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.pptx

1、“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 such as anticoagulation.Needless to say,such a valve is yet to be available.”推荐

2、推荐推荐推荐or前瞻性随机研究前瞻性随机研究Edinburgh Heart Valve Trial 533 patients;1975 to 1979 Bjork-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 Affairs Cooperative Study 575 patients;1977 to 1982 Bjork-Shiley vs.HancockHammere

3、mister,et al.New Engl J Med 1993;328:1289-96.Hammermeister,et al.J Am Coll Cardiol 2000;36:1152-8.ReoperationBloomfield,et al.Bioprostheses have a low rate of SVD in the older patient andare the PHV of choice for AVR in patients 60 to 65 years of age.Durability and patient mortality are superior wit

4、h newer compared with older bioprostheses.60 to 65 病人是首选BioprosthesisManagement of anticoagulation生存率生存率 Edinburgh Heart Valve Trial死亡率死亡率VA Cooperative StudyNeed for AnticoagulationHammermeister et al.Event-Free Life ExpectancyBioprosthesis新的生物瓣和机械瓣有更好的血流动力学。ClinicalRecommendations Mechanical Valve

5、50th percentileFor Individual PatientExplant forSVDBjork-Shiley vs.Valve Related DeathsSource:Heartjnl.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。The age at which patients may be considered for bioprosthetic valves is based on the major reduction in rate of structural valve deterioration aft

6、er age 65 and the increased risk of bleeding in this age group.Edinburgh Heart Valve TrialEvent-Free Life ExpectancyBjork-Shiley在 60 to 65 病人是首选瓣膜相关性并发症瓣膜相关性并发症VA Cooperative Study出血出血VA Cooperative Study瓣膜功能障碍瓣膜功能障碍VA Cooperative Study再次手术再次手术VA Cooperative Study生物瓣生物瓣 vs.机械瓣机械瓣AHA/ACC 标准标准 采用生物瓣的年

7、龄标准是基于采用生物瓣的年龄标准是基于65岁以上病岁以上病人结构性瓣膜毁损明显下降和出血风险明人结构性瓣膜毁损明显下降和出血风险明显升高决定的。显升高决定的。年龄年龄AHA/ACC 指南指南避免避免 华法林风险华法林风险 再次手术再次手术个体病人个体病人什么是华法林风险？什么是华法林风险？什么是再次手术的风险？什么是再次手术的风险？机械瓣风险机械瓣风险年龄年龄 vs INR 出血的时间75th percentile50th percentile25th percentileWittkowsky,Pharmacotherapy.2004CarboMedicsSt.JudeMedtronic-Ha

8、ll3.01.00.02.0P=.8FDA:OPC机械瓣血栓形成机械瓣血栓形成Reop/Endo免予并发症率免予并发症率 St.Jude AVR生物瓣风险生物瓣风险RecommendationsPatient PreferenceQuality of LifeBjork-Shiley vs.Valve Related DeathsYears after randomization533 patients;1975 to 1979,JACC:2000 15%病人 60 to 65 病人是首选Comorbidities-severe50th percentileRecommendationsHam

9、mermeister et al.Years after valve replacementNeedless to say,such a valve is yet to be available.Survival0204060801000369121502040608010003691215竞争事件竞争事件05101520253003691215结构毁损而取出结构毁损而取出45556575Age再次手术死亡率再次手术死亡率20151050%Mort.CombinedIsolated199419961998200020022004瓣膜演变瓣膜演变生物瓣生物瓣改善血流动力学改善血流动力学抗钙化抗钙

10、化耐久性延长耐久性延长机械瓣机械瓣抗凝药物治疗抗凝药物治疗Event-Free Life ExpectancyAortic Valve ReplacementRecommendations Valve ChoiceClinical situationPatient preferenceOutcomes with“new”good valves are similar to those with“older”good valves.Risks of Warfarin,JACC:2000Mechanical prosthesesDeath beforeExplantBioprosthesis,JA

11、CC:2000Bjork-Shiley vs.Bloomfield,et al.,JACC:2000免予并发症率 St.“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 such as anticoagula

