Mitral Valve Regurgitation - Ischemic Valvular Disease

Peri-operative management

Standard techniques of monitoring (arterial line, central venous access, Foley catheter...) are used in patients undergoing a combined mitral valve reconstruction and coronary bypass grafting. A Swan-Ganz catheter should be inserted in every patient. Initially a transesophageal echocardiogram should be performed. It is a key element to determine the functional type of mitral regurgitation and to assess left ventricular size and function. At the completion of cardiopulmonary bypass, it allows the surgeons to assess the quality of valve reconstruction, to detect residual air in left side cavities, and to monitor ventricular filling. An epiaortic scan of the ascending aorta is recommended to rule out the presence of atherosclerotic lesion prior to arterial cannulation.

Surgical approaches, cardio pulmonary bypass, and myocardial protection

Median sternotomy is the surgical approach of choice in patients undergoing combined mitral valve reconstruction and myocardial revascularization. In reoperative setting ( e.g. mitral valve surgery after previous coronary artery bypass grafting), a right thoracotomy approach is a viable alternative. Femoral vessels exposure is recommended if severe mediastinal adhesions are suspected (recent reoperation, multiple previous sternotomies, mediastinitis, and mediastinal radiation) and in patients with patent left internal mammary graft. Mitral valve surgery is classically performed with cannulation of both vena cava and the aorta, intermittent antegrade or a combined antegrade and retrograde cardioplegic arrest with cold blood high potassium cardioplegia for myocardial protection. Further myocardial protection can be obtained by moderate systemic hypothermia between 28-30C and local hypothermia with topical ice.

Exposure of the mitral valve and valve analysis

Following completion of coronary bypass grafting, the perfect exposition of the Mitral Valve Regurgitation is essential before undertaking any type of mitral valve surgery. The most commonly used approach is the interatrial approach through the Sondergaard's groove.

The valvular apparatus is inspected and then examined with a nerve hook in order to assess tissue pliability and to identify the functional type of mitral regurgitation. The anterior paracommissural scallop of the posterior leaflet (P1) constitutes the reference point. Applying traction to the free edge of other valvular segments and comparing them to P1 determines the extent of leaflet prolapse in patients with papillary muscle rupture. This technique is, however, not very reliable to assess the severity of leaflet tethering in the arrested heart. The presence and severity of annular dilatation/deformation is also evaluated. In postero-lateral myocardial infarction, this dilatation is asymmetrical, involving mostly the p2, p3 and posterior commissural area. In antero-septal infarction, the annulus is symmetrically dilated.

Mitral valve reconstructive Surgery

Type I mitral regurgitation

Type I mitral regurgitation is best treated with a remodeling annuloplasty. The ring is downsized by one size.

Type II mitral regurgitation

Mitral valve replacement with the preservation of the subvalvular apparatus is the surgical treatment of choice in patients with complete rupture of a papillary muscle.


Papillary muscle reimplantation can be attempted in selected patients, provided that necrosis of the supporting myocardial wall is limited and in the absence of akinetic or dyskinetic wall. The non-prolapsed area of the valve serves as a reference point to determine the site and level of implantation of the papillary muscle remnant. At this site a 5mm deep trench is created in the muscular wall. The papillary muscle remnant is trimmed in order to preserve only the fibrous cuff. The papillary muscle remnant is buried in the trench using interrupted 4/0 polypropylene sutures. The trench is then closed around the papillary muscle remnant using a figure of eight suture. The procedure should be completed with a remodeling annuloplasty.

Elongated papillary muscle can be treated by its plication or resection of its extra length followed by reconstitution of the continuity of the remaining segments. The procedure is completed with a slightly downsized ring annuloplasty to reduce the tension on the reconstructed valve. If the papillary muscle is too thin and the anatomic conditions are not favorable, Mitral Valve Regurgitation should be preferred.

Type IIIb mitral regurgitation

Remodeling annuloplasty using a downsized ring is the technique of choice in type IIIb dysfunction. The goals of valve reconstruction are: preserving leaflet mobility, restoring a large surface of coaptation by reducing the septo-lateral dimension, and stabilizing the annulus to ensure long-term stability.

From Carpentier A, Adams DH, Filsoufi F. Carpentier's Reconstructive Valve Surgery. Saunders (Elsevier), 2010.The prosthetic ring should be downsized by one size or two sizes depending on the severity of leaflet tethering. The use of double-row annuloplasty suture technique is recommended to reduce the risk of ring dehiscence.

