Valvular Heart Disease: No Longer the Realm of the Surgeon? Christopher Young St Thomas Hospital, London

Outline History, valve development and failure History, valve development and failure Surgical results and demographics Surgical results and demographics Minimal Access (including robotic) Minimal Access (including robotic) Lessons to be learnt from surgery Lessons to be learnt from surgery Summary and Conclusions Summary and Conclusions

History

Heart Valves

Tissue Fixation in Glutaraldehyde Originally – high pressure fixation Originally – high pressure fixation Moved to – Low pressure fixation Moved to – Low pressure fixation Became – Zero pressure fixation Became – Zero pressure fixation

Bioprosthetic Problem Solving Early Early Calcification Calcification Later valves Later valves Tissue engineering (composite valves / muscle bar) Tissue engineering (composite valves / muscle bar) Zero pressure fixation Zero pressure fixation Anti-calcification remedies Anti-calcification remedies Blue valves (toluidine blue) Blue valves (toluidine blue) Recent Valves Recent Valves Sorin Valves (amino acids) Sorin Valves (amino acids)

Significant Bioprosthetic Failures Dura Mater – abandoned Dura Mater – abandoned Fascia Lata – abandoned Fascia Lata – abandoned Ionescu-Shiley – abandoned Ionescu-Shiley – abandoned Autogenics - abandoned Autogenics - abandoned

Mechanism of Failure Biological – gradual failure Biological – gradual failure Mechanical – catastrophic Mechanical – catastrophic

Significant Failures Mechanical Mechanical Bjork-Shiley Bjork-Shiley Duromedics Duromedics Abrams Valve Abrams Valve

Significant Failures – Endovascular Stents Gore Tag Gore Tag Gore Thoracic Excluder ePTFE Deployment Sleeve (attached to stent structure) Self-expanding Nitinol Stent Structure ePTFE graft on blood-contact surface Radiopaque Band (both ends) Spine Structure for Columnar Support Flares for wall apposition Sealing Cuff (both ends) Sutureless Graft Attachment Product Description

Stentless Valve

Single Layer Stentless

3F Surgical Valve

Surgical Results

Data from 5th National Adult Cardiac Surgical Database Report

Surgical Progress

Minimal Access

Minimal Access Semi-continuous

Minimal Access AVR

Minimal Access – Aortic Root

Minimally Invasive Valve Replacement Percutaneous peripheral cannulation Percutaneous peripheral cannulation Heartport techniques Heartport techniques Mini-sternotomy Mini-sternotomy Mini anterior thoracotomy Mini anterior thoracotomy Surgery under epidural anaesthesia Surgery under epidural anaesthesia

Robotic Aortic Surgery 5 patients (3M/2F; 35 – 81 years) 5 patients (3M/2F; 35 – 81 years) 4 calcific AS / 1 AR 4 calcific AS / 1 AR Transverse incision 4-5 cm R 3 rd IC space Transverse incision 4-5 cm R 3 rd IC space Standard interrupted suture technique Standard interrupted suture technique No mortality/complications No mortality/complications Mean hospital stay 8.6±3 days Mean hospital stay 8.6±3 days Folliguet et al. EJCTS 28 (2005):

Robotic Aortic Surgery Da Vinci Surgical system Da Vinci Surgical system No mortality/complications No mortality/complications Mean CPB mins Mean CPB mins Mean XC mins Mean XC mins Mean ITU stay days Mean ITU stay days Mean hospital stay days Mean hospital stay days Folliguet et al. EJCTS 28 (2005):

Minimal Access Mitral Repair Port access CPB Endoclamp Multiple small incisions No rib spreading

Minimally Invasive vs Conventional Valve Replacement Overall majority of reported results similar Overall majority of reported results similar Death Death Length of stay Length of stay Complication rates Complication rates Minor negative aspects of: Minor negative aspects of: Longer X clamp times Longer X clamp times Longer bypass times Longer bypass times Increased early post-operative pain Increased early post-operative pain

Minimally Invasive vs Conventional Valve Replacement Some reports of improved outcome with keyhole approach Some reports of improved outcome with keyhole approach Lower risk redo operations Lower risk redo operations Aortic vascular procedures Aortic vascular procedures Lower transfusion requirements Lower transfusion requirements Lower incidence post-operative AF Lower incidence post-operative AF Lower post-operative pain after day 2 Lower post-operative pain after day 2

Off-Pump Valve Repair Treatment of functional ischaemic MR Treatment of functional ischaemic MR Coapsys device consists of 2 epicardial pads Coapsys device consists of 2 epicardial pads Pads then connected with flexible chord Pads then connected with flexible chord Placement TOE guided Placement TOE guided MR reduced from grade 2.7±0.8 – 0.4±0.7 MR reduced from grade 2.7±0.8 – 0.4±0.7 Grossi et al Ann Thorac Surg 2005; 80:

Surgical Problems (Cardiological Problems?)

Valve excision

Heavily calcified annulus Crush the calcium first Crush the calcium first Metal sucker Metal sucker Irrigate copiously Irrigate copiously Look for annular tears / damage Look for annular tears / damage Avoid stentless valves Avoid stentless valves ?Everting mattress sutures ?Everting mattress sutures

The small annulus A tight squeeze

Small annulus Good exposure from retraction sutures Good exposure from retraction sutures Position light and table Position light and table Enthusiastic excision / decalcification Enthusiastic excision / decalcification Do not oversize valve Do not oversize valve Consider supra-annular placement Consider supra-annular placement Do NOT use everting mattress sutures Do NOT use everting mattress sutures (Root enlargement) (Root enlargement)

The Big Annulus

Summary 1 Valve technology has evolved over 45 years with significant failures along the way (including recently) Valve technology has evolved over 45 years with significant failures along the way (including recently) Surgical results are excellent with increasing emphasis on minimal access Surgical results are excellent with increasing emphasis on minimal access

Summary 2 Increasingly elderly population with more calcific disease Increasingly elderly population with more calcific disease Surgical anatomy/pathology is varied; a one size fits all approach will not work Surgical anatomy/pathology is varied; a one size fits all approach will not work How long will the devices last and how will they fail? How long will the devices last and how will they fail?

Conclusions Proceed carefully! If things go pear-shaped Ring us – as usual, we will always be there to bail you out! This time, however, it may not be enough