Mitral valve diseases & management

Dr. Md. Rezwanul Hoque MBBS,MS,FCPS, FRCSG, FRCSEd Associate Professor Department of Cardiac Surgery BSMMU, Dhaka, Bangladesh

ANATOMY OF MITRAL VALVE

The mitral valve is composed of leaflets (valve tissue), mitral annulus, chordae tendineae, papillary muscles, and the left ventricle. The chordae tendineae and papillary muscles form the subvalvular apparatus. Commissures are identified using two anatomical landmarks: the axis of corresponding papillary muscles and the commissural Chordae. The anterior leaflet (aortic leaflet) has a semicircular shape and is attached to two fifths whereas the posterior leaflet (mural leaflet) has a quadrangular shape and is attached to three fifths of the annular circumference. The mitral valve is separated into eight segments . Anterolateral and posteromedial commissures are two segments. Two indentations on the posterior leaflet divide this structure into three anatomically individualized scallops (P1,P2,P3) The anterior leaflet has three corresponding segment( A1,A2,A3). The mitral annulus is attached to the fibrous trigones. The right fibrous trigone is a dense junctional area between the mitral, tricuspid, and noncoronary cusps of the aortic annuli and the membranous septum. The left fibrous trigone is situated at the junction of both left fibrous borders of the aortic and the mitral valve. Marginal chordae (primary chordae) are inserted on the free margin of the leaflets and function to limit leaflet prolapse. Intermediate chordae (secondary chordae) are inserted on the ventricular surface of the leaflets and relieve the valvular tissue of excess tension. Basal chordae (tertiary chordae) are limited to the posterior leaflet. They are attached to the leaflet base and connect it to the mitral annulus and the surrounding myocardial tissue.

Sellke: Sabiston & Spencer Surgery of the Chest, 7th ed., Copyright 2005 Saunders, An Imprint of Elsevier-chapter-74

Anatomy of mitral valve

Cause: MS: Rheumatic fever (Lutembacher syndrome: MS with ASD); congenital very uncommon, seen in infancy, D/D-LA myxoma MR: Rheumatic fever, infectious endocarditis, mitral valve prolapse, calcification of mitral annulus, collagen vascular disease (SLE, scleroderma), Marfan syndrome, Ehlers-Danlos syndrome, amyloidosis, sarcoidosis, LA myxoma, trauma, ischemia, congenital abnormalities Mitral prolapse: Most frequently occurs as a primary condition; also seen in collagen-vascular disease, Marfan syndrome, von Willebrand's disease, myotonic dystrophy
Sutherland, John A. Little Black Book of Cardiology, 2nd Ed,2007, Jones and Bartlett Publishers > Table of Contents > Chapter 8 Valvular Heart Disease

MS secondary to rheumatic fever in almost 99.8% of cases Congenital- Supravalvular/valvular/sub valvular Severe degenerative calcification LA myxoma Carcinoid syndrome Fabrays disease Hurlers syndrome Whipples disease Infective endocarditis

Sutherland, John A. Little Black Book of Cardiology, 2nd Ed,2007, Jones and Bartlett Publishers > Table of Contents > Chapter 8 Valvular Heart Disease

William Herring. Valvularlesionsweb.pdf.2002

Epidemiology: Rheumatic: 2/3 of patients are women; 25% of patients with rheumatic fever develop pure MS; another 40% have MS and MR (Eur Hrt J 1991;12 suppl B:77)

In a community-based sample, the prevalence of mitral valve prolapse (MVP) was 2.4% . (Nejm 1999;341:1).
Women with MVP outnumber men 2:1.

