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2	History 1954 - Charles Hufnagel - 23 pts 1953 - John Gibbon – Cardiopulm. Bypass 1960 – Albert Starr – MVR 1960 – Dwight Harken – AVR
3	1954 – Charles Hufnagel - 23 pts
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8	Aortic Stenosis Degenerative
9	Aortic Stenosis Congenital-Bicuspid
10	Aortic Stenosis Rheumatic
11	Aortic Stenosis Concentric Hypertrophy
12	Aortic Stenosis Ischemia
13	Cage and Ball Valve (Starr-Eduards)
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15	Tilting Disk Mechanical Valve
16	Bileaflet Mechanical Valve Hemodynamic- good Thomboresistance- poor Imlantability- excellent durability- good
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18	Stented Tissue Valves Hemodynamics-good Thromboresistance-good Implantability-good Durability-poor
19	Valve Selection MVR
20	Aortic Valve Replacement Prosthesis Selection
21	Homografts Hemodynamics-excellent Thoromboresistance-good Implantability-hard Durability- good (better then other tissue valves)
22	Stentless Tissue Valves Hemodynamids-excellent Thromboresistance-good Implantability-hard Durability-good?
23	Toronto SPV Stentless Tissue Valve
24	Freestyle Stentless Tissue Valve
25	Freestyle Stentless Tissue Valve
26	Valve Selection AVR
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28	Tissue vs Mechanical Valve Coumadin morbidity 1-2% per pt/year - 10-20% 10 years Quality of life Re-do surgery – low risk (5%( More tissue valves
29	Tricuspid Valve Replacement High risk of thrombosed valve Predicted survival > 12-15 y. – mechan.? More tissue valves
30	Post-op Valve anticoagulation
31	Post-op Valve Anticoagulation
32	Valve Implantation Techniques Posterior (±anterior) leaflet preservation in MVR Suturing: pledgets vs non-pledgets interrupted vs running
33	Effective Orifice Area Tissue Valves (19-25): 1.2 – 2.5 cm² Mechan. Valves (19-25:( 1.3 – 2.6 cm² Patient-Prosthesis Mismatch (EOA/BSA) 0.86-0.65 – moderate 065 > - severe AVR – 19-21 MVR - 27
34	Small Aortic Root (19 > valve) Special Mechanical Valve (Sorin Slimeline, St Jude Reagent, Carbomedics Top-Hat) Aortic Annulus Enlargement Root replacement (Ross, Stentless, Homograft) ± Konno procedure
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38	Permanent Pacemaker Implantation and Valve Surgery MVR + TVR - 30% need in PP (epicardial lead) TVR post Permanent Pacemaker Permanent Pacemaker post Mechan. TVR (Coronary Sinus lead)
39	Prosthetic Valve and Hemodyalisis High calcification rate of tissue valves Low life expectancy Anticoagulation ? (renal Tx, access) So: more tissue valves
40	Coumadine and Pregnancy First 12 weeks Last 4 weeks Heparine - large mollecules do not cross placenta Young women – consider tissue valve
41	Ross Procedure
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43	“The downside” I: Pulmonary autograft dilatation
44	Freedom from reoperation
45	What are the possible causes of autograft dilatation? Interruption of the blood supply to the pulmonary autograft Different biomechanical and structural properties Acute exposure to systemic pressure Abnormal pulmonary artery wall in BAV* De Sa MPL, et al. J Thorac Cardiovasc Surg 1999;118:588-96
46	Renaissance of the sub-coronary implantation technique?
47	Aortic root inclusion/cylinder
48	Other predictors of autograft failure Preoperative aortic insufficiency Laudito A et al. J Thorac Cardiovasc Surg 2001;122:147-53 >10% of mismatch between the pulmonary and aortic annulus David TE et al. J Thorac Cardiovasc Surg 1996;112(5):1231-7
49	“The Downside” 2: pulmonary homograft stenosis
50	“The Downside” 2: pulmonary homograft stenosis 109 patients after the Ross procedure FU: 39±20 months Homograft stenosis: 28.5% gradients > 20mmhg 4% gradients > 40mmhg Homograft insufficiency: 9% had mod or severe Raanani E, et al. Ann Thorac Surg 2000;70(6):1953-7
51	Independent predictors for stenosis: Younger donor age (p=0.03) Shorter duration of cryopreservation (0.01) Smaller homograft size (0.06) Raanani E, et al. Ann Thorac Surg 2000;70(6):1953-7
52	Ross procedure in RHD
53	Conclusion “For young adults, Ross remains a controversial operation at best…”
54	Minimally Invasive Surgery
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61	Trans-apical and Trans-catheter AVR