experience with 500 stentless aortic valve replacements · 2020. 12. 24. · experience with 500...
TRANSCRIPT
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Experience with 500 Stentless Aortic Valve Replacements
Dimitrios C. Iliopoulos, MD
Cardiac Surgeon
Ass. Professor of Surgery
University of Athens, School of Medicine
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I declare no conflict of interest
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Burden of Valve Disease in the US
Year 2000 ➔ 2030
Disease
AS 2.5 millions ➔ 4.6 millions MR 2.7 millions ➔ 4.8 millions
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Stentless Aortic Valves Ideal for:
• Patients > 60 years old
• Patients < 60 years old with ↑ risk of thromboembolism
• Small annulus
• Concomittant procedures (↓ cross – clamp time)
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Freedom SOLO • Superior haemodynamics
• Faster to implant (one suture line)
• Maximization of flow in small annuli
• Outflow side already scalloped
• May avoid annulus enlargement
• No fabric reinforcement
• Soft and pliable tissue
• Detoxified valve and ready for use
• Expected reduction of calcification
• Clinically proven design
(18 yrs of Pericarbon stented model and
10 yrs of stentless) Native at Heart
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Different Implant Techniques
Outflow suture line
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Freedom SOLO: Technique
Supra-Annular
• No material within the annulus
• 100% orifice-to-annulus ratio
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Implant Technique: Suturing
Suggested order
• Each suture is tied at the midpoint
• Running suture from the midpoint to the top of the post, taking large bites
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Implant Technique: Suturing
• Once at the top, each suture is passed through the patient aortic wall
• Adjacent sutures are then tied
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Our published initial experience…
128 patients
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Protocol
500 patients undergoing AVR with SOLO Freedom aortic valve ± Concomitant procedures
U/S: preoperatively, immediate – 3 months – 6 months – 12 months postoperatively
Mean follow up: 57 months
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Patient Demographics
Age (y) 78.5±4.4
Gender (M:F) 271:229
BSA, mean±SD 1.8±0.17
NYHA, mean±SD 2.3±0.8
I-II, n(%) 379 (76)
III-IV, n(%) 121 (24)
Euroscore II, mean±SD 9.04±2.7
High Euroscore Patients, n(%) 410 (82)
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AV Pathology: Stenosis
3%
24%
73%
Mild
Moderate
Severe
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Valves Pathology
Aortic Valve (%) Mitral Valve (%)
AV Regurgitation 21.1 MV Stenosis 9
Mixed Lesion 18.2
MV
Regurgitation 48.5
BAV 2.7 Mixed Lesion 3
Endocarditis 3
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Risk factors
Comorbidities (%)
CAD 45.5
Hypertension 75.8
DM 42.2
Renal dysfunction 12.1
Dyslipidemia 36.4
Pulmonary hypertension 12.1
AFib 27.3
Previous Cardiac Surgery (%)
CABG 6
AVR 6
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Pre-op Medication Drug Treatment (%)
Beta Blockers 73
ACE Inhibitors 39
AT Inhibitors 12
Diuretics 55
Digoxin 6
Calcium Channel Blockers
6
Statins 27
ASA 24
Clopidogrel 12
Coumadin 18
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Laboratory Work-up
Pre-op Work-up, mean±SD
Hemoglobin 12.4 ± 1.7 HCT 38.3 ± 5 RBC 4471562 ± 726933 PLT 200250 ± 50211
Post-op Work-up, mean±SD
min Hgb 9.2 ± 0.9 min HCT 27.9 ± 2.9 min RBC 3215312 ± 378519 min PLT 65219 ± 31322 Post-op Day 3.7 ± 1.4
Significantly lower in all cases
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Size of prosthesis
0
10
20
30
40
50
60
70
80
21mm 23mm 25mm 27mm
SOLO Freedom
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Intra-operative data
Transfusion, mean±SD FFP 3.9 ± 2 RBC 2.8 ± 1.6 PLT 2.9 ± 3.8
Cross-clamp time (min), mean±SD 89 ± 30 CBP time (min), mean±SD 121 ± 38 SOLO time (min), mean±SD 42.7 ± 12.4
Concomitant Operation, (%) CABG 30 MVR 21 Other 18
Solely AVR only in the 40% of the patients !!
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Post-operative data
ICU Stay (h), mean±SD 68 ± 17 Hospital Stay (d), mean±SD 8.3±2.7
In-hospital mortality (%) 4.2 Time to death (d), mean±SD 7.2±11.2 Cause of death, % Cardiogenic shock 33 Bleeding 33 Infection 33 Re-operation (%) 2 Reason for re-op (%) Bleeding 100
All patients had high Euroscore II
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U/S Data
Preoperative Postoperative 3m 6m 12m p-value
LVEDD (mm) 51.2 ± 8.23 48.4 ± 5.8 47.3 ± 7.5 46.3 ± 6.4 45.5 ± 7.9 ns
LVESD (mm) 34.3 ± 7.9 32.4 ± 8.2 31.1 ± 8.2 30.3 ± 5.8 30.1 ± 8.7 ns
IVS(mm) 12.3 ± 2.1 12.4 ± 1.9 10.3 ± 1.3 10.4 ± 1.5 10.1 ± 1.3
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0
10
20
30
40
50
60
Preoperative Postoperative 3m 6m 12m
LV End-diastolic Diameter (mm)
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0
5
10
15
20
25
30
35
40
45
Preoperative Postoperative 3m 6m 12m
LV End-systolic Diameter (mm)
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0
2
4
6
8
10
12
14
Preoperative Postoperative 3m 6m 12m
Intra-ventricular Septum (mm)
p
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0
2
4
6
8
10
12
14
Preoperative Postoperative 3m 6m 12m
Posterior Wall (mm)
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0
20
40
60
80
100
120
Preoperative Postoperative 3m 6m 12m
Peak Gradient (mmHg)
p
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0
10
20
30
40
50
60
70
Preoperative Postoperative 3m 6m 12m
Mean Gradient (mmHg)
p
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0
1
2
3
4
5
6
Preoperative Postoperative 3m 6m 12m
Peak Velocity (cm/sec)
p
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Post-op AV Regurgitation
Postoperative 3 months 6 months 12 months
Relative frequency (%)
1,6 2,2 1 1
Mean Grade
1 1 1 1
Type Left Sinus Of Valsalva
Left Sinus of Valsalva –
Paravalvular
Left Sinus Of Valsalva
Left Sinus Of Valsalva
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Kaplan-Meier Analysis
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Mortality Hazard
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Surgical tips for easy implantation
Use 4-0 for thick or 5-0 prolene for thin aortic wall Oversize the aortic root (1 or 2 size bigger) Do not hesitate to stabilize the valve with external pledgeted sutures (especially
after local decalcification) Do not hesitate to implant in calcified roots (local decalcification) 1-2 mm higher in non-coronary sinus to avoid prosthetic aortic valve replacement
insufficiency Be flexible:
no one root is perfectly symmetrical modify the implantation
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Take-home message
Easy and fast implantation
Ideal for small annulus
Excellent Hemodynamics
Earlier Left Ventricular Reverse Remodelling
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Thank you !