“Theidealprostheticvalvewouldhaveexcellenthemodynamics(similartoanormalhumanvalveinthesameposition),lastalifetime,befreeofstructuraldysfunctionorbreakdown,andrequirenoparticularmedicaltherapysuchasanticoagulation.Needlesstosay,suchavalveisyettobeavailable.”“Theidealprostheticvalvewo病人選擇和操作方法機械瓣vs生物瓣主動脈瓣替換西方觀點英文課件推薦“新”的好的瓣膜與“舊”的好的瓣膜結(jié)果相似。生物瓣在老年病人中結(jié)構(gòu)性瓣膜毀損率低。在>60to65病人是首選推薦“新”的好的瓣膜與“舊”的好的瓣膜結(jié)果相似。生物瓣在病人選擇和操作方法機械瓣vs生物瓣主動脈瓣替換西方觀點英文課件推薦新的生物瓣和機械瓣有更好的血流動力學(xué)。耐久性和病人死亡率比舊的生物瓣更好單純根據(jù)病人年齡來決定采用什么瓣膜可能不能為個體病人作出正確的決策。推薦新的生物瓣和機械瓣有更好的血流動力學(xué)。耐久性和病人or?or?前瞻性隨機研究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.前瞻性隨機研究EdinburghHeartValveTReoperationBloomfield,etal.BioprostheseshavealowrateofSVDintheolderpatientand…arethePHVofchoiceforAVRinpatients>60to65yearsofage.Durabilityandpatientmortalityaresuperiorwithnewercomparedwitholderbioprostheses.<65-70years: MechanicalprosthesisValveRelatedDeathsFreedomfromComplications

St.Clinical

RecommendationsMechanicalValveDurabilityandpatientmortalityaresuperiorwithnewercomparedwitholderbioprostheses.耐久性和病人死亡率比舊的生物瓣更好單純根據(jù)病人年齡來決定采用什么瓣膜可能不能為個體病人作出正確的決策。,JACC:2000Hammermeisteretal.Comorbidities-severeporcine(Hancock,Carpentier-Edwards)NewEnglJMed1993;328:1289-96.機械瓣

AHA/ACC標準“Theidealprostheticvalvewouldhaveexcellenthemodynamics(similartoanormalhumanvalveinthesameposition),lastalifetime,befreeofstructuraldysfunctionorbreakdown,andrequirenoparticularmedicaltherapysuchasanticoagulation.在>60to65病人是首選BioprosthesisManagementofanticoagulation05101520Yearsafterrandomization100806040200Bjork-Shiley%PorcineSource:H生存率

EdinburghHeartValveTrialP=0.39Reoperation05101520Yearsafter1008060402000246810121416BioprosthesisMechanicalProsthesisYearsaftervalvereplacementMortality%Hammermeisteretal.,JACC:2000P=0.02死亡率VACooperativeStudy1000246810121416BioprosthesisMNeedforAnticoagulationHammermeisteretal.Event-FreeLifeExpectancyBioprosthesis新的生物瓣和機械瓣有更好的血流動力學(xué)。Clinical

RecommendationsMechanicalValve50thpercentileForIndividualPatientExplantfor

SVDBjork-Shileyvs.ValveRelatedDeathsSource:Heartjnl.耐久性和病人死亡率比舊的生物瓣更好單純根據(jù)病人年齡來決定采用什么瓣膜可能不能為個體病人作出正確的決策。Theageatwhichpatientsmaybeconsideredforbioprostheticvalvesisbasedonthemajorreductioninrateofstructuralvalvedeteriorationafterage65andtheincreasedriskofbleedinginthisagegroup.EdinburghHeartValveTrialEvent-FreeLifeExpectancyBjork-Shiley在>60to65病人是首選1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementAllValve-relatedComplications%Hammermeisteretal.,JACC:2000P=0.26Bioprosthesis瓣膜相關(guān)性并發(fā)癥VACooperativeStudyNeedforAnticoagulation1000241008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementP=0.0001BioprosthesisBleeding%出血VACooperativeStudy1000246810121416MechanicalYear1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementBleeding%Hammermeisteretal.,JACC:2000P=0.0001Bioprosthesis瓣膜功能障礙VACooperativeStudy1000246810121416MechanicalYear1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementAllReoperations%Hammermeisteretal.,JACC:2000P=0.004Bioprosthesis再次手術(shù)VACooperativeStudy1000246810121416MechanicalYear生物瓣vs.機械瓣

