MITRAL RECONSTRUCTIVE SURGERY DEPARTMENT OF CARDIOTHORACIC SURGERY HOSPITAL DE SANTA MARIA LISBOA PORTUGAL
MITRAL RECONSTRUCTIVE SURGERY INDICATIONS * THE FEASIBILITY OF REPAIR SHOULD ALWAYS BE CONSIDERED FIRST IN THE SURGICAL MANAGEMENT OF MV DISEASE * THE ONLY DETERMINING FACTOR: ANATOMICAL QUALITY OF THE MITRAL APPARATUS * THE RELATIVE CONTRAINDICATIONS * SIGNIFICANT LOSS OF LEAFLET AREA * LEAFLET THICKENING AND CALCIFICATION
NORMAL MITRAL VALVE
MITRAL VALVE
LEFT VENTRICLE AND MITRAL VALVE
IMPOSSIBLE VALVULOPLASTY
FUNCTIONAL CLASSIFICATION (A. CARPENTIER) TYPE I – NORMAL LEAFLET MOTION ANNULAR DILATATION LEAFLET PERFORATION TYPE II – LEAFLET PROLAPSE CHORDAL RUPTURE OR ELONGATION PAPPILLARY MUSCLE RUPTURE OR ELONGATION TYPE III – RESTRICTED LEAFLET MOTION COMISSURAL FUSION LEAFLET THICKENING EXCESS TRACTION ON CHORDAE
MITRAL LESIONS ANATOMICAL CLASSIFICATION ( A. CARPENTIER ) ANTERIOR VALVE A1 A2 A3 POSTERIOR VALVE P1 P2 P3 COMMISSURES ANT POST
PRIMARY CHORDAE INSERTED IN THE FREE BORDERS OF THE LEAFLETS
SECONDARY CHORDAE NOT INSERTED IN THE FREE BORDERS OF THE LEAFLETS
SECONDARY CHORDAE
MITRAL RECONSTRUCTIVE SURGERY THE RHEUMATIC VALVE MORE DIFFICULT TO CONSERVE : *FIBROTIC AND CALCIUM COMPONENTS *DISTORTION OF SUBVALVULAR APPARATUS *SMALL ANNULUS HIGH RATE OF REPEAT OPERATIONS * % *THE YOUNGER THE AGE GROUP THE LESS STABLE THE REPAIR (ONGOING RHEUMATIC PROCESS)
COMMISSURAL AND CHORDAL FUSION
MITRAL STENOSIS
COMMISSUROTOMY
MITRAL COMMISSUROTOMY
INCISION OF PAPILLARY MUSCLE
PAPILLARY MUSCLE INCISION
CHORDAE FENESTRATION
PATCH ANTERIOR LEAFLET
PERICARDIAL PATCH CLOSURE POSTERIOR LEAFLET
LEAFLET PROLAPSE
POSTERIOR PROLAPSE
QUADRANGULAR RESSECTION
POSTERIOR LEAFLET CHORDAE RUPTURED
QUADRANGULAR RESECTION
ANTERIOR PROLAPSE
ANTERIOR LEAFLET CHORDAE RUPTURE
CHORDAE TRANSLOCATION
COMMISSURAL PROLAPSE
COMISSURAL CHORDAE RUPTURE
ALFIERI COMISSURAL PLASTY
LEAFLET PERFORATION
ANTERIOR LEAFLET PERFORATION
VALVE REPAIR IN ACUTE ENDOCARDITIS IMPORTANT: * ADEQUATE ANTIBIOTIC THERAPY FOR AT LEAST 1 WEEK. * LARGE EXCISION OF ALL TISSUES MACROSCOPIC INVOLVED VALVE REPAIR WITH RECONSTRUCTIVE TECHNIC * PERICARDIAL PATCH REPLACEMENT
MECHANISMS OF ISCHEMIC MR
ISCHEMIC MITRAL VALVE
ISCHEMIC PAPILAR MUSCLE
ISCHEMIC MITRAL REGURGITATION 4% PATIENTS UNDERGOING CORONARY BY PASS SURGERY IF NOT CORRECTED IT PROFOUNDLY INFLUENCES THE HOSPITAL MORTALITY AND FIVE YEAR SURVIVAL RESULTS MOSTLY FROM RESTRICTED LEAFLET MOTION RATHER THAN FROM PROLAPSE MITRAL ANNULUS DILATATION IS PRESENT IN ALL CASES AND IS THE ONLY MECHANISM OF REGURGITATION IN 50% OF THE PATIENTS ROBERT DION,THE JOURNAL OF HEART VALVE DISEASES,1993;2:
ANNULUS DISTENTION
FULLY FLEXIBLE RINGS Tissue flexibility is essential
SEMIRIGID RINGS Annular thickening / calcium Ischemic regurgitation Small anterior or posterior leaflet
FULLY FLEXIBLE C - RINGS Correct post. annular dilatation / deformation Prevent further annular dilatation after comissurotomy (tight stenosis) Small left atrium
MITRAL RING
