病人選擇和操作方法機(jī)械瓣vs生物瓣主動(dòng)脈瓣替換西方觀點(diǎn)(英文)課件

1、病人選擇和操作方法 :機(jī)械瓣 vs 生物瓣主動(dòng)脈瓣替換西方觀點(diǎn)Joseph F. Sabik, M.D.The Cleveland Clinic病人選擇和操作方法 :機(jī)械瓣 vs 生物瓣主動(dòng)脈瓣替換西“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病人選擇和操作方法機(jī)械瓣vs生物瓣主動(dòng)脈瓣替換西方觀點(diǎn)(英文)課件推薦 “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”的好的瓣膜與“舊”的好的瓣膜結(jié)果相似。生物瓣在病人選擇和操作方法機(jī)械瓣vs生物瓣主動(dòng)脈瓣替換西方觀點(diǎn)(英文)課件推薦 新的生物瓣和機(jī)械

3、瓣有更好的血流動(dòng)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(lái)決定采用什么瓣膜可能不能為個(gè)體病人作出正確的決策。推薦 新的生物瓣和機(jī)械瓣有更好的血流動(dòng)力學(xué)。耐久性和病人or?or?前瞻性隨機(jī)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.前瞻性隨機(jī)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瓣膜相關(guān)性并發(fā)癥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瓣膜功能障礙VA Cooperative Study1000246810121416MechanicalYear1008060402000246810121416MechanicalProsthesisYears after valve replacementAll Reoperations %

8、Hammermeister et al., JACC:2000P=0.004Bioprosthesis再次手術(shù)VA Cooperative Study1000246810121416MechanicalYear生物瓣 vs. 機(jī)械瓣AHA/ACC 標(biāo)準(zhǔn) 采用生物瓣的年齡標(biāo)準(zhǔn)是基于65歲以上病人結(jié)構(gòu)性瓣膜毀損明顯下降和出血風(fēng)險(xiǎn)明顯升高決定的。生物瓣 vs. 機(jī)械瓣AHA/ACC 標(biāo)準(zhǔn) 采用生年齡主要的瓣膜選擇標(biāo)準(zhǔn) 65 - 70 歲:生物瓣 65 - 70 歲:機(jī)械瓣年齡主要的瓣膜選擇標(biāo)準(zhǔn) 65 - 70 歲:生物瓣AHA/ACC 指南避免 華法林風(fēng)險(xiǎn)再次手術(shù)個(gè)體病人什么是華法林風(fēng)險(xiǎn)？什么是再次

9、手術(shù)的風(fēng)險(xiǎn)？AHA/ACC 指南個(gè)體病人機(jī)械瓣風(fēng)險(xiǎn)機(jī)械瓣風(fēng)險(xiǎn)年齡 vs INR 出血的時(shí)間75th percentile50th percentile25th percentileWittkowsky, Pharmacotherapy. 2004年齡 vs INR 出血的時(shí)間75th percentilDavid et al. 1996.CarboMedicsSt. JudeMedtronic-Hall3.01.00.02.0P = .8FDA: OPCPercent Per Year機(jī)械瓣血栓形成David et al. 1996.CarboMedicsSFree of Complicati

10、onsOther DeathsBleedingTEReop/EndoValve Related Deaths100806040200051015Yrs PostopZellner, Ann Thorac Surg: 1999免予并發(fā)癥率 St. Jude AVRFree of ComplicationsOther Dea生物瓣風(fēng)險(xiǎn)生物瓣風(fēng)險(xiǎn)Survival%Years96765226Survival%Years96765226競(jìng)爭(zhēng)事件%YearsEvent-freeSurvivalDeath beforeExplantExplant forSVD競(jìng)爭(zhēng)事件%YearsEvent-freeSurv

11、ivalD結(jié)構(gòu)毀損而取出%Years45556575Age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再次手術(shù)死亡率20%CombinedIsolated4.1%瓣膜演變生物瓣改善血流動(dòng)力學(xué)抗鈣化耐久性延長(zhǎng)機(jī)械瓣抗凝藥物治療瓣膜演變生物瓣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臨床建議-機(jī)械瓣華法林 60 歲臨床建議-機(jī)械瓣華法林病人傾向性性生活質(zhì)量機(jī)械瓣:無(wú)結(jié)構(gòu)毀損問(wèn)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。病人傾向性性生活質(zhì)量機(jī)械瓣:BioprosthesesMechanicalHomograft10080604020主動(dòng)脈瓣膜1995-2005%199519971999200520012003Bioprostheses100主動(dòng)脈瓣膜1995-200100806040200802005 單純主動(dòng)脈瓣年齡HumanRepairMechanicalBioprosthesesAge%1003030-3940

14、-4950-5960-69AVR 人群年齡 1980-1995 62 years1996 - 2005 73 years70% 合并冠心病 15 % 病人 60 to 65 years of age.Recommendations Outcomes with病人選擇和操作方法機(jī)械瓣vs生物瓣主動(dòng)脈瓣替換西方觀點(diǎn)(英文)課件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