1. Surgical Management of
Valvular Heart Disease
By R-2 M/A

2. General Considerations
 The primary causes of valve disease are
RHD, age-associated calcific valve changes
and inherited or congenital conditions (e.g.,
a bicuspid aortic valve or myxomatous
mitral valve disease).
 The prevalence of rheumatic valve disease
now is very low in the developed world
because of primary prevention of rheumatic
fever, although rheumatic valve disease
remains prevalent in the developing world.

3.  Doppler Echocardiography is the
mainstay for establishing the
diagnosis, evaluation of the valve
anatomy for feasibility of repair/
surgery and follow of the patients.
 Before deciding to go ahead with
surgery, it is important to determine
the existence and severityof other Co
morbid conditions.

4.  Most imp of these co morbid
conditions, is Ischaemic heart disease
and existing recommendations for age
and sex, must be complied with.
 Serial follow up of mild to moderate,
Asymptomatic valvular diseases with
echo is recommended to determine
the need for intervention in case of
deterioration in function.

5. 

6. Prosthetic valves
 Two types:
1}Mechanical
2} Bioprosthesis
The major differences are related to the
risk of thromboembolism (higher with
mechanical valves) and the risk of
structural deterioration of the
prosthesis.

7. Mechanical Prosthesis
 Three types:
◦ 1} Bileaflet : MC used St Jude
◦ 2} Tilting disc: Medtronic Hall value
◦ 3} Caged ball: discontinued now
All mechanical prosthetic valves have an excellent
record of durability over 25 years for the St. Jude
valve.
In the mitral position, perivalvular regurgitation appears
to occur more frequently with mechanical than with
tissue valves.
Thrombosis and thromboembolism risks are greater
with any mechanical valve in the mitral than in the
aortic position
INR values: 2-3 for Aortic position
2.5- 3.5 for Mitral position

8. Bioprosthesis
 Xenografts { porcine} : Stented or
Stentless
 Homograft Aortic valves: These are harvested
from cadavers, usually within 24 hours of donor
death.
 Pulmonary Autografts: the Ross
procedure, the patient's own pulmonary valve
and adjacent main pulmonary artery are
removed and used to replace the diseased
aortic valve and often the neighboring aorta,
with reimplantation of the coronary arteries into
the graft.
 All bioprosthetic valves have limited durability
and by 10 years the rate of primary tissue
failure averages 30%., by 15 years its 60%

9. Choice of valve
 Patient outcome after valve surgery is related
more to preoperative factors, such as age, LV
function, associated coronary artery disease, and
comorbid conditions, than to the prosthesis itself
 The major task when selecting an artificial valve
is to weigh the advantage of durability and the
disadvantages of the risks of thromboembolism
and anticoagulant treatment inherent in
mechanical prostheses on the one hand with the
advantage of low thrombogenicity and the
disadvantage of abbreviated durability of
bioprostheses on the other.
 Therefore, mechanical prostheses, usually of the
bileaflet variety, are the valves of choice for most
patients younger than 65 years.

10.  Bioprosthestic valve preferred in
◦ 1 Haemorrhagic tendency
◦ 2 Non compliance with anti
coagulants
◦ 3 >65 yrs
◦ 4 Young women , requiring AVR,
wishing to bear children.

11.  Different types of prosthetic valves. A, Bileaflet mechanical
valve (St. Jude Medical,. B, Monoleaflet mechanical valve
(MedtronicC, Caged ball valve D, Stented porcine bioprosthesis
E, Stented pericardial bioprosthesisF, Stentless porcine
bioprosthesis

12. Aortic Stenosis
 Obstruction to left ventricular (LV) outflow is
localized most commonly at the aortic valve.
 However, obstruction may also occur above the
valve (supravalvular stenosis) or below the valve
(discrete subvalvular stenosis}, or it may be caused
by hypertrophic cardiomyopathy.
 Valvular AS has three principal causes—a
congenital bicuspid valve with superimposed
calcification, calcification of a normal trileaflet
valve, and rheumatic disease.

13. The rheumatic valve is often
regurgitant, as well as stenotic.
 Patients with rheumatic AS
invariability have rheumatic
involvement of the mitral valve
 Most patients with bicuspid valves
have normal valve function until late in
life, when superimposed calcific
changes result in valve obstruction

15.  Echocardiography is the standard
approach for evaluating and following
patients with AS and selecting them for
operation
 The combination of pulsed, continuous
wave and color flow Doppler
echocardiography is helpful in detecting
and determining the severity of AR
(which coexists in about 75% of patients
with predominant AS) and in estimating
pulmonary artery pressure.

