Valular heart disease is very common in most of Afro Asian counteries mainly due to Rheumatic heart disease..Definitive treatment is surgery.which may be valve replacement or reapir. In this ppp I have discussed this subject in a simple way

1. Surgical treatment of Valvular
Heart Diseases
Dr. R S Dhaliwal
MBBS,MS,DNB(Surg),MCh,DNB(CTVSurg),
FACSFCCP,FAMS,FNCCP,FICA,FICAS
Prof of CTV Surgery UCMS
Former Prof & HOD CTV Surgery, PGIMER,
Chandigarh,India

2. Introduction
• Valvular heart disese is the commonest type
of heart disease in India and most of Afro –
Asian countries
• Rheumatic heart disease is the commonest
cause of valvular heart disease
• Mitral valve is the most common valve
involved followed by Aortic and Tricuspid
valve, rarely pulmonary valve

3. Surgical anatomy
• Heart valves function to maintain pressure
gradient between heart chambers and ensure
unidirectional flow of blood
• Atrioventricular valve – Situated between atria
and ventricle , Mitral valve between LA and LV, it
is bicuspid, Tricuspid valve lies between RA and
RV and has three cusps
• Semilunar valves – have three cusps, lies between
venticle and great vessel, Aortic valve between
LV and aorta and Pulmonary valve between PA
and RV

4. Normal heart valves

5. NYHA functional classification of LVF
• Stage 1 –Pt is asymptomatic and has no
physical limitations
• Stage II – Pt has mild symptoms when doing
activities of daily living (ADL’s)
• Class III- Pt has difficulty doing simple ADL’s
• Class IV- Pt is mostly in bed or wheel chair
and becomes breathless while doing any
simple activity

6. Mitral valve disease
• Causes of mitral valve disease
• Stenosis -
a.Rheumatic heart disease
b. Calcification of valve or MV appratus
c. Congenital (rare)
• Regurgitation
a. Rheumatic heart disease
b. MVP – M V prolapse
c. LV dilatation or hypertrophy
d Post MI regurgitation
e. Bacterial endocarditis

7. Mitral regurgitation
• Any pathology affecting the mitral valve appratus will
lead to mitral regurgitation . It can be Acute (due to
ischemic papillary muscle rupture or infective
endocarditis) or Chronic(due to rheumatic fever or
myxomatous degeneration )
• In acute MR the LV ejects blood back into a small
poorly compliant LA causing sudden rise in LA
pressure followed by rise in PV pressure (more than
oncotic pressure) leading to acute pulmonary oedema
• In chronic MR process is slow allowing LA and LV
hypertrophy and dilatation, LA is able to strech and
take regurgitant blood without increase in pressure
and protecting the pulmonary circulation.Later on LA
pressure rises causing rise in pulm venous pressure

8. INVESTIGATIONS
• ECG- P mitrale due to enlargement of LA ( P
wave absent when there is AF), RAD and RVH in
mitral stenosis, LVH in MR
• Chest X-ray- Small aorta and large PA,Large LA
Prominent ULV, RVH in MS , LVH in MR
• Echo with Doppler and TEE- It will tell about valve
pathology , stenosis or regurgitation, degree of
calcification and regurgitation, LV function and EF,
Clot in LA ,
• Cardiac catheterisation- Is done if there is no
correlation between symptoms of pt and echo
findings .Also done in older pts to rule out CAD

9. Echo in Mitral valve disease

10. Treatment of mitral valve disease
• Medical management- 1.Heart rate control –
Digoxin, beta blockers, amiodrone,
-Diuretic for pulm congestion
-Anticoagulants for AF in older pts
• Indications for Surgery-
1.Severe symptoms NYHA class III or IV
2.On Echo MVA < 1cm , mod or severe MR
3. H/O of embolism, large clot in LA present
• Mitral valve operations-
Mitral valvotomy – closed - open (on CPB )
PMBV –Percutaneous mitral ballon valvotomy
Mitral valve repair or mitral valve
replacement