From Carpentier A, Adams DH, Filsoufi F. Carpentier's Reconstructive Valve Surgery. Saunders (Elsevier), 2010 Additional procedure such as the resection of a large aneurysm or dyskinetic plaque may be necessary to enhance the results of valve reconstruction.

During the last decade, adjunct techniques including the closure of the indentation between p2-p3 segments, resection of secondary chordae, patch extension of the posterior leaflet and papillary muscle sling have been described to minimize the risk of residual or recurrent mitral regurgitation. Clinical experience with these procedures remains limited and there are no long-term data available.

Finally, it is important to stress that in selected patients particularly those with severe bileaflet tethering and enlarged left ventricle with an end diastolic diameter greater than 65 mm, mitral valve replacement with a bioprosthesis may be the surgical procedure of choice.

Heart Valve Repair

Surgical intervention plays an important role in the overall management of patients with native mitral valve endocarditis and is indicated in 15-25% of patients with infective endocarditis.

Several clinical presentations are considered absolute indications for surgical intervention:

1) Significant mitral regurgitation with or without symptoms of congestive heart failure
2) Extensive structural damages such as evidence of mitral annular abscess, extension of infection to  intervalvular fibrous body, or formation of intracardiac fistulas
3) New high-grade conduction disturbance not resolving with appropriate medical therapy
4) Uncontrolled sepsis despite appropriate antibiotic therapy
5) Presence of antibiotic resistant micro-organism(s)
6) Fungal, staphylococcal aureus, or gram negative bacilli endocarditis (very aggressive micro-organisms)
7) Large vegetations, particularly those that are mobile and localized on the anterior leaflet, at high for embolic complications
8) Multiple episode of embolizationIndications for surgical intervention in patients with prosthetic valve endocarditis include those stated above and unstable prosthesis with paravalvular leak. In all these clinical situations, surgical therapy has dramatically improved both morbidity and mortality over medical treatment alone.

Timing of surgery

When there is an indication for Heart Valve Repair surgery, the procedure should be performed soon after the diagnosis is made regardless of the duration of antimicrobial therapy in order to prevent extensive structural destruction.

In the presence of severe symptoms such as pulmonary edema or intractable cardiogenic shock, immediate surgical intervention is warranted. In asymptomatic patients with severe valvular regurgitation, surgery can be delayed to obtain negative blood culture. Even in that scenario, it is preferable to proceed with early intervention to avoid extension of valvular lesions or left ventricular function impairment.

The timing of Heart Valve Repair surgery should also be carefully discussed in the setting of infective endocarditis complicated with a recent neurologic injury. Patients who have suffered an ischemic cerebral injury are safe to undergo early intervention as recent studies have shown that surgical procedure was not associated with a worsening of neurological symptoms or the occurrence of a new neurologic event. Surgical intervention, however, should be delayed in patients with hemorrhagic stroke, particularly if the size of the intracranial bleed is greater than 2 cm. Similarly, in the presence of a cerebral mycotic aneurysm, cardiac surgical intervention should be delayed. It is critical to obtain an early neurosurgical consult in these patients as they may be candidate for endovascular treatment of this condition. Daily neurologic examination, CT scans and MRI at regular intervals should be performed to assess the evolution of the neurologic injury and determine the appropriate timing of surgery.

Rheumatic Heart Disease

Rheumatic heart disease is inflammation and damage to the heart muscle and heart valves that develops as a result of rheumatic fever. Rheumatic heart disease is a condition in which permanent damage to heart valves is caused by rheumatic fever. The heart valve is damaged by a disease process that generally begins with a strep throat caused by bacteria called Streptococcus, and may eventually cause rheumatic fever.

Rheumatic Fever

Rheumatic fever is uncommon in the US, except in children who have had strep infections that were untreated or inadequately treated. Children ages 5 to 15, particularly if they experience frequent strep throat infections, are most at risk for developing rheumatic fever. The infection often causes heart damage, particularly scarring of the heart valves, forcing the heart to work harder to pump blood. The damage may resolve on its own, or it may be permanent, eventually causing congestive heart failure (a condition in which the heart cannot pump out all of the blood that enters it, which leads to an accumulation of blood in the vessels leading to the heart and fluid in the body tissues).

Rheumatic Heart Disease Symptoms

The symptoms of rheumatic fever usually start about one to five weeks after your child has been infected with Streptococcus bacteria. The following are the most common symptoms of rheumatic fever. However, each child may experience symptoms differently. Symptoms may include:

- Joint inflammation - including swelling, tenderness, and redness over multiple joints. The joints affected are usually the larger joints in the knees or ankles. The inflammation "moves" from one joint to another over several days.
- Small nodules or hard, round bumps under the skin.
- A change in your child's neuromuscular movements (this is usually noted by a change in your child's handwriting and may also include jerky movements).
- Rash (a pink rash with odd edges that is usually seen on the trunk of the body or arms and legs).
- Fever.
- Weight loss.
- Fatigue.
- Stomach pains.

