Mitral valve repair Anatomy Mitral Stenosis Opening of

Mitral Stenosis Opening of the valve is narrowed. Normal valve opening 4 -6 cm

Pathophysiology • • High pressure in left atrium and lungs. Increase work of right

Causes of Mitral Stenosis • Rheumatic fever. • Congenital.

Rheumatic fever • Immune complexes. (Strep throat/ renal infections) • Slow process. • Repeated

Indication for surgery • Valve opening area < 1. 5 cm sq. • Gradient

Mitral Incompetence • • Valve does not close properly. Blood flows back into the

Aetiology • • • Rheumatic Fever. Endocarditis Barlow's syndrome. (Floppy valve) Ischemia. Congenital. Cardiomyopathy.

Carpentier classification • Type 1 - Normal leaflet movement, annular dilatation. (cardiomyopathy) • Type

Surgery • • • General anaesthesia. TEE on board. Cardio-pulmonary bypass. Cell saver. Repair

Type 2 – Valve prolapse • • To much thickened leaflet. Stretched out chordae.

Artificial chordoplasty and cleft repair

Type 3 b- Ischaemic incompetence • Valve dysfunction because of impaired coronary blood flow.

Mitral valve replacement • Native valve removed. • Mechanical or Tissue prosthesis.

Mechanical mitral valve replacement • • Surgical mortality Bleeding risk Thrombo-embolism Endocarditis 2% -

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Mitral valve repair

Anatomy

Mitral Stenosis Opening of the valve is narrowed. Normal valve opening 4 -6 cm sq. Symptoms 2 -2. 5 cm sq. Severe < 1 cm sq.

Pathophysiology • • High pressure in left atrium and lungs. Increase work of right ventricle. Atrial fibrillation. (palpitations) Stroke.

Causes of Mitral Stenosis • Rheumatic fever. • Congenital.

Rheumatic fever • Immune complexes. (Strep throat/ renal infections) • Slow process. • Repeated attacks. • Replacement.

Indication for surgery • Valve opening area < 1. 5 cm sq. • Gradient > 12 mm. Hg.

Mitral Incompetence • • Valve does not close properly. Blood flows back into the left atrium. Volume overload of left ventricle. Left ventricular failure.

Aetiology • • • Rheumatic Fever. Endocarditis Barlow's syndrome. (Floppy valve) Ischemia. Congenital. Cardiomyopathy.

Carpentier classification • Type 1 - Normal leaflet movement, annular dilatation. (cardiomyopathy) • Type 2 - Increased leaflet movement, prolapsing segments. (Barlow's) • Type 3 a- Restricted leaflet movement. ( Rheumatic) • Type 3 b- Ischaemic leaflet retraction

Surgery • • • General anaesthesia. TEE on board. Cardio-pulmonary bypass. Cell saver. Repair before replace.

Type 1: Annulus dilatation

Remodelling annuloplasty

Type 2 – Valve prolapse • • To much thickened leaflet. Stretched out chordae. Elongated papillary muscles. Leaflet prolaps.

Mitral valve segments

Quadrangular excision repair

TEE- Post repair

Triangular excision repair

Artificial chordoplasty

Artificial chordoplasty and cleft repair

Type 3 a- Rheumatic valves

Type 3 b- Ischaemic incompetence • Valve dysfunction because of impaired coronary blood flow. • Posterior leaflet retraction. (P 3 area) • Needs to be fixed > moderate incompetence. • Remodelling annuloplasty.

Mitral valve replacement • Native valve removed. • Mechanical or Tissue prosthesis.

Mechanical prosthesis

Tissue prosthesis

Mechanical mitral valve replacement • • Surgical mortality Bleeding risk Thrombo-embolism Endocarditis 2% - 4% 1%/year 0. 1%/year

Clotted mitral valve

Pannus ingrowth

Minimally invasive mitral surgery

The future- Robotic surgery