Guidelines for Surgical and Interventional Treatment of Valvular Haert Disease (JCS 2002) h Maze Procedure Circula

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1 Guidelines for Surgical and Interventional Treatment of Valvular Haert Disease (JCS 2002) h Maze Procedure Circulation Journal Vol. 66, Suppl. IV,

2 ACCAmerican College of Cardiology AHAAmerican Heart Association ARaortic regurgitation ASaortic stenosis AVAaortic valve area AVRaortic valve replacement CABGcoronary artery bypass grafting CADcoronary artery disease CMCclosed mitral commissurotomy CTcomputerized tomography CVPcentral venous pressure Ddend-diastolic dimension Dsend-systolic dimension EFejection fraction FSfraction shortening LVleft ventricle MAPmitral annuloplasty MRmitral regurgitation MRImagnetic resonance imaging MSmitral stenosis MVAmitral valve area MVRmitral valve replacement NYHANew York Heart Association OMCopen mitral commissurotomy PTACpercutaneous transluminal aortic commissurotomy PTMCpercutaneous transvenous mitral commissurotomy TAPtricuspid annuloplasty TRtricuspid regurgitation TStricuspid stenosis TVRtricuspid valve replacement Doppler quality of life 1262 Circulation Journal Vol. 66, Suppl. IV, 2002

3 AHAACC 1 AHAACC 1 a b 1 1 MS 2 MS MS 2 MS MS MS % % 015 % cm 2 10 Circulation Journal Vol. 66, Suppl. IV,

4 Kerley B line bronchial cuffingperivascular cuffing 4 5 2MS M pressure halftime 11 MR TR 6 5PTMC 1 PTMC 2 3 b 4 a 5 MS 1 2 PTMC 3 4 a 5 b cm cm cm cm Circulation Journal Vol. 66, Suppl. IV, 2002

5 1 2 a a 40 a 3 4 PTMC a 5 PTMC b 6 MS 2 1 MR MS MR 7 2 straight back Marfan Ehlers-Danlos MR MR MR MR MR LVEF LVEF LVEF 12 3 MR 13 flail leaflet % 14 MR 5 50 % MR MR LVEF Circulation Journal Vol. 66, Suppl. IV,

6 MR 2 MR 3 MR 4 MR 5 MR a 5 1 MR MR 2 3 a 4 MR a a 40 a MR 6 MR 1266 Circulation Journal Vol. 66, Suppl. IV, 2002

7 v MR MR MS 3 1 MS MR MS MS MR MR 2 1 MS MR MR MS MR pressure half-time MS 2 MR Fick PTMCpercutaneous transvenous mitral commissurotomy PTMC PTMC 17 MS PTMC 112 MS NYHA 1.5 cm 2 PTMC MS 12 1 MS PTMC 2 50 mmhg MS PTMC a 3 NYHAMR PTMC a 4 a 5 MS PTMC b 6 MS Circulation Journal Vol. 66, Suppl. IV,

8 mm mm mm PTMC 1 PTMC 18 MR PTMC PTMC OMC 215 PTMC 1 23 MR3 4 AR TS TR 5 16 PTMC 3 MR PTMC PTMC mm 10 mm PTMC 2 PTMC MR 3 a 4 AR TS TR a 5 a 3 PTMC 98 % 1213 mmhg 36 mmhg 1268 Circulation Journal Vol. 66, Suppl. IV, 2002

9 cm cm PTMC Inoue 981 MR 2.5 %0.3 % 1.1 %11.0 % NHLBI 738 MR 3 % 3 % 4 % 3 % NHLBI PTMC PTMC NYHA MR TR 2324 PTMC PTMC 3 5 NYHA 5 93 % MS 1948 Bailey Harken closed mitral commissurotomy, CMC 25 CMC MS 1970 open mitral commissurotomy, OMC CMC OMC MS 2627 OMC mitral valve replacement, MVR percutaneous transvenous mitral commissurotomy PTMC Device CMC PTMC 212 MS MSr MS NYHA cm cm 2 TR MS PTMC NYHA Circulation Journal Vol. 66, Suppl. IV,

