2. Mitral Valve Anatomy-important Anatomic Relationship The functional components of the mitral valve apparatus include: Annulus Leaflets Chordae Papillary muscles LV wall Abnormality in any of these component will result in mitral regurgitation.

3. SLIDE 3 - PICTURE FIGURE 1 MITRAL VALVE Lateral papillary Muscle Posterior Annulus Posterolateral commissure Anterior Annulus Anterior leaflet Anteromedial commissure Posterior leaflet (3 lobes) Chordae tendinae Medial papillary muscle

4. Left main Coronary artery Intervalvular trigone Circumflex coronary artery Anterolateral papillary muscle Posterior leaflet Left coronary sinus Noncoronary sinus Anterior leaflet Secondary Chorda tendinea Coronary Sinus Tertiary chorda tendinea Primary chorda tendinea Posteromedial papillary muscle

6. Fiber Dimensions Calculated Spherical LV Model (`100g) DIASTOLE SYSTOLE OBSERVED DOG LV

7. The left ventricular wall composed of muslce fibers, connective tissue, fat neuro- vascular structures and lymphatics

8. Photomontages assembled from electron micrographs of dog LV cells are from control (A), congestive heart failure due to mitral regurgitation (B), and recovery state after successful mitral valve surgery (C). Electron micrograph of adult LV canine myocardium. Long axes of several cells cross the figure from left to right. Arrows mark the location of boundaries between adjacent cells. Large open spaces are capillaries perfused with fixative.

9. Schematic illustration of substructure of the connective tissue matrix of the myocardium. Myocyte Struts Capillary Tendon Stranos Myofibril Weave Ephysilus

10. Systolic Torsion of LV Asymmetry of fiber radii, sarcomere length and electrical activation allows torsion of the apex relative to the base.

11. Model for generation of torque for LV wall. Vectors for force generation at the epicardial and endocardial surfaces could neutralize each other. The epicardial fibers at the epicardial surface have a longer radius and a more powerful moment arm. Sarcomere lengths, activation time, and infolding of the wall contribute to heterogencity of the relation between structure and function between the inner and outer regions of the wall. Differences in the total force generated are believed responsible for the LV systolic twist. Base Endocardium Apex Epicardium

12. Mechanism of mitral regurgitation

13. Etiology of Mitral Regurgitation in Patients Undergoing Valve Repair

14. Pathophysiological Changes in Mitral Regurgitation Decrease left ventricular impedance Increase left ventricular end-diastolic volume Increase stroke work and afterload Decrese ejection fraction and increase left ventricular end-systolic dimension Myocardial fibrosis and end-stage cardiomyopathy

15. The Natural History of Mitral Regurgitation Mitral regurgitation is a progressive disease With an increase on average of 7.5 ml/year for regurgitant volume and of 5.9 mm 2 /year for the effective regurgitant orifice. The progression of mitral regurge also cause progression of LV remodelling at the same rate.

16. Importantly, progression is not uniform, 10% of mitral regurgitation regress spontaneously The rate of reversal varies 6 weeks to 1 year

17. The Natural History of Severe Mitral Regurgitation High morbidity at 10 year:  Atrial fibrilliation - 30%  Heart Failure - 60% Sudden death at the rate of 1.8% per year

18. Timing of Surgery What information is needed to define the timing of mitral surgery? Symptoms-Functional Class Impact of Pre-operqtive symptoms on survival after mitral surgery

19. 90+2 76+5 48+4 73+3 NYHA I-II NYHA III-IV P<0.0001 100- 80- 60- 40- 20- Survival (%) N8 I-II 199 192 187 184 181 169 125 95 63 42 34 III-IV 279 249 236 227 211 201 174 183 103 74 51 Figure 1. Overall postoperative survival compared between patients in NYHA Class I/II and patients in Class III/IV – Numbers at bottom indicate patients at risk. 0 0 1 2 3 4 5 6 7 8 9 10 Years

20. Left Ventricular Function  Ejection Fraction  Left ventricular and systolic dimension Assessed by echocardiography

21. Survival (%) 53% 32% 75% Ef Ef 50-60% EF<50% P-0.0001 Years 0 2 4 6 8 10 100 80 60 40 20 0

22. Degree of mitral regurgitation-hymodynamics  Regurgitant volume (R.Vol.)  Effective regurgitant orifice (ERO) Assessed by quantitative doppler echo The respective thresholds for severe mitral regurgitation are (R.Vol.) > 60 ml. and ERO > 40mm 2

23. Timing of Surgery Translate into_when the patient seen_promptly provided no major comonbidities The concept of waiting fro signs of early LV dysfunction is not advised

24. QUESTION: Should we advise follow-up with medical treatment?

25. ANSWER: NO, even if ejection fraction is low. Operative mortality is not excessive. Post operative complications are often delayed. The precision of the prediction of the outcome is imperfect.

26. Mitral Valve Surgery  The optimal intervention for mitral surgery is valve repair. Superior hemodynamics and ventricular function. Less distortion of ventricular shape. Avoidance of prosthetic valve and related complications. Excellent long term clinical outcome.

27. Mitral Valve Repair  Leaflet plication McGoon Plication

28.   Posterior leaflet excision [carpentier] Posterior leaflet prolapse 2 to ruptured or elongated chordae. Posterior leaflet Ruptured chordae Repair leaflet Supported repair Repair annulus Excise unsupported leaflet

29. Subvalvar apparatus inspection with a nerve hook. The middle portion of the leaflets is identified

30. The central stitch is used to check the symmetricity of the orifices.

31.  Edge-Edge Technique [Alfieri] Innovative method for mitral valve repair. A running suture along the free edge of the leaflets is done.

32.  Chordal Repair Anterior leaflet prolapse Excise unsupported leaflet Anterior leaflet Ruptured\ Chordae tendineae Posterior leaflet Mobilize apposing posterior leaflet Transfer supported posteior leaflet Attach posterior leaflet and repair annulus Completed repair

33. CONCLUSION: Mitral regurgitation is a surgical issue. Timing of mitral surgery still remained one of the most vexing problems of clinical cardiac science. The concept of waiting for signs of early LV dysfunction not exists anymore. The outlook is poor for patients who are treated medically.

34. Chronic severe Mitral regurgitation No symptoms Symptoms Echocardiography Left Ventricular ejection Fraction >0.60 and end-systolic Dimension <45 mm Left Ventricular ejection Fraction >0.60 or end-systolic Dimension >45 mm Mitral valve reparable Mitral valve not reparable No atrial fibrillation or pulmonary hypertension Atrial fibrillation or pulmonary hypertension Clinical and Echocardiographic Follow-up Mitral-valve surgery (valve repair preferred if technically feasible) Ejection fraction >0.30 Ejection fraction >0.30 Mitral-valve replacement Mitral-valve replacement Management of Chronic Severe Mitral Regurgitation

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