DR NIKUNJR SHEKHADA (MBBS,MS GEN SURGERY,DNB CTS RESIDENT)

1. ACQUIRED MITRAL VALVE DISEASE
SURGICAL TREATMENT
MITRAL VALVE REPAIR
BY DR NIKUNJ
(CTS RESIDENT STAR HOSPITAL)
(Coordinator:DR P.SATYENDRANATH PATHURI)
(14/7/19)

2. • REPARABILITY
• Mitral valve repair is preferred over replacement if a successful and durable repair can be achieved.
• Mitral valve repair is performed at a lower operative mortality ratethan replacement.
• Valve repair not only avoids the risks inherent to prosthetic heart valves, but it better preserves left
ventricular function by preserving the subvalvular apparatus.
• In the case of posterior leaflet prolapse, repair has become sufficiently standardized so that repair is
the standard of care.
• the probability of successful mitral valve repair is strongly influenced by surgeon-specific mitral
procedure volume, it is recommended that more complex valves be referred to heart teams with
particular expertise in this area.

3. MITRAL VALVE REPAIR
• Mitral valve repair is the procedure of choice for correcing severe mitral regurgitation.
• Aim
1. restore a large surface of leaflet coaptation,
2. preserve leaflet mobility,
3. restore physiologic annular geometry with a remodeling annuloplasty.
• a systematic approach to reconstructive surgery should be used that includes a determination of the
mechanism of mitral regurgitation via imaging and valve analysis, application of appropriate repair
techniques depending on the culprit lesions, and assessment of the repair quality by pressurized saline
testing and echocardiography.

4. FUNDAMENTALS OF RECONSTRUCTIVE SURGERY
VALVE ANALYSIS
• The mitral valve apparatus should first be carefully examined to confirm the mechanism of regurgitation,
evaluate the feasibility of repair, and plan the technical operation
• Segmental valve analysis with a nerve hook can identify areas of leaflet prolapse or restriction.
• It should be noted that prolapse of P1 is less common, and the free margin of other valve segments can be
compared with P1 to determine severity of prolapse.

5. REMODELING RING ANNULOPLASTY
• all patients with chronic mitral regurgitation demonstrate some degree of annular dilation and benefit from
a remodeling annuloplasty.
• the annulus is weakest along the mural segments and thus typically dilates in the anteroposterior dimension.
• A remodeling ring annuloplasty restores the normal physiologic size ratio and shape of the annulus, and it
improves the surface area of leaflet coaptation.

7. • Appropriate ring sizing is based on the intercommissural distance and the surface area of the anterior
leaflet.
• There is usually a strong correlation between the intercommissural distance and the height of the
anterior leaflet. However, if the free edge of the anterior leaflet extends 2 to 4 mm beyond the inferior
edge of the selected sizer, a ring that is one size larger should be selected to prevent the risk of systolic
anterior motion of the anterior mitral valve leaflet.

8. • Simple sutures should be placed circumferentially around the mitral valve and into the mitral
annulus
• care should be taken to avoid inadvertent injury to the aortic valve leaflets by taking
shallower bites.
• the area of the anterolateral commissure to avoid iatrogenic injury to the circumflex
coronary artery and aortic leaflets.
• Since the intercommissural distance is equivalent on the anterior annulus and the ring,
sutures should be placed evenly through their corresponding places on the ring
• However, as the posterior annulus is usually dilated, the spaces of the sutures within the
annulus should be greater than their respective spacing on the ring.
• The ring is then seated to conform the annulus to the shape and size of the prosthetic ring.

9. ASSESSMENT OF REPAIR
• The quality of the repair should be evaluated with a saline test after completion of the leaflet repair and
again after ring implantation, but before tying the annuloplasty ring sutures so that the surgeon is still free
to make additional changes at each stage if corrections are necessary.
• A symmetrical line of coaptation, parallel to the posterior part of the remodeling ring and at a reasonable
distance from the left ventricular outflow tract, indicates a successful repair.
• Asymmetric coaptation lines reveal residual leaflet prolapse or restriction that requires correction
• A supplemental “ink test” can be performed to further assess the quality of the repair.
• The valve closure line is traced with a marking pen after pressurizing the ventricle with saline. Saline is
aspirated and the leaflet margins are surveyed.
• Ideal coaptation depth ranges from 4 to 10 mm. A depth less than 4 mm should be corrected by resection of
restrictive secondary chordae, cleft closure, or downsizing the annuloplasty ring
• depths greater than 10 mm are systolic anterior motion, which may require reduction of the height of the
posterior leaflet.

