Ideal aortic valve prosthesis:

no resistance to forward flow,

low stress gradient,

no leak when closed,

no damage to blood cells,

no thromboembolism,

should resist wear (durability),

should not produce noise,

easy and simple way of implantation. How to do it

Affeld, K

Anguseva, Tanja

Mitrev, Zan

UGD Academic Repository

Cardiosurgery - SkopjeCardiosur  - SkopjeReal stentless aortic valve new type of aortic root reconstructive surgerySpecial Hospital for Surgery “Fillip II”  Skopje, Macedonia*Labor for bio-fluid mechanic, Hamboldt University, Charité Campus Virchow Berlin,  GermanyMitrev Z, Anguseva T,  Affeld K*September, 2010Cardiosurgery - SkopjeAortic valve replacementStandard:- mechanical valve prosthesis- biologic  valve prosthesis ( stentled )                                                                        - stentless aortic bio-prosthesis- Homograft   ( mini root, freestyleaortic root, xenograft )- Ross procedureCardiosurgery - SkopjeIdeal aortic valve prosthesisno resistance to forward flowlow stress gradientno leak when closedno damage to blood cellsno thromboembolismshould resist  wear (durability)should not produce noise                  easy and simple way of implantation           normal aortic valve Cardiosurgery - SkopjeHow to do itCardiosurgery - SkopjeHumboldt Universität zu BerlinCharité Campus VirchowLabor für BiofluidmechanikProf. Dr.-Ing. K. AffeldBerlinDatum: 03.04.2003In vitro testing of  thereal stentless aortic valve:Cardiosurgery - SkopjeReal stentless aortic valve new type of aortic root reconstructive surgery - in vitro testThese valve parameters had been explored: 1.CO (cardiac output)2.Root mean square – in dependence of the P, 3.leckage of volume, 4. elasticity of the leaflets, 5.pressure gradient, 6.resistance of the flowCardiosurgery - SkopjeReal stentless aortic valve new type of aortic root reconstructive surgery – in vitro testRoot mean square(EOA) in dependence of CO and systolic pressure through the valve ; EOA=RMS/(51,6* p1/2);R=1333* p/MF(mean flow)Cardiosurgery - SkopjeReal stentless aortic valve new type of aortic root reconstructive surgery – in vitro test1101001000100 200 300pressuremean flow rate110COEOASystolic pressure gradient;Mean flow rateCardiac outputEffective orifice area-aorta HF SV CO MF RMS P  1/min mL L/min mL/s mL/s mmHg        AF04-030403-03 40 20 0,8 53 58 10,7 22,4°C 40 30 1,2 80 86 14,2  70 30 2,1 104 112 17,9  100 30 2,9 125 136 22,0  40 50 2,0 131 143 23,4  70 40 2,8 136 148 24,3        AF04-030403-04 40 20 0,8 53 58 10,5 37°C 40 30 1,2 80 86 13,8  70 30 2,1 103 112 17,9  100 30 2,9 126 137 21,6  40 50 2,0 132 143 23,2  70 40 2,8 137 149 23,9  70 49 3,5 169 185 32,7  Cardiosurgery - SkopjeReal stentless aortic valve new type of aortic root reconstructive surgery- our early clinical approaches Prospective study N = 115pts with severe aortic stenosis68685926233 40102030405060I II III IV VI=atherosclerotic ethyologyII=rheumatic ethyologyIII=endocarditisIV=subacute  endocarditis in patients on chronic haemodyalysisV = bicupid aortic valveCardiosurgery - SkopjePatients demographics data   N = 115 ptsAge  (years)    56 ± 7.6y    Sex (f/m)          34 / 81         The oldest patient – 72yIncluding criteria:Severe aortic valve stenosis, with aortic root not bigger than 3,5cmTrans-aortic middle pressure gradient >65mmHgPerformed investigations- Trans-thoracic echocardiography - Cathetherisation- Trans-esophageal echocardiography pre and intra-operativelyCardiosurgery - SkopjePreoperative co-morbidity          N=115pts12341523171715obesitydiabeteshypercholesterinemiahypertensionCOPDcerebrovascular diseasesubacute endocarditishaemophylia%Cardiosurgery - SkopjeCardiosur  - SkopjeReal stentless aortic valve new type of aortic root