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Corso Integrato di medicina d’urgenza, terapia intensiva e
infermieristica clinica applicata
Lezioni di Cardiochirurgia
Valvulopatie
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Valvulopatia
Mitralica
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
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
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Pathology
•Rheumatic Disease
•Myxomatous Degeneration
•Ischemic Valvulopaty
•Endocarditis
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Rheumatic mitral stenosis
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Bacterial endocarditis on A2
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
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
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
MR: Indications for Operation
•Acute symptomatic MR
•Symptomatic or Asymptomatic Patients with LV Dysfunction:
Type
Mild
Moderate
Severe
EF
0.5-0.6
0.3-0.5
<0.3
Systolic Dimension
40-50 mm
50-55 mm
>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)
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
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
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
The Perfect Valve
•Excellent hemodynamics
•Non-thrombogenic
•Durable
•Unrestricted availability
•Easily implantable
•Silent function
•Low cost
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Replacement Devices
•Mechanical valves
•Caged-ball
•Monoleaflet
•Bileaflet
• Bioprostheses
•Stented
•Porcine
•Pericardial
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UNIVERSITA’ DEGLI STUDI DI FIRENZE
•Stentless
•Porcine
•Bovine Pericardial
•Homograft
•Autograft
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.
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Braunwald Polyurethane mitral valve. First mitral
valve replacement on March 11, 1960. Teflon
chordae brought through the ventricular muscle
and secured outside the heart
Harken double
cage ball valve.
Implanted in 1960
St Jude heart valve. The most popular bileaflet mechanical valve. First
implant 1977. Pyrolytic carbon leaflets and housing. Tungsten impregnated 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.
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Mitral Homograft
Flow characteristics
ball/cage < tilting dic < bileaflet
Thrombogenic potential
ball/cage > tilting disc > bileaflet
Aortic < Mitral < both
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
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
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
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)
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
•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
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Tecniche Riparative Mitraliche
•Riparazioni Anatomiche
•Annulus
•Lembi
•Corde Tendinee
•Muscoli Papillari
•Riparazioni Funzionali
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The Quadrangular Resection
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Cattedra di Cardiochirurgia
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Chordae Tendinae
SHORTENING
REPLACEMENT
TRANSFER
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UNIVERSITA’ DEGLI STUDI DI FIRENZE
Galloway concludes, "The core concepts are: fix the leaflet pathology and remodel the
annulus and you'll have a competent valve."
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Edge-To-Edge technique
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Valvulopatia
Aortica
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
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
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Positions of the aortic valve leaflets at enddiastole 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.
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Pathology
•Congenital Malformation
•Rheumatic Disease
•Degeneration
•Endocarditis
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
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.
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Calcified Aortic Stenosis (Congenital Malformation)
•Congenitally bicuspid or unicuspid, fused commissures,
•heavy calcification, age 50-70
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Rheumatic Aortic lesions
•Fibrous thickening,
•3-cusp valve,
•mild calcification,
•rheumatic fever history in 50%
aortic steno-insufficiency
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
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
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
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
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
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.
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
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
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
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
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
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%
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Aortic valve
excision.
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Mechanical prosthesis implantation.
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UNIVERSITA’ DEGLI STUDI DI FIRENZE
Cattedra di Cardiochirurgia
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Cattedra di Cardiochirurgia
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Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
AORTIC HOMOGRAFT
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Homograft implantation: the “root” technique
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
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
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
The Ross Operation
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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.
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
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.)
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Cumulative distribution of
prosthesis internal
orifice size standardized
to body surface area
according to the Z-value.
Normal native valve sizes
are generally considered to
be those constrained within
the 95% confidence limits
of normal values,
corresponding to Z-values
of –2 and +2. A, Overall
distribution; B, distribution
stratified by type of aortic
valve prosthesis Thorac. Cardiovasc.
Surg. 2000;119:963-974.
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Aortic valve replacement: Is valve
size important? B. Medalion
Left ventricular mass index
(LVMI) preoperatively (PREOP) and 8
months after (POSTOP) aortic valve
replacement.
The homograft and stentless valves
expressed the maximum LVMI reduction.
This is evident in all cases (A) and in
patients with a preoperative LVMI of 180
g/m2 or less (B). In patients with a
preoperative LVMI of 180 g/m2 or more (C)
the homograft treatment achieved the best
results. (I = intact; H = homografts; T =
Toronto; F = freestyle; C = controls).
“Left ventricular mass reduction after aortic valve
replacement: homografts, stentless and stented
valves”
D. Maselli et al. Ann. Thorac. Surg. 1999;67:966-971.
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Reparative
aortic valve
surgery.
Reproduced
from Duran and colleagues
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