16.  cardiac catheterization is now
recommended only when
◦ noninvasive tests are inconclusive,
◦ when clinical and echocardiographic findings
are discrepant, and
◦ for coronary angiography prior to surgical
intervention.
 The most important principle in the
management of adults with AS is patient
education regarding the disease course
and typical symptoms.Patients should be
advised to promptly report the
development of any symptoms possibly
related to AS.

17. Operative Interventions
 Adolescents
In the adolescent or young adult with severe
congenital AS, balloon aortic valvotomy is recommended
for all symptomatic patients and asymptomatic patients
with a transvalvular gradient higher than 60 mm Hg or
electrocardiographic ST-segment changes at rest or with
exercise.
At surgery, simple commissural incision under
direct vision usually leads to substantial hemodynamic
improvement with low risk (i.e., mortality rate < 1%).
Despite the salutary hemodynamic results following
percutaneous or surgical valvotomy, the valve is not
rendered entirely normal anatomically. The turbulent blood
flow through the valve may subsequently lead to further
deformation, calcification, development of
regurgitation, and restenosis after 10 to 20 years, often
requiring reoperation and valve replacement later.

18.  Adults
 AVR is recommended for adults with symptomatic
severe AS, even if symptoms are mild.
 AVR also is recommended for severe AS with an
ejection fraction less than 50% and for patients with
severe asymptomatic AS who are undergoing
coronary bypass grafting (CABG) or other forms of
heart surgery.
 In selected cases, balloon valvotomy might be
reasonable as a bridge to surgery in unstable
patients or as a palliative procedure when surgery
is very high risk.
 Transcatheter aortic valve implantation (TAVI) by a
percutaneous or transapical approach is a rapidly
evolving technology that is available in Europe and
under investigation in the US for seriously ill
patients who are not candidates for conventional
surgery

19. 

20. Results
 Successful replacement of the aortic
valve results in substantial clinical and
hemodynamic improvement in patients
with AS, AR, or combined lesions.
 the operative risk ranges from 2% to
 Risk factors associated with a higher
mortality rate include a high (NYHA)
class, impairment of LV function,
advanced age, and the presence of
associated coronary artery disease.
 The 10-year actuarial survival rate of
hospital survivors in surgically treated
patients is approximately 85%

21. Aortic Regurgitation
 Causes:
A} Primary disease of the aortic valve leaflets
1} Rheumatic fever
2}IE
3}Bicuspid aortic value mild AR may
4}Calcific AS be present
B} Aortic Root Disease {secondary to marked dilation of
the ascending aorta } includes
Marfan syndrome; aortic dilation related to bicuspid
valves,[87] aortic dissection, osteogenesis imperfecta,
syphilitic aortitis, ankylosing spondylitis,Behcet syndrome,
psoriatic arthritis, arthritis associated with ulcerative colitis,
relapsing polychondritis, reactive arthritis, giant cell
arteritis, and systemic hypertension.

22.  Doppler echocardiography and color flow
Doppler imaging are the most sensitive
and accurate noninvasive techniques for
the diagnosis and evaluation of AR.
 They readily detect mild degrees of AR
that may be inaudible on physical
examination.
 . Serial studies permit determination of
the progression of AR and its effect on
the left ventricle

23. mild moderate severe

24. Indications for Operation
 Because of their excellent prognosis in the short and
medium term, operative correction should be deferred
in patients with chronic severe AR who are
asymptomatic, have good exercise tolerance, and have
an ejection fraction greater than 50% without severe LV
dilation (i.e., end-diastolic diameter ≤75 mm; end-
systolic diameter ≤55 mm) or progressive LV dilation on
serial echocardiograms
 In the absence of obvious contraindications or serious
comorbidity, surgical treatment is advisable for
symptomatic patients with severe AR and for
asymptomatic patients with
◦ an ejection fraction of 50% or less,
◦ severe LV dilation (end-diastolic diameter > 75 mm or
end-systolic diameter > 55 mm) or
◦ less severe dilation (end-diastolic diameter > 70 mm or
end-systolic diameter > 50 mm), with evidence of
progressive LV enlargement on serial echocardiograms.

25. 

