: 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)
ANATOMY of MITRAL/TRICUSPID VALVES Carpentier s Reconstructive Valve Surgery Carpentier, Adams, Filsoufi Saunders/Elsevier, 2010
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
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
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
FOUNDATION AND SCIENCE
PATHOPHYSIOLOGICAL TRIAD Pathophysiological Triad Etiology cause of the disease Lesions result from the disease Dysfunction result from the lesions
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
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
Functional Anatomy of Mitral Valve Segmental Analysis:
INTRAOP: Valve Analysis and Pathoanatomy Segmental Analysis of Mitral Valve
Functional Anatomy of Mitral Valve Annulus Leaflets Chordae Tendineae Papillary Muscles LV Wall
LESIONS - ANNULUS Annulus Lesions: Dilatation, Calcification
LESIONS - ANNULUS
Valve Snalysis and Pathoanatomy LESIONS - LEAFLETS Leaflet Lesions: Cleft / Tear Vegetations / Perforation Thickening / Commissure Fusion Calcification Billowing
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
LESIONS - LEAFLETS Pathologic clefts: Anterior leaflet May extend to annulus Present within PL scallops
LESIONS - LEAFLETS Vegetations / Perforation: Endocarditis, Trauma
LESIONS - LEAFLETS Vegetations / Perforation: Non-infectious (Libman-Sacks)
LESIONS - LEAFLETS Thickening / Commissure Fusion Anterolateral Fusion Double Commissural Fusion
Calcification Valve Analysis and Pathoanatomy LESIONS - LEAFLETS Can involve the leaflet, annulus, or both
LESIONS - LEAFLETS Leaflet Billowing: Classically with Barlow s Syndrome / Marfan Syndrome Billowing No MR Billowing + Chordal Elongation MR
LESIONS - CHORDAE Chordae Lesions: Elongation Rupture Thickening / Fusion / Shortening
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
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
Spectrum of Degenerative Disease Chordal Elongation: Posterior leaflet prolapse without rupture PREOP: POSTOP:
Spectrum of Degenerative Disease Flail Mitral Valve: Posterior leaflet prolapse with ruptured chord PREOP: POSTOP:
Spectrum of Degenerative Disease Anterior Leaflet Prolapse: Consider transfer to Reference Center?
Spectrum of Degenerative Disease Bileaflet Prolapse: Marfan syndrome / Barlow s syndrome PREOP: POSTOP:
PREOP: Valve Analysis and Pathoanatomy Forme Fruste: Bileaflet Prolapse
INTRAOP: Valve Analysis and Pathoanatomy Segmental Analysis of Mitral Valve
INTRAOP: Valve Analysis and Pathoanatomy Forme Fruste: Bileaflet Prolapse
POSTOP: Valve Analysis and Pathoanatomy Forme Fruste: Bileaflet Prolapse
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
LESIONS PAPILLARY MUSCLE Papillary Muscle Lesions: Elongation / Rupture
LESIONS PAPILLARY MUSCLE Ruptured Posteromedial Papillary Muscle POSTOP:
LESIONS LV WALL Left Ventricle Wall Lesions: Aneurysm Dilation / Dyskinesis of inferobasal wall LV Ischemia / Infarction
LESIONS LV WALL Ischemic MR Restricted leaflet motion Type IIIb: PREOP: POSTOP:
COMBINATION LESIONS 76 yo woman with severe MR, nob-bypassable circumflex underwent P2 resection and 31mm Duran Band COMING OFF PUMP:
COMBINATION LESIONS Removed true-sized flexible band placed downsized ring
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
Thank you for your attention.
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
Mitral Valve Historical Perspective Leonardo da Vinci (1452 1519)