10. VALVE REPAIR IN TYPE I DYSFUNCTION
• Annular dilation is the most common cause, which should be corrected with a complete rigid or semirigid
remodeling annuloplasty

11. VALVE REPAIR IN TYPE I DYSFUNCTION
• Type I valve regurgitation may also be secondary to leaflet perforation, commonly seen in infective
endocarditis. The management of patching such a lesion is described

12. VALVE REPAIR IN TYPE II DYSFUNCTION
• POSTERIOR LEAFLET PROLAPSE. Resection of the prolapsed area or segment has been the conventional
technique for repair of posterior leaflet prolapse.
• QUADRANGULAR RESECTION WITH OR WITHOUT SLIDING PLASTY AND TRIANGULAR RESECTION.
• initial placement of annuloplasty sutures helps lift and expose the valve to facilitate repair.
• When performing the conventional quadrangular resection stay sutures are placed around normal chordae
to delineate the prolapsed area.

14. • When the area of prolapse is less
extensive, the prolapsing area can
be excised with a triangular
resection The free edges of the
resection are then reapproximated
with polypropylene suture.

15. • excessive posterior leaflet tissue,
such as in Barlow’s disease, it is
critical to reduce the height of the
posterior leaflet to avoid systolic
anterior motion.
• Thus, a sliding leaflet plasty
technique is performed after initial
quadrangular resection.
• note that plication of a large
segment of the posterior annulus
must be avoided because the
circumflex artery may kink.

16. MINOR DRAWBACKS OF RESECTIONAL APPROACHES TO MITRAL REPAIR,
1. irreversibility of leaflet resection
2. time-consuming leaflet reapproximation with sliding annuloplasty
3. monoleaflet function
4. risk for postrepair systolic anterior motion
5. potential for dynamic mitral stenosis

17. POSTERIOR VENTRICULAR ANCHORING NEOCHORDAL REMODELING REPAIR
• Frater and colleagues described the utility of polytetrafluoroethyl- ene (PTFE) for chordal replacement in the
setting of diseased or ruptured chordae.
• Numerous modifications to artificial chordal replacement are well described, including the loop, loop-in-
loop, haircut, and butterfly techniques.
• Although neochordal construction circumvents many of the drawbacks of leaflet resection, precise sizing is
challenging and maintenance of excess leaflet tissue may risk systolic anterior motion of the mitral valve.

18. • a strategy based on a modified leaflet plication repair.
• Single suture imbrication of excess prolapsing leaflet tissue onto the noncoaptation ventricular side of the
leaflet effectively creates a smooth coaptation surface without residual prolapse.
• This technique, however, carries a theoretical risk of basing the repair on potentially diseased native chordae
and the potential for the mobile posterior leaflet to advance anteriorly, risking systolic anterior motion.
• a single PTFE suture is used to anchor, support, and remodel the posterior leaflet posteriorly

20. ANTERIOR LEAFLET PROLAPSE.
• Several techniques have been described to correct anterior leaflet prolapse. It is our preference to use
chordal techniques instead of resec-tion or papillary muscle techniques
• Triangular Resection
• Limited prolapse of the ante-rior leaflet with excess tissue can be treated with a narrow triangular
resection of the prolapsed area
• The free edges are then reapproximated with polypropylene suture.
• large resections of the anterior leaflet greatly reduce coaptation area and increase risk for failure.
• resections of the anterior leaflet should be small (no greater than 10% of the leaflet surface area)

21. CHORDAL TRANSPOSITION
• In the absence of normal secondary anterior leaflet chordae, a
posterior leaflet chordal transposition may be performed

22. ARTIFICIAL NEOCHORDAE
• ARTIFICIAL CHORDOPLASTY is particularly useful when the number of normal chordae is inadequate.
• Similar to chordal transfer, multiple artificial neochordae may be required for larger areas of leaflet prolapse,
and it is essential that no portion of the leaflet margin greater than 4 mm be left unsupported.

23. ARTIFICIAL CHORDOPLASTY

24. • DIFFICULTY
• adjusting distance between the tip of the papillary muscle and the prolapsing leaflet edge to the precise
length needed.
• fixing the PTFE suture at the correct length is challenging because the slippery nature of PTFE suture causes
knots to slide significantly.
• with suboptimal exposure, visualization of and chordal implantation into the papillary muscles can be
challenging.