AHA/ACC標準

采用生物瓣的年齡標準是基于65歲以上病人結(jié)構(gòu)性瓣膜毀損明顯下降和出血風險明顯升高決定的。生物瓣vs.機械瓣

AHA/ACC標準采用生年齡

主要的瓣膜選擇標準≥65-70歲: 生物瓣<65-70歲: 機械瓣年齡

主要的瓣膜選擇標準≥65-70歲: 生物瓣AHA/ACC指南避免

華法林風險再次手術(shù)個體病人什么是華法林風險？什么是再次手術(shù)的風險？AHA/ACC指南個體病人機械瓣風險機械瓣風險年齡vsINR

出血的時間75thpercentile50thpercentile25thpercentileWittkowsky,Pharmacotherapy.2004年齡vsINR

出血的時間75thpercentilDavidetal.1996.CarboMedicsSt.JudeMedtronic-Hall3.01.00.02.0P=.8FDA:OPCPercentPerYear機械瓣血栓形成Davidetal.1996.CarboMedicsSFreeofComplicationsOtherDeathsBleedingTEReop/EndoValveRelatedDeaths100806040200051015YrsPostopZellner,AnnThoracSurg:1999免予并發(fā)癥率

St.JudeAVRFreeofComplicationsOtherDea生物瓣風險生物瓣風險RecommendationsPatientPreference

QualityofLifeBjork-Shileyvs.ValveRelatedDeathsYearsafterrandomization533patients;1975to1979,JACC:2000<15%病人<65yearsBjork-ShileyNewEnglJMed1991;324:573-9.Yearsaftervalvereplacement生存率

EdinburghHeartValveTrial“Theidealprostheticvalvewouldhaveexcellenthemodynamics(similartoanormalhumanvalveinthesameposition),lastalifetime,befreeofstructuraldysfunctionorbreakdown,andrequirenoparticularmedicaltherapysuchasanticoagulation.VACooperativeStudy在>60to65病人是首選Comorbidities-severe50thpercentileRecommendationsHammermeisteretal.YearsaftervalvereplacementNeedlesstosay,suchavalveisyettobeavailable.Survival%Years96765226RecommendationsSurvival%Years9競爭事件%YearsEvent-free

SurvivalDeathbefore

ExplantExplantfor

SVD競爭事件%YearsEvent-free

SurvivalD結(jié)構(gòu)毀損而取出%Years45556575Age結(jié)構(gòu)毀損而取出%Years45556575Age再次手術(shù)死亡率20151050%Mort.CombinedIsolated4.1%5.8%199419961998200020022004再次手術(shù)死亡率20%CombinedIsolated4.1%瓣膜演變生物瓣改善血流動力學(xué)抗鈣化耐久性延長機械瓣抗凝藥物治療瓣膜演變生物瓣1614121086505560657075LEBioAgeofImplantationYearsLEMechEFLEMechEFLEBioEvent-FreeLifeExpectancyAorticValveReplacement16505560657075LEBioAgeofImpRecommendations

ValveChoiceClinicalsituationPatientpreferenceRecommendations

ValveChoiceCOutcomeswith“new”goodvalvesaresimilartothosewith“older”goodvalves.RisksofWarfarin,JACC:2000MechanicalprosthesesDeathbefore

ExplantBioprosthesis,JACC:2000Bjork-Shileyvs.Bloomfield,etal.,JACC:2000免予并發(fā)癥率