10 X Af MVA 1.5cm 2 MVA 1.5cm 2 PAP 60 mmhg PCWP 25 mmhg 15 mmhg PTMC MR 2 OMC MVR PTMC X MVA 1.5cm 2 MVA 1.5cm 2 PAP60mmHg PCWP 25mmHg 15mmHg OMC MVR PTMC MR 34 2 CT 1270 Circulation Journal Vol. 66, Suppl. IV, 2002

11 2 1 OMC MVR PTMC OMC MS 2 Sellors 11 MS Wilkins 19 total echo score 8 3 PTMC OMC MVR 4 Sellors MVR 29 OMCOMC 16 1 NYHA MSMVA 1.5cm 2 PTMC 2 NYHA MS OMC MVR 3 NYHA MSMVA 1.5cm 2 PTMC a a a 6080 mmhg a NYHA MS MS NYHA MS PTMC OMC 2 NYHA MSMVA1.0cm mmhg PTMC OMC MS 3 OMC 16 OMC 30 Sellors MS OMC MVR PTMC OMC MVR OMC MVR 17MVR 3132 MS MR MS 33 MS MS PTMC OMC MVR MS Circulation Journal Vol. 66, Suppl. IV,

12 OMC % MVR MS 5 % OMC 70 MVR 7 % mmhg 10 % 3438 MVR 5 % MVR 14 % 32 MS MVR 2 OMCSellors OMC % 88.9 % 84.0 % MS OMC 40 MVRMVR MVR MS follow-up MVR PTMCOMCMVR %98 %93 % OMCMVR 96 %98 % PTMC 88 % NYHA OMC 1.1 PTMC MVR 1.4 PTMCOMC 0 % MVR 1.6 % MVR 1 MR IABP MR MR LVEF LVEF 4245 LVEF 60 % 45 LVDs LVEF 46 LVDs 45 mm LVESVI 50mlm MR 1 2 MVR 3 MVR 1272 Circulation Journal Vol. 66, Suppl. IV, 2002

13 MVR MVR % MVR LVEF 60 %LVDs 45 mm MVR MR3 4 MR MR MR 6 NYHA NYHA NYHA EF60 Ds45mm EF60 Ds45mm EF60 Ds45mm no yes EF30 no yes no yes yes no MVR Circulation Journal Vol. 66, Suppl. IV,

14 MR 2 NYHA a 6 50 mmhg 60 mmhg a 7 LVEF 5060 % LVDs 45 mm a 8 LVEF 60 % LVDs 4555 mm a 9 a 10 b 11 LVEF60LVDs45mm LVEF5060LVDs4550mm LVEF3050LVDs5055mm LVEF30 LVDs55m LVEF 60 % LVDs 45 mm 45 MR MR LVEF MR LVEF 30 % 1 2 a b 3 MR b 4 MR b MR MR MR 2 MR mm % 5060 % Circulation Journal Vol. 66, Suppl. IV, 2002

15 edge to edge suture 5457 MR MR MR 5859 MR MVR MR functional mitral regurgitationfmr FMR 60 MR 61 FMR MVR 6263 MR MVR - MR 6667 MR MVR 4 MR 75 MVR MR MR 4 10 Society of Thoracic Surgeon National Database MVR 6 % 2 %CABG 13 % 9 % MVR MR CABG MVR 6 % 13 % 2 % 9 % MVR 5.7 % 30.8 % 1.3 % 6.8 % Circulation Journal Vol. 66, Suppl. IV,

16 MR LVEF 409 IVEF 60 % 5060 %50 % % 53 % 32 % 49 MVR MVR NYHA MVR vs Maze Procedure % QOL 74 Maze Procedure Left Atrial Maze Procedure Pulmonary Vein Isolation Maze Procedure 7475 Maze Procedure Maze Procedure 20 % 70 mm Maze Procedure AS 2 AS 51 % 36 % 9 % 76 AS % 27 % 23 % % 25 % 18 % AS Ross Braunwald 78 AS % AS AS4.0 ms Circulation Journal Vol. 66, Suppl. IV, 2002

