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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
-SL valves control flow of
oxygen rich blood from
lungs to body
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
Mitral Valve Anatomy
-Annulus: Fibrous ring
-Two leaflets: Valvular
tissue
-Chordae tendineae
-Papillary muscles
Mitral Regurgitation
-Regurgitation/Insufficiency
-Result of incompetent valve
-Doesn't close completely
-Blood leaks back into atrium
during systole
-MR increases the workload
of the heart
-Complications
-Cardiac arrhythmias
-CHF
-Irreversible heart damage
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
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
Diagnostic Studies
-Transthoracic Echocardiogram
-Transesophageal Echocardiogram
-Chest X-Ray
-EKG
-Holter monitor
-Cardiac Catheterization
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
Mitral Valve Repair
Annuloplasty
-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
Case Study
Patient Information
-Age/Gender: 76 year old male
-Hospital Admission on 5/27/10
-Current Symptoms:
-Dyspnea on exertion
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
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.
Patient History
-Medications at Admission:
-Aspirin 325 mg. daily
-Lotrel 5/10 one tablet daily
-Lipitor 20 mg. daily
Diagnostic Study
Transesophaegeal 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 vena
contracta is 0.9 cm. No evidence of mitral stenosis.
Conclusions: Mitral valve appears repairable and
annulus is dilated. MR is severe in several views.
Transesophageal Echo
05/28/10
Transesophageal Echo
05/28/10
Transesophageal Echo
05/28/10
Diagnostic Studies
Left 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
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
Pre and Post Op – TEE
06/10/10
Pre and Post Op - TEE
06/10/10
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
-Plavix 75 mg daily
-Furosemide 40 mg. Daily
-Metoprolol 25 mg b.i.d.
(Anti-thrombotic)
(Anti-platelet)
(Loop diuretic)
(Beta Blocker)
Follow-up
Chest 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.
Follow-up Echo
08/05/10
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.
Follow-up Echo
08/05/10 - PLAX
Follow-up Echo
08/05/10 – PSAX & MV Zoom
Follow-up Echo
08/05/10 – Apical 2C
Follow-up Echo
08/05/10 – Apical 4C
Follow-up Echo
08/05/10
Before & After MV Repair
References
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DeWitt, S. 2009, Echocardiography...From a Sonographer's
Perspective (6th Edition), Camden Printing, St. Marys, GA
Drugs.com, “Prescription Drugs, Information, Interactions and Side Effects.”
http://www.drugs.com
Accessed 24 October 2010
MedicineNet.com, “Health and Medical Information.”
http://www.medicinenet.com
Accessed 24 October 2010
Wikipedia, “The Free Encyclopedia.”
http://www.wikipedia.org/wiki/Mitral_valve; http://wikipedia.org/wiki/File:Heart_short_axis_view_papillary.jpg
Accessed 22 October 2010
Pick, A., “The Patient's Guide to Heart Valve Surgery.”
http://www.heart-valve-surgery.com/heart-valve-repair-valvuloplasty-annuloplasty.php
Accessed 29 October 2010
Mitral Valve Repair Center at The Mt. Sinai Hospital.
http://www.mitralvalverepair.org
Accessed 30 October 2010
University of Maryland Medical Center, “Mitral Valve Repair Surgery.”
http://umm.edu/heart/mitral.htm
Accessed 31 October 2010
Cleveland Clinic, “Heart and Vascular Health.”
http://my.clevelandclinic.org/heart/disorders/valve/mvrepair.aspx
Accessed 30 October 2010
E-cardiography Journal, “Vena Contracta.”
http://rwjms1.umdnj.edu/shindler/venacontracta.html
Accessed 1 Novermber 2010