Corso Integrato di medicina d’urgenza, terapia intensiva e infermieristica clinica applicata

1. Corso Integrato di medicina d’urgenza, terapia intensiva e infermieristica clinica applicata Lezioni di Cardiochirurgia Valvulopatie

2. Valvulopatia Mitralica

3. Anatomy and Pathology 1. Crucial to understand the anatomy of the mitral valve in order or perform valve repair/surgery 2. Mitral valve is composed of five separate components: a. valvular leaflets b. annulus c. chordae tendinae d. papillary muscles e. left ventricular wall

5. Pathology • Rheumatic Disease • Myxomatous Degeneration • Ischemic Valvulopaty • Endocarditis

6. Rheumatic mitral stenosis

7. Bacterial endocarditis on A2

8. MS: Indications for Operation 1. asymptomatic patients are generally not recommended for operation 2. patients with severe mitral stenosis should undergo operation a. normal orifice is 4-6 cm2 b. 2-4 cm2 is mild c. 1-2cm2 is moderate d. < 1 cm2 is severe

9. MR: Indications for Operation • Acute symptomatic MR • Symptomatic or Asymptomatic Patients with LV Dysfunction: •  TypeEFSystolic Dimension • Mild0.5-0.640-50 mm • Moderate0.3-0.550-55 mm • Severe<0.3>55 mm • (LV dysfunction will persist, symptoms diminish, risk increase) • Asymptomatic patients with atrial fibrillation or pulmonary hypertension (PAPm = >50 mmHg at rest, >60 mmHg exercise)

10. Surgical Options • Valve replacement • Mortality 2-7% • Anticoagulation • Decrease LV EF • Valve Repair (always preferable – feasible in 70-90% of pts) • Mortality 2-3% • No anticoagulation • Preservation of LV EF

11. The Perfect Valve • Excellent hemodynamics • Non-thrombogenic • Durable • Unrestricted availability • Easily implantable • Silent function • Low cost

12. Replacement Devices • Mechanical valves • Caged-ball • Monoleaflet • Bileaflet • Bioprostheses • Stented • Porcine • Pericardial • Stentless • Porcine • Bovine Pericardial • Homograft • Autograft

13. Braunwald Polyurethane mitral valve. First mitral valve replacement on March 11, 1960. Teflon chordae brought through the ventricular muscle and secured outside the heart Kay Mitral Valve.Teflon mitral valve prosthesis with artificial chordae.Implanted 1959 Original Starr-Edwards Mitral Valve. Lucite cage. Silastic rubber ball occluder. Implanted 1960. Harken double cage ball valve. Implanted in 1960

14. St Jude heart valve. The most popular bileaflet mechanical valve. First implant 1977. Pyrolytic carbon leaflets and housing. Tungsten impregna-ted leaflets. Modifications: low profile sewing cuff, and rotatable housing St Jude Quattro tissue valve.  Investigational stentless quadracuspid tissue valve for mitral valve replacement. Bovine pericardium. Carpentier-Edwards Perimount Mitral valve. Bovine pericardial tissue valve with Eligloy stent."Stress-free" fixation. Lower profile mitral tissue prosthesis. Mitral Homograft

15. Flow characteristics • ball/cage < tilting dic < bileaflet • Thrombogenic potential • ball/cage > tilting disc > bileaflet • Aortic < Mitral < both

16. Anticoagulation Management (Machanical Prosthesis) • TIA is most common event • Standardization of coagulation management (INR) • Narrow therapeutic range: balance between thrombolic and bleeding risk • ACCP recommendations: INR 2.5-3.5 • Aortic: 2.5-3.0 • Mitral: 3.0-3.5 • Both: 3.5-4.0 • Appropriate use of antiplatelet therapy

17. Mechanism of mitral insufficiency (Carpentier Classification) Type I (normal leaflet motion) Type II (leaflet prolapse)  Posterior leaflet  Anterior leaflet  Both leaflets Type III (restricted leaflet motion)

18. Leaflet Prolapse (II): an excessive motion of a leaflet overriding the plane of the annulus in systole • Leaflet Restriction (III): an incomplete closure of a leaflet remaining beneath the plane of the annulus in systole

19. Tecniche Riparative Mitraliche • Riparazioni Anatomiche • Annulus • Lembi • Corde Tendinee • Muscoli Papillari • Riparazioni Funzionali

20. The Quadrangular Resection

22. Chordae Tendinae SHORTENING REPLACEMENT TRANSFER

23. Galloway concludes, "The core concepts are: fix the leaflet pathology and remodel the annulus and you'll have a competent valve."