17 AS 2 23 AS 81 post-stenotic dilatation AS 8183 AS cm 2 ms mmhg cm AS 87 AS AS AS 1 24 LVEF 50 % X 3 4 a 5 b 6 b 7 DSA b Circulation Journal Vol. 66, Suppl. IV,

18 digital subtraction angiographydsa AR 24 3 AS AS 79 AS AS 1 14 %2 38 % 79 AS AVR AVR AS AS 8990 AVR AVR 89 AVR NYHA 90 4 AS AR AR AR AR AR 2 25 AR 91 AR 25 Marfan Reiter 1278 Circulation Journal Vol. 66, Suppl. IV, 2002

19 Marfan, relapsing polychondritisreiter, 91 AR 3 AR AR AR AR AR Bonow AR andor 6.0%pt-yr 3.5%pt-yr 0.2%pt-yr 2 AR 25%pt-yr 3 AR 10%pt-yr 2 1 AR AR AR AR AR X AR AR 300 ms E150 ms 81 AR CT 92 CT MRI AR de Musset signcorrigan pulsetraube signquincke sign Austin-Flint AR X AR AR AR AR AR AR 97 AR Circulation Journal Vol. 66, Suppl. IV,

20 AR LVEF CTMRI AR AR X 3 4 a 5 a 6 b 7 b 8 b 9 CT b 10 MRI b 3 AR AR AR AVR AR LVDs 55 mm % FS 25 % 101 LVDs 55 mm AR3 4 1 NYHA-2NYHA3LVEF 55 %4LVDsBSA 25 mmm LVDs BSA LVDs BSA AR LVDs 1 LVDs 46 LVDs 107 AR AR ACCAHA AR 1 AS AR AS AR AS AS AR AS AR AS AR AVR 1280 Circulation Journal Vol. 66, Suppl. IV, 2002

21 2 1 AR AR AS AR AR 108 AS 2 AR Fick 1 1 PTACpercutaneous transluminal aortic commissurotomy percutaneous balloon aortic valvotomy PTAV: percutaneous transluminal [balloon catheter] aortic valvuloplasty percutaneous transvalvular aortic valvuloplasty 109 AS AS AS 1 2 AS AS PTAC AS AS AVR AS PTAC MS PTMC 110 PTAC AS AS AVR AVR AS AVR AVR PTAC ACCAHA task force report 1 AS PTAC PTAC AVR PTAC AS AVR 113 ACCAHA task force report 1 AS PTAC AVR AVR PTAC a 2 PTAC b 3 b 4 AVR AS PTAC 114 AS Circulation Journal Vol. 66, Suppl. IV,

22 PTAC AS AS PTAC AS afterload mismatch AS AS 29 1 AS 2 CABG AS 3 CABG AS a 4 AS a a 0.6cm 2 a 4.0msec a b 15mm b 5 4. AS 30 LVEF50% LVEF50% AS NYHA 30 2 AS AS 1 AS AS AS AS 2 AS -6 1 BSA effective orifice areaeoa indexed EOAEOA BSA 0.85 cm 2 m mm 21 mm Circulation Journal Vol. 66, Suppl. IV, 2002

23 AS AVR risk factor CABG AVR 5 % % % CABG AVR 5 10 % % CABG AVR 5% % 2 CABG 510% % 2 Major Surgery QOL 4050 Valsalva 5 AS QOL LVEF25% 2 3 AR 4 LVEF 2549% LVEF 2549% a LVEF50% a LVEF50% a LVEF50% b 5 LVEF25% b 6 34 Circulation Journal Vol. 66, Suppl. IV,

24 AR34 AR 1 AVR EF EF50% EF EF EF50% 2 4 LVDs55 mm LVDd75 mm LVDs45 mm LVDd60 mm LVDs mm LVDd mm LVDs mm LVDd 70-75mm #1 #2 EF CTMRI #3 #4 LVDLVDs severe AR AR QOL 1 AR risk 1284 Circulation Journal Vol. 66, Suppl. IV, 2002

25 risk 126 AR NYHA LVEF 25 % NYHA LVEF 50 % LVDs 5055 mm LVDd mm NYHA LVEF 50 % LVEF 50 % 99 LVEF 50 % LVDs 55 mm LVDd 75 mm AR AVR QOL MRI LVEF NYHA QOL LVEF EF 3 AR AR 34 AR 34 LVDsmm LVDdmm BSA 1.4 m m m m m m Circulation Journal Vol. 66, Suppl. IV,

