Cardiologia - protesi valvolari cardiache

PROTESI VALVOLARI CARDIACHE

BIOPROTESI PERICARDICHE

• FASCIA LATA AUTOLOGHE
• V. POLMONARE (Intervento di ROSS)

PROTESI VALVOLARI CARDIACHE STENTED

• PORCINE
• PERICARDICHE

BIOPROTESI STENTLESS

• PORCINE
• BOVINE
• AUOTGRAFT (PERICARDICHE OMOGRAFT)

Pulmonary Autograft (Ross Procedure- 1967)

Advantages

• Viable tissue, excellent hemodynamics
• Near 0% thromboembolism, growth potential
• Non-antigenic
• Pulmonary valve equal in strength as aortic valve

Disadvantage

• Creating 2-way valve pathology from single valve disease

Results

• Freedom from re-operation 81% at 8 years
• 5-10% annular dilatation and regurgitation
• Pulmonary homograft deterioration

Technique

• Root replacement preferred
• Tailoring of aortic/pulmonary size mismatch
• Bolstering ring with Dacron strip
• Long-term follow-up still accruing

The Ross Operation

PROTESI VALVOLARI CARDIACHE

BIOPROTESI OMOLOGHE HOMOGRAFT (cadavere)

HOMOGRAFT

• AORTIC HOMOGRAFT

Homograft implantation: the "root" technique

MITRAL Homograft

PROTESI VALVOLARI CARDIACHE

BIOPROTESI BOVINE

C-EXENOGRAFT

• ANTICOAGULAZIONE
• LUNGA DURATA
• RUMORE

• TIA is most common event
• Standardization of coagulation management (INR)
• Narrow therapeutic range: balance between thrombolic and bleeding risk
• ACCP recommendations: INR 2.5-3.5
• Aortic: 2.5-3.0
• Mitral: 3.0-3.5
• Both: 3.5-4.0
• Appropriate use of antiplatelet therapy

• NO ANTICOAGULAZIONE
• DURATA MEDIA (10-12 anni)
• SILENZIOSE

• TROMBOEMBOLIA
• INFEZIONI
• LEAK

• Excellent hemodynamics
• Non-thrombogenic
• Durable
• Unrestricted availability
• Easily implantable
• Silent function
• Low cost

1. Crucial to understand the anatomy of the mitral valve in order or perform valve repair/surgery
2. Mitral

   valve is composed of five separate components:

   1. valvular leaflets
   2. annulus
   3. chordae tendinae
   4. papillary muscles
   5. left ventricular wall

   Pathology:

   • Rheumatic Disease
   • Myxomatous Degeneration
   • Ischemic Valvulopaty
   • Endocarditis

   Rheumatic mitral stenosis

   Bacterial endocarditis on A2

   Surgical Options:

   • Valve replacement
   • Mortality 2-7%
   • Anticoagulation
   • Decrease LV EF
   • Valve Repair (always preferable – feasible in 70-90% of pts)
   • Mortality 2-3%
   • No anticoagulation
   • Preservation of LV EF

   Tecniche Riparative Mitraliche:

   • Riparazioni Anatomiche
   • Annulus
   • Lembi
   • Corde Tendinee
   • Muscoli Papillari
   • Riparazioni Funzionali

   The Quadrangular Resection Chordae Tendinae:

   • SHORTENING
   • REPLACEMENT
   • TRANSFER

   Galloway concludes: "The core concepts are: fix the leaflet pathology and remodel the annulus and you'll have a competent valve"

   Edge-To-Edge technique

   Valvulopatia Aortica Anatomy and Pathology:

   1. Crucial to understand

   The anatomy of the aortic valve in order to perform valve repair/surgery:

   1. Aortic valve is composed of five separate components:
      • Valvular cusps
      • Annulus
      • Valsalva's sinus
      • Sinus-tubular junction
      • Aortic root
   2. Positions of the aortic valve leaflets:
      • End-diastole
      • End-systole
      • Single leaflet in profile during ejection as the leaflet moves from the closed position (0) to full opening
   3. Note how the fully opened leaflet tends to produce a uniform diameter above the ventricular-arterial junction to reduce turbulence that otherwise would be increased by the sinuses of Valsalva.

   Pathology:

   • Congenital Malformation
   • Rheumatic Disease
   • Degeneration
   • Endocarditis

   Congenital Malformation:

   Quadricuspid aortic (Ao) valve and unicuspid pulmonary (P) valve. The asterisk indicates the additional (fourth) leaflet of the aortic valve. Native aortic valve demonstrating fusion of the anterior commissure between the left and noncoronary cusps. A small thrombus is present on the right.

   lunula of the left cusp.

   Calcified Aortic Stenosis (Congenital Malformation)

   • Congenitally bicuspid or unicuspid, fused commissures, heavy calcification, age 50-70

   Rheumatic Aortic lesions

   • Fibrous thickening
   • 3-cusp valve
   • mild calcification
   • rheumatic fever history in 50% aortic steno - insufficiency

   Degeneration

   • Diffuse nodular calcification
   • 3-cusp valve
   • no commissural fusion

   Macroscopic appearance of healed, fibrous commissural fusion between left coronary cusp (right, held by forceps) and noncoronary (left) cusp of aortic valve

   Endocarditis

   Infective endocarditis is defined as an infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium, or a septal defect. Endocarditis can be broken down into the following categories:

   • Native valve (acute and subacute) endocarditis
   • Prosthetic valve (early and late) endocarditis
   • useEndocarditis related to intravenous drug

   Parasternal short-axis view

   and its schematic drawing with color flow imaging from patient 1, showing perforation of the noncoronary cusp (N) of the aortic valve and aortic regurgitation (AR) after patch repair of an ostium primum atrial septal defect.

   Aortic valve excision

   Mechanical prosthesis implantation.