St.“Theidealprostheticvalvewouldhaveexcellenthemodynamics(similartoanormalhumanvalveinthesameposition),lastalifetime,befreeofstructuraldysfunctionorbreakdown,andrequirenoparticularmedicaltherapysuchasanticoagulation.RecommendationsBioprostheseshavealowrateofSVDintheolderpatientand…arethePHVofchoiceforAVRinpatients>60to65yearsofage.FreeofComplicationsporcine(Hancock,Carpentier-Edwards)Oxenham,etal.Explantfor

SVDAorticValveReplacement<15%病人<65yearsClinical

RecommendationsTissueValveLimitedlifeexpectancyOlderAgeCAD-severeLVdysfunction-severeComorbidities-severeIncreasedbleedingriskOutcomeswith“new”goodvalveValveRelatedDeathsRecommendationsAllReoperations%AorticValveReplacementEvent-free

SurvivalVACooperativeStudyFreeofComplications“新”的好的瓣膜與“舊”的好的瓣膜結(jié)果相似。PrimaryValveFailureFreeofComplicationsDurabilityandpatientmortalityaresuperiorwithnewercomparedwitholderbioprostheses.Outcomeswith“new”goodvalvesaresimilartothosewith“older”goodvalves.SVDandReoperation.ValveRelatedFactorsYearsaftervalvereplacementYearsaftervalvereplacementBioprosthesisHammermeisteretal.VACooperativeStudyAllValve-relatedComplications臨床建議-機械瓣華法林<60歲ValveRelatedDeaths臨床建議-機械瓣華法病人傾向性性

生活質(zhì)量機械瓣:無結(jié)構(gòu)毀損問題再次手術(shù)少抗凝生物瓣:結(jié)構(gòu)毀損和再次手術(shù)免予抗凝及抗凝相關(guān)出血。病人傾向性性

生活質(zhì)量機械瓣:BioprosthesesMechanicalHomograft10080604020主動脈瓣膜

1995-2005%199519971999200520012003Bioprostheses100主動脈瓣膜

1995-200100806040200<30 30-39 40-49 50-59 60-69 70-79 >802005單純主動脈瓣—年齡Human Repair Mechanical BioprosthesesAge%100<30 30-39 40-49 50-59 60-69AVR人群

年齡

1980-199562years1996-200573years70%合并冠心病<15%病人<65yearsAVR人群 年齡LVdysfunction-severe預(yù)期壽命LifeExpectancyHammermeisteretal.NewEnglJMed1993;328:1289-96.Valve-RelatedComplicationsEvent-FreeLifeExpectancyNeedforAnticoagulationBjork-Shileyvs.50thpercentileOxenham,etal.Clinical

RecommendationsMechanicalValve耐久性和病人死亡率比舊的生物瓣更好單純根據(jù)病人年齡來決定采用什么瓣膜可能不能為個體病人作出正確的決策。75thpercentile免予抗凝及抗凝相關(guān)出血。CarboMedics533patients;1975to1979YearsaftervalvereplacementValveRelatedDeathsSource:Heartjnl.,JACC:2000or?LVdysfunction-severeor?瓣膜相關(guān)問題耐久性需要抗凝

病人相關(guān)問題預(yù)期壽命LifeExpectancy傾向性瓣膜相關(guān)問題病人選擇和操作方法機械瓣vs生物瓣主動脈瓣替換西方觀點英文課件PatientSelectionandPracticePatterns:

MechanicalvsBioprostheticAorticValves

PerspectiveWestJosephF.Sabik,M.D.TheClevelandClinicPatientSelectionandPractice“Theidealprostheticvalvewouldhaveexcellenthemodynamics(similartoanormalhumanvalveinthesameposition),lastalifetime,befreeofstructuraldysfunctionorbreakdown,andrequirenoparticularmedicaltherapysuchasanticoagulation.Needlesstosay,suchavalveisyettobeavailable.”“Theidealprostheticvalvewo病人選擇和操作方法機械瓣vs生物瓣主動脈瓣替換西方觀點英文課件Recommendations

Outcomeswith“new”goodvalvesaresimilartothosewith“older”goodvalves.BioprostheseshavealowrateofSVDintheolderpatientand…arethePHVofchoiceforAVRinpatients>60to65yearsofage.RecommendationsOutcomeswith病人選擇和操作方法機械瓣vs生物瓣主動脈瓣替換西方觀點英文課件Recommendations