26 predictor alvds 55 mm LVDd 75 mmlvef LVEF blvds 5055 mm LVDd 7075 mm LVEF LVEF clvds 4550 mmlvdd 6070 mm LVEF 4 a b LVEF c 2 AR AVR Ross % % % % % predictor FS27% LVDs5055mm 2527mmm 2 LVDd7075mm 3538mmm 2 RTh3.8 SBPRTh lminm 2 12 mmhg 50% mlm mlm 2 3 NYHA - EF RI45% 1286 Circulation Journal Vol. 66, Suppl. IV, 2002

27 4 AR AR LVDs 55 mm %FS 25 % 101 NYHA 126 NYHA 105 AR 129 LVDs 107 AR Ds 55 mmef 55 % AHAACC AR Ds 55 mm BSA 2.0 m 2 BSA m AR ats b c a y d 2 a 36 coaptation zone tight TR Circulation Journal Vol. 66, Suppl. IV,

28 isolated tricuspid valve disease stradding tricuspid valve intact ventricular septum TR TR b TR TS 4 Rivero-Carvallo TR c v y d TR TR TR TR TR V P4V 2 TR 5 mmhg 10 mmhg 15 mmhg 2 MS TR MS TR MS 1 1 TR TR TR TR Circulation Journal Vol. 66, Suppl. IV, 2002

29 37 1 TR 2 TR a 3 TR a 4 TR a 5 TR a 6 TR b 7 TR b 8 60mmHg TR 2 TR TR TR 36 TR TR TR 3 moderate TR 2 2 TR TR annuloplastysuture Annuloplasty Ring Annuloplasty 2 Suture Annuloplasty Kay 145 Annular Plication De Vega 146 Semicircular Annuloplasty Kay 2 bicuspidizationde Vega 1 TR Ring Annuloplasty Suture Annuloplasty TR Ring Annuloplasty No Yes Circulation Journal Vol. 66, Suppl. IV,

30 TR De Vega TR mild 66.2 % 92.0 % % 96.7 % TR 154 Kay % % 155 TR Ring Annuloplasty TR mild % % St. Jude Medical valve freedom from valve thrombosis % % Suture Annuloplasty Ring Annuloplasty Ring Annuloplasty 2 TR quality of lifeqol Ring Annuloplasty rigid ring flexible ring flexible ring flexible ring Kay 93.6%10 2De Vega96.7%10 3Carpentier-Edwards ring97.5% %1062.7% %1075.0%15 TR QOL 1290 Circulation Journal Vol. 66, Suppl. IV, 2002

31 1 1 AS MS MS AS AS MS MS AS 2 MS MS PTMC AS AS MS PTMC PTMC MS AS 2 1 AS MR ASMR ASMVP AS MR MR AS 158 MR AS 2 AS MR MR MR AS MR AS MR MR AS 3 1 AR MS MS AR MS MS AR MS AR AR AR 2 MS pressure half-time AR AR AR AR 162 Circulation Journal Vol. 66, Suppl. IV,

32 MS PTMC PTMC AR PTMC MS 4 1 MR AR MR AR AR MR 2 MR AR MR PISA 5 1 MS TR MS TR MS TR MS TR MS MS TR MSTR 6 MS AR MVR AVR MR AR AS AS 5 mmhg StenosisSRegurgitationR Circulation Journal Vol. 66, Suppl. IV, 2002

33 Sellers SR rs NYHA 10 NYHA 40 1 NYHA 2 3 NYHA NYHA QOL NYHA a a a Circulation Journal Vol. 66, Suppl. IV,

34 ARMR Sellers AS 50 mmhg MS 1.5 cm 2 AR AS MR Sellers MR AS MR MR MR MR dilated annulusleaflet prolapse restricted leaflet motion MRMr MSMs MRMS MS 41 1AM AsMs ArMs AsMr ArMr NYHA 2 NYHA A MNT 3A 4M ASMs ARMs ASMr ARMr MSAs MRAs MSAr MRAr A MNT A M ASMS ARMS A 5AM 40 ASMR ARMR M or NT 6 NYHA AMNTnone touch 1294 Circulation Journal Vol. 66, Suppl. IV, 2002

