MD 2 | PBL Case: #3, Tui

MITRAL VALVE REPLACEMENT ( PG1/2) Saipaia

Sony Ton | 10/11/2010

LI Rationale:
Context: Patient Tui Saipaia (46 yo, Male, Samoan) is diagnosed with severe mitral-valve
regurgitation (MR) and is scheduled for mitral-valve replacement surgery. The patient undergoes
surgery and recovers uneventfully.
Purpose: Provide overview of the surgical procedure, indications, post-operative-management,
and –complications.

Description:
 Goal: to reduce the risk and/or symptoms of
heart failure
 Repair of mitral valve is recommended over
valve replacement, b/c of the diminished risk
of thromboembolism. Repair may involve
reshaping valvular leaflets, adding support to
the annulus, and/or attaching the valve to
chord-like structures (chordal transposition)
 Valve replacement is necessary in the
following situations:
 Extensive ballooning of the mitral valve
 Calcification of the valvular leaflets and/or
annulus
 Prolapse of the valve at the posterior leaflet
 Damage to the valve from infection (e.g.
endocarditis)
 Procedure: general anesthesia; blood is bypassed from the heart via heart-lung machine; 3-4
hr. procedure

Indications:
Class I (benefit >>> risk)
 Symptomatic patient with acute MR*
*Emergency situation = intolerable pulmonary
congestion and hemodynamic overload
 Symptomatic (NYHA II-IV)*/asymptomatic
patients with chronic MR and mild/moderate
left-ventricle (LV) dysfunction*
*NYHA: New York Heart Association functional
classification for extent of heart failure. II: mild
dyspnea/angina & slight limitation of physical activity
IV: severe limitations and symptoms at rest
*Ejection fraction (EF) between 30-60% and/or end-
systolic dimension (ESD) <55 mm
 MD 2 | PBL Case: #3, Tui
MITRAL VALVE REPLACEMENT ( PG2/2) Saipaia
Sony Ton | 10/11/2010

Class II (benefit > risk)

 Asymptomatic patients with chronic MR and
preserved LV function* at an experienced
surgical center with90% likelihood of
successful repair (not replacement)
*EF > 60% and ESD < 40 mm
 Asymptomatic patients with chronic MR,
preserved LV function, and new onset of atrial
fibrillation
 Asymptomatic patients with chronic MR,
preserved LV function, and pulmonary
hypertension†
† Pulmonary artery systolic pressure > 50 mm Hg at rest;
or > 60 mm Hg with exercise
 Symptomatic patients (NYHA III-IV symptoms)
with chronic MR due to severe LV dysfunction
(EF <30%), despite therapy for heart failure
Class IV (risk < benefit)
 Asymptomatic patients with chronic MR and
preserved LV function*
*EF > 60% and ESD < 40 mm

Selection of Valve Prostheses for Mitral Valve Replacement:

Valves: Mechanical Tissue/Bio-prosthetic (e.g.

porcine)
Advantages Excellent durability Low thromboembolic risk
Disadvanta High thromboembolic risk Poor durability; early
ges degeneration =>
calcification (esp. in young
pts.) Mechanical Heart Valve
(St. Jude Medical)
Indications  Patients (age <65) with  Patients who cannot
long-standing atrial have warfarin therapy
fibrillation (Class I)
 Patients (age >65)
 Patients (age <65) in
sinus rhythm who are
aware of lifestyle
considerations
Post-op  Heparin for initial 2 days  Heparin for initial 2 days
manageme  Vitamin K antagonist  VKA therapy for initial 3 Bovine Tissue Valve
nt (VKA) therapy*, e.g. months (Carpentier-Edwards)
warfarin  Long-term aspirin therapy
 MD 2 | PBL Case: #3, Tui
MITRAL VALVE REPLACEMENT ( PG3/2) Saipaia
Sony Ton | 10/11/2010

*Target INR based on type of if patients are in sinus

mechanical valve rhythm and have no
 Aspirin supplementation indications for VKA (i.e.
for high-risk high-risk
thromboembolism* thromboembolism*)
(exception: high risk to *Atrial fibrillation,
bleed) hypercoagulable state, low
*Atrial fibrillation, ejection fraction
hypercoagulable state, low
ejection fraction

Complications:
 Operative mortality: 4-7% overall mortality for mitral valve replacement surgery
 4% mortality for patients (<50 years)
 17% mortality for patients (>80 years)
 Post-operative risks: infection (both valve types), bleeding, intraoperative MI, and stroke
 Thromboembolism-related: risk to develop thrombotic/hemorrhagic stroke
 Mechanical valves: 1-3% risk increase per year
 Tissue valves (w/o any anticoagulation): 1.5% risk increase per year
 Endocarditis: cumulative incidence is estimated to be 1.4% to 3.1% at 1 year and 3.2% to
5.7% at 5 years, which is the same for mechanical- and tissue-valves.
 Left ventricular rupture: incidence < 1% undergoing mitral valve-replacement with
posterior leaflet preservation/chordal-sparing techniques. Pathology consists of a dissection
pathway from the annulus or endocardial surface of the left ventricle  myocardium. Overall
mortality > 50% with aforementioned condition.

Prognosis:
 Survival rate: 50-60% in 10 years (long-term survival is almost identical between
mechanical- and tissue-valves)
 Congestive heart failure is the most common mode of death

References:
1. ACC/AHA 2006 Guidelines for the Management of Patients with Valvular Heart Disease, a 2008 Focused Update
(2008). Journal of the American College of Cardiology, 52:1-142.
2. ACCP Valvular and Structural Heart Disease Evidence-Based Clinical Guidelines, 8e (2008). Chest, 133(6).
3. Sellke: Sabiston and Spencer's Surgery of the Chest, 8e. Chapter 78: Acquired Disease of the Mitral Valve.
(MDConsult)
4. Hanson, I., Afonso, L.C., (2010). Mitral Regurgitation. eMedicine.