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Mitral Valve Repair

Valve Surgery

Valve Surgery Heart Valve Disease - Percutaneous Interventions Aorta and Aortic Valve Surgery Keyhole Approaches Surgery for Infective Endocarditis Mitral Valve Repair Minimally Invasive Heart Surgery Minimally Invasive Mitral Valve Repair Balloon Mitral Valvotomy Robotically Assisted Heart Surgery Valve Surgery FAQ Videos Biologic Valves: Built to Last

Mitral Valve Repair


Mitral Valve Repair Robotically Assisted Mitral Valve Repair Mitral Valve Repair by Sliding Leaflet video Mitral Valve Repair Frequently Asked Questions Mitral Valve repair by chordal transfer video

Written with A. Marc Gillinov, MD


Advantages of Mitral Valve Repair Minimally Invasive Mitral Valve Repair Mitral Valve Repair Surgical Techniques Mitral Valve Repair Special Situations

Mitral Valve Repair at Nation's Number One Heart Hospital


Cleveland Clinic heart surgeons have the worlds largest experience with mitral valve repair, the best option for most patients with a leaking mitral valve (mitral regurgitation). At Cleveland Clinic, nearly all leaking mitral valves are repaired rather than replaced, providing patients with ideal outcomes. The majority of these operations are performed minimally invasively, ensuring rapid recovery.

In 2006, patients traveled to Cleveland Clinic from all 50 states and 11 foreign countries to have mitral valve surgery.

Your mitral valve

Advantages of Mitral Valve Repair


Mitral valve repair is the best option for nearly all patients with a leaking (regurgitant) mitral valve and for many with a narrowed (stenotic) mitral valve. Compared to valve replacement, mitral valve repair provides better long-term survival, better preservation of heart function, lower risk of complications, and usually avoids the need for long-term use of blood thinners (anticoagulation). For these reasons, Cleveland Clinic surgeons are committed to mitral valve repair.
Advantages of Mitral Valve Repair:

Better early and late survival improved lifestyle better preservation of heart function lower risk of stroke and infection (endocarditis) no need for blood thinners (anticoagulation)

Minimally Invasive Mitral Valve Repair


Cleveland Clinic surgeons have been pioneers in the development of minimally invasive techniques for mitral valve repair. Today, nearly all mitral valve repairs can be performed through a 2 to 3 inch incision on the right side of the chest. This approach may be supplemented by use of a surgical robot, which further reduces incision size. A second minimally invasive approach through the center of the chest is available for selected patients whose anatomy is best addressed through this incision. Minimally invasive approaches may also be used for patients who require aortic valve or tricuspid valve surgery, alone or in combination with mitral valve surgery. In addition, Cleveland Clinic is a leader in research into percutaneous approaches to mitral valve repair, which may bring additional options to patients in the future. Learn about minimally invasive mitral valve repair: types of incisions; surgical options; photos and videos
Mitral valve repair surgery - Surgical techniques

Cleveland Clinic surgeons have been instrumental in the development and application of modern mitral valve repair techniques. Problems with the posterior leaflet are generally corrected by a small resection of the abnormal portion of the valve. Anterior leaflet dysfunction is managed by creation of new chords or chordal transfer. Anterior leaflet repair techniques are technically challenging, requiring a skilled and experienced surgical team to achieve the best result. All repairs include an annuloplasty, which is a complete or partial ring placed around the circumference (rim) of the valve.

Mitral valve posterior leaflet prolapse - valve repair surgery


During mitral valve repair heart surgery, triangular resection is the technique used most frequently for posterior leaflet prolapse.
Triangular Resection Mitral Valve Repair

Ruptured chords at free edge of posterior leaflet. Region to be resected is indicated.

Abnormal segment has been removed. Leaflet edges are sewn together

Annuloplasty completes the repair.

Mitral valve anterior leaflet prolapse - valve repair surgery


When there is mitral valve prolapse of the anterior leaflet, repair is more complex and requires greater surgical expertise. Two techniques used for correction of anterior leaflet prolapse are transfer of normal chords from another part of the valve (chordal transfer) and creation of artificial chords.
Chordal transfer to treat anterior leaflet prolapse

Chordal transfer to correct anterior leaflet prolapse. Posterior leaflet chordae are transferred to the unsupported free edge of the anterior leaflet. The posterior leaflet is repaired as after a quadrangular resection.
Gor-Tex chord for correction of anterior leaflet prolapse.

Chordae may be constructed from Gore-Tex sutures. A premeasured loop of Gore-Tex is affixed to the head of the papillary muscle with a pledgetted suture. The loop is then attached to the free edge of the unsupported anterior leaflet, providing support. Long-term durability is excellent. The new chordae do not rupture or elongate.

Mitral Valve RepairSpecial Situations


Mitral valve repair and atrial fibrillation

Many patients with mitral valve disease have atrial fibrillation, an abnormal heart rhythm. At the time of minimally invasive mitral valve repair, Cleveland Clinic surgeons perform an ablation (Maze procedure) in such patients with the intent of curing the atrial fibrillation.
Previous mitral valve repair with recurrent mitral regurgitation

In rare instances, a mitral valve repair may fail over time. While most surgeons replace such valves, Cleveland Clinic surgeons can frequently re-repair these valves, offering excellent long-term durability and the important advantages that go with mitral valve repair.
Previous heart surgery with recurrent mitral regurgitation

Occasionally a patient who has had previous bypass surgery, aortic valve surgery, or other heart surgery develops a new problem with the mitral valve. In these reoperative settings, Cleveland Clinic surgeons can safely and effectively repair nearly all leaking mitral valves.
Mitral valve repair for endocarditis

When infection damages a mitral valve (endocarditis), repair is particularly challenging. With extensive experience in such patients, Cleveland Clinic surgeon achieve successful repair in the majority of patients who have had endocarditis.
Mitral calcification

Occasionally a patient with mitral regurgitation has extensive calcium deposits on the valve leaflets or annulus. The calcium makes repair difficult and requires application of advanced surgical techniques and sound judgment. Cleveland Clinic surgeons have the expertise to ensure excellent outcomes in patients with calcified mitral valves. Cleveland Clinic surgeons have performed more than 11,000 mitral valve repairs, the largest number of any institution. In 2007, operative mortality for isolated mitral valve repair was 0%, compared with The Society of Thoracic Surgeons' (STS) benchmark of 1.5%. Learn more about Cleveland Clinic Mitral Valve Surgery outcomes.

Mitral valve repair surgery videos


View the following valve surgery videos: (page may take a couple minutes to load)

Mitral valve repair by posterior leaflet resection Mitral valve repair by sliding leaflet repair Mitral valve repair by chordal transfer to treat anterior leaflet prolapse Mitral valve repair by use of artificial chordae Mitral valve repair via right mini-thoracotomy Mitral valve repair via partial upper sternotomy

For more information:


Mitral valve repair frequently asked questions - answered by one of our surgeon experts! Latest Innovations in Mitral Valve Surgery - Transcript of webchat with Dr. Gillinov 4/2007 Our surgical outcomes Treatment options: heart valve surgery Valve surgery - past, present and future Heart surgery at the Cleveland Clinic

Valve surgery videos More Valve Surgery information

If you need more information about mitral valve surgery, click here to contact us , chat online with a nurse or call the Heart and Vascular Institute Resource & Information Nurse at 216/445-9288 or toll-free at 866/289-6911. We would be happy to help you. Copyright 2000-2008 Cleveland Clinic. All rights reserved. 10/08 Click here to go to the Heart & Vascular Institute Website. Know someone who could use this information? Send them this link.
Resources:

Gillinov AM, Mihaljevic T. Evolution in mitral valve surgery: Less invasive surgical approaches and less complex repair techniques. Ann Thorac Surgery 2008; in press Gillinov AM, Blackstone EH, Alaulaqui A, Sabik JF, Mihaljevic T, Svensson LG, Houghtaling PL, Johnston DR, Lytle BW. Outcomes after repair of the anterior mitral leaflet for degenerative disease. Ann Thorac Surg 2008; in press. Gillinov AM, Blackstone EH, Nowicki ER, Slisatkorn W, Al-Dossari G, Johnston DR, George KM, Houghtaling PL, Griffin B, Sabik JF 3rd, Svensson LG. Valve repair versus replacement for degenerative mitral valve disease. J Thorac Cardiovasc Surg 2008 Apr;135(4):885-93, 893.e1-2. Epub 2008 Mar 4. Gillinov AM, Banbury MK. Pre-measured artificial chordae for mitral valve repair. Ann Thorac Surg 2007; 84(6):2127-9 Gillinov AM, Svensson LG. Ablation of atrial fibrillation with minimally invasive mitral surgery. Ann Thorac Surg 2007;84(3):1041-2. Gillinov AM, Liddicoat JR. Percutaneous transvenous mitral annuloplasty. Eurointerventions 2007. Gillinov AM. Is ischemic mitral regurgitation an indication for surgical repair or replacement? J Heart Fail Rev 2006;11(3):231-239. Gillinov AM, Liddicoat JR. Percutaneous mitral valve repair. Seminar Thoracic and Cardiovasc Surg 2006 Summer;18(2):115-121.

