Surgery of Acquired Heart Defects

1. Surgery of Acquired Heart Defects

2. Definition of AHD Abnormalities of heart morphology (especially valves) acquired during extraembryonic life due to pathologic processes and adversely affecting hemodynamics.

3. Anatomy of Heart

4. Anatomy of valves

5. Normal and Diseased Valves

6. Anatomy of mitral valve

7. Anatomy of Mitral Valve

8. Anatomy of Mitral Valve

9. Anatomy of aortic valve

10. Anatomy of aortic valve

11. Anatomy of aortic valve

12. Division of AHD • BACKGROUND Organic - Non-organic (relative) • SITE Mitral – Aortic - Tricuspid –Pulmonary • HEMODYNAMICS Stenosis – Insufficiency- complex • Clinical COURSE Chronic - Acute

13. Etiology • Ischemic (mitral insufficiency) • Rheumatic (mitral stenosis) • Degenerative • Mucoid degeneration (mitral insufficiency) • Calcific degeneration (aortic stenosis) • Infective (valvular insufficiency)

14. Ischemic mitral insufficiencycurrently one of the most prevalent AHD • Acute – complication of AMI (rupture of pappilary muscle) -> cardiogenic shock / pulmonary edema (fatal in most of cases) • Chronic – restrictive type of mitral insufficiency caused by LV remodeling after myocardial infarction or due to chronic ischemia SCHOULD BE CORRECTED BY REPAIR (RIGID RING)

15. Rheumatic mitral stenosis – classic AHD with decreasing prevalence • Two times more prevalent in women • Self-aggression response to streptococcal antigens • Fibrosis and calcification of valvular endocardium • Nowadays relatively rare (antibiotics) • Correction: commissurotomy or MITRAL VALVE REPLACEMENT

16. Calcified aortic stenosis • The most prevalent AHD in the elderly, especially in men • Sometimes a problem is small diameter of aortic annulus (< 20 mm), especially in women • Correction: AORTIC VALVE REPLACEMENT (BIOPROSTHESIS)

17. Hemodynamics • COMPENSATORY MECHANISMS • Preload increase -> Excentric Hypertrophy of heart chambers • Afterload increase -> Concentric Hypertrophyof heart chambers • DECOMPENSATION • Decrease of cardiac output • Pulmonary and systemic congestion • Hypoxia • Congestive Heart Failure(CHF)

18. NEUROHORMONAL RESPONSE Sympathetic system (epinephrine) RAA mechanism (renin, aldosterone, angiotensin) AVP, cytokines (endothelin, interleukins) EFFECTS Retention of salt and water Heart remodeling (apoptosis) Catabolism Cachexy Multi-organ insufficiency Congestive Heart Failure

19. Complications of AHD • Arrhythmias (atrial fibrillation, ExV etc.) • Thrombo-embolic events (e.g. cerebral embolism with neurological dysfunctions) • Infective endocarditis

20. Diagnostics • History and physical examination • ECG, chest X-ray • ECHOCARDIOGRAPHY • Invasive examination (heart catheterization) • Blood culture

21. HISTORY: - dyspnea (NYHA I-IV) angina (CCS I-IV) edema syncope palpitation fever history of stroke PHYSICAL EXAMINATION - heart murmur arrhythmia symptoms of heart failure neurological dysfunction Medical examination

22. ECG Heart axis abnormalities p mitrale/pulmonale Atrial fibrillation ST segment negative T wave CHEST X-RAY cardiomegaly Valvular calcifications features of pulmonary congestion Pleural effusion Routine additional examinations

23. ECHOCARDIOGRAPHY • Diameters of heart chambers, heart walls thickness • Valvular morphology (calcifications, fibrosis) area of valvular ostia (cm2) • DOPPLER: valvular gradients (mmHg), degree ofregurgitation (I-IV), pulmonary pressure • LV systolic function: global (ejection fraction LVEF), regional • Intracardiac pathologies (thrombi, vegetations) • hydropericardium

24. Coronary Angiography indications in AHD before surgery • Angina or/and history of myocardial infarction • At least one risk factor of CAD e.g. age over 40 years • Ischemic etiology of a defect (mitral regurgitation) If significant lesions in coronary arteries are found the patient should undergo preoperative PCI or have CABG performed together with valvular procedure

25. Mitral Stenosis -symptoms • HISTORY: increasing dyspnea, palpitation, fatigue, cyanosis, often history of rheumatic feveror embolic events • PHYS: loud 1st heartsound, mitral diastolic murmur, arrhythmia, edema, hepatomegaly • ECG: Features of RV overload, p mitrale, often AF • X-RAY: hypertrophy of RV and LA, pulmonary congestion • ECHO: low mitral valve area, enlarged LA and RV, pulmonary hypertension >30 mmHg

26. Mitral insufficiency-symptoms • HISTORY: dyspnea, fatigue, often history of myocardial infarction • PHYS: mitral systolic murmur, arrhythmia • ECG: p mitrale, often AF, LV overload • X-RAY: left heart hypertrophy, pulmonary congestion • ECHO: enlarged LA and LV, mitral regurgitation

