mechanical pvr pearls &...

Mechanical PVR

Pearls & Pitfalls

Joseph A. Dearani, MD

Division of Cardiovascular Surgery

AATS Seattle April 2015

©2011 MFMER | slide-2

No disclosures


Outline

• Background

• Which patients, why to consider

• Old and new literature

• Techniques of PVR

• INR management

• Thrombolysis

• Summary


Background• Bioprostheses, homografts – most

common, require re-re-replacement…

• Mechanical valves durable but… require anticoagulation

• The problem…


And the competition…


Who? PVR Population – Mayo >3,000

• Conotruncal Anomalies

• native PVR – TOF, PS

• RV - PA conduit

PA-VSD, DORV, Truncus, TGA

• Failed Ross

• aortic root + PVR

Note – mechanical PVR at Mayo…2% of all PVR


Why?ACHD Reoperation (n=1,040)

Sternotomy # 2 3 4 5+

N= 630 298 78 34

Early mortality (%) 2 5 8 0

Resp failure (%) 5 6 6 15

Pacemaker (%) 4 4 4 0

Stroke (%) 1 2 3 0

Renal failure (%) 3 3 5 3

Sternal infect (%) 2 1 6 3Holst et al. Ann Thorac Surg 2011


Survival(%)

Years

#2 583 415 311 218 139 80

#3 268 208 152 108 71 36

#4 67 47 31 25 16 7

5+ 31 19 14 8 6 3

P=0.0102

3

Sternotomy (no.)

4

5+

Late Survival since Last Sternotomy

Holst et al. Ann Thorac Surg 2011


ACHD Reoperations (n=1,040)

Valve* Repair Replace

Pulmonary 4 423

Aortic 22 234

Tricuspid 162 144

Mitral 71 114

*85% of all operations were valve-related

*25% of all operations were multi-valveHolst et al. Ann Thorac Surg 2011


No anticoagulation

6/16 failed


No anticoagulation

1/4 failed


No anticoagulation

3/11 failed


With anticoagulation

1/8 failed with inadequate INR


October 1965 August 2008

33 21

Age5 66

33 yr

n= 54

Mechanical PVR

Stulak et al. Ann Thorac Surg 2010


# %

BAV s/p Ross 12 22

TOF 10 19

Truncus Arteriosus 8 15

Carcinoid 7 13

DORV 6 11

PA/VSD 5 9

TGA 3 6

Other 3 6

Preop Cardiac Diagnoses


# %

TV Replacement 15 28

Aortic root replacement 14 26

AV replacement 13 24

TV repair 7 13

MV replacement 5 9

Other 13 24

Operative DataConcomitant Procedures

0

20

40

60

80

100

0 2 4 6 8 10

Surv

ival (%

)

52 25 11 8 7 792 62 24 11 8 8

p=0.10Mechanical

Tissue

Follow-up (years)

Overall Survival

Stulak et al. Ann Thorac Surg 2010

0

20

40

60

80

100

0 2 4 6 8 10

Fre

edom

fro

mre

op

era

tio

n (

%)

52 22 11 8 7 792 62 24 11 8 6

p=0.018Mechanical

Tissue

Follow-up (years)

Freedom from Reoperation

Stulak, Dearani et al. Ann Thorac Surg 2010


Follow-upClotting/Bleeding Events – Mechanical PVR

• PE in 1 (INR 1.4)

Successful lytic therapy

• 8 late bleeding events

Epistaxis in 5

ICH (FH of AVM’s) in 1

Chest wall hematoma in 1

Menorrhagia in 1


Other new literature…

• N=121 mechanical PVR

• 70% male, mean age 23 yr

• Tetralogy of Fallot 90%

• Mean follow-up 7 years

• No early, late mortality

Dehaki et al. Thorac Cardiovasc Surg 2014


Other new literature – cont.

• PVR malfunction 8.3%

• 9 thrombosis; 8 thrombolysis, 1 reop

• Mean time 1.7 yr

• Freedom from…at 1, 5, 10 years

• Reop 100, 99, 98%

• Thrombosis 100, 93, 91%

• Bleeding (epistaxis) 98%

Dehaki et al. Thorac Cardiovasc Surg 2014


• 19 observational studies; N=299 (adult & peds)

• Mean follow-up 73 months

• Nonstructural deterioration 1.5%

• Thrombosis 2.2%

• Reoperation 0.9%

• Thrombolysis 0.5%

Mechanical PVR - Meta-Analysis

Dunne et al. Ann Thorac Surg 2015


Valve OutcomesWarfarin

%

No Warfarin

%

Non-structural

dysfunction

0.2 1.5

Thrombosis 0.6 2.2

Surgical

reintervention

0.4 0.9

Thrombolysis 0.2 0.5

Severe bleeding 0.1 0.4

Dunne et al. Ann Thorac Surg 2015


Bioprosthetic failure

3 yr % 5 yr % 10 yr %

Homograft 12 40 25 - 60

Pericardial 11 - 26 22

Contegra 20 - 27

Medtronic

Freestyle

7 - 16

Hancock II 4 - 17 50

Melody 2 - 10Dunne et al. Ann Thorac Surg 2015


Technique Native RVOT and PA

• Annulus vs proximal PA; tilt toward confluence

• Patch may not be necessary with dilated PA


Intimal Peels in Right-sided Conduits


PA

RV

Bovine Pericardial Conduit Roof

No intimal peels


Prosthesis Selection

Anticoagulation for Valves Advances

• Low intensity AC for bileaflet

aortic prostheses

• Patient INR self-testing

• Novel anticoagulants on the way


Point-of-Care INR

Instruments

Time In Range

0

25

50

75

100

Usual Care Self-TestingLafata JE. J Gen Intern Med 2000

89%

6% 5%

% T

ime i

n R

an

ge

Low

Therapeutic

High

Reduction in AE Rate

0

5

10

15

Usual Care Self Testing

Thromboembolic

Hemorrhage

Horstkotte D. J Heart Valve Dis 2004

3.6%

0.9%

11%

4.5%

Perc

en

t p

er

pt-

yr


“Thrombolysis is the

recommended initial treatment for

thrombosed right-sided

mechanical valves.”

JS Alpert JACC 2003

When it happens…

Thrombolysis• Urokinase, Streptokinase, rt-PA

• Lytic agent + heparin

• Temporary pacing with HR

• Kao et al. Tex Heart Inst J 2009

• Lengyel et al. J Heart Valve Dis 2005

• Alpert J Am Coll Cardiol 2003

• Manteiga et al. J Thorac Cardiovasc Surg 1998

• Keuleers et al. Am J Cardiol 2011

• Kogon et al. J Thorac Cardiovasc Surg 2004


Anticoagulation for PVR Mayo Clinic Practice

• Aspirin (81 mg/day) + warfarin

• Isolated PVR INR 2.5 – 3.0

• AVR + PVR INR 3.0 – 3.5


•Excellent durability

•Low risk – thrombosis, valve failure

•Consider in selected patients

• Multiple prior operations

• Receiving AC for other reasons, e.g., AVR

• Premature bioprosthetic degeneration

• INR self-testing essential

Summary – Mechanical PVR

Questions & Discussion

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