1. MITRAL RECONSTRUCTIVE SURGERY DEPARTMENT OF CARDIOTHORACIC SURGERY HOSPITAL DE SANTA MARIA LISBOA PORTUGAL

2. 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

3. NORMAL MITRAL VALVE

4. MITRAL VALVE

5. LEFT VENTRICLE AND MITRAL VALVE

6. IMPOSSIBLE VALVULOPLASTY

11. 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

12. MITRAL LESIONS ANATOMICAL CLASSIFICATION ( A. CARPENTIER ) ANTERIOR VALVE A1 A2 A3 POSTERIOR VALVE P1 P2 P3 COMMISSURES ANT POST

13. PRIMARY CHORDAE INSERTED IN THE FREE BORDERS OF THE LEAFLETS

14. SECONDARY CHORDAE NOT INSERTED IN THE FREE BORDERS OF THE LEAFLETS

15. SECONDARY CHORDAE

16. 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 * 10 - 27% *THE YOUNGER THE AGE GROUP THE LESS STABLE THE REPAIR (ONGOING RHEUMATIC PROCESS)

17. COMMISSURAL AND CHORDAL FUSION

18. MITRAL STENOSIS

24. COMMISSUROTOMY

25. MITRAL COMMISSUROTOMY

26. INCISION OF PAPILLARY MUSCLE

27. PAPILLARY MUSCLE INCISION

28. CHORDAE FENESTRATION

29. PATCH ANTERIOR LEAFLET

30. PERICARDIAL PATCH CLOSURE POSTERIOR LEAFLET

31. LEAFLET PROLAPSE

32. POSTERIOR PROLAPSE

33. QUADRANGULAR RESSECTION

34. POSTERIOR LEAFLET CHORDAE RUPTURED

35. QUADRANGULAR RESECTION

36. ANTERIOR PROLAPSE

37. ANTERIOR LEAFLET CHORDAE RUPTURE

41. CHORDAE TRANSLOCATION

42. COMMISSURAL PROLAPSE

43. COMISSURAL CHORDAE RUPTURE

44. ALFIERI COMISSURAL PLASTY

45. LEAFLET PERFORATION

46. ANTERIOR LEAFLET PERFORATION

47. 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

48. MECHANISMS OF ISCHEMIC MR

49. ISCHEMIC MITRAL VALVE

50. ISCHEMIC PAPILAR MUSCLE

51. 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;2:536-543

52. ANNULUS DISTENTION

53. FULLY FLEXIBLE RINGS Tissue flexibility is essential

54. SEMIRIGID RINGS Annular thickening / calcium Ischemic regurgitation Small anterior or posterior leaflet

55. FULLY FLEXIBLE C - RINGS Correct post. annular dilatation / deformation Prevent further annular dilatation after comissurotomy (tight stenosis) Small left atrium

56. MITRAL RING

58. 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

59. Mitral Reconstructive Surgery January 88 – January 02 14 years P701 Patients P69 % Female / 31 % Male PAge : 1.5 - 83 y (51.9 ±16) PPediatric Age : 1 – 16 y 30 pat. (4.4%) Hospital de Santa Maria Lisboa - Portugal

60. 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

61. MITRAL RECONSTRUCTIVE SURGERY N = 701 FUNCTIONAL CLASS Pre - Op ( NYHA) II 13% III 65% IV 22% Hospital de Santa Maria Lisboa - Portugal

62. 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

63. 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

64. MITRAL REDO

66. 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

67. 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

68. 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

69. ARTIFICIAL CHORDAE

70. 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

71. Reconstructive Surgery of the mitral valve CAUSES OF REOPERATION Progression of the disease Suture deiscence Inadequate primary surgery Wrong surgical indication Technical error

72. 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

73. MITRAL RECONSTRUCTIVE SURGERY ( patients / years )

74. Reconstructive Surgery of the Mitral Valve INCIDENCE LAST 14 YEARS 76.1 % LAST 12 YEARS 82.2 % SERVIÇO DE CIRURGIA CARDIOTORÁCICA, H. SANTA MARIA