26.  The standard surgical approach for chronic
AR is valve replacement. Concurrent aortic
root replacement is performed when aortic
dilation is the cause or accompanies valve
dysfunction
 However, there is growing experience with
surgical aortic valve repair, which is a viable
option for selected patients in experienced
centers
 When AR is caused by leaflet perforation
resulting due to infective endocarditis, a
pericardial patch can be used for repair
 Aneurysmal dilation of the ascending aorta
requires excision, replacement with a graft
that includes a prosthetic valve, and
reimplantation of the coronary arteries.

27.  The mortality rate ranges from 3% to
8% in most medical centers.
 A large percentage of patients
exhibits striking improvement in
symptoms
 With the continued improvement of
surgical techniques and results, it will
likely become possible to extend the
recommendation for operative
treatment to asymptomatic patients
with severe AR, normal LV systolic
function, and only mild LV dilation.

28. MITRAL STENOSIS
 The predominant cause of MS is rheumatic
fever, with rheumatic changes present in 99%
of stenotic mitral valves excised at the time of
mitral valve (MV) replacement.
 About 25% of all patients with rheumatic heart
disease have isolated MS, and about 40%
have combined MS and MR.
 Multivalve involvement is seen in 38% of MS
patients, with the aortic valve affected in about
35% and the tricuspid valve in about 6%. The
pulmonic valve is rarely affected.
 Two thirds of all patients with rheumatic MS are
female.

29.  Doppler Echo is the gold standard for
diagnosis and quantification of severity of
MS.
 The transmitral gradient is also calculated
and any coexisting MR is quantitated.
 Evaluation of the morphology of the valve is
helpful for predicting the hemodynamic
results and outcome of percutaneous BMV.
 When transthoracic images are suboptimal,
TEE is appropriate. TEE is also necessary to
exclude left atrial thrombus and evaluate MR
severity when percutaneous BMV is
considered .
 Routine diagnostic cardiac catheterization is
not recommended for the evaluation of MS.

30.  Patients with an echocardiographic score of 8
or less generally have a more favorable result
from mitral balloon valvuloplasty than do those
with a score higher than 8

31. 

32. Balloon Mitral Valvotomy
 Patients with mild to moderate MS who are
asymptomatic frequently remain so for years,
and clinical outcomes are similar to age-
matched normal patients.
 However, severe or symptomatic MS is
associated with poor long-term outcomes if
the stenosis is not relieved mechanically .
 Percutaneous BMV is the procedure of
choice for the treatment of MS so that
surgical intervention is now reserved for
patients who require intervention and are not
candidates for a percutaneous procedure.[

33.  This percutaneous technique consists of
advancing a small balloon flotation catheter
across the interatrial septum (after
transseptal puncture), enlarging the
opening, advancing a large (23- to 25-mm)
hourglass-shaped balloon (the Inoue
balloon), and inflating it within the orifice
 Alternatively, two smaller (15- to 20-mm) side
by side balloons across the mitral orifice may
be used.
 TEE should be performed just prior to BMV to
exclude left atrial thrombus and confirm that
MR is not moderate or severe.

34. Inoue Balloon Technique for Percutaneous Mitral Balloon Valvotomy.A.
After transseptal puncture, the deflated balloon catheter is advanced across
the interatrial septum, then across the mitral valve and into the left ventricle.
B.-D. The balloon is inflated stepwise within the mitral orifice.

35.  Commissural separation and fracture of nodular
calcium appear to be the mechanisms
responsible for improvement in valvular function.
 The hemodynamic results of BMV have been
favorable with reduction of the transmitral
pressure gradient from an average of
approximately 18 to 6 mm Hg, a small
(average, 20%) increase in cardiac output, and
an average doubling of the calculated mitral
valve area, from 1 to 2 cm2.
 Results are especially impressive in younger
patients without severe valvular thickening or
calcification. Elevated pulmonary vascular
resistance declines rapidly, although usually not
completely.

36.  The reported mortality rate has ranged from 1% to 2%..
 Complications include cerebral emboli and cardiac
perforation, each in approximately 1% of patients.
 And the development of MR severe enough to require
operation in another 2% (approximately 15% develop
lesser, but still undesirable, degrees of MR).
 Approximately 5% of patients are left with a small
residual atrial septal defect, but this closes or
decreases in size in most.

 Rarely, the defect is large enough to cause right-sided
heart failure; this complication most often is seen in
conjunction with an unsuccessful mitral valvotomy

37.  Indications for BMV:
1}Symptomatic patients with moderate to
severe MS (i.e., a mitral valve area < 1 cm2/m2
body surface area [BSA] or <1.5 cm2 in normal-
sized adults) and with favorable valve
morphology, no or mild MR, and no evidence of
left atrial thrombus.
Even mild symptoms, such as a subtle decrease
in exercise tolerance, are an indication for
intervention because the procedure relieves
symptoms and improves long-term outcome with a
low procedural risk.
2}Moderate to severe MS with PHT with a
PASP >50 mm Hg at rest or 60 mm Hg with
exercise.

