MITRAL VALVE

SURGERY

Normal Valve Function

Maintain forward flow and prevent reversal of

flow.

Valves open and close in response to pressure

differences (gradients) between cardiac
chambers.

Abnormal Valve Function

Valve Stenosis
Obstruction to valve flow
Hemodynamic hallmark pressure gradient

Valve Regurgitation, Insufficiency, Incompetence

Inadequate valve closure back leakage

A single valve can be both stenotic and regurgitant ;

but both lesions cannot be severe!!

Combinations of valve lesions can co-exist :

Single disease process
Different disease processes
One valve lesion may cause another
Certain combinations are particularly burdensome (AS & MR)

Mitral Valve Disease :

Etiology

Mitral Stenosis

Rheumatic - 99.9%!!!
Congenital
Prosthetic valve stenosis
Mitral Annular Calcification
Left Atrial Myxoma

Acute Mitral Regurgitation

Infective endocarditis
Ischemic Heart disease
Papillary ms rupture
Mitral valve prolapse
Chordal rupture
Chest trauma

Chronic Mitral
Regurgitation
Ischemic Heart disease
Papillary ms dysfunction
Inferior & posterior MI
Mitral Valve prolapse
Infective endocarditis
Rheumatic
Prosthetic
Mitral annular calcification
Cardiomyopathy
LV dilatation

Carpentiers Functional
Class
Dysfunction
Lessions
Etiology
Type I
Normal Leaflet Motion

Annular Dilatation
Leaflet Perforation

Ischemic CMP, DCMP

Endocarditis

Type II
Increased Leaflet Motion
(Leaflet Prolapse)

Elongation or Rupture of
Chordae

Degenerative Barlows,
Marfans and Fibroelastic
Disease
Endocarditis, Rheumatic,
Trauma
Ischemic CMP

Elongation or Rupture of PM
Type III-A
Restricted Leaflet Motion
(Systole & Diastole)

Leaflet Thickening/retraction
Chordal Thickening/fusion
Commisural fusion

Rheumatic Disease
Carcinoid Disease

Type III-B
Restricted Leaflet Motion
(Systole)

PM displacement
Leaflet tehtering

Ischemic CMP
Dilated CMP

ELEMENTS OF MITRAL VALVE

APPARATUS

Annulus
Leaflets
Subvalvar apparatus
- Chordae tendinae
- Papillary muscles
- LV

MITRAL ANNULUS

Mitral annulus is a
dynamic structure
Has a sphincter like
function, effectively
decreasing the valve
area by about a quarter
during systole
This is secondary to
contraction and
relaxation of the
basoconstrictor
muscles (bulbospiral
and sinospiral)
Dilatation of the
annulus occurs
posteriorly

IMPORTANT STRUCTURES
SURROUNDING THE MITRAL
ANNULUS

AML

PML

MITRAL LEAFLETS

Covered with endocardium

Commissural areas
(identified by presence
of commissural chordae)
divide the continuous
mitral veil into two
leaflets:
- Anterior (aortic) leaflet
- Posterior leaflet

ANTERIOR MITRAL LEAFLET

Semicircular or triangular
Attached to around 3/8th of circumference
of the mitral annulus
Has common attachment to the cardiac
skeleton with
-left coronary cusp
of aortic valve

-half of non-coronary cusp

POSTERIOR MITRAL LEAFLET

Quadrangular in shape
Attached to around 5/8th of the
circumference of the mitral annulus
Margin has two indentations, forming three
scallops:
- Anterolateral
- Middle
- Posteromedial
Cleft chordae insert into these
indentations

SUBVALVAR APPARATUS
PAPILLARY MUSCLES

Two groups of LV papillary muscles

- Anterolateral
- Posteromedial
Each group supplies chordae to
their respective halves of both
leaflets
Arise from the anterior and
posterior walls of the left ventricle
respectively
Tip points towards the respective
commissure

SUBVALVAR APPARATUS
CHORDAE TENDINAE

Fibrous strings that

originate from tiny nipples
on the apical portion of
the two papillary muscles
Majority have branching
pattern, either soon after
their origin from the
papillary muscles, or just
before their insertion into
the leaflets

SUBVALVAR APPARATUS
CHORDAE TENDINAE
C h o rd a e T e n d in a e
C o m m is s u ra l
c h o rd a e

C h o rd a e o f
A n te rio r l e a fl e t

M a in c h o rd a e

P a ra m e d ia l
c h o rd a e

C h o rd a e o f
P o s te rio r l e a fl e t
P a ra c o m m i s s u ra l B a s a l c h o rd a e
c h o rd a e

R ou g h zo ne
c h o rd a e

C l e ft c h o rd a e

Mitral Regurgitation

Mitral Regurgitation

Primary MR
Disease of mitral valve causes it to leak
Imparting volume overload on the LV

Secondary MR
Disease of the LV causes wall motion

abnormalities
Ventricular dilatation
Annular dilatation

Mitral Regurgitasi

Color flow jet area

Vena contracta width

measurement

Chronic Mitral Regurgitation LVVO

LVVO
LV dilatation
Eccentric hypertrophy

Increased LA pressure
Pulmonary HTN
Dyspnea
Atrial arrhythmias
Low output state

Pathophysiology ;
Acute vs Chronic Mitral Regurgitation

Acute MR
Normal (noncompliant) LA
Increase LA pressure
Acute Pulmonary Edema

Chronic MR
Dilated, compliant LA
LA pressure normal or

slightly increased
Fatigue, low output state
Atrial arrhythmias- a. fib.

Most patients fall between

these two extremes!!