MITRAL RECONSTRUCTIVE SURGERY REPAIR TECHNIQUES LEVEL MANEUVER ANNULUS REDUCTION LEAFLETS RESECTION ENLARGEMENT CHORDS RESECTION SHORTENING TRANSPOSITION REPLACEMENT COMMISSURES SPLITTING RESECTION PAPPILARY MUSCLES SPLITTING SHORTENING REPOSITIONING
Mitral Reconstructive Surgery January 88 – January years P701 Patients P69 % Female / 31 % Male PAge : y (51.9 ±16) PPediatric Age : 1 – 16 y 30 pat. (4.4%) Hospital de Santa Maria Lisboa - Portugal
Mitral Reconstructive Surgery N = 701 ETIOLOGY RHEUMATIC FEVER 62 % DEGENERATIVE 27 % ENDOCARDITIS 5.1 % ISCHEMIC 4.3 % OTHER 1.6 % Hospital de Santa Maria Lisboa - Portugal
MITRAL RECONSTRUCTIVE SURGERY N = 701 FUNCTIONAL CLASS Pre - Op ( NYHA) II 13% III 65% IV 22% Hospital de Santa Maria Lisboa - Portugal
Mitral Reconstructive Surgery N=701 PMitral Stenosis : 38.4 % PMixed Lesions : 27.7 % PMitral Insufficiency : 33.9 % POPERATIVE MORTALITY 2.3 % Hospital de Santa Maria Lisboa - Portugal
Reoperation for Failure of Mitral Valve Repair P55 Patients 7.8% PSurgery: Mitral Replacement 33 pat. 60 % Mitral Replacement 33 pat. 60 % Mitral Replasty 22 pat. 40% Mitral Replasty 22 pat. 40% Hospital de Santa Maria Lisboa - Portugal
MITRAL REDO
Conclusions - I PPopulation with: PHigh incidence of restritive lesions of rheumatic fever etiology ( 62 % ) PIncidence of pediatric age: <16 y ( 4. 4 % ) PGood results, at 14 years, with a reoperation rate of 7.8 % PRepeat successful mitral valve repair in 40 % of the patients PNeed to minimize the incidence of mitral repair failure Hospital de Santa Maria Lisboa - Portugal
Conclusions - II Minimizing the incidence of repair failure PSurgeon experience PDecreasing prevalence of rheumatic fever. PCareful patient selection PPrecise application of surgical techniques PEco monitoring PElimination of unsuccessful techniques Hospital de Santa Maria Lisboa - Portugal
Conclusions - III Elimination of unsuccessful techniques PIf extensive subvalvular deformation: no valvuloplasty PTo prevent further annular dilatation, after comissurotomy (tight stenosis): use of flexible rings PRupture of previous shortened chordae (Invag. Chordopexy) PSliding cordopexy PChordae transfer PPTFE chordae Hospital de Santa Maria Lisboa - Portugal
ARTIFICIAL CHORDAE
Reconstructive Surgery of the Mitral Valve ADVERSE FACTORS * Valve with acute inflamatory signs = not indication to reconstruction * Rigid / small posterior or anterior leaflet = extension with pericardium * Mixed lesions * Surgeon
Reconstructive Surgery of the mitral valve CAUSES OF REOPERATION Progression of the disease Suture deiscence Inadequate primary surgery Wrong surgical indication Technical error
Reconstructive Surgery of the mitral valve IMPORTANT Spend time analizing the valve Quantity and flexibility of valvular tissue Types of combined lesions Geometry / Simetry Apposition / Coaptation
MITRAL RECONSTRUCTIVE SURGERY ( patients / years )
Reconstructive Surgery of the Mitral Valve INCIDENCE LAST 14 YEARS 76.1 % LAST 12 YEARS 82.2 % SERVIÇO DE CIRURGIA CARDIOTORÁCICA, H. SANTA MARIA