This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition.

Mitral Valve Replacement


by Ricker Polsdorfer, MD

Definition | Parts Involved | Reasons | Risk Factors | Expect | Outcome En Espaol (Spanish Version)

Definition
When the mitral valve in the heart is incompetent or tight, it may need to be replaced.

Parts of the Body Involved


The mitral valve controls blood flow through the left side of the heart.

Reasons for Procedure


Fully-functioning, competent heart valves permit free, one-way flow of blood. Diseased valves either leak, causing back flow, or narrow, causing restricted flow. In either case, the condition can be life threatening. Sometimes the valve can be repaired. At other times it must be replaced surgically. Rheumatic fever, infections, and congenital defects are the most common diseases of the mitral valve.

Risk Factors for Complications During the Procedure


The demands of open heart surgery are severe. The better your general health, the less likely you will experience a complication. Diabetes, heart disease, blood clotting disorders, and cancer are some of the risk factors that must be evaluated before you undergo this procedure.

What to Expect
Prior to Procedure
Only half to three-quarters of all mitral valves can be repaired. You will be thoroughly evaluated. Your doctor will evaluate both your general health and the condition of your heart and circulation. Expect several heart tests including an electrocardiogram (EKG) and an echocardiogram (using ultrasound). You will most likely be in the hospital for several days before the surgery.

Also, in the days leading up to your procedure:


Do not to eat or drink anything starting the night before your procedure. Tell your doctor about any medications, herbs, or supplements that you are taking.

Anesthesia
You will have a general anesthetic.

Description of the Procedure


The standard open procedure requires an incision be made the length of your breast bone. The breast bone will be split lengthwise to expose your heart. You will be put on a heartlung machine so that your heart can stop during the procedure. Your heart will be opened, and a substitute valve will be sewn into place. This valve may be mechanical (metal and plastic), such as a St. Jude valve, or made of tissue. Tissue valves most commonly come from a pig (porcine valve) or a cow (bovine valve), but they may also be supplied by a human donor or even manufactured from your own tissues. Mitral Valve Replacement

2008 Nucleus Medical Art, Inc. Newer techniques, including robot-assisted procedures, are being developed that require smaller incisions.

After Procedure

You will remain in the hospital for several days so doctors can observe any complications, stabilize your heart function, and instruct you in homecare and activities.

How Long Will It Take?


The surgery takes approximately 2 to 5 hours.

Will It Hurt?
Your chest and back will be sore following the surgery.

Possible Complications
Every complication possible from major surgery can follow open heart surgery. Bleeding, infection, and drug reactions are the most common. Strokes and heart attacks also occur rarely.

Average Hospital Stay


You will probably spend 1 to 3 days in the intensive care unit (ICU) and a week in a regular hospital room.

Postoperative Care
If you have a mechanical valve, you will need to take blood thinners for an extended period of time to prevent blood clots. You may also need to take antibiotics during dental and certain other procedures to prevent infection. You will be prescribed a carefully graded return to your usual activities over 4 to 12 weeks and probably participate in a cardiac rehabilitation program. Mechanical valves last a lifetime. Tissue valves last 7 to 14 years and then must be replaced.

Outcome
If your valve is repaired and you have no complications, you will likely do well and be able to return to normal activities.

Call Your Doctor If Any of the Following Occurs

Excessive nausea, diarrhea, constipation, or stomach pain

Vomiting Fever Worsening ankle swelling Weight gain over two pounds in two days Dizzy or lightheaded when standing Confusion Tingling in hands and feet Extremely slow or fast pulse Irregular heartbeat Skin rash Unusual bruising or bleeding Trouble breathing Chest pain Coughing up blood Bloody or tarry bowel movement Severe headache Drainage from the incision(s) Burning urine

RESOURCES: American Heart Association http://www.americanheart.org The Society of Thoracic Surgeons http://www.sts.org Texas Heart Institute http://www.texasheartinstitute.org University of Maryland Heart Center http://www.umm.edu CANADIAN RESOURCES: Mount Sinai Hospital, Canada http://www.mtsinai.on.ca University of Ottawa Heart Institute http://www.ottawaheart.ca/
REFERENCES:

The Cardiothoracic Surgery Network website. Available at: http://www.ctsnet.... . Accessed August 31, 2005. Mitral valve disease. Cleveland Clinic website. Available at: http://www.clevela... . Accessed 8/31/05. Accessed August 31, 2005.

Mitral valve regurgitation. Mayo Clinic website. Available at: http://www.mayoclinic.com/ . Accessed August 31, 2005. Society of Thoracic Surgeons website. Available at: http://www.sts.org/doc/4107 . Accessed August 31, 2005.

Last reviewed November 2007 by J. Peter Oettgen, MD All EBSCO Publishing proprietary, consumer health and medical information found on this site is accredited by URAC. URAC's Health Web Site Accreditation Program requires compliance with 53 rigorous standards of quality and accountability, verified by independent audits. To send comments or feedback to our Editorial Team regarding the content please email us at HLEditorialTeam@ebscohost.com.

This content is reviewed regularly and is updated when new and relevant evidence is made available. This information is neither intended nor implied to be a substitute for professional medical advice. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with questions regarding a medical condition. Editorial Policy | Privacy Policy | Terms and Conditions | Support Copyright 2008 EBSCO Publishing All rights reserved.

HOW I DO IT Minimal access mitral valve replacement


D. RICHENS#, R.S. JUTLEY*, M. BAKER+ and M. SHAJARF
# +

Consultant Cardiac Surgeon, *Specialist Registrar, Trent Cardiothoracic Rotation, Chief Perfusionist, Cardiac Anaesthetist, Nottingham City Hospital, UK

Background Patient selection

Surgical technique Postoperative care

References

Keywords: Minimally invasive, mitral valve, endoclamp, trans-oesophageal echocardiography, double lumen tube Minimally invasive mitral valve surgery has recently been advocated as an alternative to the conventional median sternotomy approach. It has serval documented advantages and requires a close relationship betweeen the surgeons, anaesthetist and perfusionist for a successful outcome. This article demonstrates our surgical technique for replacement of the mitral valve. The various aspects of the specialised equipment used are also described
J.R.Coll.Surg.Edinb., 47, October 2002, 676-680

BACKGROUND
Surgery to the mitral valve has traditionally been performed through the median sternotomy.1 However, this approach is associated with complications such as infection, dehiscence, mediastinitis and neurological problems, some of which have an unacceptably high mortality rate. 2-4 As a speciality, cardiac surgery arguably has been one of the slowest to adopt the minimally invasive or limited access surgical approach. However, since the mid-1990s it has rapidly gained popularity, led by pioneers such as Hugo Vanermen in Aalst, Belgium. 5-7 There are now several studies that demonstrate such techniques offer patients a shorter intensive therapy unit (ITU) and in-patient stay, lowers blood transfusions rates, is associated with less wound discomfort and facilitates a more rapid return to work. 8-11 On balance, although the technique has a higher disposable items and revenue cost, intensive care and hospital stay is shorter. This, along with a more rapid rehabilitation has a lower cost for the community. This article describes our minimally invasive technique for replacement of the mitral valve using the Port Access SystemTM (Heartport, Redwood City, CA).

PATIENT SELECTION FOR SURGERY


This approach is particularly useful for its cosmetic result and may be applied to either mitral stenosis or incompetence, atrial septal defects and atrial myxomata. It is also useful in re-operations to avoid the inherent complications with re-sternotomy and dissection of pericardial adhesions necessary to obtain adequate surgical exposure of the mitral valve. The approach may be also used in a heavily calcified aorta where application of the conventional cross-clamp carries a risk of embolism and vessel wall trauma. There are some relative contraindications to the minimally invasive approach. These include a previous right thoracotomy with an adherent right lung, severe mitral valve annulus calcification, a dilated ascending aorta greater than 4.5 cm in diameter and severe pulmonary hypertension. However, each patient must be assessed on his or her own individual merit prior to surgery.

PATIENT COUNSELLING
The patients must be made aware that the potential risks of the procedure are similar to those expected by the conventional approach. Specifically, they are counselled about the risks of peri-operative myocardial infarction, cerebro-vascular events and bleeding along with the complications of cardiopulmonary bypass and anaesthesia. In addition, consent is obtained for conversion to sternotomy or thoracotomy in case of operative difficulty or complications.