11. Surgical options for heart valve
diseases
• Opening the Stenosed (narrow) valve by closed
or open heart techniques –Mital,aortic or
pulmonary valvotomy
• Repair of valves by open heart techniques –
Mitral and tricuspid valve repair are common and
quite successful , Aortic valve repair is uncomm-
on and results are not as good as mitral
• Valve replacement- When valve is badly
deformed and damaged or calcified it is replaced
by Prosthetic valve which may be Mechanical or
Biological valves (stented, stentless or homograft)

12. Comparing options for heart valve surgery
Advantages Disadvantages
Valve repair Preservation of structure
Improved hemodynamics
Avoid long term anticoagu
lation
Technically difficult
Varible failure rate
Valve replacement
Mechanical valves Readily available , Life long
durability, Can be used in any
age group, Extensive
experience and follow up
Needs life long anticoagu
lation,
Susceptibility to infection
Biological valves
Stented Readily avilable, Short period
of anticoagulents
Limited life span
Stentless Readily available, Good
hemodynamics,Short period
of anticoagulents
Difficult to implant
Limited life span
Homograft No anticoagulation , Good
hemodynamics,
Technically difficult,
Not readily available

13. Prosthetic valves

14. Types of prosthetic valves
• Mechanical valves- can be used in any age group to
replace any valve, are very durable
• A. Ball and Cage valve- first generaion valves . A spherical
occuluder ( barium coated silastic ball) is retained within
a metal cage Starr Edwards valve belonged to this class
• B.Tilting disc valve- The best known examples are Bjork –
Shiley model ( now withdrawn) and TTK valve (Indian).It
has single disc which is restrained by struts
• C.Bileaflet valve- It has two cusps (disc occuluders) in a
sewing ring .St Jude medical valve is the best example
The major disadvantage of mechanical valve is thrombo
embolism , life long systemic anticoagulation is done
which subjects the patient to medication, tests and
constant threat of hemorrhagic complications ( intracere
bral, epistaxis and GIT bleeding)

15. Mechanical valves-Starr Edwards valve
Ball Cage valve
Pt with S E valve 40 yrs after operation

16. Prosthetic valves (Mechanical)
Sree Chitra TTK valve (Pride of India)
Tilting Disc valve

17. Prosthetic valves (Mechanical)
Bileaflet valves

18. Types of prosthetic valves
• Biological valves- Does not require anticoagulation
a.Autograft –Pt’s own valve Pulmonary valve of pt is removed
and put in aortic position and replacing pulmonary valve with
aortic homograft ( Ross procedure ).It has excellent
hemodynamics and long term results It is technically
demanding operation
b. Homograft or allogaft –removed from cadavers, antibiotic
sterlised,cryo preserved.Good hemodynam ics, no
anticoagulent Technically difficult to insert, in short supply and
uncertain life span
C.Heterograft or xenograft- from animal tissue like glutaralde
hyde treated porcine (pig) valves) mounted on stents.Stent
mounted Bovine pericardial valves is another type of
heterograft valve. Stented valves have a life span of 10-15 yrs
Stentless valves are expected to have less late calcific
degeneration but technically more difficult to insert.
Homo and Heterografts are indicated in pts over 60 yrs age
or where anticoagulants are contraindicated ( bleeding
diathesis, uncontroled hypertension , GIT ulcers etc)

19. Prosthetic valves -Bioprosthesis
Porcine valve
Bovine pericardial valve
AorticHomograft

20. Mialtral valve operations
• Median sternotomy is the common incision, left or right thoracotmy
may be used and mitral valve can be approached through LA or
through RA across IAS and through LA append
• Closed mitral valvotomy- It was the first operation for releif of
mitral stenosis.Heart is approached by left thoracotomy, finger is put
in left atrium and mital valve is felt, a Tubb’s dilator is passed from LV
apex across mitral valve and valve is opened with dilator, mortality
< 1%
• Percutaneous mitral ballon valvotomy PMBV- It is a catheter
based approach, a special ballon tipped catheter is passed through
femoral vein to RA and into LA across IAS and across MV and ballon
is inflated and valve is opened
• Open mitral valvotomy- It is done on CPB and was started in pts
of mitral stenosis with presence of clot in the left atrium. Mital valve
is opened under vision ,fused chordae and papillary muscles are
seperated and decalcification is done.
• Mitral valve repair – Carpentier developed a functional
classification for valve reconstruction for mitral regurgitation
based on structure of cusps, chordae tendinae and papillary
muscles