Ischemic Mitral
Regurgitation

Caused by CAD,distinguished from

organic MV disease.
Valve leaflets and chordae appear
normal.
LV dysfunction
Three mechanisms :
(1) ruptured PM, (2) infarcted PM
without rupture,(3) functional
regurgitation.

Mechanisms of Ischemic
Mitral Regurgitation
Reversible ischemia
Transientleftventriculardilatation/dysfunction
Myocardial infarction
Rupturedpapillarymuscle
Infarctedbutunrupturedpapillarymuscle
Functional
Leftventriculardilatation/dysfunction
Annulardilatation
Leftventriculardilatation/dysfunctionand
annulardilatation

Functional ischemic mitral regurgitation occurs

when ventricular dilatation and dysfunction cause
leaflet tethering, preventing normal leaflet
coaptation

Class 1 indications for mitral

valve repair or replacement

Symptomatic acute severe MR

Development or presence of NYHA class
II-III-IV symptoms in patients with chronic
severe MR in the absence of severe LV
dysfunction (EF < 30% or end systolic
dimension > 55 mm
Asymptomatic patients with chronic severe
MR and mild-moderate LV dysfunction (EF
30-60% or end systolic dimension 40 mm

Mitral Stenosis

Etiology

Rheumatic heart disease

Non-rheumatic heart disease
Severe mitral annular and/or leaflet

calcification
Congenital mitral valve deformities
Malignant carcinoid syndrome
Neoplasm
LA thrombus
Endocarditic vegetations

Diagnostic

A4CH

MS -Pathophysiology

Restriction of blood flow

from LALV during
diastole.
Normal MVA 4-6cm2.
Mild MS 2-4cm2.
Severe MS < 1.0cm2.

MV Pressure gradient
MV grad ~ MV flow//MVA.
Flow = CO/DFP (diastolic

filling period).

As HR increases, diastole
shortens disproportionately
and MV gradient increases.

Count.

MV gradient Increase
LA press
Pulmonary HTN
Passive
Reactive- 2nd stenosis
RV Pressure Overload
RVH
RV failure
Tricuspid
regurgitation
Systemic Congestion

Mitral Valve Repair

Valve Exposure :

Interatrial approach
through Waterston
Groove
Transatrial Oblique
Approach
Transatrial
Longitudinal septal
approach

Valve Repair in Type I

Dysfunction

Annular dilatation:
annuloplasty

Leaflet perforation
endocarditisdebri
dementpatch
pericardium

Valve Repair in Type II

Dysfunction
Posterior leaflet Prolaps : quadrangular resectionplication posterior

annulusdirect suture of the leaflet

Barlows diseasequadrangular resectionsliding leaflet,P1 & P3

detachedcompression suture at post. annulusgap closed interrupted sutures

Classic Flail
P2 Segmen

Quadrangular
Resection

Valve Repair in Type II

Dysfunction
Classic
sliding
Valvuloplasty

Anterior Leaflet Prolapse

Four basic techniques to repair true prolapse of

the anterior leaflet
Reduction of the chordal height by implatation technique
Artificial PTFE chordae
Chordal transfer from posterior to anterior leaflet
Edge to edge technique

Chordal shortening by implantation

into papillary muscles
incising the papillary muscle,
placing the redundant anterior leaflet
chords within the muscle,
and then sewing the papillary muscle
over the chord, thus
entrapping the chordae and
shortening it

Chordal Transfer
A resection of the
flail chordae of the anterior
leaflet is carried out, and an
adjacent
segment of the posterior leaflet
is then resected from the
posterior leaflet and then
transferred to the gap
produced by
the anterior leaflet resection

Artificial chordae
(PTFE)
Placing a mattress
suture with a pledget
on the pappilary
muscle to which the
redundant or
ruptured chord has
been attached
Two ends of the
double-armed are
then brought up
through the edge of
the leaflet that needs
to be lowered

Edge-to-edge
technique
The edge-to-edge repair is a
technique in which the anterior
leaflet and posterior leaflet are
sewn together at the coaptation
line, producing a double-orifice
mitral valve

Valve Repair in Type

IIIDysfunction

Correction achieved by treating each

type of lesion : Leaflet restriction :
chordal thickening,retraction,fusion.
ThickeningResection secondary
chordae,Fusionchordal
fenestration.Retractionpericardial
patch enlargement.

Open Commisurotomy

With rheumatic valvular disease, mitral stenosis

is caused by restricted leaflet mobility. Partial
fusion of the commissures with a well-defined
border between the anterior and posterior
leaflets is ideal.

The repair technique requires continued

observance of the chordal support mechanism.
With traction applied to the major chords of the
anterior leaflet near the commisure, a furrow or
dimple is created where the leaflets should be
incised and separated.

Mitral Valve
Replacement

The indications for mitral valve replacement are variable

and undergoing evolution. Because of increasing use of
reparative techniques, particularly for mitral
regurgitation, replacement or repair of a mitral valve
often depends on the experience of the operating
surgeon

Indications for Bioprosthetic

Valve Replacement

Patients in any age group in sinus rhythm who

wish to avoid anticoagulation may prefer a
bioprosthetic valve
e.g., patients with a history of gastrointestinal

bleeding
preferred in patients over age 65 in sinus rhythm
In a woman who desires to become pregnant

In patient who will not take warfarin, is

incapable of taking warfarin, or has clear
contraindication to warfarin therapy

Indications for mechanical

Valve Replacement

In patients less than 65 years of age

with long standing atrial fibrilation

Late morbidity

Thromboembolism
Anticoagulant Hemorrhagic
Structural valve degeneration
Perivalvular leakage
Endocarditis

Thank You