Newertissueandmechanicalprosthesesaffordsuperiorhemodynamics….Durabilityandpatientmortalityaresuperiorwithnewercomparedwitholderbioprostheses.Arbitrarycutoffsdictatingvalvechoicebasedonagemaynotgiveappropriateweighttoindividualpatientperspectives.RecommendationsNewertissueor?or?ProspectiveRandomizedTrialsEvent-free

SurvivalComorbidities-severeValve-RelatedComplications75thpercentileExplantfor

SVD“Theidealprostheticvalvewouldhaveexcellenthemodynamics(similartoanormalhumanvalveinthesameposition),lastalifetime,befreeofstructuraldysfunctionorbreakdown,andrequirenoparticularmedicaltherapysuchasanticoagulation.VACooperativeStudyHeart2003;89:715-21.Whatistheactuallikelihoodandriskofreoperation?FreedomfromComplications

St.Mechanicalprostheses,JACC:2000FreeofComplicationsBioprosthesisTheClevelandClinicYearsaftervalvereplacementRecommendationsHammermeisteretal.Valve-RelatedComplicationsProspectiveRandomizedTrialsEdinburghHeartValveTrial533patients;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.ProspectiveRandomizedTrialsP05101520Yearsafterrandomization100806040200Bjork-Shiley%PorcineSource:HSurvival

EdinburghHeartValveTrialP=0.3905101520Yearsafterrandomizat1008060402000246810121416BioprosthesisMechanicalProsthesisYearsaftervalvereplacementMortality%Hammermeisteretal.,JACC:2000P=0.02MortalityVACooperativeStudy1000246810121416BioprosthesisM1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementAllValve-relatedComplications%Hammermeisteretal.,JACC:2000P=0.26BioprosthesisValve-RelatedComplicationsVACooperativeStudy1000246810121416MechanicalYear1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementP=0.0001BioprosthesisBleeding%BleedingVACooperativeStudy1000246810121416MechanicalYear1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementBleeding%Hammermeisteretal.,JACC:2000P=0.0001BioprosthesisPrimaryValveFailureVACooperativeStudy1000246810121416MechanicalYear1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementAllReoperations%Hammermeisteretal.,JACC:2000P=0.004BioprosthesisReoperationVACooperativeStudy1000246810121416MechanicalYearTissuevs.Mechanical

AHA/ACCCriteria

Theageatwhichpatientsmaybeconsideredforbioprostheticvalvesisbasedonthemajorreductioninrateofstructuralvalvedeteriorationafterage65andtheincreasedriskofbleedinginthisagegroup.Tissuevs.Mechanical

AHA/ACCAge

MajorCriteriaforValveSelection≥65-70years: Tissueprosthesis<65-70years: MechanicalprosthesisAge

MajorCriteriaforValveSBasisofAHA/ACCGuidelinesAvoidRisksofWarfarinReoperationForIndividualPatientWhatistheriskofwarfarin?Whatistheactuallikelihoodandriskofreoperation?BasisofAHA/ACCGuidelinesForMechanicalValveRiskMechanicalValveRiskPercentPerYearComorbidities-severeBjork-Shileyvs.Bjork-Shileyvs.Mechanicalvalves:Durabilityandpatientmortalityaresuperiorwithnewercomparedwitholderbioprostheses.,JACC:2000RecommendationsFreeofComplicationsProsthesisEvolutionRisksofWarfarin免予抗凝及抗凝相關(guān)出血。PatientRelatedFactors,JACC:2000533patients;1975to1979Wittkowsky,Pharmacotherapy.FreeofComplications533patients;1975to1979AgevsINR

TimeofMajorBleeding75thpercentile50thpercentile25thpercentileWittkowsky,Pharmacotherapy.2004PercentPerYearAgevsINR

