Patients undergoing mitral valve reconstruction often require additional procedures to address the following associated disorders: left atrial thrombus formation, atrial calcification, giant left atrium, and atrial fibrillation. LEFT ATRIAL THROMBUS FORMATION Thrombus formation in the left atrium ( Fig. 16-1 ) is frequently observed in long-lasting rheumatic valvular disease, triggered enlarged left atrium, atrial fibrillation, endocardial lesions, and low cardiac output. In degenerative valvular disease, atrial…

The term “Systolic Anterior Motion” (SAM) defines a systolic displacement of the distal portion of the anterior leaflet of the mitral valve towards the outflow tract of the left ventricle (LV). This abnormal motion, first described in “muscular subvalvular aortic stenosis,” has two possible consequences: left ventricular outflow tract (LVOT) obstruction and mitral valve regurgitation ( Fig. 15-1 ). Open full size image FIGURE 15-1 SAM…

The most important functional characteristic of type IIIb dysfunction, compared to type IIIa, is a pure systolic restricted leaflet motion with preserved leaflet pliability. The most common causes of this dysfunction are ischemic myocardial disease, idiopathic dilated cardiomyopathy, and end-stage heart disease from other causes. The functional “trait commun” * * See Glossary . of these different etiologies is the tethering of the mitral valve leaflets…

The great majority of valvular diseases with diastolic-restricted leaflet motion have a rheumatic origin. The limitation of the motion of the leaflets is due to commissural fusion, leaflet thickening, chordae fibrosis, and occasionally calcifications. These lesions produce either pure mitral valve stenosis or mitral regurgitation or combined valve stenosis and regurgitation. VALVE STENOSIS Mitral valve stenosis was the first mitral valve dysfunction to be treated surgically…

A commissural leaflet prolapse is a valve dysfunction typically seen in bacterial endocarditis or in degenerative valvular diseases. The cause of the prolapse is either chordae rupture in bacterial endocarditis or chordae elongation in degenerative diseases. The extent of the prolapse can be defined as limited or extensive. A limited prolapse involves the commissural leaflet and measures 5 mm or less of the leaflet margin (…

Type II posterior leaflet dysfunction is the most frequent dysfunction in mitral valve regurgitation caused by degenerative valvular disease. It can also be encountered in other etiologies such as bacterial endocarditis, and even rheumatic valvular disease in young children. The prolapse usually affects P2 but can be extended to P3 and more rarely P1. It is generally due to chordae rupture and/or elongation. A special feature…

Normal mitral valve function implies that the free edge of the leaflets remains at the same level and 5 to 10 mm below the plane of the orifice during systole to ensure proper leaflet coaptation and valve competency. Leaflet prolapse (or functional type II) is a valve dysfunction in which the free edge of a leaflet overrides the plane of the mitral orifice during systole .…

Besides annular dilatation, the mitral valve annulus can be severely affected by other specific pathological processes, such as extensive calcification or abscesses. In rare circumstances, the annulus may present either a post-traumatic or an idiopathic pseudoaneurysm. These lesions are frequently associated with other valvular or subvalvular lesions, which should be addressed during the same operative procedure. The annulus itself requires specific techniques of reconstruction, the surgical…

In the early years of valve surgery, annular dilatation was considered the primary cause of mitral valve regurgitation. With the exception of McGoon's techniques of posterior leaflet plication, the usual repair techniques involved pledgetted sutures placed at the commissures or fabric bands supporting the annulus, in such a manner that the mitral valve orifice was constricted arbitrarily to two finger breaths and the posterior leaflet advanced…

MITRAL VALVE EXPOSURE After extracorporeal circulation has been instituted, adequate exposure of the mitral valve is mandatory to perform a safe and effective operation. Pericardial adhesions, if present, are released up to the apex. The interatrial approach is used in most instances ( Fig. 7-1 ). It provides better access to the mitral valve than the classic direct atrial approach and less damage than Dubost's biatrial…

Since Général Baron Nicolas Corvisart, Napoléon's physician, recognized that heart failure may be due to mitral valve regurgitation following chordae rupture, multiple studies have emphasized the extreme complexity of the pathophysiology of the mitral valve. The pathophysiological triad and functional classification, briefly introduced in Chapter 2 , can help overcome this complexity. According to the triad, the description of mitral valve disease is facilitated by a…

The anatomy of heart valves is usually described with respect to transverse or longitudinal sections of the heart, which provide optimal viewpoints of the heart's different structures ( Fig. 5-1 ). These anatomical views have limited practical value to surgeons because during an operation surgeons observe the mitral valve from the left atrium. The purpose of this chapter is therefore to describe the surgical anatomy of…

In the operating room, standard monitoring techniques (e.g., central venous line, arterial line, bladder catheter) are used. Swan-Ganz catheter monitoring is useful in high-risk patients with elevated pulmonary pressure or depressed ventricular function. An external defibrillator is placed in mini-invasive surgery, right thoracotomy, and redo operations. A double-lumen endotracheal tube is used in patients undergoing a right thoracotomy approach. CO 2 insufflation (4 L/min) is instituted…

Sound perioperative management of the patient undergoing a valve operation requires careful attention to details to ensure an optimal outcome. PREOPERATIVE INVESTIGATIONS All patients undergoing valvular surgery should have a complete workup including clinical examination, chest x-ray, transthoracic echocardiography, and anesthesia consultation. In addition, laboratory tests are used to detect any biological or bacteriological anomalies. In diabetic patients, it is important to assess the effectiveness of…

During the cardiac cycle the heart's four valves ( Fig. 2-1 ) channel blood flow in a single direction: from the atria to the ventricles and from the ventricles to the aorta and pulmonary artery. The numerous diseases that can alter the structure and function of these valves should be identified by a process of “valve analysis” involving cardiologists and surgeons. The challenge is to establish…