12、tion.RecommendationsBioprostheses have a low rate of SVD in the older patient andare the PHV of choice for AVR in patients 60 to 65 years of age.Free of Complicationsporcine(Hancock,Carpentier-Edwards)Oxenham,et al.Explant forSVDAortic Valve Replacement 15%病人 65 yearsClinicalRecommendations Tissue V

13、alveLimited life expectancyOlder AgeCAD-severeLV dysfunction-severeComorbidities-severeIncreased bleeding riskValve Related DeathsRecommendationsAll Reoperations%Aortic Valve ReplacementEvent-freeSurvivalVA Cooperative StudyFree of Complications“新”的好的瓣膜与“旧”的好的瓣膜结果相似。Primary Valve FailureFree of Comp

14、licationsDurability and patient mortality are superior with newer compared with older bioprostheses.Outcomes with“new”good valves are similar to those with“older”good valves.SVD and Reoperation.Valve Related FactorsYears after valve replacementYears after valve replacementBioprosthesisHammermeister

15、et al.VA Cooperative StudyAll Valve-related Complications临床建议临床建议-机械瓣机械瓣华法林华法林 60 岁岁病人倾向性性病人倾向性性生活质量生活质量机械瓣机械瓣:无结构毁损问题无结构毁损问题 再次手术少再次手术少 抗凝抗凝生物瓣生物瓣:结构毁损和再次手术结构毁损和再次手术 免予抗凝及抗凝相关出血。免予抗凝及抗凝相关出血。BioprosthesesMechanicalHomograft10080604020主动脉瓣膜主动脉瓣膜1995-2005100806040200802005 单纯主动脉瓣单纯主动脉瓣年龄年龄HumanRepairM

16、echanicalBioprosthesesAVR 人群人群年龄年龄 1980-1995 62 years 1996-2005 73 years70%合并冠心病合并冠心病 15%病人病人 65 yearsLV dysfunction-severe预期寿命Life ExpectancyHammermeister et al.New Engl J Med 1993;328:1289-96.Valve-Related ComplicationsEvent-Free Life ExpectancyNeed for AnticoagulationBjork-Shiley vs.50th percenti

17、leOxenham,et al.ClinicalRecommendations Mechanical Valve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。75th percentile免予抗凝及抗凝相关出血。CarboMedics533 patients;1975 to 1979Years after valve replacementValve Related DeathsSource:Heartjnl.,JACC:2000or瓣膜相关问题瓣膜相关问题 耐久性耐久性 需要抗凝需要抗凝 病人相关问题病人相关问题 预期寿命预期寿命Lif

18、e Expectancy 倾向性倾向性Patient Selection and Practice Patterns:Mechanical vs Bioprosthetic Aortic ValvesPerspective WestJoseph 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 st

19、ructural dysfunction or breakdown,and require no particular medical therapy such as anticoagulation.Needless to say,such a valve is yet to be available.”RecommendationsRecommendationsorProspective Randomized TrialsEvent-freeSurvivalComorbidities-severeValve-Related Complications75th percentileExplan

20、t forSVD“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 such as anticoagulation.VA Cooperative StudyHeart 2003;89:715-21.What i

21、s the actual likelihood and risk of reoperation?Freedom from Complications St.Mechanical prostheses,JACC:2000Free of ComplicationsBioprosthesisThe Cleveland ClinicYears after valve replacementRecommendationsHammermeister et al.Valve-Related ComplicationsProspective Randomized TrialsEdinburgh Heart V

22、alve Trial 533 patients;1975 to 1979 Bjork-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 Affairs Cooperative Study 575 patients;1977 to 1982 Bjork-Shiley vs.HancockHammeremister,et al.New Engl J Med 1993;328:12

23、89-96.Hammermeister,et al.J Am Coll Cardiol 2000;36:1152-8.Survival Edinburgh Heart Valve TrialMortalityVA Cooperative StudyValve-Related ComplicationsVA Cooperative StudyBleedingVA Cooperative StudyPrimary Valve FailureVA Cooperative StudyReoperationVA Cooperative StudyTissue vs.MechanicalAHA/ACC C