TiDavidetal.1996.CarboMedicsSt.JudeMedtronic-Hall3.01.00.02.0P=.8FDA:OPCPercentPerYearMechValveThrombosisDavidetal.1996.CarboMedicsSFreeofComplicationsOtherDeathsBleedingTEReop/EndoValveRelatedDeaths100806040200051015YrsPostopZellner,AnnThoracSurg:1999FreedomfromComplications

St.JudeAVRFreeofComplicationsOtherDeaBioprostheticValveRiskBioprostheticValveRiskSurvival%Years96765226Survival%Years96765226CompetingEvents%YearsEvent-free

SurvivalDeathbefore

ExplantExplantfor

SVDCompetingEvents%YearsEvent-frExplantforSVD%Years45556575AgeExplantforSVD%Years45556575ABasisofAHA/ACCGuidelines<65-70years: MechanicalprosthesisBioprosthesisNewEnglJMed1993;328:1289-96.Comorbidities-severeBioprosthesesForIndividualPatientBjork-Shileyvs.,JACC:2000BioprosthesesVeteransAffairsCooperativeStudy575patients;1977to1982預(yù)期壽命LifeExpectancyAVRPopulationBioprosthesisNeedlesstosay,suchavalveisyettobeavailable.EdinburghHeartValveTrialFreeofComplications533patients;1975to1979VACooperativeStudyGreaterfreedomfromreoperationValveReoperationsMortality20151050%Mort.CombinedIsolated4.1%5.8%199419961998200020022004BasisofAHA/ACCGuidelinesValProsthesisEvolutionBioprosthesisImprovedhemodynamicsAnti-calcificationEnhanceddurabilityMechanicalprosthesesManagementofanticoagulationProsthesisEvolutionBioprosthe1614121086505560657075LEBioAgeofImplantationYearsLEMechEFLEMechEFLEBioEvent-FreeLifeExpectancyAorticValveReplacement16505560657075LEBioAgeofImpRecommendations

ValveChoiceClinicalsituationPatientpreferenceRecommendations

ValveChoiceCClinical

RecommendationsTissueValveLimitedlifeexpectancyOlderAgeCAD-severeLVdysfunction-severeComorbidities-severeIncreasedbleedingriskClinical

RecommendationsTissuClinical

RecommendationsMechanicalValveWarfarinforotherindication<60yearsClinical

RecommendationsMechaPatientPreference

QualityofLifeMechanicalvalves:FreedomfromSVDGreaterfreedomfromreoperationAnticoagulationBioprostheses:SVDandReoperation.Freedomfromanticoagulationandanticoagulation-relatedhemorrhagePatientPreference

QualityofBioprosthesesMechanicalHomograft10080604020AorticValveProstheses

1995-2005%199519971999200520012003Bioprostheses100AorticValveP100806040200<30 30-39 40-49 50-59 60-69 70-79 >802005IsolatedAorticValve

ProsthesisbyAgeHuman Repair Mechanical BioprosthesesAge%100<30 30-39 40-49 50-59 60-69AVRPopulation Age1980-199562years1996-200573years70%ofpatientswithCAD<15%ofpatients<65yearsAVRPopulation Ageor?or?ValveRelatedFactorsDurabilityNeedforAnticoagulationPatientRelatedFactorsLifeExpectancyPreferencesValveRelatedFactors“Theidealprostheticvalvewouldhaveexcellenthemodynamics(similartoanormalhumanvalveinthesameposition),lastalifetime,befreeofstructuraldysfunctionorbreakdown,andrequirenoparticularmedicaltherapysuchasanticoagulation.Needlesstosay,suchavalveisyettobeavailable.”“Theidealprostheticvalvewo推薦新的生物瓣和機械瓣有更好的血流動力學(xué)。耐久性和病人死亡率比舊的生物瓣更好單純根據(jù)病人年齡來決定采用什么瓣膜可能不能為個體病人作出正確的決策。推薦新的生物瓣和機械瓣有更好的血流動力學(xué)。耐久性和病人前瞻性隨機研究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.前瞻性隨機研究EdinburghHeartValveT05101520Yearsafterrandomization100806040200Bjork-Shiley%PorcineSource:H生存率