27. Aortic stenosis-symptoms • HISTORY: often asymptomatic, later dyspnea, angina and syncope, sudden death • PHYS: aortic systolic murmur • ECG: features of left ventricular overloadand hypertrophy • X-RAY: „aortic” heart silhouette • ECHO: concentric LV hypertrophy, high aortic systolic gradient

28. Aortic insufficiency - symptoms • HISTORY: dyspnea, angina • PHYS: aortic diastolic murmur, high and tense pulse • ECG: features of LV hypertrophy • X-RAY: „aortic” heart silhouette • ECHO: enlargement of LA and LV, aortic regurgitation

29. Indications for Surgery in AHDStrategy • Optimal timing (too early – increased risk of accumulation of long-term outcomes, too late – worse results due to irreversible cardiomyopathy (remodeling) and CHF • Method of correction (to repair or to replace? If replace, what kind of prosthesis should be used?) • Indications to other procedures (e.g. CABG, surgery of aorta etc.) may accelerate a decision of AHD correction so that it could be performed simultaneously

30. Aortic stenosis – indications for surgery • Symptomatic (dyspnea, angina, syncope) patients with severe aortic stenosis (gradient > 50 mmHg in ECHO) • Patients with moderate to severe aortic stenosis (gradient > 30 mmHg) referred to other cardiac surgery e.g. CABG • Asymptomatic patients with severe aortic stenosis and impaired LV function (EF<50%)

31. Aortic regurgitation– indications for surgery • Symptomatic patients (NYHA class II-IV) with severe aortic regurgitation (III-IV degree in ECHO) and LV diastolic diameter (LVdD) > 6,0 cm • Regardless to symptoms, patients with severe aortic regurgitation if: • LVEF <50% or LVdD > 7,5 cm • Referred to other cardiac surgery

32. Mitral stenosis – indications for surgery • Symptomatic patients (NYHA class II-IV) with moderate to severe mitral stenosis – mitral valve area (MVA) <1,5 cm2 • Regardless to symptoms, patients with severe stenosis (MVA < 1 cm2) and severe pulmonary hypertension (>60 mmHg)

33. Mitral insufficiency – indications to surgery • Symptomatic patients (NYHA class II-IV) with significant mitral regurgitation (III-IV degree in ECHO) and LV hypertrophy > 6 cm • Regardless to symptoms, patients with significant mitral regurgitation if: • EF<60% • Atrial fibrillation • Pulmonary hypertension > 50 mm Hg

34. Tricuspid insufficiency – indications for surgery (usuallyannuloplasty) Patients referred to other valvular procedures (usually mitral), with severe tricuspid regurgitation (III-IV degree in ECHO), pulmonary hypertension and enlarged right atrium

35. Patient’s preparation to scheduled correction of AHD • Optimal medical treatment (digitalis, diuretics, ACE inhibitors, beta-blockers) • Cure or remission of co-morbidities that can effect outcomes (e.g. peptic ulcer, inflammatory foci) • Red cells concentrate – 2 units (autotransfussion, family donation)

36. Almost every surgical correction of AHD requires use of CARDIO-PULMONARY BY-PASS (CPB)

37. Scheme of CPB

38. Types of Cannulation for CPB aorto-caval with two-stage atrial cannula (CABG, AVR) Bicaval (MVR, tricuspid) Direct bicaval with right angled venous cannula Antegrade cardioplegia cannula with root vent Retrograde cardioplegia cannula

39. AHD - choice of correction method

40. REPAIR (PLASTY) Should be always considered if possible in mitral and tricuspid insufficiency Method of choice in ischemic mitral insuff. The most physiological AHD correction No need for anticoagulation REPLACEMENTcalcified mitral and aortic stenosis infective endocarditis If no chance for effective repair (excessive valve damage) in insufficiency Inexperienced surgeon No intraoperative TEE available Repair or Replace the valve?

41. Mechanical valve prostheses

42. ADVANTAGES- high durability- easy to implant- widely available- easy to store DISADVANTAGES- necessity of lifelong anticoagulation- less physiological- higher gradients Characteristics of mechanical prostheses

43. Preferences in choice of mechanical valve bileaflet

45. Biological valve prostheses

46. Bioprosthesis (Carpantier-Edwards)

48. ADVANTAGES - more physiologicalflow- lower gradient (especially stentless)- no need for anticoagulation (unless AF) DISADVANTAGES- lower durability (calcification)- more difficult to implant (esp. stentless)- troublesome for storage (esp. homografts) Characteristics of biological valves

49. MECHANICAL Previously implanted mechanical valve in other position Chronic renal failure ondialysis Necessity of anticoagulation for other reasons BIOLOGICAL Counter-indications for anticoagulation Age over 65 years Women in reproductive age Choice of prosthesis

50. Surgery of Mitral and Tricuspid Valves