35 AS AR RS AR Sellers AS 30 mmhg MS Open mitral commissurotomyomc AS AVR 30 AS AVR MR MVR MR MVR MR MR MVR AR AVR AVR MVR MVR % % Circulation Journal Vol. 66, Suppl. IV,

36 mmhg 38.5 % 181 NYHA Paravalvular leak follow-up 1.01 %patient-year 195 MVR 0.5 % 196 actuarial survival rate %85.6 %84.4 %82.4 % QOL 1 infective endocarditisie Osler IE IE IE controversies MRSA IE 1296 Circulation Journal Vol. 66, Suppl. IV, 2002

37 IE X NYHA IE 10 mm 10 mm mm 3 IE 30 % % IE 1995 IE 11 % 213 IE mycotic aneurysm CTMRI a 6 a 7 10 mm a a a 12 b Circulation Journal Vol. 66, Suppl. IV,

38 MRA 5 IE 1 CAD CABG % % % % 10.2 % 13.3 % CAD 2 1 CAD CABG 3.0 % CABG 2.0 % 34 CAD 2 CAD AS MR AS CAD MR AVR CAD CAD CAD CAD CABG CABG AVR AVR AVR CABG AVR AS cm mmhg AS123 prospective study 1298 Circulation Journal Vol. 66, Suppl. IV, 2002

39 228 jet velocity 3 msec 8 %event-free survival 84 %2 jet velocity 3 4 msec 17 % 66 %4 msec 40 % 21 % AS 4 eventfree survival 59 % 80 AS % 229 CABG AVR AS AS 23AS AS AR CAD MR CAD CABG CABG 230 MR CABG CAD CAD CABG 49 CABG 4 CAD MR CABG MR MR MR CABG MR CABG 5 CAD CAD CABG CABG 2 CABG 3 CABG AS 3050 mmhg 34 msec 4 CABG MR 5 CABG AS AR MR % 34 a a Circulation Journal Vol. 66, Suppl. IV,

40 ARMarfan annuloaortic ectasiaaae sino-tubular junction AR AAE AR AR 5 cm AR 5 cm cm cm CABG CABG AR Bentall AR AR 4 6 cm cm cm cm a 3 AR 4.0 cm a Circulation Journal Vol. 66, Suppl. IV, 2002

41 CT IE 2040 % 247 IE CTMRI % 44 % % 17 % % 10 % % 11 %4 7 % 2.3 % 2 20 % 246 TIA carotid arterial duplex scan MR angiogram 7090 % % CEA % CEA 256 TIA CT MRIMRA CT mm Circulation Journal Vol. 66, Suppl. IV,

42 % 7080 mmhg stroke 515 % SHA CT MRImagnetic resonance angiographymra 10 mm mm 1 2SHA shower emboli 262 CT Type 1-porcelain aorta: extensive, circumferential medial calcification of the ascendingtype 2- ragged, friable, ulcerated intraluminal disease Type 3- liquid intramural disease : grumous, liquid, toothpaste-like, cholesterol debris of atherosclerosis within the aortic wall 265 Type 3 debris 3 mm chronic obstructive pulmonary diseasecopd mm 3 CT 1302 Circulation Journal Vol. 66, Suppl. IV, 2002

43 Spirometry Spirometry % 50 % room air PCO2 50 mmhg PO2 70 mmhg NO 275 COPD COPD % 50 % 2 PO2 70 mmhg PCO2 50 mmhg 1 CABG 277 Cr mgdl 2 30 ml 278 LOS Circulation Journal Vol. 66, Suppl. IV,

44 aortic no-touch technique 021 % NYHA CABG % Ca mgdl 2 30ml ICG Circulation Journal Vol. 66, Suppl. IV, 2002

45 ICG % Child 291 C 2000 IUL mgdl 49 % Child B 50 % ICG % 2 Child BC IUL 4 2mgdl 49 % 1 1 Starr-Edwards 2 Björk-Shiley Medtronic-Hall Omnicarbon St. Jude Medical 100 CarboMedics Bicarbon TEKNA Mira ATS Jyros Circulation Journal Vol. 66, Suppl. IV,

