Università degli Studi di Messina
UOC di Cardiochirurgia
Azienda Ospedaliera Universitaria
Policlinico “G. Martino”
dir. Prof. Roberto Gaeta
PROTESI VALVOLARI
CARDIACHE
- corso integrato malattie apparato cardiovascolare e respiratorio -
Prof R Gaeta
Chirurgia Cardiaca (SSD Med 23)
PROTESI VALVOLARI
CARDIACHE
PALLA

ARTIFICIALI
DISCO
BIDISCO
AUTOLOGHE

BIOPROTESI
OMOLOGHE
ETEROLOGHE
PROTESI VALVOLARI CARDIACHE
ARTIFICIALI
STARR-EDWARDS
PALLA
MAGOVERN
SMELOFF-CUTTER
Kay Mitral Valve. Teflon
mitral valve prosthesis with
artificial chordae.
Implanted 1959
Original Starr-Edwards
Mitral Valve. Lucite cage.
Silastic rubber ball
occluder. Implanted 1960.
Braunwald Polyurethane mitral valve. First
mitral valve replacement on March 11, 1960.
Teflon chordae brought through the ventricular
muscle and secured outside the heart
Harken double
cage ball valve.
Implanted in 1960
Albert Starr, MD, Ph D
STARR - EDWARDS
STARR EDWARDS
MAGOVERN
SMELOFF-CUTTER
PROTESI VALVOLARI CARDIACHE
ARTIFICIALI
BEALL
MONODISCO
BJORK SHILEY
SORIN
MEDTRONIC HALL
LILLEHEI KASTER
BEALL
BJORK-SHILEY
BJORK-SHILEY
SORIN
MEDTRONIC HALL
LILLEHEI KASTER
PROTESI VALVOLARI CARDIACHE
ARTIFICIALI
ST. JUDE
BIDISCO
CARBOMEDICS
DUROMEDICS
SORIN
ST. JUDE
ST. JUDE
CARBOMEDICS
SORIN
Flow characteristics
ball/cage < tilting dic < bileaflet
Thrombogenic potential
ball/cage > tilting disc > bileaflet
Aortic < Mitral < both
PROTESI VALVOLARI
CARDIACHE
PALLA

ARTIFICIALI
DISCO
BIDISCO
AUTOLOGHE

BIOPROTESI
OMOLOGHE
ETEROLOGHE
PROTESI VALVOLARI CARDIACHE
BIOPROTESI
PERICARDICHE
AUTOLOGHE
FASCIA LATA
V. POLMONARE
(Intervento di ROSS)
PROTESI VALVOLARI CARDIACHE
STENTED
•PORCINE
BIOPROTESI
•PERICARDICHE
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
XENOGRAFT
C-E
HANCOCK
MITROFLOW
C-E
C-E
C-E
C-E
HANCOCK
HANCOCK
MITROFLOW
MITROFLOW
PROTESI VALVOLARI CARDIACHE
ARTIFICIALI
•ANTICOAGULAZIONE
•LUNGA DURATA
•RUMORE
Anticoagulation Management
(Machanical Prosthesis)
•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
PROTESI VALVOLARI CARDIACHE
BIOLOGICHE
•NO ANTICOAGULAZIONE
•DURATA MEDIA (10-12 anni)
•SILENZIOSE
PROTESI VALVOLARI CARDIACHE
•TROMBOEMBOLIA
•INFEZIONI
•LEAK
The Perfect Valve
•Excellent hemodynamics
•Non-thrombogenic
•Durable
•Unrestricted availability
•Easily implantable
•Silent function
•Low cost
Valvulopatia Mitralica
Anatomy and Pathology
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:
a. valvular leaflets
b. annulus
c. chordae tendinae
d. papillary muscles
e. 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 or perform valve repair/surgery
2. Aortic valve is composed of five separate
components:
a. valvular cusps
b. annulus
c. Valsalva’s sinus
d. sinus-tubular junction
e. Aortic root
Positions of the aortic valve leaflets at enddiastole and end-systole and of a single leaflet in
profile during ejection as the leaflet moves from
the closed position (0) to full opening. Note how
the fully opened leaflet tends to produce a
unifom 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
•Endocarditis related to intravenous drug use
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.
Mechanical
valved conduit
implantation.
A.
The
valve
and
proximal conduit are
sutured to the annulus
with everting, pledgeted
mattress sutures.
B. If necessary, the distal
aortic
layers
are
oversewn. C. A proximal
coronary button is sutured
to a hole made in the
prosthesis.
D. Completed graft with
both coronary arterial
buttons attached and the
distal
anastomosis
finished.
Reimplantation of the aortic valve
in patients with annuloaortic
ectasia and aortic root aneurysm.
(Reproduced with permission from
David TE, Feindel CM, Bos J.
Repair of the aortic valve in
patients with aortic insufficiency
and aortic root aneurysm. J
Thorac Cardiovasc Surg
1995;109:345–52.)
Reparativ
e aortic
valve
surgery.
Reproduced from Duran and
colleagues
Il futuro...