SURGICAL TECHNIQUE
Patient Anaesthesia The procedure is performed under a general anaesthetic. Radial arterial lines are placed in both arms to monitor inadvertent occlusion of the innominate artery by the endoclamp balloon. A double-lumen endotracheal tube is used to allow single left lung ventilation. An 8.3-Fr percutaneous endopulmonary catheter is then floated through the right internal jugular vein to the pulmonary artery and used as a vent during the procedure. This allows a bloodless surgical field. The vent position is initially checked with the pressure waveform but later confirmed with the trans-oesophageal echocardiography (TOE) (Figure 1). A single intravenous dose of 1.5 g of cefuroxime is administered on induction of anaesthesia and a urinary catheter passed. A TOE probe is inserted and an initial inspection of the mitral valve is performed to evaluate mitral anatomy and function for the possibility of repair or replacement. As the delivery of anterograde cardioplegia depends on the competency of the aortic valve, the valve morphology is also assessed with the TOE probe. Any significant aortic regurgitation would preclude anterograde cardioplegia delivery necessitating the placement of a retrograde cannula into the coronary sinus through the right internal jugular vein. Trans-oesophageal echocardiography measurement of the proximal aorta determines the amount of saline to be used in filling the balloon that isolates the heart. For example, a 3 cm diameter aorta would require 30 mls of contrast for balloon filling maintained at a filling pressure of 300 mmHg. Moreover, assessment of the shape of the aorta gives an indication whether the occluding balloon is likely to be effective. In our experience, a fusiform and tortuous aorta can make balloon siting difficult. Anaesthesia is maintained prior to and during cardiopulmonary bypass (CPB) using total intravenous anaesthesia (TIVA). Prior to transfer to the operating room, external pads are placed across the chest wall to allow both external defibrillation and pacing, if required, at the end of the procedure. Patient Set-up The patient is placed supine on the operating table. Adequate exposure is usually achieved by placing a rolled up towel between the scapulae (Figure 2). The patient is prepped with an iodinebased solution from mid-thigh to the neck. The groin is always

prepped last. The patient is draped exposing the anterior and right lateral chest wall and both groin areas. An Iodoban adhesive strip is then applied to the exposed areas, thus, minimising the risk of infection and contamination. Surgical Incisions and Cardiopulmonary Bypass The mitral valve is exposed through a 6cm right anterior thoracotomy (working port) through the fourth intercostal space. The incision is positioned such that 25% is medial to the midclavicular point and 75% lateral to it. A soft tissue retractor, usually of medium size, is then inserted (Figure 3). A 5mm port is then placed in the seventh intercostal space in the mid-axillary line. This port is used initially for CO2 gas insufflation and later for cardiotomy suction. Carbon dioxide is used to fill the pleural cavity because of its high solubility. Any residual air in the left side of the heart following the procedure, therefore, is easily absorbed thereby minimising the risk of air embolism. The port is connected to CO2 gas, which is run at 3-4 l/min. A second 5mm port is then introduced for the videoscope through the fourth intercostal space in the mid-axillary line. Left single-lung ventilation is commenced only after these ports are in place. A 2mm incision is made medial to the working port in the fourth intercostal space. Under direct vision with a 30 videoscope the handle of the customised atrial retractor is introduced into the right pleural cavity. Direct visualisation avoids injury to the right internal mammary artery that courses 1-2 cm lateral to the sternal edge.

Figure 1: Mid-oesophageal short axis bi-caval view during TOE. The pulmonary artery catheter (arrow) may be seen in the right atrium as it is floated into the pulmonary artery through the superior vena cava (SVC).

Figure 2: Positioning of the patient in theatre. A trans-eosophageal echocardiogram is seen in place along with an endopulmonary vent positioned via the right internal jugular vein.

Figure 3: A medium sized soft tissue retractor is seen inserted into the 6cm working port. The right lung may be seen in the incision.

Figure 4: The wire tip over which the venous cannula is threaded (arrow) can be seen in the right atrium having been introduced through the inferior vena cava.

Figure 5: The 28-F venous catheter with the introducer and sharper, stiffer mandril.

Figure 6: The 28-F venous catheter is introduced over the guide wire into the right atrium (arrow) taking care that the stiffer mandril is withdrawn before full placement.

Figure 7: The 23-F arterial cannula with the Y-connector for passage of the endoclamp into the aortic root. Once the various ports are in place, a 4cm transverse incision is made in the right groin and the femoral artery and vein dissected free in preparation for cannulation. The patient is heparinised and the vessels cannulated after 4/0 PTFE purse strings are in place to secure the cannulae. The venous cannula is inserted first but in each case the Seldinger technique is used under guidance with the TOE. With the venous cannula insertion, once the guide wire is seen in the right atrium (Figure 4) the track is gently dilated. The 28-F cannula (Figure 5) is then gently threaded into the atrium over a mandril. However,

before its final and full placement in the atrium the mandril is withdrawn to avoid puncturing the thin-walled right atrial appendage. A TOE image of a satisfactory positioning may be seen in Figure 6. Similarly, the 23-F arterial cannula (Figure 7) is only inserted once the guide wire is visualised in the descending aorta, thereby, excluding the possibility of intimal dissection. With the cannula in place, a specialised balloontipped endoaortic catheter (Figures 8 and 9) is introduced through an arm of the Yconnector of the femoral arterial cannula, (EndoclampTM, Heartport, Redwood City, CA) and positioned in the aortic root. The triple-lumen 10.5-Fr catheter is designed to occlude the aorta, deliver the cardioplegia and vent the aortic root. Placement is again performed under TOE guidance and over a guide wire. In our unit, we prefer to leave the guide wire in place but withdrawn into the endoaortic catheter tip in cases of accidental balloon rupture. The final positions of the various catheter and cannulae may be seen in Figure 10. The patient is then placed on cardiopulmonary bypass and cooled to 26-28C using a standard membrane oxygenator and roller pump. Venous drainage may be assisted by an additional pump. Mitral Valve Exposure and Surgery Using a 0 videoscope, the pericardium is opened using an upside down T-shaped incision placed 1 cm anterior to the phrenic nerve. The left flap is sutured back onto itself while the right flap is sutured to the underside of the soft tissue retractor. The lower edge of the incision is retracted with the aid of stay sutures brought out through the skin in the fifth intercostal space. The incision with its retraction gives an excellent view of the left and right atria. The endoaortic balloon is then inflated gently under TOE vision. The amount of contrast for filling and the balloon pressure is determined by the aortic root size as previously described. It is important that the root pressure falls to less than 10 mmHg with a cardiopulmonary bypass perfusion pressure of greater than 40 mmHg. The pressures in both radial artery catheters must also be equal to exclude inadvertent balloon inflation at the level of the neck vessels. Diastolic arrest of the heart is then achieved by a single dose of cold crystalloid cardioplegia delivered anterogradely into the aortic root as seen in Figure 11. Once the heart has stopped, the aortic root is vented while at the same time monitoring the root pressure. The mitral valve is exposed by opening the left atrium just posterior to the intra-atrial groove and anterior to the right pulmonary veins. A cardiotomy sucker is placed in the chamber through the 5-mm CO2 port to evacuate blood from the pulmonary veins for return to the venous reservoir. The blade of the trans-thoracic customised atrial retractor (Figure 12) is attached to the handle and the roof of the left atrium lifted. The mitral valve is now fully exposed with the anterior leaflet hanging free like a curtain. The mitral valve apparatus is inspected and assessed using long-handled single-shafted instruments that minimise visual obstruction of the surgeon. Mitral valve replacement is then performed using standard techniques (Figure 13). In our unit we use interrupted 2/0 Ethibond

pledgted sutures with the Teflon pledgets placed on the inflow side. We also preserve the sub-valvular apparatus, demonstrated to result in improved left ventricular haemodynamics.12 Due to the limited surgical incision and distance of the mitral annulus from the chest wall, it is usually necessary to use a knot pusher.

Figure 8: The 10.5-Fr endoaortic catheter that is positioned through an arm of the arterial return line in the femoral artery has three lumens. Lumen A is used for antegrade cardioplegia delivery, aortic root venting and active suctioning during de-airing prior to termination of CPB. Lumen B is used to inflate the balloon and monitor pressure. Lumen C continuously monitors the aortic root pressure via a port distal to the balloon. The left atriotomy is closed under direct vision with continuous 4/ 0 polypropylene suture. As the surgeon ties the suture, the anaesthetist inflates the left lung to fill the atrium and aid in de-airing the chamber. With the endoclamp balloon still inflated, the aortic root is then placed on active suction to allow thorough de-airing. The TOE probe allows the surgeon to observe the process in the realtime. Once all the air is removed, the balloon is slowly deflated to re-perfuse the heart. During re-perfusion a left atrial catheter is inserted for post-operative fluid management and temporary atrial and ventricular pacemaker wires placed. The function and movement of the prosthetic mitral valve is assessed as the heart recovers. After rewarming the patient is separated from CPB and the arterial and venous cannulae removed after heparin has been reversed with protamine. Haemostasis is secured after which the right lung is inflated and two 30-F chest drains are placed, one through the videoscope port site. The chest, groin and port incisions are then closed in layers. A note is taken of the bypass time and balloon inflation time and the patient transferred to the ITU, ventilated and sedated with a propofol infusion.

Figure 9: The arterial and venous lines are seen in the right groin. The arterial line has a Y-connection that allows the endoaortic catheter to be positioned in the aortic root. The white arrow demonstrates the oxygenated arterial return from the CPB machine through the second arm of the arterial line.

