Mitral Valve Surgery

dr Sihar Deddy K Siahaan

Outline
Anatomi Mitral
Patofisiologi
Etiologi Mitral Valve Disease
Diagnostik
Rekomendasi Surgical pada katub Mitral
Stenosis dan Regurgitasi
Pendekatan bedah dalam operasi Mitral
Valve surgery
Tehnik Bedah Katub mitral
Journal
Anatomi Mitral Valve
Slide arthur Hill,,Departement
Cardiothoracic Surgery San
Pathophysiology of TRIAD

Etiology--The cause of disease

Lesion--result from the disease

Dysfunction-- Result from the lesion

 Patofisiologi Mitral Regurgitasi
Mitral regurgitation

Systolic (Retrograde) ejection into LA

Acute Chronic

Volume overload in LA & LV ed LVafterload (into LA)

ed LA, LV Pressure ed LA/LV size/ compliance

Pulmonary edema ed Cardiac output LA dilatation ed contractility

AF CO
Pulmonary congestion
 Rheumatic fever involving mitral valves

Valve leaflet thickening and fusion of commissures

Increased rigidity of valve leaflets

Thickening, fusion and contracture of chordae & papillary heads

Leaflet calcification (long standing MS)

Progressive reduction in
mitral valve orifice area

Mitral Stenosis
 Pathophysiology Mitral Stenosis
Obstruction

Increased left atrial pressure Maintains LV Cardiac Output

Increased pulmonary venous

Exertional dyspnea
and capillary pressures

Reflex pulmonary arteriolar Decreasing the amount of blood

constriction flowing through the lungs which
lessens the likelihood of pulmonary
Pulmonary Hypertension edema

Right Ventricular Hypertrophy

RV Failure
 Mitral Valve Disease: Etiology
Mitral Stenosis
Rheumatic - 99.9%
Congenital
Prosthetic valve stenosis
Mitral Annular Calcification
Left Atrial Myxoma
Acute Mitral Regurgitation
Infective endocarditis
Ischemic Heart disease
Papillary ms rupture
Mitral valve prolapse
Chordal rupture
Chest trauma
Chronic Mitral
Regurgitation
Ischemic Heart disease
Papillary ms dysfunction
Inferior & posterior MI
Mitral Valve prolapse
Infective endocarditis
Rheumatic
Prosthetic
Mitral annular calcification
Cardiomyopathy
LV dilatation
Diagnostik Test
Echocardiografy :
Menilai valve area gradient
Degree of mitral insufficiency
Pembesaran left atrium
Mengkaji tingkat calcifikasi pada anulus
Menilai tekanan pulmonal
Evaluasi fungsi ventrikel
Cardiac chateterization :
Coronary angiography
Evaluasi jantung kanan dan tekanan pulmonal
Elektrocardiography:
P mitral
Deviasi axis ke kanan
AF
Chest Radiology:
pembesaran LA
vascularisasi meningkat
Mitral Valve Disease

Mitral Stenosis
Thickened, deformed MV
leaflets
2D MVA
Doppler Gradient
Associated RVH, PHTN,
TR,MR, LV function
vegetations
Mitral Regurgitation
Determine etiology
leaflets, chordae, MVP, MI
Doppler severity of MR jet
LV function
Video Echo Mitral Valve
Normal Flail
Wilkins Score

Bonowet al, ACC/AHA Guideline

2006
Recommendations for Surgical
Mitral Valve Repair for Mitral Stenosis
Class I
1. Patients with NYHA functional class III to IV symptoms, moderate or severe
MS (MVA 1.5 cm2),*and valve morphology favorable for repair if PMBV is
not available.
2. Patients with NYHA functional class III to IV symptoms, moderate or severe
MS (MVA 1.5 cm2),*and valve morphology favorable for repair if a left atrial
thrombus is present despite anticoagulation.
3. Patients with NYHA functional class III to IV symptoms, moderate or severe
MS (MVA 1.5 cm2),*and a nonpliable or calcified valve, with the decision to
proceed with either repair or replacement made at the time of surgery.
Class IIb Patients in NYHA functional class I, with moderate or severe MS
(MVA 1.5 cm2)* and valve morphology favorable for repair who have had
recurrent embolic events while on adequate anticoagulation.
Class III Patients with NYHA functional class II to IV symptoms and mild MS.