24、riteria 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.AgeBasis of AHA/ACC GuidelinesAvoid Risks of Warfarin ReoperationFor Individual Pat

25、ientWhat is the risk of warfarin?What is the actual likelihood and risk of reoperation?Mechanical Valve RiskPercent Per YearComorbidities-severeBjork-Shiley vs.Bjork-Shiley vs.Mechanical valves:Durability and patient mortality are superior with newer compared with older bioprostheses.,JACC:2000Recom

26、mendationsFree of ComplicationsProsthesis EvolutionRisks of Warfarin免予抗凝及抗凝相关出血。Patient Related Factors,JACC:2000533 patients;1975 to 1979Wittkowsky,Pharmacotherapy.Free of Complications533 patients;1975 to 1979Age vs INR Time of Major Bleeding75th percentile50th percentile25th percentileWittkowsky,

27、Pharmacotherapy.2004CarboMedicsSt.JudeMedtronic-Hall3.01.00.02.0P=.8FDA:OPCMech Valve ThrombosisReop/EndoFreedom from Complications St.Jude AVRBioprosthetic Valve RiskSurvival0204060801000369121502040608010003691215Competing Events05101520253003691215Explant for SVD45556575AgeBasis of AHA/ACC Guidel

28、ines 65-70 years:Mechanical prosthesisBioprosthesisNew Engl J Med 1993;328:1289-96.Comorbidities-severeBioprosthesesFor Individual PatientBjork-Shiley vs.,JACC:2000BioprosthesesVeterans Affairs Cooperative Study575 patients;1977 to 1982预期寿命Life ExpectancyAVR PopulationBioprosthesisNeedless to say,su

29、ch a valve is yet to be available.Edinburgh Heart Valve TrialFree of Complications533 patients;1975 to 1979VA Cooperative StudyGreater freedom from reoperationValve Reoperations Mortality20151050%Mort.CombinedIsolated199419961998200020022004Prosthesis EvolutionBioprosthesisImproved hemodynamicsAnti-

30、calcificationEnhanced durabilityMechanical prosthesesManagement of anticoagulationEvent-Free Life ExpectancyAortic Valve ReplacementRecommendations Valve ChoiceClinical situationPatient preferenceClinicalRecommendations Tissue ValveLimited life expectancyOlder AgeCAD-severeLV dysfunction-severeComor

31、bidities-severeIncreased bleeding riskClinicalRecommendations Mechanical ValveWarfarin for other indication 60 yearsPatient PreferenceQuality of LifeMechanical valves:Freedom from SVD Greater freedom from reoperation AnticoagulationBioprostheses:SVD and Reoperation.Freedom from anticoagulation and a

32、nticoagulation-related hemorrhageBioprosthesesMechanicalHomograft10080604020Aortic Valve Prostheses1995-2005100806040200802005 Isolated Aortic ValveProsthesis by AgeHumanRepairMechanicalBioprosthesesAVR PopulationAge 1980-1995 62 years 1996-2005 73 years70%of patients with CAD 15%of patients 65 year

33、sorValve Related Factors Durability Need for Anticoagulation Patient Related Factors Life Expectancy Preferences“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 requi

34、re no particular medical therapy such as anticoagulation.Needless to say,such a valve is yet to be available.”推荐推荐前瞻性随机研究前瞻性随机研究Edinburgh Heart Valve Trial 533 patients;1975 to 1979 Bjork-Shiley vs.porcine(Hancock,Carpentier-Edwards)Bloomfield,et al.New Engl J Med 1991;324:573-9.Oxenham,et al.Heart

35、2003;89:715-21.Veterans Affairs Cooperative Study 575 patients;1977 to 1982 Bjork-Shiley vs.HancockHammeremister,et al.New Engl J Med 1993;328:1289-96.Hammermeister,et al.J Am Coll Cardiol 2000;36:1152-8.生存率生存率 Edinburgh Heart Valve Trial再次手术再次手术VA Cooperative StudyAVR 人群人群年龄年龄 1980-1995 62 years 1996-2005 73 years70%合并冠心病合并冠心病 15%病人病人 65 yearsRecommendations