病人选择和操作方法机械瓣vs生物瓣主动脉瓣替换西方观点（英文）

病人选择和操作方法:

机械瓣vs生物瓣主动脉瓣替换

西方观点JosephF.Sabik,M.D.TheClevelandClinic“Theidealprostheticvalvewouldhaveexcellenthemodynamics(similartoanormalhumanvalveinthesameposition),lastalifetime,befreeofstructuraldysfunctionorbreakdown,andrequirenoparticularmedicaltherapysuchasanticoagulation.Needlesstosay,suchavalveisyettobeavailable.”推荐“新〞的好的瓣膜与“旧〞的好的瓣膜结果相似。生物瓣在老年病人中结构性瓣膜毁损率低。在>60to65病人是首选推荐新的生物瓣和机械瓣有更好的血流动力学。耐久性和病人死亡率比旧的生物瓣更好单纯根据病人年龄来决定采用什么瓣膜可能不能为个体病人作出正确的决策。or?前瞻性随机研究EdinburghHeartValveTrial533patients;1975to1979Bjork-Shileyvs.porcine(Hancock,Carpentier-Edwards)Bloomfield,etal.NewEnglJMed1991;324:573-9.Oxenham,etal.Heart2003;89:715-21.VeteransAffairsCooperativeStudy575patients;1977to1982Bjork-Shileyvs.HancockHammeremister,etal.NewEnglJMed1993;328:1289-96.Hammermeister,etal.JAmCollCardiol2000;36:1152-8.05101520Yearsafterrandomization100806040200Bjork-Shiley%PorcineSource:Heartjnl生存率

EdinburghHeartValveTrialP=0.391008060402000246810121416BioprosthesisMechanicalProsthesisYearsaftervalvereplacementMortality%Hammermeisteretal.,JACC:2000P=0.02死亡率VACooperativeStudy1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementAllValve-relatedComplications%Hammermeisteretal.,JACC:2000P=0.26Bioprosthesis瓣膜相关性并发症VACooperativeStudy1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementP=0.0001BioprosthesisBleeding%出血VACooperativeStudy1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementBleeding%Hammermeisteretal.,JACC:2000P=0.0001Bioprosthesis瓣膜功能障碍VACooperativeStudy1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementAllReoperations%Hammermeisteretal.,JACC:2000P=0.004Bioprosthesis再次手术VACooperativeStudy生物瓣vs.机械瓣

AHA/ACC标准

采用生物瓣的年龄标准是基于65岁以上病人结构性瓣膜毁损明显下降和出血风险明显升高决定的。年龄

主要的瓣膜选择标准≥65-70岁: 生物瓣<65-70岁: 机械瓣AHA/ACC指南防止华法林风险再次手术个体病人什么是华法林风险？什么是再次手术的风险？机械瓣风险年龄vsINR

出血的时间75thpercentile50thpercentile25thpercentileWittkowsky,Pharmacotherapy.2004Davidetal.1996.CarboMedicsSt.JudeMedtronic-Hall3.01.00.02.0P=.8FDA:OPCPercentPerYear机械瓣血栓形成FreeofComplicationsOtherDeathsBleedingTEReop/EndoValveRelatedDeaths100806040200051015YrsPostopZellner,AnnThoracSurg:1999免予并发症率

St.JudeAVR生物瓣风险Survival%Years96765226竞争事件%YearsEvent-free

SurvivalDeathbefore

ExplantExplantfor

SVD结构毁损而取出%Years45556575Age再次手术死亡率20151050%Mort.CombinedIsolated4.1%5.8%199419961998200020022004瓣膜演变生物瓣改善血流动力学抗钙化耐久性延长机械瓣抗凝药物治疗1614121086505560657075LEBioAgeofImplantationYearsSource:LEMechEFLEMechEFLEBioEvent-FreeLifeExpectancyAorticValveReplacementRecommendations

ValveChoiceClinicalsituationPatientpreferenceClinical

RecommendationsTissueValveLimitedlifeexpectancyOlderAgeCAD-severeLVdysfunction-severeComorbidities-severeIncreasedbleedingrisk临床建议-机械瓣华法林<60岁病人倾向性性

生活质量机械瓣:无结构毁损问题再次手术少抗凝生物瓣:结构毁损和再次手术免予抗凝及抗凝相关出血。BioprosthesesMechanicalHomograft10080604020主动脉瓣膜

1995-2005%199519971999200520012003100806040200<30 30-39 40-49 50-59 60-69 70-79 >802005单纯主动脉瓣—年龄Human Repair Mechanical BioprosthesesAge%AVR人群