Figure 10: The various lines placed in the heart during the minimally invasive mitral valve replacement approach. The endoaortic balloon catheter is seen threaded up the aorta with its final position in the ascending aortic arch (A). With the balloon inflated cardioplegia is delivered into the coronary arteries through one of the lumens. Venous drainage is through a cannula in the right atrium (B). The endopulmonary vent is positioned in the pulmonary artery after passage through the tricuspid and pulmonary valve (C). For retrograde cardioplegia delivery an additional catheter can be passed into

the coronary sinus via the internal jugular vein under TOE control (D). Illustration courtesy of Heartport, Redwood City, CA.

Figure 11: Mid-oesophageal aortic valve long axis view. The balloon inflated in the aortic root shown illustrated within the circle. Cardioplegia is being delivered in anterograde fashion. The aortic valve is seen closed allowing passage of the cardioplegia into the coronary arteries.

Figure 12: The customised atrial retractor. The handle is screwed onto the blade after it is introduced into the chest cavity through a 2mm incision. The blade lifts the roof of the atrium exposing the mitral valve.

Figure 13: Mitral valve replacement using a mechanical valve seen held on a specialised valve holder. Interrupted non-absorbable 2/0 sutures are used to secure the valve. Due to limited access a knot pusher is used.

POSTOPERATIVE CARE
After transfer to ITU, blood is obtained for arterial gas analysis, clotting studies, haematology and biochemistry. The patient is extubated in ITU once there is no excessive bleeding from the drains, he or she is warm, has a stable haemodynamic status and appropriate level of oxygenation. The drains are usually removed the following day if there is less than 100 mls drainage in the previous 4 hours and there is no air leak. Central venous and arterial monitoring lines are also removed the day following surgery. Anti-coagulation is commenced at this point to achieve a target INR of 2.5 - 3.5 by discharge. The patient is then gently mobilised with the ward physiotherapist aiming for the patient to climb a flight of stairs by the 3rd to 4th post-operative day. Discharge is typically on day 4 with surgical review planned 6 weeks after surgery.

REFERENCES
1. Lillehei CW, Gott VL, DeWall RA, Varco RL. The surgical treatment of stenotic or regurgitant lesions of the mitral and aortic valves by direct vision using a pumpoxygenator. J Thorac Surg 1958; 35: 154-191

2. Zacharias A, Habib RH. Factors predisposing to median sternotomy complications. Deep vs superficial infection. Chest 1996; 110: 1173-8 3. Bryan AJ, Lamarra M, Angelini GD, West RR,Breckenridge IM. Median sternotomy wound dehiscence: a retrospective case control study of risk factors and outcome. J R Coll Surg Edinb 1992; 37: 305-8 4. Hanson MR, Breuer AC, Furlan AJ, Lederman RJ,Wilbourn AJ, Cosgrove DM, Loop FD, Estafanous FG. Mechanism and frequency of brachial plexus injury in open-heart surgery: a prospective analysis. Ann Thorac Surg 1983; 36: 675-9 5. Acuff TE, Landreneau RJ, Griffith BP, Mack MJ.Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996; 61: 135-7 6. Benetti FJ, Ballester C, Sani G, Doonstra P, Grandjean J. Video assisted coronary bypass surgery. J Card Surg 1995; 10: 620-5 7. Glower DD, Landolfo KP, Clements F, Debruijn NP, Stafford-Smith M, Smith PK, Duhaylongsod F. Mitral valve operation via Port Access versus median sternotomy. Eur J Cardiothorac Surg 1998; 14: S143-7 8. Vanermen H, Wellens F, De Geest R, Degrieck I, Van Praet F. Video-assisted PortAccess mitral valve surgery: from debut to routine surgery. Will Trocar-Port-Access cardiac surgery ultimately lead to robotic cardiac surgery. Semin Thorac Cardiovasc Surg 1999; 11: 223-34 9. Cohn LH, Adams DH, Couper GS, Bichell DP, Rosborough DM, Sears SP, Aranki SF. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Surg 1997; 226: 421-6 10. Chitwood R Jr. Video-assisted mitral valve surgery: using the Chitwood clamp. Oper Techn Thorac Cardiovasc Surg 2000; 5: 176-189 11. Schroeyers P, Wellens F, De Geest R, Degrieck I, Van Praet F, Vermeulen Y, Vanermen H. Minimally invasive video-assisted mitral valve repair: short and mid-term results. J Heart Valve Dis 2001; 10: 579-83 12. Yun KL, Sintek CF, Miller DC, Schuyler GT, Fletcher AD, Pfeffer TA, Kochamba GS, Khonsari S, Zile MR. Randomized trial of partial versus complete chordal preservation methods of mitral valve replacement: A preliminary report. Circulation 1999; 100(19 Suppl): II90-4 Copyright: 12 August 2002 Correspondence: D. Richens, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK

Case Report : Mitral Stenosis


July 30th, 2007 by Asta Qauliyah Jantung adalah sebuah pompa muskuler yang memiliki empat katup, yang terbuka dan tertutup untuk menjaga agar darah mengalir pada arah yang tepat. Katup mitral menghubungkan atrium kiri dengan ventrikel kiri.

Penyakit katup jantung menyebabkan kelainan-kelainan pada aliran darah yang melintasi katup-katup tersebut. Katup normal memiliki dua ciri aliran yang kritis : aliran searah dan aliran yang tidak dihalangi. Katup akan terbuka jika tekanan dalam ruang jantung di proksimal katup lebih besar dari tekanan dalam ruang atau pembuluh di sebelah distal katup. Daun katup sedemikian responsifnya sehingga perbedaan tekanan yang kecil (kurang dari 1 mmHg) antara dua ruang jantung sudah mampu membuka dan menutup daun katup tersebut. Katup yang terserang penyakit dapat menimbulkan dua jenis gangguan fungsional: (1) insufisiensi katup-daun katup tidak dapat menutup dengan rapat sehingga darah dapat mengalir balik (sinonimnya adalah regurgitasi katup dan inkompetensi katup); dan (2) stenosis katup-lubang katup mengalami penyempitan sehingga aliran darah mengalami hambatan. Insufisiensi dan stenosis dapat terjadi bersamaan pada satu katup, dikenal sebagai lesi campuran atau sendiri-sendiri. Yang terakhir ini disebut lesi murni. (10) Mitral stenosis adalah suatu penyempitan jalan aliran darah ke ventrikel. Pasien dengan mitral stenosis secara khas memiliki daun katup mitral yang menebal, kommisura yang menyatu, dan korda tendineae yang menebal dan memendek. (7) Diameter transversal jantung biasanya dalam batas normal, tetapi kalsifikasi dari katup mitral dan pembesaran sedang dari atrium kiri dapat terlihat. Meningkatnya tekanan vena pulmonalis menyebabkan diversi darah yang nampak dengan radiografi berupa pelebaran relatif pembuluh darah untuk bagian atas paru dibandingkan dengan pembuluh darah untuk bagian bawah paru. (18) Penyempitan katup mitral menyebabkan katup tidak terbuka dengan tepat dan menghambat aliran darah antara ruang-ruang jantung kiri. Ketika katup mitral menyempit (stenosis), darah tidak dapat dengan efisien melewati jantung. Kondisi ini menyebabkan seseorang menjadi lemah dan nafas menjadi pendek serta gejala lainnya. (13) INSIDENS Di negara-negara maju, insidens dari mitral stenosis telah menurun karena berkurangnya kasus demam rematik sedangkan di negara-negara yang belum berkembang cenderung meningkat. Katup mitral adalah katup jantung yang paling banyak terkena pada pasien dengan penyakit jantung rematik. Dua pertiga pasien kelainan ini adalah wanita.Gejala biasanya timbul antara umur 20 sampai 50 tahun. Gejala dapat pula nampak sejak lahir, tetapi jarang sebagai defek tunggal. Mitral stenosis kongenital lebih sering sebagai bagian dari deformitas jantung kompleks. (7,9) ETIOLOGI Penyebab tersering dari mitral stenosis adalah demam reumatik. Penyebab yang agak jarang antara lain : mitral stenosis kongenital, lupus eritematosus sistemik (SLE), artritis reumatoid (RA), atrial myxoma, dan endokarditis bacterial. Selain itu, virus seperti coxsackie diduga memegang peranan pada timbulnya penyakit katup jantung kronis.(2) Gejala dapat dimulai dengan suatu episode atrial fibrilasi atau dapat dicetuskan oleh kehamilan dan stress lainnya terhadap tubuh misalnya infeksi (pada jantung, paru-paru, etc) atau gangguan jantung yang lain. (7,9,15)

