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Mitral Valve Repair Case Study Deborah Jeanne Warner November 10, 2010

Mitral Valve Repair Case Study Deborah Jeanne Warner November 10, 2010. Heart Valves. -Four valves control the direction of blood flow -System of one-way doors assure unidirectional flow through chambers -AV valves control flow of oxygen depleted blood from body to lungs

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Mitral Valve Repair Case Study Deborah Jeanne Warner November 10, 2010

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  1. Mitral Valve Repair Case Study Deborah Jeanne Warner November 10, 2010

  2. Heart Valves -Four valves control the direction of blood flow -System of one-way doorsassure unidirectional flow through chambers -AV valves control flow of oxygen depleted blood from body to lungs -SL valves control flow of oxygen rich blood from lungs to body

  3. The Mitral Valve -Mitral valve: between left atrium & ventricle -Diastole: blood leaves the atria, flows through open mitral valve and into ventricle -Pressure in ventricle increases, closing MV -Prevents blood leaking back into the atrium during systole -Assures the blood in left ventricle will be ejected through aortic valve into aorta to supply oxygenated blood to body

  4. Mitral Valve Anatomy -Annulus: Fibrous ring -Two leaflets: Valvular tissue -Chordae tendineae -Papillary muscles

  5. Mitral Regurgitation -Regurgitation/Insufficiency -Result of incompetent valve-Doesn't close completely -Blood leaks back into atriumduring systole -MR increases the workload of the heart -Complications-Cardiac arrhythmias -CHF-Irreversible heart damage

  6. Causes of MR -Rheumatic fever-Annulus dilatation-Mitral annular calcification-Leaflets that are flail, prolapse and/or stenotic-Endocarditis-Chordae tendineae elongation or rupture-Papillary muscle fibrosis, calcification, or rupture-Prior myocardial infarction-Prosthetic valve dysfunction-Congenital anomalies-Age related wear and tear

  7. Signs and Symptoms Will depend on the severity and cause: -Fatigue-Decreased exercise capacity-Dyspnea-Orthopnea-Supraventricular arrhythmias (Atrial Fib)-Palpitations-Lightheadedness-High pitched systolic murmur

  8. Diagnostic Studies -Transthoracic Echocardiogram -Transesophageal Echocardiogram -Chest X-Ray -EKG -Holter monitor -Cardiac Catheterization

  9. Treatment for Mitral Regurgitation -Surgery is the only proven treatment -Preferred surgery is repair of the native valve -Advantages of MV repair over replacement-Lower mortality at the time of operation -Significantly lower risk of stroke, and lower rate of infection -Improved long term survival -Better preservation of heart function -Blood thinners not required -Same survival curve as normal population -Improved quality of life

  10. Mitral Valve RepairAnnuloplasty -Annuloplasty: Technique that repairs annulus -If annulus is dilated, leaflets unable to coapt -Result is MR -Sutures sewn round ring -Annuloplasty ring provides additional support

  11. Case StudyPatient Information -Age/Gender: 76 year old male -Hospital Admission on 5/27/10 -Current Symptoms: -Dyspnea on exertion

  12. Physical Examination -5/27/2010: -Blood Pressure: 157/86 -Heart Rate: 48 -Respiratory Rate: 16 -Lungs: Clear -Heart: Grade II/VI systolic murmur heard, cardiac sounds and S2 are normal -Abdomen: Soft, non-tender -Extremities: No edema

  13. Patient History -Medical History: -Coronary Artery Disease:1/2009-Stent placed in RCA -Dyslipidemia -Hypertension -Episodes of bradycardia and ventricular ectopy -Mild COPD -Previous echocardiogram (TTE) on 1/21/2009:Preserved systolic function with mild mitral leaflet calcification, moderate mitral regurgitation, left atrium moderately enlarged.

  14. Patient History -Medications at Admission: -Aspirin 325 mg. daily -Lotrel 5/10 one tablet daily -Lipitor 20 mg. daily

  15. Diagnostic StudyTransesophaegeal Echo Findings on 5/28/10:-Left Ventricle: Chamber size, wall motion, contractility and LV function are normal-Left Atrium: Moderately enlarged-Right Ventricle: Chamber size and function normal-Right Atrium: Cavity size is normal-Mitral Valve: Mild mitral leaflet calcification. Severe mitral regurgitation observed. The mitral valve venacontracta is 0.9 cm. No evidence of mitral stenosis.Conclusions: Mitral valve appears repairable and annulus is dilated. MR is severe in several views.

