valve surgery v.rohn. valve surgery history before the era of ecc 1925 – suttar – first...
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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