Mitral Valve Surgery (eBook)

Mitral Valve Surgery 2
Copyright page 3
Series Preface 4
Contents 6
Contributors 8
Part I Anatomy, Pathology, and Natural Historyof Mitral Valve Disease 10
1: Surgical Anatomy of the Mitral and Tricuspid Valve 11
Introduction 11
Fibrous Skeleton of the Heart 11
Mitral Valve: The Functional Unit 13
The Structure of the Functional Unit 13
Mitral Valve Annulus 14
Mitral Valve Leaflets 15
Mitral Valve Chordae Tendinae 17
Mitral Valve Papillary Muscles 18
Physiology of the Functional Unit 18
Mitral Valve Annular Dynamics 18
Mitral Valve Leaflet Physiology 19
Mitral Valve Papillary Muscles 20
Left Ventricular Muscle 20
Summary of the Impact of Mitral Valve Physiology 20
Mitral Valve Functional Unit Co-location: Surgical Considerations 21
Tricuspid Valve: The Functional Unit 21
The Structure of the Functional Unit 21
Tricuspid Valve Annulus 22
Tricuspid Valve Leaflets 23
Tricuspid Valve Chordae Tendinae 24
Tricuspid Valve Papillary Muscles 24
Physiology of the Functional Unit 24
Tricuspid Valve Annular Dynamics 24
Tricuspid Valve Leaflet Physiology 25
Tricuspid Valve Papillary Muscle Physiology 25
Tricuspid Valve Functional Unit Co-location: Surgical Considerations 25
Right Coronary Artery 25
Conduction Tissue 25
Aortic and Mitral Valve 26
Summary 26
References 26
2: Pathology and Classification of Mitral Valve Disease 28
Introduction 28
Mitral Stenosis 28
Rheumatic Mitral Stenosis 28
Mitral Annular Calcification 29
Immune Mediated Mitral Stenosis 29
Carcinoid Heart Disease and Drug Induced Valvular Heart Disease 29
Congenital Mitral Valve Stenosis 30
Pathophysiology of Mitral Stenosis 30
Mitral Regurgitation 31
Ischemic and Functional Mitral Regurgitation 32
Mitral Valve Prolapse 32
Rheumatic Mitral Regurgitation 33
Mitral Annular Calcification 33
Infective Endocarditis 33
Congenital Mitral Regurgitation 34
Pathophysiology of the Mitral Valve Regurgitation 34
Prosthetic Heart Valves 34
Prosthetic Valve Endocarditis 35
Structural Dysfunction 35
Nonstructural Dysfunction 35
References 35
3: Chronic Mitral Regurgitation 37
Anatomy of the Mitral Valve Apparatus 37
Mechanisms of Chronic Mitral Regurgitation 38
Pathophysiology 39
Determinants of Regurgitant Volume 39
LV Mechanics in MR 39
LV Compensation 39
LV Decompensation 40
Epidemiology 40
Symptoms 40
Physical Examination 41
Laboratory Investigations 41
Electrocardiography 41
Chest Roentgenogram 41
Echocardiography 41
Etiology 42
Repairability 44
Cardiac Catheterization 44
Natural History 44
Indications for Mitral Valve Surgery 44
Surgical Considerations 46
References 46
4: Chronic Ischemic Mitral Regurgitation 49
Introduction 49
Prevalence and Prognostic Impact 49
Mechanisms of Ischemic MR 49
Impaired Contractile Function 50
Increased Leaflet Tethering 50
Annular Dilatation 51
Dynamic Nature of Ischemic MR 52
Evaluation of Patients with Ischemic MR 53
Echocardiography 53
Stress Echocardiography 53
Magnetic Resonance Imaging 54
Coronary Angiography 54
Management of Patients with Ischemic MR 54
Myocardial Revascularization 54
Cardiac Resynchronization Therapy 54
Medical Treatment 54
Surgical Approaches 55
Mitral Valve (MV)Repair 55
Mitral Valve Replacement 55
Indications for Mitral Valve Surgery 55
References 55
5: Asymptomatic Mitral Valve Regurgitation: Watchful Wait or Early Repair? Review of the Current Evidence 58
Introduction 58
Severe Mitral Regurgitation 58
Existing Guidelines 58
Current State of Valve Repair 59
What Is the Outcome of Patients with Asymptomatic Severe Mitral Regurgitation? 59
Echocardiographic Assessment 60
Severity of Mitral Regurgitation 60
Etiology and Mechanism 61
Left Ventricular Function 61
Other Abnormalities 61
The Place of Exercise Testing and Exercise Echocardiography 61
Frequency of Review 62
Studies on Improving Mitral Services 62
IS There a Need for a Randomized Study? 62
References 63
Part II Mitral Valve Repair and ReplacementTechniques 64
6: Mitral Valve Prosthesis Insertion with Preservation of the Sub-Valvar Apparatus 65
Introduction 65
Surgical Strategies for Preservation of the Atrio-Ventricular Loop During Insertion of a Mitral Prosthesis 67
Surgical Techniques 67
Annular Calcification 69