38. 3}Symptomatic patients who are at
high risk for surgery, even when valve
morphology is not ideal.
These include very old frail patients, patients with
associated severe ischemic heart
disease, patients in whom MS is complicated by
pulmonary, renal, or neoplastic disease,
4} Women of childbearing age in
whom MV replacement is
undesirable, and pregnant women with
MS.

39. Surgical Valvotomy
 Three operative approaches are available for
the treatment of rheumatic MS:
 1) closed mitral valvotomy using a transatrial
or transventricular approach
 2) open valvotomy (i.e., valvotomy carried out
under direct vision with the aid of
cardiopulmonary bypass, which may be
combined with other repair techniques, such
as leaflet resection, chordal procedures, and
annuloplasty when MR is present and
 3) MV replacement

40.  Surgical intervention for MS is recommended for
patients with
severe MS and significant symptoms (NYHA
Class III or IV) when BMV is not available,
BMV is contraindicated because of persistent
left atrial thrombus or moderate to severe MR, or
when the valve is calcified.
Surgery also is reasonable for patients with severe
MS and severe pulmonary hypertension when BMV
is not possible and may be considered for patients
with moderate to severe MS with recurrent embolic
events despite anticoagulation.

42.  In patients with AF, a left atrial maze or AF ablation
procedure typically is done at the time of surgery to
increase the likelihood of long-term sinus rhythm.
 Open valvotomy is feasible and successful in more
than 80% of patients referred for this procedure, with an
operative mortality of 1%, rate of reoperation for MV
replacement of 0% to 16% at 36 to 53 months, and 10-
year actuarial survival rates of 81% to 100%.
 Mitral valvotomy, whether percutaneous or operative
and open or closed, is palliative rather than curative
and, even when successful, there is some degree of
residual mitral valve dysfunction.
 On clinical grounds alone, based on the reappearance
of symptoms, the incidence of restenosis has been
estimated to range widely, from 2% to 60%.

43. Causes of symptoms after valvotomy
(1) An inadequate first operation with
residual stenosis
(2) Increased severity of MR, either at
operation or as a consequence of
infective endocarditis
(3) Progression of aortic valve disease
(4) Development of coronary artery
disease.
 True restenosis occurs in less than 20%
of patients who are followed for 10 years

44. Mitral Valve Replacement
 MV replacement is recommended for
symptomatic patients with severe MR when
BMV or surgical MV repair is not possible
 Usually, MV replacement is required for
patients with
1)combined MS and moderate or severe MR,
2)those with extensive commissural
calcification, severe fibrosis, and subvalvular
fusion, and
3)those who have undergone previous
valvotomy.
The operative mortality rate for isolated MV
replacement ranges from 3% to 8%

45. Mitral Regurgitation
 The mitral valve apparatus involves the
mitral leaflets, chordae tendineae,
papillary muscles, and mitral annulus.
Abnormalities of any of these structures
may cause MR.
 The major causes of MR include
◦ Rheumatic heart disease,
◦ Infective endocarditis
◦ Annular calcification,
◦ Cardiomyopathy, and
◦ Ischemic heart disease
◦ Mitral valve prolapse (MVP)

46.  The natural history of MR is highly variable and
depends on a combination of the volume of
regurgitation, state of the myocardium, and
cause of the underlying disorder.
 Asymptomatic patients with mild primary MR
usually remain in a stable state for many years
 Regurgitation tends to progress more rapidly in
patients with connective tissue diseases, such as
the Marfan syndrome, than in those with chronic
MR of rheumatic origin.
 Acute rheumatic fever is a frequent cause of
isolated severe MR in adolescents in developing
nations, and these patients often have a rapidly
progressive course

47.  Indication for Surgical treatment:
◦ 1}patients with functional disability
◦ 2}patients with no symptoms or only mild
symptoms but with progressively
deteriorating LV function or progressively
increasing LV dimensions, as documented by
noninvasive studies.
 In patients considered for surgery, two-
dimensional transthoracic or TEE with
Doppler evaluation and color flow
Doppler imaging provide detailed
assessment of mitral valve structure and
function.