EdinburghHeartValveTrialP=0.3905101520Yearsafterrandomizat1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementAllReoperations%Hammermeisteretal.,JACC:2000P=0.004Bioprosthesis再次手術(shù)VACooperativeStudy1000246810121416MechanicalYearAVR人群

年齡

1980-199562years1996-200573years70%合并冠心病<15%病人<65yearsAVR人群 年齡病人選擇和操作方法機械瓣vs生物瓣主動脈瓣替換西方觀點英文課件Recommendations

Outcomeswith“new”goodvalvesaresimilartothosewith“older”goodvalves.BioprostheseshavealowrateofSVDintheolderpatientand…arethePHVofchoiceforAVRinpatients>60to65yearsofage.RecommendationsOutcomeswith“Theidealprostheticvalvewouldhaveexcellenthemodynamics(similartoanormalhumanvalveinthesameposition),lastalifetime,befreeofstructuraldysfunctionorbreakdown,andrequirenoparticularmedicaltherapysuchasanticoagulation.Needlesstosay,suchavalveisyettobeavailable.”“Theidealprostheticvalvewo病人選擇和操作方法機械瓣vs生物瓣主動脈瓣替換西方觀點英文課件推薦“新”的好的瓣膜與“舊”的好的瓣膜結(jié)果相似。生物瓣在老年病人中結(jié)構(gòu)性瓣膜毀損率低。在>60to65病人是首選推薦“新”的好的瓣膜與“舊”的好的瓣膜結(jié)果相似。生物瓣在病人選擇和操作方法機械瓣vs生物瓣主動脈瓣替換西方觀點英文課件推薦新的生物瓣和機械瓣有更好的血流動力學(xué)。耐久性和病人死亡率比舊的生物瓣更好單純根據(jù)病人年齡來決定采用什么瓣膜可能不能為個體病人作出正確的決策。推薦新的生物瓣和機械瓣有更好的血流動力學(xué)。耐久性和病人or?or?前瞻性隨機研究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.前瞻性隨機研究EdinburghHeartValveTReoperationBloomfield,etal.BioprostheseshavealowrateofSVDintheolderpatientand…arethePHVofchoiceforAVRinpatients>60to65yearsofage.Durabilityandpatientmortalityaresuperiorwithnewercomparedwitholderbioprostheses.<65-70years: MechanicalprosthesisValveRelatedDeathsFreedomfromComplications

St.Clinical

RecommendationsMechanicalValveDurabilityandpatientmortalityaresuperiorwithnewercomparedwitholderbioprostheses.耐久性和病人死亡率比舊的生物瓣更好單純根據(jù)病人年齡來決定采用什么瓣膜可能不能為個體病人作出正確的決策。,JACC:2000Hammermeisteretal.Comorbidities-severeporcine(Hancock,Carpentier-Edwards)NewEnglJMed1993;328:1289-96.機械瓣

AHA/ACC標準“Theidealprostheticvalvewouldhaveexcellenthemodynamics(similartoanormalhumanvalveinthesameposition),lastalifetime,befreeofstructuraldysfunctionorbreakdown,andrequirenoparticularmedicaltherapysuchasanticoagulation.在>60to65病人是首選BioprosthesisManagementofanticoagulation05101520Yearsafterrandomization100806040200Bjork-Shiley%PorcineSource:H生存率

EdinburghHeartValveTrialP=0.39Reoperation05101520Yearsafter1008060402000246810121416BioprosthesisMechanicalProsthesisYearsaftervalvereplacementMortality%Hammermeisteretal.,JACC:2000P=0.02死亡率VACooperativeStudy1000246810121416BioprosthesisMNeedforAnticoagulationHammermeisteretal.Event-FreeLifeExpectancyBioprosthesis新的生物瓣和機械瓣有更好的血流動力學(xué)。Clinical

