mitral valve repair case study deborah jeanne warner november 10, 2010
TRANSCRIPT
Mitral Valve Repair
Case Study
Deborah Jeanne Warner November 10, 2010
Heart Valves-Four valves control the
direction of blood flow
-System of one-way doorsassure unidirectional flow through chambers
-AV valves control flow of oxygen depleted blood from body to lungs
-SL valves control flow of oxygen rich blood from lungs to body
The Mitral Valve
-Mitral valve: between left atrium & ventricle
-Diastole: blood leaves the atria, flows through open mitral valve and into ventricle
-Pressure in ventricle increases, closing MV
-Prevents blood leaking back into the atrium during systole
-Assures the blood in left ventricle will be ejected through aortic valve into aorta to supply oxygenated blood to body
Mitral Valve Anatomy
-Annulus: Fibrous ring
-Two leaflets: Valvular tissue
-Chordae tendineae
-Papillary muscles
Mitral Regurgitation
-Regurgitation/Insufficiency
-Result of incompetent valve-Doesn't close completely
-Blood leaks back into atriumduring systole
-MR increases the workload of the heart
-Complications-Cardiac arrhythmias -CHF-Irreversible heart damage
Causes of MR
-Rheumatic fever-Annulus dilatation-Mitral annular calcification-Leaflets that are flail, prolapse and/or stenotic-Endocarditis-Chordae tendineae elongation or rupture-Papillary muscle fibrosis, calcification, or rupture-Prior myocardial infarction-Prosthetic valve dysfunction-Congenital anomalies-Age related wear and tear
Signs and Symptoms
Will depend on the severity and cause:
-Fatigue-Decreased exercise capacity-Dyspnea-Orthopnea-Supraventricular arrhythmias (Atrial Fib)-Palpitations-Lightheadedness-High pitched systolic murmur
Diagnostic Studies
-Transthoracic Echocardiogram
-Transesophageal Echocardiogram
-Chest X-Ray
-EKG
-Holter monitor
-Cardiac Catheterization
Treatment for Mitral Regurgitation
-Surgery is the only proven treatment
-Preferred surgery is repair of the native valve
-Advantages of MV repair over replacement-Lower mortality at the time of operation-Significantly lower risk of stroke, and lower rate
of infection-Improved long term survival-Better preservation of heart function-Blood thinners not required-Same survival curve as normal population-Improved quality of life
Mitral Valve RepairAnnuloplasty
-Annuloplasty: Technique that repairs annulus
-If annulus is dilated, leaflets unable to coapt
-Result is MR
-Sutures sewn round ring
-Annuloplasty ring provides additional support
Case StudyPatient Information
-Age/Gender: 76 year old male
-Hospital Admission on 5/27/10
-Current Symptoms:
-Dyspnea on exertion
Physical Examination
-5/27/2010:
-Blood Pressure: 157/86
-Heart Rate: 48
-Respiratory Rate: 16
-Lungs: Clear
-Heart: Grade II/VI systolic murmur heard, cardiac sounds and S2 are normal
-Abdomen: Soft, non-tender
-Extremities: No edema
Patient History
-Medical History:
-Coronary Artery Disease:1/2009-Stent placed in RCA
-Dyslipidemia
-Hypertension
-Episodes of bradycardia and ventricular ectopy
-Mild COPD
-Previous echocardiogram (TTE) on 1/21/2009:Preserved systolic function with mild mitral leaflet calcification, moderate mitral regurgitation, left atrium moderately enlarged.
Patient History
-Medications at Admission:
-Aspirin 325 mg. daily
-Lotrel 5/10 one tablet daily
-Lipitor 20 mg. daily
Diagnostic StudyTransesophaegeal Echo
Findings on 5/28/10:-Left Ventricle: Chamber size, wall motion, contractility and LV function are normal-Left Atrium: Moderately enlarged-Right Ventricle: Chamber size and function normal-Right Atrium: Cavity size is normal-Mitral Valve: Mild mitral leaflet calcification. Severe mitral regurgitation observed. The mitral valve venacontracta is 0.9 cm. No evidence of mitral stenosis.