48.  The decision to replace or to repair the
valve is of critical importance, and MV
repair is strongly recommended
whenever possible.
 Replacement involves the operative
risk, as well as the risks of
thromboembolism and anticoagulation
in patients receiving mechanical
prostheses.
 Operative mortality rates of 3% to 9%

49.  Surgical treatment substantially improves
survival in patients with symptomatic MR
 Preoperative factors, such as age younger
than 60 years, NYHA Class I or II, cardiac
index exceeding 2.0 liters/min/m2, LV end-
diastolic pressure less than 12 mm Hg, and a
normal ejection fraction and end-systolic
volume, all correlate with excellent immediate
and long-term survival rates.
 Both preoperative LV ejection fraction and
end-systolic diameter are important
predictors of short- and long-term outcomes

51. Tricuspid Regurgitation
 The most common cause of TR is not intrinsic
involvement of the valve itself (i.e., primary
TR) but rather dilation of the right ventricle
and of the tricuspid annulus causing
secondary (functional) TR.
 This may be a complication of RV failure of
any cause.
 It is observed in patients with RV
hypertension secondary to any form of
cardiac or pulmonary vascular disease, most
commonly mitral valve disease.
 RV systolic pressure greater than 55 mm Hg
will cause functional TR.

52.  At the time of mitral valve surgery in patients with TR
secondary to pulmonary hypertension, the severity of
the regurgitation should be assessed by palpation of the
tricuspid valve.
 Patients with mild TR without annular dilation usually do
not require surgical treatment.
 However, even mild TR should be repaired if there is
dilation of the tricuspid annulus, because the TR is likely
to progress in severity if left untreated.
 When organic disease of the tricuspid valve (Ebstein
anomaly or carcinoid heart disease) causes TR severe
enough to require surgery, valve replacement is usually
needed.
 Tricuspid endocarditis in IV drug users, usually, total
excision of the tricuspid valve without immediate
replacement can generally be tolerated by these
patients, who usually do not have associated pulmonary
hypertension.

53. Pulmonary stenosis & Regurgitation
 The congenital form is the most common
cause of pulmonic stenosis (PS).
 Rheumatic inflammation of the pulmonic
valve is very uncommon, is usually
associated with involvement of other valves,
and rarely leads to serious deformity.
 Management of congenital PS focuses on
balloon dilation.
 Pulmonic regurgitation (PR) can result from
dilation of the valve ring secondary to
pulmonary hypertension (of any cause) and
t/t consists of managing the primary etiology.

54. Multivalvular Diseases
 Multivalvular involvement is caused frequently by
rheumatic fever and various clinical and
hemodynamic syndromes can be produced by
different combinations of valvular abnormalities.
 In patients with multivalvular disease, the clinical
manifestations depend on the relative severity of
each of the lesions.
 When the valvular abnormalities are of
approximately equal severity, clinical manifestations
produced by the more proximal (upstream) of the
two valvular lesions (i.e., the mitral valve in patients
with combined mitral and aortic valvular disease and
the tricuspid valve in patients with combined
tricuspid and mitral valvular disease) are generally
more prominent than those produced by the distal
lesion. Thus, the proximal lesion tends to mask the
distal lesion

55.  Mitral Stenosis and Aortic Valve Disease
◦ Aortic valve involvement is present in about one third of
patients with rheumatic MS. Rheumatic aortic valve
disease may result in primary regurgitation, stenosis, or
mixed stenosis and regurgitation.
◦ Echocardiography is of decisive value in the evaluation of
patients with rheumatic disease and allows accurate
diagnosis of the presence and severity of multivalve
involvement, taking into consideration the altered flow
conditions with serial lesions.
◦ Because double-valve replacement is associated with
increased short- and long-term risks, balloon mitral
valvotomy can be the first procedure if MS is the
predominant lesion, with subsequent AVR when needed. If
percutaneous balloon valvotomy is not an option or
concurrent AVR is needed, surgical valvotomy may be
considered as an option.

56. Aortic and Mitral Regurgitation
 Relatively infrequent combination of lesions may be caused by
rheumatic heart disease, prolapse of both the aortic and the
mitral valves because of myxomatous degeneration, or dilation of
both annuli in patients with connective tissue disorders.
 Clinical features of AR usually usually predominate.
 The relative severity of each lesion can be assessed best by
Doppler echocardiography and contrast angiography.
.
 MR that occurs in patients with AR secondary to LV dilation often
regresses following AVR alone.
 If severe, the MR may be corrected by annuloplasty at the time
of AVR. An intrinsically normal mitral valve that is regurgitant
because of a dilated annulus should not be replaced.

57. 
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