21. Mitral valve replacement
• MVR is done in – 1. Calcific MS 2. Severe MR
3.Thickened distorted leaflets and subvalvular
appratus , valve not suitable for repair
4.Significant MR after repair
• Surgical technique -Heart is exposed through
midsternotomy , pt put on CP bypass, mitral valve
is approached through left atrium, it is excised
and a prosthe tic valve is sutured with synthetic
stiches above the annulus Left atrium is closed
and pt is weaned of CPB

22. Complications of Prosthetic valves
• Structural valve failure
• Paravalvular leak
• Thrombosis and thromboembolism
• Prosthetic valve endocarditis
• Postoperative management –
• Antithrombotic therapy
• Antibiotic prophylaxis

23. Mitral valve reconstruction
• Prosthetic ring annuloplasty – For annular dilatation and to
restore annular shape
• Quadrangular resection of posterior leaflet – For MR due
to chordal rupture or elongation
• Sliding plasty with quadrangular resection - Used to
eliminate systolic anterior motion of anterior leaflet
• Chordal shortening or Chordal transposition – For anterior
leaflet prolapse due to chordae elongation or chordal
rupture
• Edge to edge repair (Alfieri stich) – Stiching free edge of
prolapsed leaflet to corresponding free edge of opposite
leaflet Results of repair for regurgitant lesions
are better than stenotic lesions and repair is possible
more with degenerative lesions than rheumatic lesions or
endocarditis.Mortality is 1-3% and reoperation rate is 1-7%
at 5yrs.There is no need of prolonged anticoagulation

24. Mitral stenosis
• The commonest cause of MS is rheumatic fever
causing carditis .The leaflet and subvalvular
appratus becomes thickenedand distorted
leading to narrowing of mitral valve orifice
• Normal mitral valve area is 4-6cmsm2.Symptom
starts when it is < 1cm. L A pressure rises and
pulmonary congestion occcurs ,pulm venous and
arterial hypertension.Left atrial hypertrophy
occurs which leads to atrial fibrillation.Pulm hype
rtension causes RVH and CHF

25. Mitral stenosis
• Clinical features- Asymptomatic for long time
--Fatigue -Dyspnoea -Cough -Hemoptysis
–AF irregular pulse -palpitations -Oedema feet -
Loud S 1 , O S ,MDM with PSA, - Crepitations
Raised JVP - Liver enlarged
• Investigations-1. ECG – P mitrale (LAH) if no AF ,RVH
2.X- ray Chest- Large LA,PA , RVH, Prominent PA and
ULPV , normal LV
• Echo with Color doppler- will tell size of valve, any clot,
presence of calcium and MR
• Cardiac Cath.- Indicated in older pts for CAD, degree of
PAH and when there is discrepency between
symptoms and echo findings

26. Treatment of Mitral stenosis
• Medical management – 1.Contol of heart
rate - Digoxin Amiodrone
Diuretics for CHF
Anticoagulents in old pts with AF
• Closed mitral valvotomy
• Open mitral valvotomy ( on CP Bypass)
• Catheter based PMBV
• Mitral valve replacement

27. Closed mitral valvotomy
Logan Tubb’s dilator

28. Aortic valve disease
• Causes of aortic valve disease -
Aortic Stenosis -
* Congenital bicuspid valve
* Rheumatic heart disease *
Acquired calcification with age
Aortic Regurgitation-
* RHD * Infective endocarditis
* Congenital * Inflamatory – SLE ,
* Aortic root dilatation-Marfan synderome Aortic
dissection
* Systemic diseases- Syphilis Ulcerarive
colitis

29. Aortic stenosis
• There is pressure gradient across aortic valve in AS
unlike aortic sclerosis where there is no gradient.
Congenital bicuspid valve is seen in 1% of population
• Normal adultaortic valve orifice area is 3-4cms Degree
of aortic stenosis can be Mild (area > 1.5cms)
,Moderate (area 1-1.5cms) and Severe (area <1 cm)In
severe AS with normal cardiac output a pressure
gradient over 50mm occurs. LV decompensation occurs
,LVED rises and LVF starts
• Clinical features- Asymptomatic -Dyspnoea
Angina - Syncope -Associated CAD in
50% pts - Low volume pulse - Aortic
component of S 2 absent - ESM preceded by click in
aortic area radiating to carotids vessels