RecommendationsMechanicalValve50thpercentileForIndividualPatientExplantfor

SVDBjork-Shileyvs.ValveRelatedDeathsSource:Heartjnl.耐久性和病人死亡率比舊的生物瓣更好單純根據(jù)病人年齡來決定采用什么瓣膜可能不能為個體病人作出正確的決策。Theageatwhichpatientsmaybeconsideredforbioprostheticvalvesisbasedonthemajorreductioninrateofstructuralvalvedeteriorationafterage65andtheincreasedriskofbleedinginthisagegroup.EdinburghHeartValveTrialEvent-FreeLifeExpectancyBjork-Shiley在>60to65病人是首選1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementAllValve-relatedComplications%Hammermeisteretal.,JACC:2000P=0.26Bioprosthesis瓣膜相關(guān)性并發(fā)癥VACooperativeStudyNeedforAnticoagulation1000241008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementP=0.0001BioprosthesisBleeding%出血VACooperativeStudy1000246810121416MechanicalYear1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementBleeding%Hammermeisteretal.,JACC:2000P=0.0001Bioprosthesis瓣膜功能障礙VACooperativeStudy1000246810121416MechanicalYear1008060402000246810121416MechanicalProsthesisYearsaftervalvereplacementAllReoperations%Hammermeisteretal.,JACC:2000P=0.004Bioprosthesis再次手術(shù)VACooperativeStudy1000246810121416MechanicalYear生物瓣vs.機械瓣

AHA/ACC標準

采用生物瓣的年齡標準是基于65歲以上病人結(jié)構(gòu)性瓣膜毀損明顯下降和出血風險明顯升高決定的。生物瓣vs.機械瓣

AHA/ACC標準采用生年齡

主要的瓣膜選擇標準≥65-70歲: 生物瓣<65-70歲: 機械瓣年齡

主要的瓣膜選擇標準≥65-70歲: 生物瓣AHA/ACC指南避免

華法林風險再次手術(shù)個體病人什么是華法林風險？什么是再次手術(shù)的風險？AHA/ACC指南個體病人機械瓣風險機械瓣風險年齡vsINR

出血的時間75thpercentile50thpercentile25thpercentileWittkowsky,Pharmacotherapy.2004年齡vsINR

出血的時間75thpercentilDavidetal.1996.CarboMedicsSt.JudeMedtronic-Hall3.01.00.02.0P=.8FDA:OPCPercentPerYear機械瓣血栓形成Davidetal.1996.CarboMedicsSFreeofComplicationsOtherDeathsBleedingTEReop/EndoValveRelatedDeaths100806040200051015YrsPostopZellner,AnnThoracSurg:1999免予并發(fā)癥率

St.JudeAVRFreeofComplicationsOtherDea生物瓣風險生物瓣風險RecommendationsPatientPreference

QualityofLifeBjork-Shileyvs.ValveRelatedDeathsYearsafterrandomization533patients;1975to1979,JACC:2000<15%病人<65yearsBjork-ShileyNewEnglJMed1991;324:573-9.Yearsaftervalvereplacement生存率

EdinburghHeartValveTrial“Theidealprostheticvalvewouldhaveexcellenthemodynamics(similartoanormalhumanvalveinthesameposition),lastalifetime,befreeofstructuraldysfunctionorbreakdown,andrequirenoparticularmedicaltherapysuchasanticoagulation.VACooperativeStudy在>60to65病人是首選Comorbidities-severe50thpercentileRecommendationsHammermeisteretal.YearsaftervalvereplacementNeedlesstosay,suchavalveisyettobeavailable.Survival%Years96765226RecommendationsSurvival%Years9競爭事件%YearsEvent-free

SurvivalDeathbefore

ExplantExplantfor

SVD競爭事件%YearsEvent-free

SurvivalD結(jié)構(gòu)毀損而取出%Years45556575Age結(jié)構(gòu)毀損而取出%Years45556575Age再次手術(shù)死亡率20151050%Mort.CombinedIsolated4.1%5.8%199419961998200020022004再次手術(shù)死亡率20%CombinedIsolated4.1%瓣膜演變生物瓣改善血流動力學(xué)抗鈣化耐久性延長機械瓣抗凝藥物治療瓣膜演變生物瓣1614121086505560657075LEBioAgeofImplantationYearsLEMechEFLEMechEFLEBioEvent-FreeLifeExpectancyAorticValveReplacement16505560657075LEBioAgeofImpRecommendations