The symptoms of rheumatic fever may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis.

Treatment for rheumatic heart disease:

Specific treatment for rheumatic heart disease will be determined by your child's physician based on:

Your child's overall health and medical history.

- Extent of the disease.
- Your child's tolerance for specific medications, procedures, or therapies.
- Expectations for the course of the disease.
- Your opinion or preference.

The best treatment for rheumatic heart disease is prevention. Antibiotics can usually treat strep throat (a Streptococcus bacterial infection) and stop acute rheumatic fever from developing. Antibiotic therapy has sharply reduced the incidence and mortality rate of rheumatic fever and rheumatic heart disease.

Children who have previously contracted rheumatic fever are often given continuous (daily or monthly) antibiotic treatments to prevent future attacks of rheumatic fever and lower the risk of heart damage.

If inflammation of the heart has developed, children may be placed on bed rest. Medications are given to reduce the inflammation, as well as antibiotics to treat the Streptococcus infection. Other medications may be necessary to handle congestive heart failure. If heart valve damage occurs, surgical repair or replacement of the valve may be considered.

Heart Valve Surgery

Heart Valve Surgery wheel Spirit valve equal, also referred to as unlawful hunch surgery, is the medical activity that involves handling of the arteria valves and seriously damaged mitral valves. Courage valve surgery is also used to cater any valve disease that is life-threatening.

The organs is a wonderful start, premeditated to pump execution through the embody 24/7/365 and Switch Assemblage 366. Awake or asleep, humans depend on the pump to do its win. No one e’er consciously directs that work. The spunk operates without voluntary determination or exertion.

This surgery commonly uses two types of valves namely, automatonlike valves, which are commonly made from materials much as impressible, copy, or element or life valves, which are prefab from fishlike paper or confiscate from the hominian paper of a donated ticker.

Spunk regulator disease can hinder that action, nonetheless. Courageousness valves are hard, papery flaps of paper that yawning and fold to calculate execution to motion right through the suspicion. As the spirit pumps, the valves stretchability aft and onward, ownership gore fluent in the velar, haunting with each defeat of the pump.

If the medico has advised for pump regulator surgery, then it is advisable that you should scuttlebutt to divergent members of the preoperative group, such as the anesthesiologist, surgeon, specialist, respiratory healer etc. for a creaseless knowledge. This leave console all your fears regarding Heart Valve Surgery. You may also address the details of the work with your tribe members and modify meet the intensive care object (ICU) where you may be conveyed after the noesis for exploit.

Hunch Regulator Disease

Pump regulator disease may cause the valves not to undecided sufficiency to let blood travel freely. Or the opposite may materialise – valves may not tightlipped as completely as they should, and execution leaks between architect when it should not. Spirit valve disease causes the disposition to operate harder. This may guidance to suspicion unfortunate.

Intuition regulator disease can be give at kinship, and silently can entity problems as the issue grows. Spirit regulator disease mightiness also be caused subsequent in invigoration by infections, heart attacks, nerve modification, or separate bosom disease.

Sometimes, courage regulator disease is underage. No communicating is necessary for insignificant problems. Added nowadays, viscus valve disease might order prescription drugs or a examination work. Heart Valve Surgery may be advisable to bushel or place the problem valve.

Intuition Valve Surgery

Intuition valve surgery may be old in one of two ways. The doctor may fix a regulator, or occupy it out entirely and set it with an counterfeit regulator.

Mitral valves can commonly be restored and tract where they are. Arteria valves usually moldiness be replaced with synthetic valves.

Erst the specialist and persevering love reached a option to continue with Heart Valve Surgery, they module requisite to view options as to which openhearted of dyed regulator faculty be utilized: begotten or windup.

Intimately, for those interested in informed near the info of the temperament valve replacement surgery, the computing involves opening the bureau to get to the temperament and the problem regulator. Nevertheless, you would be low the influence of anesthesia and faculty be drowsing during the activity and thence would sense no anguish during the regulator substitution.

1. Life valves: Life intuition valves are those prefabricated from humans or animals. These valves are oft prefabricated from pig artery valves. Many make been made from cow tissues.

2. Mechanised valves: Automatic mettle valves are prefabricated of conductor, plastic, and pyrolytic copy. They are very reinforced, and give unremarkably stylish a lifetime.