References 71
7: How I Assess and Repair the Barlow Mitral Valve: The Respect Rather Than Resect Approach 72
Definition 72
Valve Assessment 73
Echocardiographic Analysis 73
Surgical Valve Analysis 73
Free Edge Mobility 73
Excess of Tissue 74
Mucoid Degeneration 74
Surgical Strategy 74
Repair of the Posterior Leaflet 76
Leaflet Mobility 76
The Goal of a Smooth and Vertical Surface of Coaptation 77
Intermediary Surgical Test 77
Repair of the Anterior Leaflet 77
Ring Annuloplasty 77
Control of the Result 78
Surgical Control 78
Echocardiographic Control 78
References 79
8: How I Assess and Repair the Barlow Mitral Valve: The Edge-to-Edge Technique 80
Introduction 80
The Edge-to-Edge Technique for Bileaflet Prolapse in Barlow’s Disease 80
Surgical Technique and Results 81
The Edge-to-Edge Technique for Anterior Leaflet Prolapse 84
The Edge-to-Edge Technique for Commissural Prolapse 84
The Minimally Invasive Approach Option 85
Edge-to-Edge Repair and Annuloplasty 85
Double Orifice Edge-to-Edge Repair and Hemodynamics 86
Edge-to-Edge Repair and the Risk of Functional Mitral Stenosis 86
References 87
9: How I Assess and Repair the Barlow Mitral Valve 88
Valve Assessment 91
Surgical Exposure 93
Strategies for Surgical Repair 94
References 98
10: Ischemic Mitral Regurgitation 99
Introduction 99
Definitions and Mechanisms 99
Consequences of Ischemic Mitral Regurgitation 99
Surgical Treatment of Ischemic Mitral Regurgitation 101
Alternative Surgical Strategies 102
Outcome of Surgical Treatment 102
References 104
11: Minimally Invasive Mitral Valve Surgery 106
Introduction 106
Minimally Invasive Surgical Approaches 106
Right Mini-Thoracotomy 106
Robotically Assisted Right Thoracic Approach 109
Partial Sternotomy 109
Minimally Invasive Approaches: Comparison of Technical Considerations and Patient Selection 109
Results of Minimally Invasive Mitral Valve Surgery 110
Valve Repair 110
Mortality and Morbidity 110
Benefits of Minimally Invasive Mitral Valve Surgery 111
Cosmesis 111
Postoperative Pain 112
Hospital Length of Stay and Recovery 112
Transfusion 112
Wound Infection 112
Cost 112
Benefits: Summary 113
Repair Techniques 113
Posterior Prolapse 113
Triangular Resection 113
Folding Plasty 113
Anterior Prolapse 113
Commissural Prolapse 114
Recommendations 114
Future Directions 114
References 114
12: Mitral Stenosis 117
Etiology and Epidemiology 117
Pathology and Pathophysiology 117
Natural History 119
Clinical Features 120
Physical Exam and Diagnostic Tests 120
Electrocardiography 121
Chest X-Ray 121
Echocardiography 121
Intervention 121
Closed Surgical Commissurotomy 121
Open Surgical Commissurotomy 122
Percutaneous Mitral Balloon Valvuloplasty 123
Indication 125
References 127
Part III Other Conditions 130
13: Atrial Fibrillation: Non Surgical Management 131
Introduction 131
Pathophysiology and Electrophysiology 131
Clinical Classification 132
Pharmacological Agents 132
General Non surgical Management Strategies 133
Rate Control in Acute AF 133
Cardioversion in Acute AF 134
Paroxysmal AF 134
Persistent AF 135
Permanent AF 137
Nonpharmacological Treatments for AF 137
Antithrombotic Therapy 138
Future Perspectives 138
Conclusion 140
References 140
14: Ablation of Atrial Fibrillation with Cardiac Surgery 142
Introduction 142
Rationale for Surgical Ablation 142
AF Prevalence 142
AF Dangers 142
AF Mechanisms and Implications for Surgical Ablation 143
The Maze Procedure 143
New Approaches to Surgical Ablation of Atrial Fibrillation 145
Lesion Sets 145
A Review of the Available Energy Sources 145
The Left Atrial Appendage 147
Challenges and Future Directions 147
Reporting Results 147
Ablation Technology and Intraoperative Assessment 147
Minimally Invasive Approaches 147
Conclusions 148
References 148
15: Tricuspid Regurgitation: Natural History, Assessment, and Intervention 151
Natural History 151
Clinical Features 152
TR Assessment 152
Surgical Treatment 155
Patients with Annular Dilatation with or Without Regurgitation 157
Patients with Annular Dilatation with Moderate or Severe TR with Some Degree of Tethering 157
Patients with Annular Dilatation with Severe Tethering 157
Conclusion 158
References 158
Index 160