LA hypertrophy- dilatation- AF- mural thrombus LV normal, comparatively smaller PA pressure high leading to PVR PR, RV dilatation from pressure overload TR due to RV dilatation RA dilates due to volume overload RVF

William Herring. Valvularlesionsweb.pdf.2002

William Herring. Valvularlesionsweb.pdf.2002

PAH- Pulmonary vascular change-PVR Chronic oedema of interstitial tissue and alveoli leading to fibrosis Pulmonary hemosiderin deposit- calcification Rupture of pulmonary capillaries - haemoptysis

William Herring. Valvularlesionsweb.pdf.2002

William Herring. Valvularlesionsweb.pdf.2002

William Herring. Valvularlesionsweb.pdf.2002

MS: Normal mitral orifice is 5-6 cm2; orifice is reduced in MS due to fusion of commissures and thickening of cusps and/or chordae. A gradient develops when valve area is reduced to 2 cm2. LA pressure 25 mm Hg when valves 1 cm2 (critical MS). MR: Disorders of mitral leaflets, chordae, or papillary muscles produce a leak. Impedance to LV emptying in systole is reduced and EF remains normal or increased until LV pump failure develops. Mitral prolapse: Myxomatous proliferation of mitral leaflets and chordae cause billowing of mitral leaflets.

Sutherland, John A. Little Black Book of Cardiology, 2nd Ed,2007, Jones and Bartlett Publishers > Table of Contents > Chapter 8 - Valvular Heart Disease

Exertional dyspnoea; orthopnoea; palpitations. Symptoms are usually less in chronic MR than in MS but are acute and severe in acute MR. 15% of patients with MS have angina-like chest pain. The frequencies of chest pain and dyspnoea are similar among subjects with and without prolapse. MS: Prominent jugular A wave; RV heave (if RV enlarged); increased S1 and P2; opening snap; diastolic rumble at apex; longer murmur = more severe MS MR: S1 normal or decreased; S2 widely split; P2 increased in pulmonary HT; S3 gallop; late/holosystolic murmur radiating to axilla that varies little with cycle length or inspiration Mitral prolapse: Mid-systolic click, late systolic murmur that decreases with squatting, increases with administration of amyl nitrite and Valsalva manoeuvre (strain) Haemoptysis is more common in MS than in MR. MS: Symptoms manifest 15-20 year after an episode of rheumatic fever and progress over 3-4 year.

Sutherland, John A. Little Black Book of Cardiology, 2nd Ed,2007, Jones and Bartlett Publishers > Table of Contents > Chapter 8 - Valvular Heart Disease

ECG: LAE, coarse AF, incomplete RBBB in MS. Only 15% with MR show LAE. Echocardiogram: MS: To confirm dx; determine mean gradient, mitral valve area, PA pressure, and RV dimensions; evaluate valve; identify other valve lesions. Echocardiographic mitral morphology score: Leaflet rigidity, leaflet thickening, valvular calcification, and subvalvular disease are each graded from 1+ to 4+. MR: Initial assessment of MR and LV function and to identify cause; subsequently for periodic measure of LV function and dimensions in asymptomatic patients, for changing symptoms, and after valve repair/replacement In asymptomatic patients, echo quantification of MR (regurgitant volume, effective regurgitant orifice) predicts clinical outcome . Mitral prolapse: In all patients, to demonstrate systolic billowing of leaflets and to assess severity of MR; repeat study for changing symptoms and/or to follow degree of prolapse and MR and chamber dimensions; for suspected infectious endocarditis
Sutherland, John A. Little Black Book of Cardiology, 2nd Ed,2007, Jones and Bartlett Publishers > Table of Contents > Chapter 8 - Valvular Heart Disease

TEE: Mitral valve disease with inadequate transthoracic echocardiogram or suspected LA thrombus or endocarditis; also used intraoperatively Chest X-ray: MS: Enlargement of LA, RV, or RA, pulmonary arteries; pulmonary oedema MR: Enlargement of LV or LA; CHF Cardiac catheterization:
MS: Indicated to assess MR severity in candidates for balloon valvotomy if clinical and echocardiographic data are discordant; to measure PA, LA, and LV diastolic pressures if clinical and echo/Doppler data are discordant with the severity of MS by 2-D and Doppler echocardiography; or to gauge hemodynamic response of PA and LA pressures during exercise if clinical symptoms and resting hemodynamics are discordant MR: For patients with angina, prior MI, or suspected ischemia; for patients with CAD risk factors who are scheduled for mitral valve surgery; or for patients with inconclusive/discrepant noninvasive studies

Sutherland, John A. Little Black Book of Cardiology, 2nd Ed,2007, Jones and Bartlett Publishers > Table of Contents > Chapter 8 - Valvular Heart Disease