ANATOMI Sebenarnya jantung memutar ke kiri dengan apeks terangkat ke depan. Rotasi ini menempatkan bagian jantung kanan ke anterior, di bawah sternum, dan bagian kiri jantung relatif ke posterior.(3) Dikutip dari kepustakaan 20 Jantung terletak dalam mediastinum dirongga dada, yaitu diantara kedua paru-paru. Perikardium yang meliputi jantung terdiri dari dua lapisan; lapisan dalam disebut pericardium viseralis dan lapisan luar disebut pericardium parietalis. Jantung sendiri terdiri atas tiga lapisan; lapisan terluar disebut epikardium, lapisan tengah merupakan lapisan otot yang disebut miokardium, sedangkan lapisan terdalam yaitu lapisan endotel disebut endokardium. Ruangan jantung bagian atas, atrium, secara anatomi terpisah dari ruangan jantung sebelah bawah atau ventrikel, oleh suatu annulus fibrosus. Keempat katup jantung terletak dalam cincin ini. (3) Dikutip dari kepustakaan 3 Secara fungsional jantung dibagi menjadi alat pompa kanan dan alat pompa kiri, yang memompa darah vena menuju sirkulasi paru-paru, dan darah bersih ke peredaran darah sistemik. Pembagian fungsi ini mempermudah konseptualisasi dari urutan aliran darah secara anatomi; vena kava, atrium kanan, ventrikal kanan, arteri pulmonalis, paru-paru, vena pulmonalis, atrium kiri, ventrikel kiri, aorta, arteria, arteriola, kapiler, venula, vena, vena kava. (3) Dikutip dari Kepustakaan 3 Batas kiri jantung terdiri atas tonjolan yang bulat lonjong atau setengah bulat, terdiri dari: a) Tonjolan I : paling atas adalah arkus aorta, merupakan setengah bulatan yang kira-kira sebesar ibu jari, berhubungan langsung dengan aorta desenden. b) Tonjolan II : disebabkan oleh arteri pulmonalis, pada umumnya lebih kecil, kadangkadang sukar terlihat. Pada sistolik jantung, tonjolan ini akan lebih nyata. c) Tonjolan III : disebabkan oleh aurikel atrium kiri, biasanya tidak tampak kecuali jika ada pembesaran atrium kiri. d) Tonjolan IV : dibentuk oleh dinding luar ventrikel kiri. Pada batas kanan jantung juga terdapat 4 tonjolan: e) Tonjolan I : disebabkan oleh vena kava superior, merupakan pelebaran di sisi mediastinum. f) Tonjolan II : disebabkan oleh aorta asenden, merupakan garis lurus mengarah ke atas menuju ke arkus aorta. Batas vena kava dengan aorta asenden sukar ditetapkan tanpa aortogram. g) Tonjolan III : kadang-kadang ada tonjolan kecil yang disebabkan oleh vena azygos. h) Tonjolan IV : tonjolan besar adalah atrium kanan. (17) PATOFISIOLOGI Mitral stenosis murni terdapat pada kurang lebih 40% dari semua penderita penyakit jantung reumatik. Terdapat periode laten antara 10-20 tahun, atau lebih, setelah suatu

episode penyakit jantung rematik; dengan demikian tidak akan terjadi onset dari gejala mitral stenosis sebelumnya. (7) Penyempitan dari katup mitral menyebabkan perubahan pada peredaran darah, terutama di atas katup. Ventrikel kiri yang berada di bawah katup tidak banyak mengalami perubahan kecuali pada mitral stenosis yang berat, ventrikel kiri dan aorta dapat menjadi kecil.(16,17) Luas normal orifisium katup mitral adalah 4-6 cm2. Ketika daerah orifisium ini berkurang hingga 2 cm2 maka akan terjadi peningkatan tekanan atrium kiri yang dibutuhkan agar aliran transmitral tetap normal. Mitral stenosis yang parah terjadi ketika pembukaan berkurang hingga 1 cm2. Pada tahap ini dibutuhkan tekanan atrium kiri sebesar 25 mmHg untuk mempertahankan cardiac output yang normal. (2,7) Mitral stenosis menghalangi aliran darah dari atrium kiri ke ventrikel kiri selama fase diastolic ventrikel. Untuk mengisi ventrikel dengan adekuat dan mempertahankan curah jantung, atrium kiri harus menghasilkan tekanan yang lebih besar untuk mendorong darah melampaui katup yang menyempit. Karena itu, selisih tekanan atau gradient tekanan antara kedua ruang tersebut meningkat. Dalam keadaan normal selisih tekanan tersebut minimal. (10) Otot atrium kiri mengalami hipertrofi untuk meningkatkan kekuatan memompa darah. Makin lama peranan kontraksi atrium makin penting sebagai faktor pembantu pengisian ventrikel. Dilatasi atrium kiri terjadi oleh karena volume atrium kiri meningkat karena ketidakmampuan atrium untuk mengosongkan diri secara normal. Peningkatan tekanan dan volume atrium kiri dipantulkan ke belakang ke dalam pembuluh paru-paru. Tekanan dalam vena pulmonalis dan kapiler meningkat, akibatnya terjadi kongesti paru-paru, mulai dari kongesti vena yang ringan sampai edema interstitial yang kadang-kadang disertai transudasi dalam alveoli. (10,18) Pada akhirnya, tekanan arteria pulmonalis harus meningkat sebagai akibat dari resistensi vena pulmonalis yang meninggi. Respon ini memastikan gradient tekanan yang memadai untuk mendorong darah melalui pembuluh paru-paru. Akan tetapi, hipertensi pulmonalis meningkatkan resistensi ejeksi ventrikel kanan menuju arteria pulmonalis. Ventrikel kanan memberi respons terhadap peningkatan beban tekanan ini dengan cara hipertrofi. (10,18) Lama kelamaan hipertrofi ini akan dikuti oleh dilatasi ventrikel kanan. Dilatasi ventrikel kanan ini nampak pada foto jantung pada posisi lateral dan posisi PA. Pembesaran ventrikel kanan ini lama kelamaan mempengaruhi fungsi katup trikuspid. Katup ini akan mengalami insufisiensi. Kalau ventrikel kanan mengalami kegagalan, maka darah yang mengalir ke paru berkurang. Dilatasi ventrikel kanan akan bertambah, sehingga kemungkinan terjadinya insufisisiensi katup trikuspid semakin besar pula. (17,18) Dikutip dari kepustakaan 10 DIAGNOSIS 1. Gambaran klinik; Gambaran klinis penyakit ini adalah sebagai berikut; a) Riwayat demam reumatik akut, meskipun banyak pasien yang tidak lagi mengingatnya b) Riwayat murmur c) Effort-induced dyspnea, merupakan keluhan yang paling banyak, sering dicetuskan oleh latihan berat, demam, anemia, timbulnya atrial fibrilasi, atau kehamilan.

d) Lemah setelah bergiat e) Hemoptisis karena ruptur vena bronkial yang tipis dan berdilatasi f) Nyeri dada karena iskemia ventrikel kanan, menyerupai aterosklerosis koroner atau emboli koroner g) Tromboemboli h) Palpitasi i) Batuk rekuren. Tanda dari pemeriksaan fisis yang ditemukan tergantung perkembangan penyakit dan tingkat dekompensasi kordis yang menyertai. Antara lain sebagai berikut: a) Sianosis perifer dan fasial b) Distensi vena jugular c) Distress pernafasan, menandakan adanya edema paru d) Diastolic thrill yang dapat diraba di atas apeks e) Bunyi S1 yang keras diikuti bunyi S2 dan opening snap, paling baik di linea sternalis kiri f) Digital clubbing g) Embolisasi sistemik h) Tanda-tanda gagal jantung kanan pada mitral stenosis berat meliputi ascites, hepatomegali, dan edema perifer i) Jika terjadi hipertensi pulmonal, dapat ditemukan kuat angkat pada ventrikel kanan, dan peninggian bunyi P2. (7,9,13,15) 2. Gambaran Radiologi Mitral stenosis menyebabkan perubahan pada bentuk jantung dan perubahan-perubahan pada pembuluh darah paru-paru. Perubahan pembuluh darah paru ini tergantung pada beratnya mitral stenosis dan kondisi dari jantung. Konveksitas dari dari batas kiri jantung mengindikasikan bahwa stenosis menonjol. Pada kebanyakan kasus terdapat dua kelainan yakni stenosis mitral dan insufisiensi mitral, dimana salah satunya menonjol. Ventrikel kiri juga sangat melebar ketika insufisiensi mitral terlibat secara signifikan. (6,16) Tanda-tanda radiologis klasik dari pasien dengan mitral stenosis yaitu adanya double contour yang mengarah pada adanya pembesaran atrium kiri, serta adanya garis-garis septa yang terlokalisasi.(8) Pada keadaan yang moderat dan berat tampak perubahan perubahan sebagai berikut; Perubahan pada jantung: 1. Proyeksi Postero-Anterior (PA) Terlihat batas kanan jantung menonjol (Panah) dan batas kiri jantung mencembung karena pembesaran atrium kiri (Panah ganda). Bronkus utama kiri terangkat (Panah bulat). (11) Dikutip Dari Kepustakaan 11 2. Proyeksi Lateral. Pada proyeksi ini dengan menggunakan kontras tampak pembesaran atrium kiri yang mendorong esofagus 1/3 tengah ke belakang. Batas ventrikel kiri di bagian bawah belakang, tidak melewati vena cava inferior.

