Lecture notes for medical students

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2. Introduction & History.

3. Introduction & History.
• In patients with valvular heart disease,
cardiac surgery aims to restore
normal valve function through either repair or
replacement of the diseased valve.
• Surgery of valvular heart disease started more than
50 years ago .
• Techniques became standardized for most types
of repair and replacement procedures,
• surgical management of valvular heart disease still
continues to evolve to respond to the changing
profile of patients.

4. Introduction & History.
• Reconstructive valvular surgery is the
preferred surgical procedure, especially for
the diseased mitral valve.
• Valve replacement is the standard procedure
for the diseased aortic valve.
• Age and cardiac rhythm are the main
determinants for choosing between a
mechanical and a biologic artificial valve.

5. Extracorporeal Circulation

6. Extracorporeal Circulation
• prerequisite for open heart interventions
because it permits arrest of the heart and
cessation of ventilation.
• Venous blood is drained through cannulas
placed in the right atrium or in the venae
cavae.
• Blood is oxygenated by a membrane
oxygenator.
• returned to the patient with the aid of a
roller pump through a cannula in the
ascending aorta.

7. Extracorporeal Circulation
• Extracorporeal circulation requires
anticoagulation with heparin, which is
neutralized after separation from
cardiopulmonary bypass with an
appropriate dose of protamine.

8. Myocardial protection
• Accomplished by injection of a cold (4°C)
cardioplegic solution, derived from the
extracorporeal circuit and cooled by the
heat exchange system.
• Diastolic arrest of the heart occurs as a
result of the drop in temperature and the
addition of potassium chloride (20 mmol/L)
to the cardioplegic solution.

9. The heart has 4 valves:

10. The heart has 4 valves:
• The mitral valve and tricuspid valve, which
control blood flow from the atria to the
ventricles.
• The aortic valve and pulmonary valve,
which control blood flow out of the
ventricles.

11. Indications
• Stenosis.
• Insufficiency –Regurgitation.
• Stenosis+Regurgitation

12. Position
• Supine

13. Anesthesia
• Endotracheal controlled inhalational
anesthesia.

14. Intraoperative
Transesophageal Echography

15. Intraoperative
Transesophageal Echography
• All patients undergoing a valve repair
undergo intraoperative assessment of the
result by transesophageal echography
• Any persistent valve dysfunction is
immediately treated.

16. Incision:
• A median sternotomy is the operative
approach of choice for most valvular
procedures.
– the entire heart becomes accessible,
– does not alter the respiratory function
– rapid healing with a very low rate of scar
infection
• Reoperation/ Cosmetic
– mini-sternotomy
– thoracotomy

17. Valvular Reconstructive Surgery

18. Valvular Reconstructive Surgery
• Valvular reconstruction is especially
relevant for procedures involving the mitral
and the tricuspid valves.

19. Mitral Valve Repair

20. Mitral Valve Repair
• Rheumatic Valve Disease
• Myxomatous degeneration of the mitral
valve, so-called Barlow’s disease
• Fibroelastic deficiency
• Infectious Endocarditis
• Ischemic Mitral Insufficiency
• papillary muscle dysfunction
• End-stage dilated cardiomyopathy

21. Mitral Valve Repair
• Leaflet Reconstruction.
• The remodeling ring annuloplasty
• Correction of papillary muscles.
• Mitral valve repair, when it is technically
feasible, offers better long-term results than
mitral valve replacement with either
bioprosthetic or mechanical prostheses.

22. Tricuspid Valve Repair
• Functional Tricuspid Insufficiency
• Organic Tricuspid Insufficiency
• Rheumatic fever
• Infectious endocarditis
• In carcinoid syndrome
• traumatic papillary muscle or chordal rupture as
well as tricuspid leaflet tearing is occasionally
encountered after blunt trauma to the chest;
 Repair of the tricuspid valve comprises
commissurotomy and ring annuloplasty.

23. Aortic Valve Repair
• Replacement is the standard treatment of a
diseased aortic valve. On occasion, reconstructive
surgery of the aortic valve can be performed.

24. Valve Replacement
• The diseased valve is removed together with
eventual fragments of calcium adherent to the
annulus
• Any prosthetic valve consists of two elements:
– a sewing ring for fixation to the valvular orifice,
generally made of Dacron and occasionally reinforced
with silicone;
– a mobile section that allows opening and closure of the
orifice during the cardiac cycle.

25. Valve Replacement
• According to the nature of the mobile
component, artificial valves are divided into
two categories-
– mechanical and
– biologic.
• Age and cardiac rhythm are among the main
determinants for choosing a specific
artificial valve

26. Mechanical Prosthetic Valves
• The most important risk linked to the use of
a mechanical valve is valvular thrombosis.
• Need lifelong systemic anticoagulation.

27. Biologic Valves
• Biologic valves are separated into three
groups on the basis of the origin of the
biologic material:
– heterografts (animal origin),
– homografts (human donor),
– autografts (tissues derived from the patient).
• bioprosthetic valves are subjected to
degeneration.

28. Autograft Valves
• The use of autograft valves is limited to
transfer of the pulmonary valve to the aortic
position, known as the Ross procedure.
• A pulmonary homograft is subsequently
implanted into the vacated position.
• dysfunction is usually well tolerated in the
pulmonary position .

29. choice
• The choice of an artificial valve must first take
into account the age of the patient.
• In children -The Ross procedure is the operation
of choice for aortic valve replacement.
• Adults younger than 70 years -mechanical
prosthesis.
• If life expectancy does not exceed 10 years a
bioprosthesis .
• In Patients Older than 70 Years-bioprosthesis

30. Closed Mitral Valvotomy
• Historically, surgical commissurotomy was
the standard treatment for relief of mitral
stenosis.
• Percutaneous mitral balloon valvuloplasty
(PMBV) has since become the treatment of
choice for mitral stenosis.
• Catheter inserted from femoral vein > Rt.
Atrium > puncture the septum > Mitral
valve > Inflate balloon.

31. • Transcatheter aortic-valve implantation.

32. Complications
• Thromboembolism.
• Degeneration.
• Failure
• Paravalvular leak

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