Management of Patients with

Valvular Heart Disease,AHA/ACC
Recommendations for Mitral Valve
Replacement for Mitral Stenosis
Class I Patients with moderate or severe MS
(MVA1.5 cm2)* and NYHA functional class III to
IV symptoms who are not considered candidates
for PMBV or mitral valve repair.
Class IIa Patients with severe MS (MVA 1
cm2)* and severe pulmonary hypertension (PA
systolic pressure >60 to 80 mm Hg) with NYHA
functional class I to II symptoms who are not
considered candidates for PMBV or mitral valve
repair

Management of Patients with

Valvular Heart Disease,AHA/ACC
 Recommendations for Mitral Valve Surgery
in Nonischemic Severe Mitral Regurgitation

Class I
1. Acute symptomatic MR for which repair is likely.
2. Patients with NYHA functional class II, III, or IV symptoms with normal LV function defined as EF >0.60 and
ESD <45 mm.
3. Symptomatic or asymptomatic patients with mild LV dysfunction, EF 0.50 to 0.60, and ESD 45 to 50 mm.
4. Symptomatic or asymptomatic patients with moderate LV dysfunction, EF 0.30 to 0.50, and/or ESD 50 to 55
mm.
Class IIa
1. Asymptomatic patients with preserved LV function and atrial fibrillation.
2. Asymptomatic patients with preserved LV function and pulmonary hypertension (PA systolic
pressure >50 mm Hg at rest or >60 mm Hg with exercise).
3. Asymptomatic patients with EF 0.50 to 0.60 and ESD <45 mm and those with EF >0.60 and ESD 45 to 55
mm.
4. Patients with severe LV dysfunction (EF <0.30 and/or ESD >55 mm) in whom chordal preservation is highly
likely.
Class IIb
1. Asymptomatic patients with chronic MR with preserved LV function for whom mitral valve repair is highly
likely.
2. Patients with MVP and preserved LV function who have recurrent ventricular arrhythmias despite medical
therapy.
Class III Asymptomatic patients with preserved LV function for whom significant doubt exists about the
feasibility of repair. Management of Patients with Valvular Heart
Disease,AHA/ACC guideline,Robert Bonow
Recommendations for Valve
Replacement With a Mechanical Prosthesis

Class I
1. Patients with an expected long life span.
2. Patients with a mechanical prosthetic valve already in place in a
position different from that of the valve to be replaced.
Class IIa
1. Patients in renal failure, on hemodialysis, or with hypercalcemia.
2. Patients requiring warfarin therapy because of risk factors* for
thromboembolism.
3. Patients 65 years for AVR and 70 years for MVR.
Class IIb
Valve rereplacement for biological valve with thrombosis.
Class III
Patients who cannot or will not take warfarin therapy

Management of Patients with

Valvular Heart Disease,AHA/ACC
Recommendations for
Valve Replacement With a Bioprosthesis

Class I
1. Patients who cannot or will not take warfarin therapy.
2. Patients 65 years of age* who need AVR and do not have risk factors for
thromboembolism.
Class IIa
1. Patients considered to have possible compliance problems with warfarin
therapy.
2. Patients >70 years of age* who need MVR and do not have risk factors for
thromboembolism.
Class IIb
1. Valve rereplacement for mechanical valve withthrombosis.
2. Patients <65 years of age.*
Class III
1. Patients in renal failure, on hemodialysis, or with hypercalcemia.
2. Adolescent patients who are still growing
Management of Patients with
Valvular Heart Disease,AHA/ACC
 Mitral Valve Repair vs. Replacement

Cleveland Clinic surgeons performed 1,164 mitral valve procedures

in 2005; 69% were valve repairs.
 Conclusion : mitral valve repair is clearly
superior to MV replacement

lower operative risk

better preservation of ventricular function
lower risk of thromboembolic complications
less need for anticoagulation
improved hemodynamic performance
lower risk for endocarditis
better long-term survival
lower costs
 Guideline Management Valvular
Heart Disease, ESC/EACTS 2012