William Herring. Valvularlesionsweb.pdf.2002

William Herring. Valvularlesionsweb.pdf.2002

William Herring. Valvularlesionsweb.pdf.2002

William Herring. Valvularlesionsweb.pdf.2002

William Herring. Valvularlesionsweb.pdf.2002

William Herring. Valvularlesionsweb.pdf.2002

ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary

Indicated for patients with class II-IV symptoms and valve area 1.5 cm2 or valve area > 1.5 cm2 and pulmonary HT (PA systolic pressure 50 mm Hg at rest or 60 mm Hg with exercise) and mild or no MR, no LA thrombus, and reasonable valve morphology, or for asymptomatic patients with the same characteristics and pulmonary HT, AF, or pregnancy .

Circ 2004;109:1572

ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary

Atrial fibrillation LA thrombus H/O thromboembolism Severe MS, LA>55 mm

Surgery is indicated in symptomatic patients (NYHA class III or IV) with moderate to severe mitral stenosis (MVA <1.5 cm2, gradient> 10 mm Hg) who are not appropriate for, or who have failed balloon valvulotomy. There is also a subset of asymptomatic patients with severe mitral stenosis and severe pulmonary hypertension with no favourable morphology for percutaneous balloon valvulotomy. Mitral valve surgery is recommended in this subgroup of patients in order to prevent right ventricular failure. In patients with mild asymptomatic mitral stenosis (valve area >1.5 cm2 and mean gradient <5 mm hg), no further evaluation is required after the initial workup. These patients usually remain stable for years and should be treated medically with a close follow up.

Sellke: Sabiston & Spencer Surgery of the Chest, 7th ed., Copyright 2005 Saunders, An Imprint of Elsevier-chapter-74

Symptomatic and gradient> 10mm Hg CHF- NYHA-2,3 Associated moderate to severe MR Unavailable or unsuccessful PBMV LA thrombus Asymptomatic with severe PAH

ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary

ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary

William Herring. Valvularlesionsweb.pdf.2002

A, posterior prolapse due to chordae tendineae rupture. B, anterior prolapse due to elongation, thinning and rupture of chordae tendineae. C, anterior and posterior prolapse secondary to elongation of the chordae tendineae and myxomatous degeneration of several segments; note the pathologic clefts in the posterior leaflet. D, Barlow's disease with myxomatous degeneration of both leaflets.

William Herring. Valvularlesionsweb.pdf.2002

William Herring. Valvularlesionsweb.pdf.2002

Type I, normal leaflet motion; Type II, increased leaflet motion (leaflet prolapse); Type IIIa restricted leaflet motion during diastole and systole; Type IIIb restricted leaflet motion predominantly during systole.

Surgical Criteria for the Classification of Degenerative Mitral Valve Disease

FED Annulus Normal or near normal valve size (annulus <32 mm) Thin transparent w/o excess tissue Single segment involvement Involved segment is thick and distended Elongated in the affected segment, w/ or w/o rupture No billowing of the adjacent segments

BD Severely dilated annulus

Leaflets

Thick w/ excess tissue Multi segmental involvement

Chords

Thickened, calcified, elongated, restricted w/ or w/o rupture Multi segmental billowing

Billowing characteristics

ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary

 Symptomatic severe MR Asymptomatic severe MR with LVEF<60%, LVESD>40 mm Pulmonary HTN New onset atrial fibrillation congenital abnormality of valve apparatus

William Herring. Valvularlesionsweb.pdf.2002

William Herring. Valvularlesionsweb.pdf.2002

Median sternotomy- complete, upper or lower hemisternotomy Right anterolateral thoracotomy Minimally invasive MV surgerydirect vision, video assisted, video directed robot assisted, robotic telemanipulation

Sellke: Sabiston & Spencer Surgery of the Chest, 7th ed., Copyright 2005 Saunders, An Imprint of Elsevier-chapter-74

