2. Mechanical
Bileaflet eg St Jude Medical, Carbomedics
Tilting disc/Single disc eg Medtronic Hall
Ball cage eg Star Edwards
Bioprosthesis /Tissue
Stented Porcine –Medtronic Hancock
, Carpentier- Edwards
Stentless Porcine -St. Jude Medical Toronto
SPV , Medtronic Mosaic
Pericardial bovine Carpentier-Edwards
Perimount
3.
4.
5.
6. Cadavers –within 24 hours
Subcoronary position or the valve and a
portion of attached aorta are implanted as a
root replacement with reimplantation of
coronary arteries into the graft.
Advantages
superior hemodynamic, low
thrombogenicity, avoidance of early
endocarditis
Disadvantages
Higher SVD, prone to calcification, prosthetic
AR
7. Pts own pulmonary valve and adjacent main
pulm artery-removed-replace diseased aortic
valve with implantation of the coronary
arteries into the graft
Human pulm or aortic homograft inserted
into pulm position
8. Advantage
endocarditis risk low ,durable
Disadvantage
pulmon homograft stenosis (postop
inflammatory reaction)
should not be performed in bicuspid aortic
vavle and dilated aortic roots
Choice-children , adults of life
expectancy>20yrs and women who wish to
become pregnant
9. Bileaflet valve are the most commonly
implanted mechanical valve
Low bulk
Flat profile
Superior hemodynamic
10. Heart sounds
The closure of the mechanical valve accentuates
the normal heart sound and the intensity of the
sound is proportional to the mass of the closure
device in the prosthetic valve
Lack of accentuation of the opening or closure
sound of the valve suggests an abnormality, such
as the presence of thrombus, vegetation or
pannus and should be investigated.
11. Opening is always less intense than closure
If there are 2 prosthetic valve all mechanical
heart sounds are loud
Opening and closing are high frequency
sounds and should be differentiated from S3
and S4
Complete absence of an opening sound in a
patient with a disk or bileaflet is not unusual
such as heavy built or hyperinflated lung
12. Prosthetic aortic valves
Systolic ejection murmer-prosthetic valve effective
area is less than that of native valve, thus there is a
mild inherent aortic stenosis
Absenc of SEM
low cardiac output
hyperinflated lungs
Abnormality of prosthetic valve
Diastolic murmur-perivalvular leak or valvular
regurgitation, thrombus
13. Mitral valve
Usually do not produce murmurs.
Occasionally low freq rumble in mid diastole in
thin persons and due to smaller effective
size.
A holosystolic murmur-malfunction of valve or
perivalvular leak.
Any murmur with a mechanical tricuspid valve
should prompt an investigation for etiology
14. Type of AORTIC PROSTHESI MITRAL PROSTHESI
valve S S
Normal Abnormal Normal Abnormal
findings findings findings findings
Bileaflet (St. Aortic High
Jude cc diastolic OC frequency
medical) S1OC murmur holosystoli
Decreased c murmur
intensity of Decreased
SEM p2 closing s2 DM intensity of
click CC closing
click
15. Mechanical valve
Warfarin should begin 2 days after operation
Aortic valve –target INR 2-3 if no risk factors
If higher risk for thrombosis eg AF,previous
thromboembolism target INR 2.5-3.5
For all valves in the mitral position target INR
2.5-3.5
Low dose aspirin 75-100mg
16. Bioprosthetic valve
During first 3 post op months while the
sewing ring becomes endothelized there is
risk of thrombosis so warfarin is given
If no risk factors present then warfarin not
given
If risk factors –previous embolism,thrombus
in the left atrium at operation, remain in AF
postoperatively ,need for anticoagulaion
persists
17.
18. Aortic valve replacement
Class 1
Mechanical prosthesis in patients with a
mechanical valve in the mitral or tricuspid
position
Bioprosthesis in patients of any age who will
not take warfarin or who have major medical
contraindications to warfarin therapy
19. Class 2a
Patient consideration is a reasonable
consideration in the selection of valve
prosthesis. Mechanical prosthesis is
reasonable for AVR in pts <65yrs who do not
have contraindication to anticoagulation
20. Cont….
A bioprosthesis is reasonable for AVR in
patients <65yr who elect to receive this valve
for lifestyle considerations after detiled
discussions of the risks of
anticoagulantversus the likelyhood that a
second AVR may be neede in the future
21. Cont…
Bioprosthesis is reasonable for patients
>=65yr without risk factors for
thromboembolism
Homograft is reasonable for patients
undergoing repeat AVR with active prosthetic
valve endocarditis
23. Mitral valve replacement
Class1
Bioprosthesis in patients who will not take
warfarin, is incapable of taking warfarin, or
has clear contraindication to warfarin therapy
24. Class 2a
Mechanical prosthesis reasonable for patients
<65yr with longstanding AF
Bioprosthesis is reasonable in patients
>=65yr
25. Bioprosthesis reasonable for patients
<65yrin sinus rhythym who elect to receive
this valve for life style considerations after
detailed discussions of the risks of
anticoagulation versus the likelyhood that a
second MVR replacement may be necessary in
future.
26.
27.
28.
29. Prosthetic endocarditis
Prosthetic dehiscence
Prosthetic dysfunction -
Obstruction: usually thrombotic
Regurgitation
Hemolysis
Structural failure
Thromboemboli
Hemorrhage with anticoagulant therapy
Valve prosthesis–patient mismatch
Prosthetic replacement
Late mortality, including sudden, unexplained death
32. Palpation
Thrill
Bifid apical impulse
New right or left ventricular heaves
Auscultation
Decreased intensity of valve closure sound
Loss of previous heard opening sounds
New gallops
Systolic murmur with mitral prosthesis
Any diastolic murmur
General
Prolonged fever without obvious source
Embolic phenomenon
33. First outpatient postop visit 3-4 week after
hospital discharge for baseline assessment of
valve function and left ventricular remodelling
New regurgitant murmur
Development of new or changing
cardiovascular symptoms
Lack of improvement or deterioration of
functional capacity or cardiovascular
symptoms after valve replacement
34. Every 6 month in asymptomatic patients with
bioprosthetic valve degeneration and >=mild
regurgitation
Patients with suspected valve obstruction
caused by thrombus or pannus growth
Patients with suspected PVE
35. All patients with PHV need appropriate
antibiotics for prophylaxis against infective
endocarditis
Patients with rheumatic heart disease
continue to need antibiotics as prophylaxis
against the recurrence of rheumatic carditis
Adequate antithrombotic therapy is needed
for appropriate patients
36. Several syndromes are peculiar to the postoperative
period.
• Postperfusion syndrome
3rd or 4th postoperative week.
fever, splenomegaly, and atypical lymphocytes;
benign and self-limited.
• Postpericardiotomy syndrome
fever and pleuropericarditis.
2nd and 3rd postoperative week, but can appear as late
as 1 year after surgery
self-limited, most patients benefit from taking
antiinflammatory drugs
• Even though the pericardium is left open at the
end of surgery, cardiac tamponade has been known to
occur during the first 6 weeks and needs to be relieved.
