣vs生物瓣主動脈瓣替換西方觀點（英文）課件

1、病人選擇和操作方法 :機械瓣 vs 生物瓣主動脈瓣替換西方觀點Joseph F. Sabik, M.D.The Cleveland Clinic“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 particular medical therapy suc

2、h as anticoagulation. Needless to say, such a valve is yet to be available.”推薦 “新”的好的瓣膜與“舊”的好的瓣膜結(jié)果相似。生物瓣在老年病人中結(jié)構(gòu)性瓣膜毀損率低。在 60 to 65 病人是首選推薦 新的生物瓣和機械瓣有更好的血流動力學(xué)。耐久性和病人死亡率比舊的生物瓣更好單純根據(jù)病人年齡來決定采用什么瓣膜可能不能為個體病人作出正確的決策。or?1008060402000246810121416BioprosthesisMechanicalProsthesisYears after valve replacementM

3、ortality%Hammermeister et al., JACC:2000P=0.02死亡率VA Cooperative Study1008060402000246810121416MechanicalProsthesisYears after valve replacementAll Valve-related Complications%Hammermeister et al., JACC:2000P=0.26Bioprosthesis瓣膜相關(guān)性并發(fā)癥VA Cooperative Study1008060402000246810121416MechanicalProsthesisYe

4、ars after valve replacementP=0.0001BioprosthesisBleeding%出血VA Cooperative Study年齡主要的瓣膜選擇標(biāo)準(zhǔn) 65 - 70 歲:生物瓣 65 - 70 歲:機械瓣AHA/ACC 指南避免 華法林風(fēng)險再次手術(shù)個體病人什么是華法林風(fēng)險？什么是再次手術(shù)的風(fēng)險？機械瓣風(fēng)險年齡 vs INR 出血的時間75th percentile50th percentile25th percentileWittkowsky, Pharmacotherapy. 2004Free of ComplicationsOther DeathsBleed

5、ingTEReop/EndoValve Related Deaths100806040200051015Yrs PostopZellner, Ann Thorac Surg: 1999免予并發(fā)癥率 St. Jude AVR生物瓣風(fēng)險Survival%Years96765226競爭事件%YearsEvent-freeSurvivalDeath beforeExplantExplant forSVD結(jié)構(gòu)毀損而取出%Years45556575Age再次手術(shù)死亡率20151050%Mort.CombinedIsolated4.1%5.8%199419961998200020022004瓣膜演變生物瓣改

6、善血流動力學(xué)抗鈣化耐久性延長機械瓣抗凝藥物治療1614121086505560657075LE BioAge of ImplantationYearsSource: LE MechEFLE MechEFLE BioEvent-Free Life ExpectancyAortic Valve ReplacementRecommendations Valve ChoiceClinical situationPatient preferenceClinicalRecommendations Tissue ValveLimited life expectancyOlder AgeCAD-severeL

7、V dysfunction-severeComorbidities-severeIncreased bleeding risk臨床建議-機械瓣華法林 60 歲病人傾向性性生活質(zhì)量機械瓣:無結(jié)構(gòu)毀損問題再次手術(shù)少抗凝生物瓣:結(jié)構(gòu)毀損和再次手術(shù)免予抗凝及抗凝相關(guān)出血。BioprosthesesMechanicalHomograft10080604020主動脈瓣膜1995-2005%199519971999200520012003100806040200802005 單純主動脈瓣年齡HumanRepairMechanicalBioprosthesesAge%AVR 人群年齡 1980-1995 62

8、 years1996 - 2005 73 years70% 合并冠心病 15 % 病人 60 to 65 years of age.Recommendations Newer tissue and mechanical prostheses afford superior hemodynamics. Durability and patient mortality are superior with newer compared with older bioprostheses. Arbitrary cutoffs dictating valve choice based on age may

9、 not give appropriate weight to individual patient perspectives.or?Prospective Randomized TrialsEdinburgh 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.Veterans Af

10、fairs 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;36:1152-8.05101520Years after randomization100806040200Bjork-Shiley%PorcineSource: HSurvival Edinburgh Heart Valve TrialP=0.3910

11、08060402000246810121416BioprosthesisMechanicalProsthesisYears after valve replacementMortality%Hammermeister et al., JACC:2000P=0.02MortalityVA Cooperative Study1008060402000246810121416MechanicalProsthesisYears after valve replacementAll Valve-related Complications%Hammermeister et al., JACC:2000P=

12、0.26BioprosthesisValve-Related ComplicationsVA Cooperative Study1008060402000246810121416MechanicalProsthesisYears after valve replacementP=0.0001BioprosthesisBleeding%BleedingVA Cooperative Study1008060402000246810121416MechanicalProsthesisYears after valve replacementBleeding%Hammermeister et al.,

13、 JACC:2000P=0.0001BioprosthesisPrimary Valve FailureVA Cooperative Study1008060402000246810121416MechanicalProsthesisYears after valve replacementAll Reoperations %Hammermeister et al., JACC:2000P=0.004BioprosthesisReoperationVA Cooperative StudyTissue vs. MechanicalAHA/ACC Criteria The age at which

14、 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. AgeMajor Criteria for Valve Selection 65 - 70 years:Tissue prosthesis 65 - 70 years:Mechanical prosthesisB

15、asis of AHA/ACC GuidelinesAvoid Risks of WarfarinReoperationFor Individual PatientWhat is the risk of warfarin?What is the actual likelihood and risk of reoperation?Mechanical Valve RiskAge vs INR Time of Major Bleeding75th percentile50th percentile25th percentileWittkowsky, Pharmacotherapy. 2004Dav

16、id et al. 1996.CarboMedicsSt. JudeMedtronic-Hall3.01.00.02.0P = .8FDA: OPCPercent Per YearMech Valve ThrombosisFree of ComplicationsOther DeathsBleedingTEReop/EndoValve Related Deaths100806040200051015Yrs PostopZellner, Ann Thorac Surg: 1999Freedom from Complications St. Jude AVRBioprosthetic Valve

17、RiskSurvival%Years96765226Competing Events%YearsEvent-freeSurvivalDeath beforeExplantExplant forSVDExplant for SVD%Years45556575AgeValve Reoperations Mortality20151050%Mort.CombinedIsolated4.1%5.8%199419961998200020022004Prosthesis EvolutionBioprosthesisImproved hemodynamicsAnti-calcificationEnhance

18、d durabilityMechanical prosthesesManagement of anticoagulation1614121086505560657075LE BioAge of ImplantationYearsSource: LE MechEFLE MechEFLE BioEvent-Free Life ExpectancyAortic Valve ReplacementRecommendations Valve ChoiceClinical situationPatient preferenceClinicalRecommendations Tissue ValveLimited life expectancyOlder AgeCAD-severeLV dysfunction-severeComorbidities-severeIncreased bleeding riskClinicalRecommendations Mechanical ValveWarfarin for other indication 60 yearsPati