46 Structural valvular deterioration 2 Nonstructural dysfunction 3 Valve thrombosis 4 Embolism 5 Bleeding event 6 Prosthetic valve endocarditis Author Valve No. of mean FU Embolism Bleeding Thrombosis Endocarditis Paravalvulartype pts yrs %pt-yr %pt-yr %pt-yr %pt-yr leak%pt-yr AVR Aoyagi 1994 SJM Nakano 1994 SJM Copeland 1995 CM Borman 1998 BC Butchart 2001 MH Khan 2001 SJM MVR Aoyagi 1994 SJM Nakano 1994 SJM Copeland 1995 CM Borman 1998 BC Butchart 2001 MH Khan 2001 SJM SJMSt. Jude Medical CMCarboMedids BCBicarbon MHMedtronic-Hall 55 Author Valve No. of mean FU Embolism Bleeding Thrombosis Endocarditis Paravalvulartype pts yrs %pt-yr %pt-yr %pt-yr %pt-yr leak%pt-yr Kinsley 1986 SJM Armenti 1987 SJM Burchhardt 1988 SJM Arom 1989 SJM Czer 1990 SJM Smith 1993 SJM De Luca 1993 CM Nakano 1994 SJM Ibrahim 1995 SJM Baucet 1995 SJM Copeland 1995 CM Borman 1998 BC Butchart 2001 MH SJMSt. Jude Medical CMCarboMedids BCBicarbon MHMedtronic-Hall 1306 Circulation Journal Vol. 66, Suppl. IV, 2002

47 INRInternational Normalized Ratio International Sensitivity Index 298 INR 13 % AVR INR MVR INR a 1 MVR INR mg b 1 2 AVR INR mg 2 MVR INR INR INR INR INR European Society of Cardiology Starr-Edwards Björk- Shiley standard Medtronic- Hall St. Jude Medical American College of Chest Physicians ACCAHA % INR % INR INR INR prospective Circulation Journal Vol. 66, Suppl. IV,

48 INR 2.0 aptt INR 1.5 INR 2.0 b 1 72 INR 2.0 INR 1.5 INR 2.0 study INR INR INR INR INR INR 2.0 aptt K INR 1 INR LDH BUN Circulation Journal Vol. 66, Suppl. IV, 2002

49 g 50 mgkg PO g 50 mgkg IV or IM mg 20 mgkg PO 1 2 g 50 mgkg PO 1 2 g 50 mgkg PO mg 15 mgkg PO mg 20 mgkg IV 30 1 g 25 mgkg IV or IM 30 POIVIM g IM or IV 1.5 mgkg 120 mg g IM or IV 1 g PO 2 50 mgkg IM or IV 2 g 1.5 mgkg mgkg IM or IV 25 mgkg g IV mgkg 120 mg IM or IV mgkg IV mgkg 120 mgim or IV 30 POIVIM Ross 320 Ross Circulation Journal Vol. 66, Suppl. IV,

50 AVR 65 a AVR AVR 4 TVR b 1 MVR AVR cryopreserved allograft AVR 3 INR AVR 3 3 MVR 3 INR INR a 1 MVR 3 b 1 AVR mg 2 MVR mg 1 MVR Circulation Journal Vol. 66, Suppl. IV, 2002

51 62 AVR MVR AVR MVR Burr, et al Carpentier-Edwards standard Carpentier-Edwards supraannular Pelletier, et al Carpentier-Edwards standard Carpentier-Edwards supraannular Burdon, et al Hancock I Hancock MO Khan et al (AVR) Hancock I 7.3 (MVR) Hancock MO Jamieson et al Carpentier-Edwards standard Marchand et al Carpentier-Edwards Banbury et al Carpentier-Edwards David et al (AVR) Hancock II 6.9 (MVR) SPV Circulation Journal Vol. 66, Suppl. IV,

52 Ross AHA ACC AHAACC AHAACC Circulation Journal Vol. 66, Suppl. IV, 2002

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