25. • Alternatively, a PTFE suture can be passed through the papillary muscle and then through the free margin of
the prolapsing segment. Following implantation of the annuloplasty ring, the PTFE suture is tied in the
setting of a pressurized ventricle.
• The knot can then be secured at the appropriate level, where coaptation is restored and the visualized
regurgitant flow is eliminated.
• This freehand technique is more versatile and less complex, but it requires a degree of judgment and skill for
determining the proper chord length and for tying without slipping the knot, thereby overly shortening the
neochord.

26. DOUBLE ORIFICE EDGE-TO-EDGE REPAIR.
• Alfieri’s edge- to-edge technique effectively creates a double orifice mitral valve and may be used to correct
posterior, anterior, or bileaflet prolapse

27. • If the prolapsing or flail segment does not involve A2 or P2, the valve will be rendered asymmetric with this
repair and the size of the two orifices will differ.
• The overall mitral valve area is assessed by direct inspection; however, when in doubt, Hegar dilators can be
inserted into each orifice.
• A total valve area greater than 2.5 cm2 is acceptable for average-size patients.

28. COMMISSURAL PROLAPSE
• Commissural prolapse is effectively treated with resection of the prolapsed area and sliding plasty of the
adjacent paracommissural segments (e.g., A1 and P1 sliding plasty for anterolateral commissural prolapse).
• Additional inverting sutures should be placed in the neocommissure to prevent residual regurgitation.
• Infrequently, a patient will have commissural prolapse secondary to rupture of a two-headed papillary
muscle. In this situation, the prolapse can be corrected with reattachment to the remaining papillary muscle.
• papillary muscle sliding plasty and shortening are useful options for the correction of extensive commissural
and paracommissural prolapse.

29. VALVE REPAIR IN TYPE IIIA DYSFUNCTION
• Repair of type IIIa dysfunction must address leaflet immobility and restriction.
• Leaflet immobility is primarily related to commissural and chordal fusion.
• These lesions should be addressed with commissurotomy and chordal fenestration

30. • The diastolic restriction of leaflet motion characteristic of type IIIa dysfunction can be corrected with leaflet
augmentation .

31. • To account for the new posterior leaflet size, an annuloplasty ring should be chosen that is one size larger
than that recommended by standard sizing techniques.
• The anterior leaflet can also be augmented in a similar fashion; however, a vertical leaflet incision is
commonly used.
• The patch is sized to the natural gap created by the leaflet incision. Because the anterior leaflet is
augmented, an annuloplasty ring should be chosen that is the true size of the new anterior leaflet.

32. VALVE REPAIR IN TYPE IIIB DYSFUNCTION
• Remodeling annuloplasty with an undersized ring is the standard technique to repair type IIIb dysfunction
• the insertion of an undersized prosthetic ring in a severely dilated annulus can cause excessive tension on
the sutures, thereby predisposing to ring dehiscence.

33. ANNULAR DECALCIFICATION AND ANNULAR RECONSTRUCTION
• Annular calcification complicates mitral valve surgery.
• The risks of atrioventricular disruption, paravalvular leak, and valve dehiscence are all increased I
• Annular decalcification is executed by separation of the leaflet from the annulus and en bloc removal of
calcium deposits.
• Often, annular reconstruction is required to repair localized atrioventricular disruption following calcium
excision.
• débridement of annular abscesses in the treatment of infective endocarditis may necessitate annular
reconstruction.
• David and colleagues and Carpentier and colleagues have described different techniques for mitral annular
reconstruction.

34. • David’s technique, mitral annular reconstruction is conducted using autologous or glutaraldehyde-fixed
bovine pericardium.
• The posterior annulus is reconstructed with a semicircular pericardial patch.
• The patch is usually 2 cm wide but must be wide enough to cover the defect.
• One of the margins of this strip is sutured to the smooth endocardium of the inflow of the left ventricle, and
the other margin is sutured to the posterior left atrial wall with a continuous 3-0 polypropylene suture.
• The detached posterior leaflet is then reattached to the pericardial patch at the level of the original annulus.
• In patients with complete destruction of the annulus, a circumferential patch is tailored for annular
reconstruction.
• An annuloplasty ring is then secured to the pericardial patch. Similar techniques use felt.

35. • In Carpentier’s technique the mitral annulus is reconstructed with figure-of-eight atrioventricular mattress
sutures to minimize use of foreign material.