Valve Analysis and Pathoanatomy: THE MITRAL VALVE

Transcription

1 : THE MITRAL VALVE Marc R. Moon, M.D. John M. Shoenberg Chair in CV Disease Chief, Cardiac Surgery Washington University School of Medicine, St. Louis, MO Secretary, American Association for Thoracic Surgery AATS International Cardiovascular Symposium 2017 Sao Paulo, Brazil Disclosures: Edwards, Medtronic (Speaker)

2 ANATOMY of MITRAL/TRICUSPID VALVES Carpentier s Reconstructive Valve Surgery Carpentier, Adams, Filsoufi Saunders/Elsevier, 2010

3 Mitral Valve Historical Perspective Hinge Junction between atrial and valvular tissue Annulus Fibrosus where leaflet attaches to connective tissue 2 mm external and deep to hinge 3-D saddle shape

4 Mitral Valve Historical Perspective Duirng systole: 20-30% reduction in orifice area 3.8 ± 0.7 cm/m 2 to 2.9 ± 0.6 cm/m 2 annulus is displaced 5 to 10 mm apically Annular contraction facilitates valve competency

5 Concomitant, Functional MR Functional Anatomy of Mitral Valve Chordae Tendineae - Primary (marginal): - From pap tip to leading edge - Prevent prolapse during systole - Secondary (intermediary): - Insert on leaflet ventricular surface - strut chords (2 solitary, thicker) - Valvular-Ventricular Interaction - Tertiary (basal): - From ventricular wall to post leaflet

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7 FOUNDATION AND SCIENCE

8 PATHOPHYSIOLOGICAL TRIAD Pathophysiological Triad Etiology cause of the disease Lesions result from the disease Dysfunction result from the lesions

9 ETIOLOGY Etiology: Helps establish pre/postop medical Tx Expected complexity of valve repair Most important predictor of long-term prognosis Primary: congenital, inflammatory, degenerative, calcification, endocarditis, trauma, tumors Secondary: Ischemic MR, DCM, HOCM, Afib

10 Carpentier s Functional Classification of MR I: normal leaflet motion (annular dilation) II: excessive leaflet motion (prolapse, rupture) III: restricted leaflet/chord motion - IIIa: rheumatic - IIIb: ischemic

11 Functional Anatomy of Mitral Valve Segmental Analysis:

12 INTRAOP: Valve Analysis and Pathoanatomy Segmental Analysis of Mitral Valve

13 Functional Anatomy of Mitral Valve Annulus Leaflets Chordae Tendineae Papillary Muscles LV Wall

14 LESIONS - ANNULUS Annulus Lesions: Dilatation, Calcification

15 LESIONS - ANNULUS

16 Valve Snalysis and Pathoanatomy LESIONS - LEAFLETS Leaflet Lesions: Cleft / Tear Vegetations / Perforation Thickening / Commissure Fusion Calcification Billowing

17 LESIONS - LEAFLETS Non-Pathologic Clefts Posterior leaflet indentations between P1-P2 or P2-P3 are not pathologic clefts Supported by chordae function like commissures to facilitate opening do not extend to annulus

18 LESIONS - LEAFLETS Pathologic clefts: Anterior leaflet May extend to annulus Present within PL scallops

19 LESIONS - LEAFLETS Vegetations / Perforation: Endocarditis, Trauma

20 LESIONS - LEAFLETS Vegetations / Perforation: Non-infectious (Libman-Sacks)

21 LESIONS - LEAFLETS Thickening / Commissure Fusion Anterolateral Fusion Double Commissural Fusion

22 Calcification Valve Analysis and Pathoanatomy LESIONS - LEAFLETS Can involve the leaflet, annulus, or both

23 LESIONS - LEAFLETS Leaflet Billowing: Classically with Barlow s Syndrome / Marfan Syndrome Billowing No MR Billowing + Chordal Elongation MR

24 LESIONS - CHORDAE Chordae Lesions: Elongation Rupture Thickening / Fusion / Shortening

25 Spectrum of Degenerative Disease Fibroelastic Deficiency myxomatous change Collagen deficiency Older patients, single segment, short history Barlow s Disease diffuse involvement Younger patients, multiple segments, longer history, large valve size Eur Heart J 2010; 31:1958

26 Spectrum of Degenerative Disease Red = prolapse on 3-D analysis Fibroelastic Deficiency Ruptured thin P3 chord with rupture, limited excess tissue Barlow s Disease Multi-segment prolapse, excess leaflet tissue Eur Heart J 2010; 31:1958

27 Spectrum of Degenerative Disease Chordal Elongation: Posterior leaflet prolapse without rupture PREOP: POSTOP:

28 Spectrum of Degenerative Disease Flail Mitral Valve: Posterior leaflet prolapse with ruptured chord PREOP: POSTOP:

29 Spectrum of Degenerative Disease Anterior Leaflet Prolapse: Consider transfer to Reference Center?

30 Spectrum of Degenerative Disease Bileaflet Prolapse: Marfan syndrome / Barlow s syndrome PREOP: POSTOP:

31 PREOP: Valve Analysis and Pathoanatomy Forme Fruste: Bileaflet Prolapse

32 INTRAOP: Valve Analysis and Pathoanatomy Segmental Analysis of Mitral Valve

33 INTRAOP: Valve Analysis and Pathoanatomy Forme Fruste: Bileaflet Prolapse

34 POSTOP: Valve Analysis and Pathoanatomy Forme Fruste: Bileaflet Prolapse

35 LESIONS - Chord Thickening / Fusion Likelihood of Repair subvalvular involvement minimal severe/ca 2+ Pliable Leaflets yes probably no Rigid Leaflets probably yes no Carpentier s Reconstructive Valve Surgery Carpentier, Adams, Filsoufi, 2010

36 LESIONS PAPILLARY MUSCLE Papillary Muscle Lesions: Elongation / Rupture

37 LESIONS PAPILLARY MUSCLE Ruptured Posteromedial Papillary Muscle POSTOP:

38 LESIONS LV WALL Left Ventricle Wall Lesions: Aneurysm Dilation / Dyskinesis of inferobasal wall LV Ischemia / Infarction

39 LESIONS LV WALL Ischemic MR Restricted leaflet motion Type IIIb: PREOP: POSTOP:

40 COMBINATION LESIONS 76 yo woman with severe MR, nob-bypassable circumflex underwent P2 resection and 31mm Duran Band COMING OFF PUMP:

41 COMBINATION LESIONS Removed true-sized flexible band placed downsized ring

42 PRINCIPLES FOR SUCCESS Goals of valve assessment: Establish a precise diagnosis preop ECHO or introop Determine most appropriate treatment option Segmental Valve Analysis: Localize and categorize dysfunction Complete full inventory of specific lesions One lesion, one technique principle for complex repair

43 Thank you for your attention.

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45 FUNDAMENTALS OF MV REPAIR Three fundamental principles of MV repair: 1. Preserve or restore normal leaflet motion 2. Provide a large surface of leaflet coaptation 3. Remodel and stabilize the annulus

46 Mitral Valve Historical Perspective Leonardo da Vinci ( )