30. Aortic stenosis
• Investigations – 1. ECG - LVH with strain pattern
(ST depression with inverted t waves in chest lead
2. Chest X-ray – Prominent aorta, LVH with lung
congestion occurs with LVF
3.Echocardiography – Will tell about size of the
valve ,calcification , LV function and AR Other
valves are assesed
4. Card.Cath. – It is done when there is associated
CAD and when there is discrepency between
symptoms and echo findings of pt

31. Types of Aortic stenosis
Anatomical level Causes
Subvalvular stenosis Congenital memberane
I H S S
Long standing A S
Valvular Senile degeneration
Degeneration in bicuspid valve
Rheumatic disease
Supravalvular stenosis Congenital – William’s synderome
Part of aortic arch synderome

32. Aortic stenosis
• Natural history – 80-90% untreated symptom
-atic pts of AS die within 10 yrs
• Indications for Surgery -
- A peak systolic gradient > 50 mm is
indication for surgery
- Aortic valve area < 0.75 cms2
- AS with–CAD, LV dysfunction,arrhythmias
silent ischemia

33. Aortic regurgitation
• Causes of AR-
1. Valve leaflet disease-
Congenital bicuspid valve
Rheumatic heart disease
Infective endocarditisary
2. Aortic wall pathology -
Inflamatory - SLE, Rheumatoid arthritis
Ankylosing spondylitis
Systemic disease – Tertiary syphilis
Degenerative – Marfan synderome, aortic
root dissection, senile aortopathy causng
aortic root/ annular dilatation

34. Aortic regurgitation
• Pathophysiology-
In Acute aortic regurgitation leak causes
volume overload on LV causing rise in LVED which
leads to premature closure of mitral valve and
rise in LA pressure. This results in sudden
hemodynamic unstability, hypotension and acute
pulmonary oedema In Chronic AR this process is
slow and gradual leading to compensatory LV
dilatation to accommodate regurgitant volume
LVH occurs to maintain cardiac output.Systolic
and diastolic function of LV is abnormal and
sudden deterioration of patient can occur

35. Aortic regurgitation
• Clinical features- Chronic AR remains asymp tomatic
untill LV begins to fail and symptoms start -
Dyspnoea on exertion -Angina -Water
hammer (collapsing) pulse - Wide pulse pressure
- Thrusting apex beat – High pitched EDM along left
sternal border - Low frequency late diastolic murmur
at apex
• Investigations – 1.ECG- LVH with strain pattern
2. Chest X-ray- cardiomaegaly, large asc aorta
3.Echocardiography- Tells about aortic root size and LV
dimensions,degree of AR and about mital valve
3. Card.Cath.- Coronary angiography is done in older
pts to rule out CAD

36. Aortic regurgitation
• Medical managent- Vasodilators
Antianginal drugs
• Indications for Surgery -
-Class III or IV symptoms
-Echo criteria- LVED >70mm LVES > 50mm
E S dimensions > 50mm E D dimensions> 70 mm
-Aortic valve disease with CAD
• Aortic valve surgery – 1.Aortic valvotomy –
In congenital aortic stenosis in children
2 PCBV – Has role in aortic stenosis in children
and old pts ( unfit for surgery)
3. Aortic valve replacement- a. Severe AR
b.Calcific AS c. AS,AR

37. Aortic valve replacement
• Surgical technique- 1. Aortic valvotomy – is done
on CP Bypass for congenital bicuspid valve in
children
• Aortic valve replacement – Midsternotomy
Heart is exposed and pt put on CP Bypass
Aorta cross clamped and opened ,direct intra
coronary cardioplegia is given , diseased aortic
valve is excised and replaced with a prosthetic
valve using synthetic sutures, aorta closed and pt
weaned of CPB
• Results – operative mortality 5%
5 yrs survival 75-85%

38. Thank you