Conclusions: Mitral valve appears repairable and annulus is dilated. MR is severe in several views.
Transesophageal Echo05/28/10
Transesophageal Echo05/28/10
Transesophageal Echo05/28/10
Diagnostic StudiesLeft heart catheterization
-Coronary angiogram on 6/9/10:
– Left main trunk is normal
– Left anterior descending has mild disease of 40% in the mid LAD
– Circumflex ostial 50% narrowed followed by 100% occlusion of the circumflex
– Right Coronary artery - mild plaquing of 20% in the proximal to mid segment
– Conclusion: Mild to Moderate coronary disease
Mitral Valve Repair
-Diagnosis: Severe Mitral Regurgitation
-6/10/10: Patient had surgery to repair MV
-Intraoperative TEE confirmed severe MR
-Intraoperative inspection of the mitral valve
-Surgical repair of mitral valve via ring annuloplasty was performed. Anterior leaflet sized to a 28 mm St. Jude ring.
-Excellent coaptation of the anterior-posterior leaflet upon completion of repair.
-Postoperative TEE – no residual MR
Pre and Post Op – TEE06/10/10
Pre and Post Op - TEE06/10/10
Hospital Course
-Mitral valve repair with ring annuloplasty
-Thoracentesis of right pleural effusion
-Burst of atrial fibrillation
-Nephrology consult for renal dysfunction
-Discharge medications:-Aspirin 325 mg daily (Anti-thrombotic)-Plavix 75 mg daily (Anti-platelet) -Furosemide 40 mg. Daily (Loop diuretic)-Metoprolol 25 mg b.i.d. (Beta Blocker)
Follow-upChest X Ray
-08/05/10 -PA and LAT views of chest
-Impression:1) There is mild cardiomegaly.
2) Overall improvement of the bilateral pulmonary infiltrates most likely related to pneumonia or asymmetric pulmonary edema.
3) Stable bilateral pleural effusions.
Follow-up Echo08/05/10
Findings:
-Left ventricle chamber size and systolic function are normal.-Moderate bilateral atrial enlargement.-Right ventricle cavity size and systolic function are normal.-Mild aortic leaflet calcification is visualized.-Mitral valve leaflets are mildly thickened. (mitral valve has been repaired previously) There is
mild mitral regurgitation observed with no evidence of mitral stenosis.
Follow-up Echo08/05/10 - PLAX
Follow-up Echo08/05/10 – PSAX & MV Zoom
Follow-up Echo08/05/10 – Apical 2C
Follow-up Echo08/05/10 – Apical 4C
Follow-up Echo08/05/10
Before & After MV Repair
References DeWitt, S. 2009, Echocardiography...From a Sonographer's
Perspective (6th Edition), Camden Printing, St. Marys, GA
Drugs.com, “Prescription Drugs, Information, Interactions and Side Effects.”http://www.drugs.comAccessed 24 October 2010
MedicineNet.com, “Health and Medical Information.”http://www.medicinenet.comAccessed 24 October 2010
Wikipedia, “The Free Encyclopedia.”http://www.wikipedia.org/wiki/Mitral_valve; http://wikipedia.org/wiki/File:Heart_short_axis_view_papillary.jpgAccessed 22 October 2010
Pick, A., “The Patient's Guide to Heart Valve Surgery.”http://www.heart-valve-surgery.com/heart-valve-repair-valvuloplasty-annuloplasty.phpAccessed 29 October 2010
Mitral Valve Repair Center at The Mt. Sinai Hospital.http://www.mitralvalverepair.orgAccessed 30 October 2010
University of Maryland Medical Center, “Mitral Valve Repair Surgery.”http://umm.edu/heart/mitral.htmAccessed 31 October 2010
Cleveland Clinic, “Heart and Vascular Health.”http://my.clevelandclinic.org/heart/disorders/valve/mvrepair.aspxAccessed 30 October 2010
E-cardiography Journal, “Vena Contracta.”http://rwjms1.umdnj.edu/shindler/venacontracta.htmlAccessed 1 Novermber 2010