主动脉瓣移植的临床展望课件.ppt

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ValveProsthesis
Mechanical
types:caged-ball,tilting-disk,bi-leaflet
advantage:durability
limitation:thrombogenicity
Bioprosthetic
types:heterografts,homografts
advantage:shorttermanticoagulation
limitation:structuralfailure
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MechanicalValveProsthesis
Types
caged-ball(Starr-Edwards)
tilting-disk(Medtronic-Hall)
bileaflet(StJude)
Advantage:durability(1)
Limitation:thrombogenicity
;335:407-416
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BioprostheticHeterografts
advantage
longtermanticoagulationunnecessary(1)
limitation:structuralfailure
leafletcalcification&tissuedegenerationleadingtovalvularregurgitation
stenosisisuncommon
rateofporcinevalvedegeneration26%(aortic),39%(mitral)in10yrs(2)
;329:524-529
;49:370-383
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BioprostheticHomografts
1956-firstaorticvalvehomograftwasusedinthedescendingthoracicaortaforaorticregurgitation
1962-firstsub-coronaryuse
highincidenceofpost-opfailure*
(years) 5 10 15 20
survivalrate(%) 85 66 53 38
re-operation(%) 22 62 85 95
*Circulation1991;84(suppl3):III81-III88
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BioprostheticHomografts
earlypreservationtechniques
formaldehyde,chlorhexidine,propiolactone,ethyleneoxide,-irridiation,freezingat-70oC
graftsarenonviable
highincidenceofcusprupture
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BioprostheticHomograftsadvances
Improvingvalvedurability
newerpreservationtechniques:cryopreservationbyliquidnitrogenwithlow-doseantibiotics
homovitalgrafts(freshunpreserved)
reducedtimeforgraftprocurement
donorratherthanautopsyspecimens
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BioprostheticHomograftsUniversityofAlabama
1981-1991
cryopreservedaorticgraftsin178pts
survivalrate
91%at1year
85%at8years
freedomfromre-operation
95%at8years
JThoracCardiovascSurg1993;106:154-165
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BioprostheticHomograftsPrinceCharlesHsopital
1975-1994
cryopreservedaorticgraftsin680pts
%
survivalrate
77%at10year;45%at20years
freedomfromre-operation
69%at15years
O’;60:S65-S70
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HomovitalhomograftsLondon
graftsareharvested,storedintissueculturemedium,andusedin3days
275graftsimplantedover13years:147subcoronary,128aorticroot
notransmissionofdiseasereported
cumulativesurvival
85%at10yrs(94%intheaorticrootgp)
freedomfromre-op:91%in10yrs
JThoracCardiovascSurg1995;110:186-193
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BioprostheticHomograftsimplantationtechniques
Freehandscallopedtechnique
retentionofminimaldonortissue
technicallychallenging,requireexactsizingtopreventregurgitation
Cylindertechnique
retentionofnativeaorticsinusesandsinotubularjunction
requirescoronaryreimplantation
AnnThoracSurg1996;62:1069-1075