reconstructive surgery Post-operative echoAccepted as a patent in USA 09.12.2008Cardiosurgery - SkopjeReal stentless aortic valve ultrasound evaluation bicuspid valvePre-op.evaluation Post-op.evaluationCardiosurgery - SkopjeResults I                        N= 115 pat. Middle aorta cross-clamping time           61±9.6min Middle bypass time                                  82±12.5minIntra-operative TEE data Dp/dt  = 0.07 0,015; SS= 22±3.2 EAO cm2=3.6±0,8; CO = 6,5±2.9lAverage systolic valve gradient 14±6.8mmHgAverage mean valve gradient 7±5.6mmHgCardiosurgery - SkopjeResults  II            N= 115 pts Early survival (30 days)           94.8% (8pts)      Other main complication:Bleeding                                    5 pat  (3 surg.ethyology)      Ventilation time                        6.8h±2.2         Stroke                                        2 (1 with left side hemiparesis) 3pts (with preoperative terminal renal failure) with CVVHD (Prismaflex Gambro) 5 days                 Length of ICU stay                   8.6d ±2.1         Hospital stay                             14.4 ±3.2      Patients have been treated with anti-aggregates (Tbl.Aspirin 0,1 1x1)Simvastatin Follow up period                      4-84 monthsCardiosurgery - SkopjeDobutamin stress echo n = 36ptsProtocol:- (5 g/kg/min)dobutamin-dosage was doubled on every 3 min-up to 12min-followed parameters: CO,PG syst. and mean through the aortic valve, dp/dt, and systolic separation (SS).0-stadium I-stadiumCardiosurgery - SkopjeDobutamin stress echo n = 36ptsRemarkable: in all pts CO increased in a linear module with a pressure gradient . 56mmHg, was the highest measured systolic pressure gradient in the IVth stadium, with a CO 7-9l/min,and dp/dt as in normal valve, with a good SSIV-stadium recoveryCardiosurgery - SkopjeProportional ratio of Systolic pressure gradient and mean flow rate    n = 36pts020406080100120140SPGmean flowrateSPG 24 38 48 56 16mean flow rate 83 100 110 116 1003min 6min 9min 12min recoveryBasic parametersSPG=14 ± 3.5mean flow rate=64 ± 9.5Cardiosurgery - SkopjeProportional ratio of EAO and CO during dobutamin stress echo n = 36pts012345678910EOACOEOA 3 4 4 5 4CO 5 6 7 9 63min 6min 9min 12min recoveryBasic parametersEOA=3.2 ± 1.5CO=6.2 ± 2.5EOA=CO/√sist.mean press.gradientCardiosurgery - SkopjeLate complications and NYHA class3 patient re-operated 1-due to aortic regurgitation bigger than +2 as a result of dilatation of the aortic annulus1-due to calcium degeneration of the leaflets1-due to infective endocarditis Late mortality  0%.Follow up 4-84 months433708360510152025303540preoperative postoperativeNYHA class IVNYHA class IIINYHA class IICardiosurgery - SkopjeActuarial survival01020304050607080901000m 1m 3m 12m 24m 48m 84RealstentlessAo valveprosthesis%Follow up 4 to 84monthsSurvival 94,8% -- early mortality rate 5,2%(8pts)Pre-op.                                        Post.op.Real stentless aortic valve ultrasound evaluation aortic inuficientyCardiosurgery - SkopjeReplacement Aortic Valve  Leaflets in a patient with a small aortic root  case report68y.old womenSevere symptomatic aortic stenosisSmall aortic root – 16,9mmSevere calcificated ascending aorta up to aortic archOnce deleted operation-because of her conditionPre-operative echocardiographyCardiosurgery - SkopjeSmall-root case report operation6 months follow up Excellent haemodinamicNormal quality of lifeCardiosurgery - SkopjeSmall-root case report  3D TEE approachnormal aortic valve,perpendicular viewPre operativePost operativeCardiosurgery - SkopjeEACTS  2010Techno-colegueAward nominee(printed Daily News)Cardiosurgery - Skopje] 

Real stentless aortic valve new type of aortic root reconstructive surgery

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