Pezzella AT et al. Texas heart journa, 10(2), 1983

Pezzella AT et al. Texas heart journa, 10(2), 1983

The entire mitral valve apparatus must be carefully examined to confirm the mechanism of mitral regurgitation, to assess the feasibility of repair, and to plan the exact operative technique. The endocardium of the left atrium is examined for jet lesions, which indicate opposite leaflet prolapse. The mitral annulus is examined to assess the severity of annular dilatation, which can be asymmetrical. The valvular apparatus is examined with a nerve hook to assess tissue pliability and to identify leaflet prolapse or restriction according to segmental valve analysis. The anterior paracommissural scallop of the posterior leaflet (P1) is often intact and rarely prolapsing in patients with degenerative disease. The P1 segment constitutes the reference point. Applying traction to the free edge of other valvular segments and comparing them with P1 determines the extent of leaflet prolapse or restriction
Sellke: Sabiston & Spencer Surgery of the Chest, 7th ed., Copyright 2005 Saunders, An Imprint of Elsevier-chapter-74

Remodelling ring annuloplasty Posterior leaflet quadrangular resection/ triangular resection Sliding leaflet repair/ leaflet perforation repair Chordal transfer Chordal transposition Artificial chordoplasty Papillary muscle sliding plasty/shortening Annular decalcification & reconstruction
Sellke: Sabiston & Spencer Surgery of the Chest, 7th ed., Copyright 2005 Saunders, An Imprint of Elsevier-chapter-74

Dr. Farzan Filsoufi, Dr. Alain Carpentier, and Dr. David Adams at work on their upcoming textbook "Carpentier's Valve Reconstruction".

The Alfieri technique

The surgical edge-to-edge technique was first described in early 1990`s (Alfieri) Over 1,500 pts reported in the literature Safe, effective, durable No occurrence of mitral stenosis Facilitates proper leaflet coaptation Degenerative - anchor flail / prolapsing leaflets Functional - Coapt tethered leaflets to reduce time and force required to close valve Creates tissue bridge

Catheter-Based Mitral Valve Repair

MitraClip System

59

Lower operative mortality Better late outcome Curative Avoids anticoagulation unless atrial fibrillation Open Afib ablation

Continuing Medical Implementation

Valve replacement:
Mortality 2-7% Anti-coagulation Decreased LVEF

Tissue prosthetic valve degeneration Mechanical prosthetic valve dysfunction/ thrombosis

Valve repair Mortality 2-3% No anticoagulation (unless Afib) Preservation of LVEF Valve repair always preferable Feasible in 70-90% of patients

Continuing Medical Implementation

...bridging the care gap

Mechanical valve thromboembolism, bleed from anticoagulation Bioprosthetic valve limited durability (degeneration) Chordal/subvalvular apparatus preservation
EF preop/postop 60% to 36% VS 63% to 61% in a comparative study

Continuing Medical Implementation

...bridging the care gap

According to their increased difficulty, minimally invasive approaches are divided into four categories: limited incision with direct vision (level 1), video-assisted (level 2), video-directed and robot-assisted (level 3), and robotic telemanipulation (level 4).

There are three main approaches to minimally invasive mitral valve repair: Totally Endoscopic Mitral Valve Repair Mini-Sternotomy Mitral Valve Repair Mini-Thoracotomy Mitral Valve Repair
All approaches require putting on a heart-lung machine (cardiopulmonary bypass), but they also all cause less trauma than open heart surgery.

Potential advantages of totally endoscopic mitral valve repair: Shorter hospital stay Less pain and scarring Reduced risk of infection Less blood loss and need for blood transfusions Faster recovery Quicker return to normal activities

1. RIGHT ATRIOTOMY 2. INCISION IN THE INTERATRIAL SEPTUM

1. STAY SUTURE IN IAS 2. INSPECTION OF MV

1. SIZING TO SELECT APPROPRIATE ANNULOPLASTY RING SIZE 2. ANNULAR STITCHES

1. ANNULOPLASTY RING APPLIED 2. SUTURES PASSED THROUGH RING

1. RING APPLIED 2. IAS CLOSED

RA TOMY CLOSED

Algorithm for interpreting abnormally high transprosthetic pressure gradients after aortic or mitral valve replacement.

Body surface area; DVI, Doppler velocity index EOA, effective orifice area; FU, follow-up; PPM, prosthesispatient mismatch.

Pibarot P , Dumesnil J G Heart 2012;98:69-78

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