Surgical management of valvular heart disease


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Surgical management of valvular heart disease

  1. 1. Surgical Management ofValvular Heart Disease By R-2 M/A
  2. 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. 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. 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. 5.
  6. 6. Prosthetic valves Two types: 1}Mechanical 2} BioprosthesisThe major differences are related to therisk of thromboembolism (higher withmechanical valves) and the risk ofstructural deterioration of theprosthesis.
  7. 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. 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 patients 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. 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. 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. 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. 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. 13. The rheumatic valve is oftenregurgitant, 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
  14. 14.  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.
  15. 15.  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.
  16. 16. Operative Interventions Adolescents In the adolescent or young adult with severecongenital AS, balloon aortic valvotomy is recommendedfor all symptomatic patients and asymptomatic patientswith a transvalvular gradient higher than 60 mm Hg orelectrocardiographic ST-segment changes at rest or withexercise. At surgery, simple commissural incision underdirect vision usually leads to substantial hemodynamicimprovement with low risk (i.e., mortality rate < 1%). Despite the salutary hemodynamic results followingpercutaneous or surgical valvotomy, the valve is notrendered entirely normal anatomically. The turbulent bloodflow through the valve may subsequently lead to furtherdeformation, calcification, development ofregurgitation, and restenosis after 10 to 20 years, oftenrequiring reoperation and valve replacement later.
  17. 17.  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
  18. 18.
  19. 19. 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%
  20. 20. 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 presentB} Aortic Root Disease {secondary to marked dilation ofthe ascending aorta } includes Marfan syndrome; aortic dilation related to bicuspidvalves,[87] aortic dissection, osteogenesis imperfecta,syphilitic aortitis, ankylosing spondylitis,Behcet syndrome,psoriatic arthritis, arthritis associated with ulcerative colitis,relapsing polychondritis, reactive arthritis, giant cellarteritis, and systemic hypertension.
  21. 21.  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
  22. 22. mild moderate severe
  23. 23. 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.
  24. 24.
  25. 25.  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.
  26. 26.  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.
  27. 27. 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.
  28. 28.  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.
  29. 29.  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
  30. 30.
  31. 31. 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.[
  32. 32.  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.
  33. 33. Inoue Balloon Technique for Percutaneous Mitral Balloon Valvotomy.A.After transseptal puncture, the deflated balloon catheter is advanced acrossthe interatrial septum, then across the mitral valve and into the left ventricle.B.-D. The balloon is inflated stepwise within the mitral orifice.
  34. 34.  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.
  35. 35.  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
  36. 36.  Indications for BMV: 1}Symptomatic patients with moderate tosevere MS (i.e., a mitral valve area < 1 cm2/m2body surface area [BSA] or <1.5 cm2 in normal-sized adults) and with favorable valvemorphology, no or mild MR, and no evidence ofleft atrial thrombus. Even mild symptoms, such as a subtle decreasein exercise tolerance, are an indication forintervention because the procedure relievessymptoms and improves long-term outcome with alow procedural risk. 2}Moderate to severe MS with PHT with aPASP >50 mm Hg at rest or 60 mm Hg withexercise.
  37. 37. 3}Symptomatic patients who are athigh risk for surgery, even when valvemorphology is not ideal.These include very old frail patients, patients withassociated severe ischemic heartdisease, patients in whom MS is complicated bypulmonary, renal, or neoplastic disease, 4} Women of childbearing age inwhom MV replacement isundesirable, and pregnant women withMS.
  38. 38. 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
  39. 39.  Surgical intervention for MS is recommended for patients with severe MS and significant symptoms (NYHAClass III or IV) when BMV is not available, BMV is contraindicated because of persistentleft atrial thrombus or moderate to severe MR, orwhen the valve is calcified.Surgery also is reasonable for patients with severeMS and severe pulmonary hypertension when BMVis not possible and may be considered for patientswith moderate to severe MS with recurrent embolicevents despite anticoagulation.
  40. 40.  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%.
  41. 41. 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
  42. 42. 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 with1)combined MS and moderate or severe MR,2)those with extensive commissuralcalcification, severe fibrosis, and subvalvularfusion, and3)those who have undergone previousvalvotomy.The operative mortality rate for isolated MVreplacement ranges from 3% to 8%
  43. 43. 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)
  44. 44.  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
  45. 45.  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.
  46. 46.  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%
  47. 47.  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
  48. 48. 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.
  49. 49.  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.
  50. 50. 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.
  51. 51. 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
  52. 52.  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.
  53. 53. 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.
  54. 54.  THANK YOU