Valve Surgery

V.Rohn

Valve Surgery

History

before the era of ECC• 1925 – Suttar – first successful digital

commisurolysis of mitral valve• 1952 – Hufnagel – first mechanical „ball and

cage“ valve implanted to the descending aorta

Valve Surgery

History

With ECC • 1960 – Harken – aortic valve replacement with

the „ball and cage“ valve• 1960 – Starr – replacement of the mitral valve

Valve Surgery

• 1962 – Heimbecher – first use of the homograft in the mitral position

• 1967 – Ross – autograft of pulmonary valve in the aortic position

• 1971 – Carpentier – introduction of „bioprosthesis“, e.g. xenograft as a valve replacement

• 1983 – Carpentier –mitral valve plasty (reconstruction) concept

Aortic Valve Stenosis

Etiology– degenerative– congenital (bicuspid valve)– rheumatic

Symptoms– angina pectoris– syncope– dyspnea

Aortic valve Anatomy

Stenosis of the aortic valve

Indications for surgery– symptoms– asymptomatic – AVA 0,75cm2/m2 and less– pressure gradient 45 – 50mmHg– low EF is not a contraindication

Procedure– Aortic valve replacement

Aortic valve regurgitation

Etiology– multiple

Symptoms– None - very long time – angina pectoris– dyspnea

Aortic valve regurgitation

Indication for surgery– Symptoms – or first signs of LV function deterioration

• EF < 55 %• Dilatation of LV (EDD > 75 mm, ESD > 50 mm)

Procedure– Replacement – Reconstruction

Aortic valve Replacement

Aortic root enlargement – Manougian, Nicks

Allograft, Pulmonary autograft

Percutaneous or transapical implantation – 1965 Davies

Lancet 1965;62:926—9.

Endovascular or transapical AVR

Copyright ©2009 The American Association for Thoracic Surgery

Boodhwani M. et al.; J Thorac Cardiovasc Surg 2009;137:286-294

Repair-oriented functional classification of aortic insufficiency (AI) with description of disease mechanisms and repair techniques used

Aortic Valve Repair

Mitral stenosis

Etiology– mostly rheumatic

Symptoms– long time asymptomatic– dyspnea– embolization (atrial fib.)

Indication for surgery– valve area less than 0,8 cm2/m2– pressure gradient above 8-10 mmHg

Mitral stenosis

percutaneous balloon valvuloplasty„closed“ commissurotomy„open“ commissurotomy replacement

Mitral stenosis – open commissurotomy

Mitral stenosis – closed commissurotomy

Mitral regurgitation

Etiologyrheumatic

Degenerative mitral regurg. (fibroelastic, myxomatous, Barlow disease)

Ischemic

symptoms– dyspnea– a.fib., embolization

Mitral regurgitation

Indication– regurgitation more than 2-3/5 (echo,

ventriculography)– LV dilatation (ESD more than 55 mm)– LV dysfunction, EF decrease

Procedure – 90% of degenerative mitral valves are

amenable to repair– replacement with preservation of the

subvalvular apparatus

Mitral valve - anatomy

Mitral valve repair – Valve Exposure

Mitral valve repair- quadrangular resection of the posterior leaflet

Chordal transfer

Ischemic Mitral Regurgitation

Ischemic Mitral Regurgitation

Undersized Annuloplasty

Tricuspid valve

Etiology

• Congenital – ASD, VSD, Ebstein disease • pacemaker or automatic internal cardiac

defibrillation (AICD) wires • carcinoid• lupus erythematosus, cor pulmonale, inferior

myocardial infarction, scleroderma • Functional- secondary to cardiac valvular

pathology (mostly mitral valve disease) • up to 20% of patients undergoing mitral valve

replacement receive a tricuspid annuloplasty• less than 2% require replacement

Indication to surgery

• during left-sided valve surgery when TR annulus is dilated

• >21 mm/m2; >70 mm intra-operatively; >3.5 cm at TTE

• Symptomatic stenosis or regurg.

De Vega plasty

Rings and Bands

Tricuspid valve repalcement

Valve Prosthesis

• biological• mechanical• homograft• autograft

Mechanical vs biological

• lifelong anticoagulation therapy

• degeneration

ESC guidelines 2007