Guideline Management Valvular

Heart Disease, ESC/EACTS 2012
Algoritme Mitral Stenosis
Mohammed AlOsaimi
Surgical approach to the Mitral
Valve
Convensional :
Median Sternotomi
Minimal Invasiv
Torakotomi
Partial sternotomi
Video assisted
Robotic Da Vinci
Mitral Valve Exposure
Valve exposure
Excellent exposure is
key performing
successful MV
exploration and repair
Superior-septal
incision
 Right atriotomy is
across the atrial
appendage and
extends inferiorly
parallel to and near
the AV groove
 The incision is extended
medially and superiorly
as well.
The LA is opened in the
fossa ovalis superiorly
and vertically across the
atrial septum until it join
the RA incision.
Extends onto the superior
dome of the LA and
underneath the
ascending aorta.
Animasi Right Toracotomy
approach for Mitral Valve Surgery
 Prinsip of Mitral Valve Surgery
1. Perioperative mangement
2. Surgical Incisions and CPB
3. Mitral Valve Exposure and Intraoperative
valve analysis

Principles of reconstructive surgery in degenarative

mitral valve disease. Farzan
filsoufi,Carpintier,Thoracic and cardiovascular surg
19:103-110,2007
Valve Repair in Type I
Dysfunction
Annular dilatation : annuloplasty
Leaflet perforation : endocarditis
debridement patch pericardium
Valve Repair in Type II
Dysfunction
Posterior leaflet Prolaps :
quadrangular resection plication
posterior annulus direct suture of
the leaflet
Barlows disease quadrangular
resection sliding leaflet, P1 & P3
detached compression suture at
post. Annulus gap closed
interrupted sutures
 Anterior Leaflet Prolapse

Triangular Resection

Chordal Transfer : secondary position to the free margin of

anterior leaflet.

Chordal transposition : absence of normal secondary

chordae, marginal chordae of posterior segment apposite to
the prolapsed area

Artificial Chordoplasty : distance between the base of PM &

free margin leaflet Gore-Tex suture.

PM Sliding Plasty : elongation of multiple chordae from a PM

PM Shortening
 Valve Repair in Type IIIA
Dysfunction
Correction achieved by treating each type of
lesion : Leaflet restriction : chordal thickening,
retraction, fusion.
Thickening Resection secondary chordae
Fusion chordal fenestration.
Retraction pericardial patch enlargement.

Valve Repair in Type IIIB Dysfunction

Ringannuloplasty
Reconstructive Valve Surgery,
Carpentier, Adams,Filsoufi
Placing Sutures within the annulus

Reconstructive Valve Surgery,

Carpentier, Adams,Filsoufi
Placing Sutures within the annulus

Reconstructive Valve Surgery,

Carpentier, Adams,Filsoufi
Placing Sutures within the annulus

Reconstructive Valve Surgery,

Carpentier, Adams,Filsoufi
Lesi Anulus-Abses dan debridement

Reconstructive Valve
Surgery, Carpentier,
Triangular resection

Reconstructive Valve Surgery,

Carpentier, Adams,Filsoufi
Anterior leaflet transposition

Reconstructive Valve Surgery,

Carpentier, Adams,Filsoufi
Posterior leaflet transposition

Reconstructive Valve Surgery,

Carpentier, Adams,Filsoufi
Artificial chordae

Reconstructive Valve Surgery,

Carpentier, Adams,Filsoufi
Papilary muscle sliding Plasty

Reconstructive Valve Surgery,

Carpentier, Adams,Filsoufi
Chordae shortening

Reconstructive Valve Surgery,

Carpentier, Adams,Filsoufi
Papillary muscle ruptur

Reconstructive Valve Surgery,

Carpentier, Adams,Filsoufi
Papillary muscle elongation

Reconstructive Valve Surgery,

Carpentier, Adams,Filsoufi
Posterior leaflet prolaps
Quadrangular resection w/ annular plication

Reconstructive Valve Surgery,

Carpentier, Adams,Filsoufi
 Quadrangular resection w/ leaflet height adjustment

Reconstructive Valve Surgery,

Carpentier, Adams,Filsoufi
Technique in Type II commisural
and bileaflet prolapse

Reconstructive Valve Surgery,

Carpentier, Adams,Filsoufi
Commisural fusion : Commissurotomy
Thank You