  16. Transesophageal Echo05/28/10

  17. Transesophageal Echo05/28/10

  18. Transesophageal Echo05/28/10

  19. Diagnostic StudiesLeft heart catheterization -Coronary angiogram on 6/9/10: • Left main trunk is normal • Left anterior descending has mild disease of 40% in the mid LAD • Circumflex ostial 50% narrowed followed by 100% occlusion of the circumflex • Right Coronary artery - mild plaquing of 20% in the proximal to mid segment • Conclusion: Mild to Moderate coronary disease

  20. Mitral Valve Repair -Diagnosis: Severe Mitral Regurgitation -6/10/10: Patient had surgery to repair MV -Intraoperative TEE confirmed severe MR -Intraoperative inspection of the mitral valve -Surgical repair of mitral valve via ring annuloplasty was performed. Anterior leaflet sized to a 28 mm St. Jude ring. -Excellent coaptation of the anterior-posterior leaflet upon completion of repair. -Postoperative TEE – no residual MR

  21. Pre and Post Op – TEE06/10/10

  22. Pre and Post Op - TEE06/10/10

  23. Hospital Course -Mitral valve repair with ring annuloplasty -Thoracentesis of right pleural effusion -Burst of atrial fibrillation -Nephrology consult for renal dysfunction -Discharge medications:-Aspirin 325 mg daily (Anti-thrombotic)-Plavix 75 mg daily (Anti-platelet) -Furosemide 40 mg. Daily (Loop diuretic)-Metoprolol 25 mg b.i.d. (Beta Blocker)

  24. Follow-upChest X Ray -08/05/10 -PA and LAT views of chest -Impression:1) There is mild cardiomegaly.2) Overall improvement of the bilateral pulmonary infiltrates most likely related to pneumonia or asymmetric pulmonary edema.3) Stable bilateral pleural effusions.

  25. Follow-up Echo08/05/10 Findings: -Left ventricle chamber size and systolic function are normal. -Moderate bilateral atrial enlargement. -Right ventricle cavity size and systolic function are normal. -Mild aortic leaflet calcification is visualized. -Mitral valve leaflets are mildly thickened. (mitral valve has been repaired previously) There is mild mitral regurgitation observed with no evidence of mitral stenosis.

  26. Follow-up Echo08/05/10 - PLAX

  27. Follow-up Echo08/05/10 – PSAX & MV Zoom

  28. Follow-up Echo08/05/10 – Apical 2C

  29. Follow-up Echo08/05/10 – Apical 4C

  30. Follow-up Echo08/05/10

  31. Before & After MV Repair

  32. References • DeWitt, S. 2009, Echocardiography...From a Sonographer'sPerspective (6th Edition), Camden Printing, St. Marys, GA • Drugs.com, “Prescription Drugs, Information, Interactions and Side Effects.”http://www.drugs.comAccessed 24 October 2010 • MedicineNet.com, “Health and Medical Information.”http://www.medicinenet.comAccessed 24 October 2010 • Wikipedia, “The Free Encyclopedia.”http://www.wikipedia.org/wiki/Mitral_valve; http://wikipedia.org/wiki/File:Heart_short_axis_view_papillary.jpgAccessed 22 October 2010 • Pick, A., “The Patient's Guide to Heart Valve Surgery.”http://www.heart-valve-surgery.com/heart-valve-repair-valvuloplasty-annuloplasty.phpAccessed 29 October 2010 • Mitral Valve Repair Center at The Mt. Sinai Hospital.http://www.mitralvalverepair.orgAccessed 30 October 2010 • University of Maryland Medical Center, “Mitral Valve Repair Surgery.”http://umm.edu/heart/mitral.htmAccessed 31 October 2010 • Cleveland Clinic, “Heart and Vascular Health.”http://my.clevelandclinic.org/heart/disorders/valve/mvrepair.aspxAccessed 30 October 2010 • E-cardiography Journal, “Vena Contracta.”http://rwjms1.umdnj.edu/shindler/venacontracta.htmlAccessed 1 Novermber 2010

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