24. Edge-To-Edge technique

26. Valvulopatia Aortica

27. Anatomy and Pathology 1. Crucial to understand the anatomy of the aortic valve in order or perform valve repair/surgery 2. Aortic valve is composed of five separate components: a. valvular cusps b. annulus c. Valsalva’s sinus d. sinus-tubular junction e. Aortic root

28. Positions of the aortic valve leaflets at end-diastole and end-systole and of a single leaflet in profile during ejection as the leaflet moves from the closed position (0) to full opening. Note how the fully opened leaflet tends to produce a unifom diameter above the ventricular-arterial junction to reduce turbulence that otherwise would be increased by the sinuses of Valsalva.

30. Pathology • Congenital Malformation • Rheumatic Disease • Degeneration • Endocarditis

31. Congenital Malformation Quadricuspid aortic(Ao)valve and unicuspid pulmonary (P)valve. The asterisk indicates the additional (fourth) leaflet of the aortic valve. Native aortic valve demonstrating fusion of the anterior commissure between the left and noncoronary cusps. A small thrombus is present on the right lunula of the left cusp.

32. Calcified Aortic Stenosis (Congenital Malformation) • Congenitally bicuspid or unicuspid, fused commissures, • heavy calcification, age 50-70

33. Rheumatic Aortic lesions • Fibrous thickening, • 3-cusp valve, • mild calcification, • rheumatic fever history in 50% aortic steno-insufficiency

34. Degeneration • Diffuse nodular calcification, • 3-cusp valve, • no commissural fusion Macroscopic appearance of healed, fibrous commissural fusion between left coronary cusp (right, held by forceps) and noncoronary (left) cusp of aortic valve

35. Endocarditis • Infective endocarditis is defined as an infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium, or a septal defect. Endocarditis can be broken down into the following categories: • Native valve (acute and subacute) endocarditis • Prosthetic valve (early and late) endocarditis • Endocarditis related to intravenous drug use

36. Parasternal short-axis view and its schematic drawing with color flow imaging from patient 1, showing perforation of the noncoronary cusp (N) of the aortic valve and aortic regurgitation (AR) after patch repair of an ostium primum atrial septal defect.

37. AS: Indications for operation • Symptomatic Aortic Stenosis • CHF • Angina Pectoris • Syncope • Hemodinamic severity (ecocolorDoppler) • ∆P ≥ 50 mmHg • Aortic Valve Area ≤ 0.75 cm2 or AVAi ≤ 0.4 cm2/m2 • Asymptomatic aortic stenosis – Hemodynamic severity with • Progressive LV enlargement • Decline of LV EF

38. Aortic Incompetence · Cusp prolapse or cicatricial shortening of cusps with rolled edges · Annulo-aortic ectasia is a disease of the aorta rather than the valve itself · Dilation of sinus aorta, cystic medial necrosis, failure of coaptation of cusps

39. AI: Indications for Operation • Symptomatic Aortic Incompetence • Asymptomatic aortic regurgitation – Hemodynamic severity with • Progressive LV enlargement • Decline of LV EF • Hemodinamic severity (ecocolorDoppler) • LVEDD > 80 mm, LVESD > 55 mm, LVEF < 50%

40. Aortic valve excision.

41. Mechanical prosthesis implantation.

45. AORTIC HOMOGRAFT

46. Homograft implantation: the “root” technique

47. Pulmonary Autograft (Ross Procedure- 1967) • Advantages • Viable tissue, excellent hemodynamics • Near 0% thromboembolism, growth potential • Non-antigenic • Pulmonary valve equal in strength as aortic valve • Disadvantage • Creating 2-way valve pathology from single valve disease • Results • Freedom from re-operation 81% at 8 years • 5-10% annular dilatation and regurgitation • Pulmonary homograft deterioration • Technique • Root replacement preferred • Tailoring of aortic/pulmonary size mismatch • Bolstering ring with Dacron strip • Long-term follow-up still accruing

48. The Ross Operation

49. Mechanical valved conduit implantation. A. The valve and proximal conduit are sutured to the annulus with everting, pledgeted mattress sutures. B. If necessary, the distal aortic layers are oversewn. C. A proximal coronary button is sutured to a hole made in the prosthesis. D. Completed graft with both coronary arterial buttons attached and the distal anastomosis finished.

50. Reimplantation of the aortic valve in patients with annuloaortic ectasia and aortic root aneurysm. (Reproduced with permission from David TE, Feindel CM, Bos J. Repair of the aortic valve in patients with aortic insufficiency and aortic root aneurysm. J Thorac Cardiovasc Surg 1995;109:345–52.)