ValveChoiceClinicalsituationPatientpreferenceRecommendations

ValveChoiceCOutcomeswith“new”goodvalvesaresimilartothosewith“older”goodvalves.RisksofWarfarin,JACC:2000MechanicalprosthesesDeathbefore

ExplantBioprosthesis,JACC:2000Bjork-Shileyvs.Bloomfield,etal.,JACC:2000免予并發(fā)癥率

St.“Theidealprostheticvalvewouldhaveexcellenthemodynamics(similartoanormalhumanvalveinthesameposition),lastalifetime,befreeofstructuraldysfunctionorbreakdown,andrequirenoparticularmedicaltherapysuchasanticoagulation.RecommendationsBioprostheseshavealowrateofSVDintheolderpatientand…arethePHVofchoiceforAVRinpatients>60to65yearsofage.FreeofComplicationsporcine(Hancock,Carpentier-Edwards)Oxenham,etal.Explantfor

SVDAorticValveReplacement<15%病人<65yearsClinical

RecommendationsTissueValveLimitedlifeexpectancyOlderAgeCAD-severeLVdysfunction-severeComorbidities-severeIncreasedbleedingriskOutcomeswith“new”goodvalveValveRelatedDeathsRecommendationsAllReoperations%AorticValveReplacementEvent-free

SurvivalVACooperativeStudyFreeofComplications“新”的好的瓣膜與“舊”的好的瓣膜結(jié)果相似。PrimaryValveFailureFreeofComplicationsDurabilityandpatientmortalityaresuperiorwithnewercomparedwitholderbioprostheses.Outcomeswith“new”goodvalvesaresimilartothosewith“older”goodvalves.SVDandReoperation.ValveRelatedFactorsYearsaftervalvereplacementYearsaftervalvereplacementBioprosthesisHammermeisteretal.VACooperativeStudyAllValve-relatedComplications臨床建議-機械瓣華法林<60歲ValveRelatedDeaths臨床建議-機械瓣華法病人傾向性性

生活質(zhì)量機械瓣:無結(jié)構(gòu)毀損問題再次手術(shù)少抗凝生物瓣:結(jié)構(gòu)毀損和再次手術(shù)免予抗凝及抗凝相關(guān)出血。病人傾向性性

生活質(zhì)量機械瓣:BioprosthesesMechanicalHomograft10080604020主動脈瓣膜

1995-2005%199519971999200520012003Bioprostheses100主動脈瓣膜

1995-200100806040200<30 30-39 40-49 50-59 60-69 70-79 >802005單純主動脈瓣—年齡Human Repair Mechanical BioprosthesesAge%100<30 30-39 40-49 50-59 60-69AVR人群

年齡

1980-199562years1996-200573years70%合并冠心病<15%病人<65yearsAVR人群 年齡LVdysfunction-severe預(yù)期壽命LifeExpectancyHammermeisteretal.NewEnglJMed1993;328:1289-96.Valve-RelatedComplicationsEvent-FreeLifeExpectancyNeedforAnticoagulationBjork-Shileyvs.50thpercentileOxenham,etal.Clinical

RecommendationsMechanicalValve耐久性和病人死亡率比舊的生物瓣更好單純根據(jù)病人年齡來決定采用什么瓣膜可能不能為個體病人作出正確的決策。75thpercentile免予抗凝及抗凝相關(guān)出血。CarboMedics533patients;1975to1979YearsaftervalvereplacementValveRelatedDeathsSource:Heartjnl.,JACC:2000or?LVdysfunction-severeor?瓣膜相關(guān)問題耐久性需要抗凝

病人相關(guān)問題預(yù)期壽命LifeExpectancy傾向性瓣膜相關(guān)問題病人選擇和操作方法機械瓣vs生物瓣主動脈瓣替換西方觀點英文課件PatientSelectionandPracticePatterns:

MechanicalvsBioprostheticAorticValves

PerspectiveWestJosephF.Sabik,M