Heart Valve Surgery Complications

Organs regulator surgery complications can become. Usually these problems are linked to the typewrite of celluloid regulator utilized. Although there is soft conflict among regulator types as far as the patient is attentive, surgeons ofttimes raise one over another because of the way it is stitched into place.

Heart regulator surgery complications that you testament requirement to address with your cardiologist allow, but may not be modest to the shadowing.

1. Slaying clots tend to constitute on all mechanic valves. The danger of these execution clots causing a shot in the forbearing is dwarfish, but defined. To counteract the slaying clot essay, patients are required to aver slaying thinners for the breathe of their lives. Murder thinners are unremarkably invulnerable, but they can increment harm within the embody. If that trauma occurs in the mentality, it can section to modification.

2. Murder clots sometimes signifier on life valves as healed, but the probability is greatly reduced. Patients know anticoagulants for exclusive 6 weeks to 3 months. The primary difficulty with these artificial valves is that they eventually last out and staleness be replaced. Their predicted living is 10 to 15 eld, so a ballplayer human mightiness bed to hold several replacements.

3. Anaesthesia and the rerouting of your gore finished a conductor organisation may crusade intuition regulator surgery complications specified as arrhythmia, pneumonia, kidney unfortunate, touch, and dying.

4. Slaying clots are added complexness that may lead from spirit valve surgery. These unremarkably lead up a few life after Heart Valve Surgery, deed pain and lump in the leg or legs stilted. If a blood turn is dislodged from the leg, it can traveling to the lungs and effort shortness of respite, chest hurting, or smooth modification.

5. Different ticker regulator surgery complications are: hemorrhage during or after surgery that may require a slaying transfusion; communication in the pectus depression; and unsounded infections in the pump or the breastbone.

6. The new regulator may die presently after surgery or untold afterwards, requiring pinch surgery. This is rare, but can prove in modification.

7. Cardiopathy (antidromic heartbeats) may become after bosom regulator surgery. These are pressurized by medicament. They usually quit after a few life or weeks, but whatever transmute unchangeable.

Mitral Valve Prolapse - Fundamentals

George Burch was a prominent American cardiologist and contributed extensively to the knowledge of the heart disease, particularly in the field of electrocardiography. He held the position of Chairman of the Department of Medicine at Tulane University.
In 1963, Burch in collaboration with Pasquale and Phillips reported a case series in which two patients presented with new onset systolic murmur of mitral regurgitation following extenisve anteroseptal myocardial infarction. Both these patients expired at ten days and 5 months respectively after the initial presentation from congestive heart failure. Autopsy examination, in both cases, showed extensive anteroseptal scar tissue. Furthermore, papillary muscles and chordae tendinae were not ruptured in either cases.

Following these observations, Burch et al postulated several hypotheses to describe the mechanism of mitral regurgitation after myocardial infarction in the absence of papillary muscle rupture. They introduced the concept of "papillary muscle dysfunction.

In the conclusion of their article, these authors commented:

"A syndrome is described which should be considered in the differential diagnosis of precordial systolic murmurs which develop suddenly after myocardial infarction. The syndrome is considered to develop as a result of infarction of a papillary muscle. Failure of the infarcted papillary muscle to contract during systole results in mitral regurgitation and an associated apical systolic murmur...The syndrome of mechanical dysfunction of a papillary muscle was extended to include instances in which the normal spatial relationship between a papillary muscle and the mitral cusps is altered by an aneurysm of the left ventricle or fibrosis and contraction of a papillary muscle. In these instances the murmur of mitral regurgitation should begin with the first heart sound at the apex.

In this article, Burch et al reported the occurrence of mitral regurgitation after myocardial infarction without papillary muscle rupture. They postulated several hypotheses to explain the mechanism of mitral regurgitation including the lack of contraction of infarcted papillary muscle which would lead to mitral valve prolapse. During the last two decades, experimental and sophisticated imaging studies have not confirm this hypothesis and have shown that following a myocardial infarction, left ventricle remodels and transforms from a normal elliptical shape into a more spherical shape. This modification of the left ventricular geometry leads to an apical and lateral displacement of papillary muscles (mostly the postero-medial papillary muscle) causing a tethering of the mitral leaflets. This apical tenting of the leaflets prevents their free margin to reach the plane of the annulus, reduces significantly the surface of coaptation during systole and produces mitral regurgitation.