3. Proyeksi Oblik Kanan Depan(RAO) Deviasi yang minimal dari esophagus disebabkan oleh pembesaran atrium kiri. Posisi ini tidak begitu membantu untuk diagnosis mitral stenosis. (5) 4. Proyeksi Oblik Kiri Depan(LAO) Daerah terang yang normal antara antrium kiri dengan bronkus utama kiri menghilang disertai dengan elevasi bronkus utama kiri. Ventrikel kiri normal. Teradapat sedikit penonjlan dari atrium kanan. Tetapi secara umum jantung kanan dalam keadaan normal. (5) Dikutip Dari Kepustakaan 5 Perubahan pada paru dan pembuluh-pembuluh darahnya 1. Perubahan pada pembuluh darah Baik arteri maupun vena menjadi lebih menonjol terutama arteri, dengan ujung pembuluh yang berdekatan dengan hilus menjadi lebih terlihat, dan pembuluh distal memanjang keluar ke perifer paru.(19) 2. Udema paru Pada mitral stenosis udema paru dapat terjadi pada jaringan interstitial dan dalam ruangan alveolar. Udema interstitial menyebabkan paru berbercak-bercak tipis, halus, sehingga gambaran radiolusensi dari paru berubah menjadi suram. (6) 3. Garis Kerley (garis septa) Garis ini muncul di lapangan paru bagian tepi-tepi dan kebanyakan di lapangan bawah. Garis-garis ini disebut garis kerley atau garis septa. Garis ini sering terdapat pada sinus kostoprenikus dan mewakili adanya cairan dalam jaringan interlobaris.(19) Garis ini disebut juga Kerley B lines, agak spesifik untuk stenosis mitral dengan edema paru. (7,9) Dikutip dari kepustakaan 14 4.Hemosiderosis Mitral stenosis yang disertai dengan hipertensi pulmonal yang kronis akan menyebabkan dilatasi kapiler dan hemorage. Akibatnya besi bebas akan terkumpul pada daerah interstitial jaringan yang akan tampak sebagai bayangan nodul pada radiograf. (18) Ekokardiografi adalah metode noninvasif yang paling sensitif dan spesifik untuk mendiagnosa mitral stenosis, tetapi tidak dapat digunakan untuk menentukan derajat keparahan dari stenosis mitral.(2) Daun katup menebal dan nampak paralel, dengan densitas echo agak nampak sebagai garis tipis yang bergerak dengan cepat. Fusi komisura nampak sebagai gerakan anterior paralel dari daun katup posterior. Terlihat Hockey stick appearance dari katup mitral anterior. Dengan menggunakan teknik dua dimensi, seluruh bagian katup mitral dan orifisiumnya dapat divisualisasikan.(12) Teknik color Doppler dapat mengevaluasi gradien transvalvuler, tekanan arteri pulmonalis, dan ada tidaknya regurgitasi mitral yang menyertai.(3,9,13) Dikutip dari kepustakaan 1

Ekokardiografi sangat bermanfaat dalam evaluasi stenosis katup mitral: 1) Pertama, pada pasien yang sakit berat, gambaran ekokardiografi gerakan mitral yang normal menyingkirkan stenosis mitral sebagai penyebab untuk distress pasien. 2) Kedua, sewaktu stenosis mitral ada, maka ekokardiogram dapat memperlihatkan pembesaran atrium kiri, gerakan bersamaan daun mitral anterior dan posterior, penguranagn gerakan katup mitral yang mengurangi lereng EF daun mitral anterior dan kalsifikasi katup; perkiraan kasar keparahan obstruksi dapat dibuat dengan 2D Echo. 3) Ketiga, ekokardiografi Doppler dapat mendeteksi keparahan stenosis mitral dengan pengukuran tekanan setengah hari, yang merupakan waktu yang diperlukan agar tekanan diastolic seketika turun mencapai setengah nilai puncaknya; lebih parah obstruksi, lebih memanjang tekanan setengah hari.(4) DIAGNOSIS BANDING 1) Insufisiensi mitral (17,18) Bentuk jantung pada insufisiensi mitral ini hampir sama dengan stenosis mitral. Pada insufisiensi mitral, ventrikel kiri nampak besar; sedang pada stenosis mitral ventrikel kiri normal atau mengecil.(17) 2) Regurgitasi Aorta Hipertrofi ventrikel kiri yang jelas, pengurangan bunyi jantung pertama (S1) dan tidak adanya opening snap pada auskultasi menyokong kearah regurgitasi aorta.(4) PENGOBATAN Tidak ada pengobatan yang dibutuhkan jika gejala-gejala tidak ditemukan atau hanya ringan saja. Rujukan ke rumah sakit hanya dibutuhkan untuk diagnosis atau penanganan gejala yang berat. Tak ada obat yang dapat mengoreksi suatu defek katup mitral. Hanya saja obat-obatan tertentu dapat digunakan untuk mengurangi gejala dengan mempermudah kerja pemompaan jantung dan mengatur irama jantung, misalnya diuretik untuk mengurangi akumulasi cairan di paru. Antikoagulan dapat membantu mencegah terbentuknya bekuan darah pada jantung dengan kerusakan katup. Antibiotik diberikan bila pasien akan menjalani tindakan bedah, tindakan dentologi, atau tindakan medis tertentu lainnya. (10,15) Tindakan bedah dapat dilakukan untuk mengoreksi kelainan ini. Kadang-kadang katup dapat dibuka teregang dengan suatu prosedur yang disebut dengan balloon valvuloplasty. Pada balloon valvuloplasty, sebuah balon berujung kateter disusupkan melewati vena dan akhirnya sampai ke jantung. Ketika berada di dalam katup balon dikembangkan lalu memisahkan daun katup. Pilihan lainnya adalah bedah jantung untuk memisahkan fusi kommisura. Jika katup rusak berat dapat dilakukan mitral valve repair atau mitral valve replacement. (7,9,15) PROGNOSA Prognosis penyakit ini bervariasi. Gangguan dapat saja ringan, tanpa gejala, atau menjadi berat. Riwayat yang banyak terjadi pada mitral stenosis adalah: a) Timbulnya murmur 10 tahun setelah masa demam rematik b) 10 tahun berikutnya gejala berkembang c) 10 tahun berikutnya sebelum penderita mengalami sakit serius. Komplikasi dapat berat atau mengancam jiwa. Mitral stenosis biasanya dapat dikontrol

dengan pengobatan dan membaik dengan valvuloplasty atau pembedahan. Tingkat mortalitas post operatif pada mitral commisurotomy adalah 1-2% dan pada mitral valve replacement adalah 2-5%. (7,9) Popularity: 2% [?] Stenosis Mitral Written by Irfan Arief Tuesday, 31 July 2007 Dokter yang terhormat, Penyakit-penyakit apa saja yang dapat mengacaukan diagnosis dari penyakit stenosis mitral dan apa ciri khas dari penyakit-penyakit tersebut yang sama atau mirip dengan stenosis mitral baik dari gejala maupun pemeriksaan fisiknya. Apa pula tanda khas dari stenosis mitral. Wassalam, Reni Jawaban: Ibu Reni yth. Terima kasih anda telah menggunakan website kami untuk berkomunikasi. Menjawab pertanyaan Anda, Mitral stenosis adalah penyempitan katup mitral (yang memisahkan serambi kiri dan bilik kiri jantung), umumnya kelainan ini disebabkan oleh demam reumatik. Infeksi berawal di tenggorokan akibat kuman streptokokus beta hemolitikus. Katup mitral yang menyempit berakibat hambatan aliran darah dari serambi kiri ke bilik kiri, akibatnya darah kebendung di serambi kiri dan pembuluh penghubung serambi ini dengan paru. Selanjutnya paru-paru pun mengalami edema paru (cairan masuk ke jaringan paru), dan pasien mengalami sesak nafas, batuk-batuk bahkan riak yang dikeluarkan bisa mengandung darah. Seringkali ditafsirkan sebagai penyakit TBC. Sesak nafas sering timbul malam hari, lebi enak kalau posisi tidur dengan bantal tinggi. Dengan stetoskop, seorang yang ahli bisa membedakan mitral stenosis dengan penyakit paru. Bagi orang awam, tentu saja sulit. Pemeriksaan yang sangat penting di samping pemeriksaan fisik dengan stetoskop adalah: EKG, foto rontgen dan ekokardiografi. Biaya untuk semua ini di Pusat Jantung Nasional Harapan Kita Rp.440.000.- Bila anda mempunyai fasilitas Askes, anda hanya perlu membayar Rp. 60.000.- Untuk pasien tak mampu, yang sudah lengkap surat-surat keterangannya, bisa dibebaskan dari biaya. Kalau pemeriksaan-pemeriksaan ini sudah dikerjakan dengan baik, niscaya diagnosis bisa

ditegakkan dengan pasti. Sebaiknya ibu segera memeriksakan diri pada Ahli Jantung yang mempunyai fasilitas tersebut diatas. Sehingga dapat segera diputuskan : perlu intervensi apa tidak, dan intervensi itu apakah cukup dengan pelebaran katup mitral menggunakan balon ataukan operasi reparasi katup atau penggantian katup mitral. Kami tunggu kedatangan anda di RS Jantung dan Pembuluh Darah Harapan Kita. Wassalam, Dr. Anna Ulfah Rahayoe, SpJP

Questions and Answers about Mitral Valve Disease and Valve Repair
What are the symptoms of a leaking mitral valve?