年龄

1980-199562years1996-200573years70%合并冠心病<15%病人<65yearsor?瓣膜相关问题耐久性需要抗凝

病人相关问题预期寿命LifeExpectancy倾向性PatientSelectionandPracticePatterns:

MechanicalvsBioprostheticAorticValves

PerspectiveWestJosephF.Sabik,M.D.TheClevelandClinic“Theidealprostheticvalvewouldhaveexcellenthemodynamics(similartoanormalhumanvalveinthesameposition),lastalifetime,befreeofstructuraldysfunctionorbreakdown,andrequirenoparticularmedicaltherapysuchasanticoagulation.Needlesstosay,suchavalveisyettobeavailable.”RecommendationsOutcomeswith“new〞goodvalvesaresimilartothosewith“older〞goodvalves.BioprostheseshavealowrateofSVDintheolderpatientand…arethePHVofchoiceforAVRinpatients>60to65yearsofage.Recommendations

Newertissueandmechanicalprosthesesaffordsuperiorhemodynamics….Durabilityandpatientmortalityaresuperiorwithnewercomparedwitholderbioprostheses.Arbitrarycutoffsdictatingvalvechoicebasedonagemaynotgiveappropriateweighttoindividualpatientperspectives.or?ProspectiveRandomizedTrialsEdinburghHeartValveTrial533patients;1975to1979Bjork-Shileyvs.porcine(Hancock,Carpentier-Edwards)Bloomfield,etal.NewEnglJMed1991;324:573-9.Oxenham,etal.Heart2003;89:715-21.VeteransAffairsCooperativeStudy575patients;1977to1982Bjork-Shileyvs.HancockHammeremister,etal.NewEnglJMed1993;328:1289-96.Hammermeister,etal.JAmCollCardiol2000;36:1152-8.05101520Yearsafterrandomization100806040200Bjork-Shiley%PorcineSource:HeartjnlSurvival

EdinburghHeartValveTrialP=0.391008060402000246810121416BioprosthesisMechanicalProsthesisYearsaftervalvereplacementMortality%Hammermeisteretal.,JACC:2000P=0.02MortalityVACooperativeStudy1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementAllValve-relatedComplications%Hammermeisteretal.,JACC:2000P=0.26BioprosthesisValve-RelatedComplicationsVACooperativeStudy1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementP=0.0001BioprosthesisBleeding%BleedingVACooperativeStudy1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementBleeding%Hammermeisteretal.,JACC:2000P=0.0001BioprosthesisPrimaryValveFailureVACooperativeStudy1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementAllReoperations%Hammermeisteretal.,JACC:2000P=0.004BioprosthesisReoperationVACooperativeStudyTissuevs.Mechanical

AHA/ACCCriteria

Theageatwhichpatientsmaybeconsideredforbioprostheticvalvesisbasedonthemajorreductioninrateofstructuralvalvedeteriorationafterage65andtheincreasedriskofbleedinginthisagegroup.Age

MajorCriteriaforValveSelection≥65-70years: Tissueprosthesis<65-70years: MechanicalprosthesisBasisofAHA/ACCGuidelinesAvoidRisksofWarfarinReoperationForIndividualPatientWhatistheriskofwarfarin?Whatistheactuallikelihoodandriskofreoperation?MechanicalValveRiskAgevsINR

TimeofMajorBleeding75thpercentile50thpercentile25thpercentileWittkowsky,Pharmacotherapy.2004Davidetal.1996.CarboMedicsSt.JudeMedtronic-Hall3.01.00.02.0P=.8FDA:OPCPercentPerYearMechValveThrombosisFreeofComplicationsOtherDeathsBleedingTEReop/EndoValveRelatedDeaths100806040200051015YrsPostopZellner,AnnThoracSurg:1999FreedomfromComplications

St.JudeAVRBioprostheticValveRiskSurvival%Years96765226CompetingEvents%YearsEvent-free

SurvivalDeathbefore

ExplantExplantfor

SVDExplantforSVD%Years45556575AgeValveReoperationsMortality20151050%Mort.CombinedIsolated4.1%5.8%199419961998200020022004ProsthesisEvolutionBioprosthesisImprovedhemodynamicsAnti-calcificationEnhanceddurabilityMechanicalprosthesesManagementofanticoagulation1614121086505560657075LEBioAgeofImplantationYearsSource:LEMechEFLEMechEFLEBioEvent-FreeLifeExpectancyAorticValveReplacementRecommendations

ValveChoiceClinicalsituationPatientpreferenceClinical

RecommendationsTissueValveLimitedlifeexpectancyOlderAgeCAD-severeL