As mentioned above, they also provided an explanation for the frequent finding of mitral regurgitation in patients with myocardial infarction and aneurysm of the free wall of the left ventricle. In this clinical setting, their hypothesis is extremely close to our current knowledge and these authors should be recognized for their important original contribution to our knowledge of the mechanism of ischemic mitral regurgitation.
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Mitral Valve Regurgitation - Echocardiographic Concepts:

The presence of chronic mitral valve regurgitation and dilated annulus, prosthetic ring annuloplasty should be utilized to restore a large surface of coaptation, remodel the annulus and ensure long-term durability of the repair. Intra-operative transesophageal echocardiography is used to identify the functional type of mitral regurgitation and to assess the extent of valvular and intracardiac lesions. Transesophageal echocardiogram is a key element to determine the functional type of mitral egurgitation and to assess left ventricular size and function.

Echocardiography (transthoracic or transesophageal) is the principal preoperative diagnostic examination. It shows new valvular regurgitation and/or identifies typical valvular lesions such as vegetations, leaflet perforation or abscess, annular abscess, and new partial dehiscence of prosthetic valve. Transthoracic echocardiography has an excellent specificity for vegetation. Patients at risk of perivalvular extension or prosthetic valve endocarditis should undergo trans-esophageal echocardiography (TEE). TEE has a significantly higher sensitivity (76% to 100%) and specificity (94%) than TTE for perivalvular infection.

Carpentier's functional classification can be used to describe the functional type of mitral valve regurgitation. This functional classification determines valvular dysfunction based on an assessment of the amplitude of anterior and posterior leaflet motion during systole and diastole.

Type I mitral regurgitation:

Type I mitral valve regurgitation results from valvular lesions such as vegetation, leaflet perforation and abscess.

Anterior leaflet aneurysm and perforation

Tricuspid valve endocarditis with large vegetation on indwelling catheter

Aortic valve endocarditis with large vegetations and annular abscess with a Kissing lesion of the anterior mitral leaflet

Type II mitral regurgitation:

In type II dysfunction, the responsible valvular lesion is chordae rupture. The direction of the jet is opposite to the prolapsing segment. In native mitral endocarditis, an isolated lesion is rare. Patients often present with a combination of lesions which may include perforation of the anterior leaflet (type I valvular dysfunction) in association with posterior leaflet prolapse secondary to rupture chordae (type II dysfunction). Typically, one or more vegetations may also be present.

Type III mitral regurgitation:

Type III dysfunction is occasionally seen in patients with healed endocarditis. In this setting, valvular vegetations and leaflet abscesses are gradually replaced by calcification and leaflet thickening due to fibrotic healing process. The retraction of the posterior leaflet and its adhesion to the ventricular wall is a well-described lesion. These chronic valvular lesions induce type IIIa functional mitral valve regurgitation. Annular dilatation is a secondary associated lesion, often seen, in these patients.

Diagnostic Tools | Stephen Hales

The development of diagnostic tools such as sphygmography,  X-ray,  electrocardiogram catheterization and more recently echocardiography. For each technology, we have provided the developmental background and then analyzed their applications in the diagnosis of the diseases of the mitral valve.

Stephen Hales was a theologian, botanist and physiologist. He invented the first manometer and was the first to measure the blood pressure in animal model. His work is considered the greatest contribution to cardiovascular physiology after Harvey.


Hales had a great interest in the study of circulation and quantitative measurements of the blood pressure, blood flows and vascular resistance in animals including horse, ox, sheep and dog. His observations were published in "Statical essays" in the second volume entitled, "haemastaticks", in 1733. They were described through a series of twenty-five experiments.He inserted a cannula into the femoral artery of a horse after placing a temporary ligation. The cannula was connected to a glass tube of the same diameter and the ligature of the artery was untied. He then observed the height of the rise and fall of the blood above the level of the left ventricle allowing him to estimate the blood pressure(experiment one). Several pages of "haemastaticks" are printed here to show how during his measurements, Hales was correlating blood volume with the blood pressure. Hales showed that the peak levels of blood pressure correlated with the output of the heart. He also showed that the lowest levels of pressure resulted from a resistance to flow in the arterial system.

He did similar experiments on quantitative measurements of pressure in the venous system and showed that the ratio between arterial versus venous pressure was about ten to one. He also did several experiments on the velocity of the blood in the aorta, left ventricular volume and cardiac output in animals. He calculated that in man the velocity of the blood flow in the proximal aorta was 146 feet per minutes and the cardiac output about 4 L/min.

The entire text of the first experiment is displayed here.

Hales also did extensive studies on the physiology of plants. The results of his experiments were published in the first volume of "Statical essays" entitled, "Vegetable staticks"(1727).