Many patients with mitral valve disease are asymptomatic (have no symptoms), even with a leak that is severe. When symptoms develop, they include shortness of breath, fatigue, loss of energy, swelling of the ankles and palpitations (extra or skipped heart beats).
How is a leaky mitral valve diagnosed?

The first step involves listening with a stethoscope. Using a stethoscope, the doctor hears a murmur, which represents turbulent blood flow across an abnormal valve. The diagnosis is confirmed by an echocardiogram. Ultrasound is used in an echocardiogram to allow the doctor to visualize the heart valves and determine the severity and cause of the leak. In most patients, a standard transthoracic echocardiogram (a probe placed on the skin of the chest) is adequate to visualize the valve. Sometimes a transesophageal echocardiogram (a probe passed through the mouth into the esophagus) is necessary to more closely visualize the valve; this is an outpatient procedure.
What is mitral valve prolapse?

Mitral valve prolapse is a common condition in which the mitral valve leaflets are floppy or loose. Mitral valve prolapse is diagnosed by echocardiography. Most patients with mitral valve prolapse do not have a leaky valve and do not require surgery. When a valve with prolapse has a severe leak, surgery should be considered.

Mitral Valve Prolapse


What are the indications for surgical repair of a leaking mitral valve?

Surgery should be considered when the leak is severe. In most facilities, the regurgitation (leak) is graded on a scale from 0 to 4, with 0 being no leak and 4 being a severe leak. Surgery should be considered in virtually all patients with a leak that is graded as a 4 (severe) and in some patients with a leak that is graded as a 3 (moderately severe). When a patient with mitral regurgitation develops symptoms, a decrease in heart function, or an increase in heart size, surgery is recommended. Surgery should also be considered when a patient develops atrial fibrillation, which is an irregular heartbeat. Surgery is also recommended in many asymptomatic patients who have a severe leak; in these patients, surgery improves long-term survival.
What is the chance that a leaky mitral valve can be repaired?

Nearly 100%. The most common cause of mitral regurgitation is a condition called degenerative mitral valve diseasethis is also called mitral valve prolapse, myxomatous mitral valve disease, and a floppy mitral valve. Such valves can be repaired (rather than replaced) in more than 95% of patients. Cleveland Clinic heart surgeons have the worlds largest experience with mitral valve repair.
What is the chance that a leaky mitral valve can be repaired minimally invasively?

Nearly 100%. When a patient requires isolated mitral valve surgery for a degenerative valve, at Cleveland Clinic we can perform the operation through a 2 to 4 inch skin incision in 95% of cases. We offer several different minimally invasive approaches, including a small incision on the right chest, a small incision in the mid-line, and

robotically assisted procedures. Expertise with several approaches enables us to determine the best procedure for each patient, optimizing results.
What is the risk of mitral valve surgery?

For asymptomatic patients having mitral valve repair, the operative risk is approximately 1 in 1000. Risk in symptomatic patients remains well under 1%. The presence of coronary artery disease or other conditions that require surgical treatment will affect your individual risk. Ask your doctor about your surgical risk.
What is the durability of a mitral valve repair?

After mitral valve repair, 95% of patients are free of reoperation at 10 years, and this statistic is similar at 20 years. Thus, reoperation is uncommon after a successful mitral valve repair. An echocardiogram is recommended annually to assess valve function. In addition, patients who had valve surgery must take steps to prevent infection and reduce the risk of endocarditis (an infection of the valve).
Why is it important to have my surgery at a center with a large experience in mitral valve repair?

Mitral valve repair is the best option for nearly all patients with a leaking (regurgitant) mitral valve and for many with a narrowed (stenotic) mitral valve. Compared to valve replacement, mitral valve repair provides better long-term survival, better preservation of heart function, lower risk of complications, and usually avoids the need for long-term use of blood thinners (anticoagulation). For these reasons, Cleveland Clinic surgeons are committed to mitral valve repair. Advantages of Mitral Valve RepairBetter early and late survival, improved lifestyle, better preservation of heart function, lower risk of stroke and infection (endocarditis), no need for blood thinners (anticoagulation) Mitral valve repair is more challenging than mitral valve replacement, and experienced surgeons are more likely to be able to repair the valve and ensure an excellent outcome.

Valve Surgery - Past, Present, Future


Written with A. Marc Gillinov, M.D. Department of Cardiovascular and Thoracic Surgery

Valve Surgery - the past


As long ago as 1400, Leonardo de Vinci described in great detail the anatomy of the aortic and mitral valves. But it wasn't until the 1950s, that great strides were made in the journey to develop surgical treatments for those with valve disease. These included

innovations such as the heart-lung machine, the use of bioprosthetic (pig and calf) valves and the first aortic valve surgery. Over the past years, many more advances have improved outcomes for those who have valve disease and need valve repair. These include:

improved diagnostic techniques better timing for surgical intervention the introduction of valve repair, improvements in replacement valves, and improvements in surgical techniques, most notably, the introduction of minimally invasive surgery

Valve Surgery - The present: Improvements in surgical technique for valve surgery
Minimally invasive valve surgery

In 1996, Cleveland Clinic surgeon Delos M. Cosgrove, M.D., performed the world's first minimally invasive heart valve surgery. Since that time, improvements in the type of incision and surgical techniques have led to a proven, successful minimally invasive approach to valve surgery. Chest wall incisions used for heart surgery

Median sternotomy incision

Minimally invasive approach: partial upper sternotomy

Minimally invasive approach: small right thoracotomy incision

There are a variety of minimally invasive approaches. We favor a small skin incision and a partial sternotomy as this provides excellent access to both aortic and mitral valves, enabling the surgeon to achieve as complete and successful an operation as that performed through a standard incision. Minimally invasive surgery has many benefits compared to traditional surgery:

Lower hospital risk Smaller incision - smaller scar (2 to 4 inches instead of the 6 to 8 inches required for traditional valve surgery) Shorter hospital stay - in many cases, only 3 to 5 days are needed (instead of the average 5 to 7 days for traditional surgery) Shorter recovery time after discharge Less bleeding Less potential for infection Less pain and trauma

Future innovations will include smaller ports (incisions) and use of video and robotics to move toward a completely endoscopic approach. In addition, advances in percutaneous, non-surgical approaches may lead us toward even less invasive heart valve repair and replacement.

Photo of Cosgrove-Edwards Annuloplasty band with permission from Edwards Lifesciences In the early 1990s, Dr. Cosgrove, Department Chairman of Cardiovascular and Thoracic Surgery at the Cleveland Clinic Heart Center, developed an annuloplasty system, designed to help support the valve annulus, while maintaining the normal shape and function of the valve.

Valve repair

Valve repair is now the method of choice for surgical treatment of mitral valve disease thanks to improvements in techniques over the past 20 years. Through valve repair, the natural anatomy of the heart valve is maintained. The surgeon repairs the tissue of the damaged valve and usually implants an annuloplasty ring to provide extra support to the valve. For mitral and tricuspid valve disease, the surgeon is able to:

Repair prolapsing (floppy) leaflets Open fused leaflets Remove calcium deposits Support and tighten an enlarged annulus by attaching a ring or band

Bicuspid aortic valve disease (two leaflets instead of three) is a very common type of aortic valve disease. When there is a leak, the surgeon may be able to reshape the aortic valve leaflets, allowing the valve to open and close more easily. Click here for information, illustrations and videos regarding mitral valve repair
Valve replacement

When valve repair is not possible, replacement of the diseased valve with a new heart valve is performed. Although valve replacement surgery has been performed since the 1950s, refined techniques and materials have improved the outcomes and options. Sapirstein and Smith 1 state there are qualities which would define the "ideal valve:"

The valve functions like the patient's own normal heart valve The valve permits normal forward flow and prevents any backflow when closed The opening and closing of the valve is synchronized with the normal heart cycle Flow through the valve is smooth and the material the valve is made of does not promote clotting The valve is easy to implant so that all surgeons have the same results After valve surgery, the patient does not have to make any changes in lifestyle (take medications, not be at risk for infection, not hear the new valve) The valve should be durable

Although there may be no valves today that precisely meet each of the criteria, current valves are coming closer to this ideal. There are two options for replacing a heart valve: mechanical valves and tissue (bioprosthetic) valves.
Mechanical valves:

Mechanical valves are made totally of mechanical parts that are tolerated well by the body. The bileaflet valve (pictured below) is used most often. It consists of two carbon leaflets in a ring covered with polyester knit fabric. Mechanical heart valves are made in many sizes to fit any size heart, from large to very small. St. Jude Medical Mechanical Heart Valves Photographs posted with permission from St. Jude Medical

St. Jude Medical Mechanical Heart Valve

SJM Regent Valve The St. Jude Medical Regent valve is available for aortic valve replacements, and the standard St. Jude Medical is used in the mitral or aortic valve positions. The St. Jude heart valve was the first bileaflet mechanical heart valve (St. Jude Medical (SJM)). This valve has a track record spanning 3 decades of excellent results. This bileaflet mechanical heart valve is designed and manufactured of pyrolytic carbon.

The Carbomedics Prosthetic Heart Valve (CPHV) Photographs posted with permission from CarboMedics

Top Hat Supra-Annular Aortic Valve

Standard Mitral Valve Carbomedics manufactures a variety of bileaflet mechanical heart valves. The Top Hat Supra-Annular valve is used for aortic valve replacement and the standard valve in the mitral position. A third valve, the Reduce R Aortic Valve may also be used for aortic valve replacement. The valve housing and leaflets are made of Pyrolite carbon, a unique form of carbon which Carbomedics engineers discovered in the sixties. Attached to the carbon housing is a reinforcing band of titanium and attached to the titanium band is a suture ring of PET fabric. A metallic nitinol wire holds the titanium ring to the housing with an interference groove system. Pyrolite is biocompatible. There are advantages and drawbacks to mechanical valves. Advantages: Mechanical valves are very durable. They are designed to last a lifetime. Disadvantages: Due to the artificial material involved, patients who receive these valves require lifelong treatment with a blood-thinning (anticoagulant) medication. Bloodthinners are medications (such as warfarin or Coumadin) that delay the clotting action of the blood. They help prevent clots from forming on the mechanical valve, which can cause a heart attack or stroke.
Tissue valves (also called biologic or bioprosthetic valves):

Tissue valves (also called biologic or bioprosthetic valves) are made of human or animal tissue. They may have some artificial parts to help give the valve support and to aid placement. There are three types of tissue valves: pig tissue (porcine), cow tissue (bovine), and human (allografts or homografts).

Porcine stented valve - Information and photographs posted with permission from Edwards Lifesciences The porcine stented valve was the first generation of porcine tissue valves. They have been available for more than 30 years. The valves are made from natural porcine aortic valves, but may be used for aortic or mitral valve replacement. They are trimmed and then fixed in buffered glutaraldehyde at high pressure. The valves are mounted on flexible stents (frames). The bottom of the valve is covered with a seamless knitted polytetrafluoroethylene cloth. This material helps to facilitate the healing and ingrowth of tissue around the implanted valve.

Porcine stentless valve - Information and photographs posted with permission from Edwards Lifesciences The porcine stentless valve is used for aortic valve replacement. The valve is made from a natural porcine aortic valve and is fixed in buffered glutaraldehyde solution at a low pressure.

No stents or synthetic sewing rings are used. Therefore, these valves are very similar to the homograft valve (see below). These valves are technically more difficult to implant but are useful in patients with small hypertrophied hearts.

The Carpentier-Edwards PERIMOUNT Pericardial Bioprosthesis - Information and photographs posted with permission from Edwards Lifesciences Valves built to last This valve is made of bovine pericardial tissue (tissue from a cow heart) that has been preserved in a buffered glutaraldehyde solution and mounted on a flexible frame and a sewing ring of molded silicone rubber, which allows the surgeon to sew the valve to the patient. Both the frame and the sewing ring are covered with a knitted polytetrafluoroethylene (PTFE) cloth. The aortic pericardial bioprosthesis has been implanted internationally since 1981, and in the United States since 1991. In the summer of 2000, Carpentier-Edwards released a PERIMOUNT valve for the mitral position. The benefit of this valve is enhanced durability, which is related to the use of pericardium and the specific bioengineering involved in the valve design. Click here to learn more about the durability of these valves.

Aortic Valve Allograft - the Homograft Valve A homograft (also called allograft) is a valve that has been removed from a donated human heart, preserved and frozen under sterile conditions. Homografts are ideal valves for aortic valve replacement, especially when the aortic root is diseased or there is infection. The heart's natural anatomy is preserved and patients do not need to be on any blood-thinner medications. Although the limited availability is a drawback in some settings, we maintain a large supply. Information and photographs posted with permission from CryoLife, Inc. Ross Procedure The Ross procedure involves switching your pulmonary valve to the aortic valve position and then placing a pulmonary homograft. This is a very complex procedure; however it has many benefits, especially for young patients with aortic valve disease. Techniques, such as the Ross Procedure are examples of innovative ways surgeons are able to treat valve disease while protecting the heart's natural functioning. Click here to learn more. There are advantages and drawbacks to biologic valves. Advantages: Most patients do not need to be on lifelong blood-thinner medication, unless they have other conditions (such as atrial fibrillation) which warrant it. Drawbacks: Biologic valves, traditionally, were not considered as durable as mechanical valves, especially in younger people. Previously available biologic valves usually needed to be replaced after about 10 years. However , recent studies on the PERIMOUNT aortic valve, show that these valves may last at least 17 years without decline in function. This represents a new milestone in durability of biologic valves. Atrial fibrillation

Atrial fibrillation is the most common cause of an irregular heart beat. Cleveland Clinic Foundation Heart Center surgeons can now eliminate this abnormal rhythm in patients with atrial fibrillation who require valve surgery. Click here to learn more about surgical treatments for atrial fibrillation.

Valve surgery today at the Cleveland Clinic Foundation offers patients state of the art, minimally invasive treatment options with excellent long-term results. Your surgeon and cardiologist use many variables (your age, lifestyle, medical condition, heart anatomy and diagnostic test results) to decide what is the best treatment for you. Click here to learn more about valve disease, symptoms, diagnosis and treatment . Click on the links below to find a Cleveland Clinic cardiovascular surgeon who performs valve surgery Click here to learn more about heart valve surgery from the Cleveland Clinic Heart and Vascular Institute Learn more about heart surgery topics To obtain a surgical consultation, or if you have additional questions or need more information, you may contact us by :

Email, using the Contact Us Form. Call the Heart & Vascular Institute Resource Nurse at 216/445-9288 or toll-free 866/289-6911.

Webmail and phone calls are answered between 8:30 am to 4:00 pm on regular business days. Resources: 1. Sapirstein JS, Smith PK. The "ideal" replacement heart valve. American Heart J 2001; 141:856-860. 2. Gillinov AM. Chordal transfer for repair of anterior leaflet prolapse. Multimedia Manual of Cardiothoracic Surg, 2005. 3. Gillinov AM, Garcia MJ. When is concomitant aortic valve replacement indicated in patients with mild-moderate stenosis undergoing coronary revascularization? Curr Cardiol Reports, 2005;7(2):101-4. 4. Gillinov AM, Cosgrove DM. Percutaneous heart valve repair and replacement. Endovascular Today, 2004;3:31-4. 5. Gillinov AM, Cosgrove DM. Cosgrove ring annuloplasty for functional tricuspid regurgitation. Op Techni Thorac Cardiovasc Surg, 2003;8:184-7. 6. Gillinov AM, Cosgrove DM. Current status of mitral valve repair. Am Heart Hosp J, 2003;1:47-54.

7. Gillinov AM, Faber CN, Houghtaling PL, Blackstone EH, Lam BK, Diaz R, Lytle BW, et al. Repair versus replacement for degenerative mitral valve disease with coexisting ischemic heart disease. J Thorac Cardiovasc Surg, 2003;125:1350-62. 8. Gillinov AM, Banbury MK, Cosgrove DM. Hemisternotomy approach for aortic and mitral valve surgery. J Card Surg, 2000;15:15-20. 9. Gillinov AM, Banbury MK, Cosgrove DM. Is minimally invasive heart valve surgery a paradigm for the future? Curr Cardiol Rep, 1999;1:318-22. Review. 10. Banbury MK, Cosgrove DM 3rd, Thomas JD, Blackstone EH, Rajeswaran J, Okies JE, Frater RM. Hemodynamic stability during 17 years of the CarpentierEdwards aortic pericardial bioprosthesis. Ann Thorac Surg. 2002 May;73(5):1460-5 11. Gillinov AM, Cosgrove DM, Blackstone EH, Diaz R, Arnold JH, Lytle BW, Smedira NG, Sabik JF, McCarthy PM, Loop FD. Durability of mitral valve repair for degenerative disease. J Thorac Cardiovasc Surg 1998;116:734-43. 12. World View Through 8 Centimeters: An International Tele-Symposium on Minimally Invasive Direct Access Valve Surgery, Edwards CVS Division and the Cleveland Clinic Foundation, 1997 13. http://www.edwards.com* 14. http://www.carbomedics.com/patients_links.asp 15. http://www.cryolife.com* 16. http://www.sjm.com* *a new browser window will open with these links. The inclusion of links to other web sites does not imply any endorsement of the material on the web sites or any association with their operators