1. Mitral Valve Repair Case Study Deborah Jeanne Warner November 10, 2010

2. Heart Valves -Four valves control the direction of blood flow -System of one-way doors assure 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

3. 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

4. Mitral Valve Anatomy -Annulus: Fibrous ring -Two leaflets: Valvular tissue -Chordae tendineae -Papillary muscles

6. Mitral Regurgitation -Regurgitation/Insufficiency -Result of incompetent valve -Doesn't close completely -Blood leaks back into atrium during systole -MR increases the workload of the heart -Complications - Cardiac arrhythmias -CHF -Irreversible heart damage

7. 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

8. 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

9. Diagnostic Studies -Transthoracic Echocardiogram -Transesophageal Echocardiogram -Chest X-Ray -EKG -Holter monitor -Cardiac Catheterization

10. 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

11. Mitral Valve Repair Annuloplasty -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

12. Case Study Patient Information -Age/Gender: 76 year old male -Hospital Admission on 5/27/10 -Current Symptoms: -Dyspnea on exertion

13. 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

14. 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.

15. Patient History -Medications at Admission: -Aspirin 325 mg. daily -Lotrel 5/10 one tablet daily -Lipitor 20 mg. daily

16. Diagnostic Study Transesophaegeal 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 vena contracta is 0.9 cm. No evidence of mitral stenosis. Conclusions: Mitral valve appears repairable and annulus is dilated. MR is severe in several views.

17. Transesophageal Echo 05/28/10

20. Diagnostic Studies Left 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

21. 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

22. Pre and Post Op – TEE 06/10/10

23. Pre and Post Op - TEE 06/10/10

24. 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)

25. Follow-up Chest 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.

26. Follow-up Echo 08/05/10 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.

27. Follow-up Echo 08/05/10 - PLAX

28. Follow-up Echo 08/05/10 – PSAX & MV Zoom

29. Follow-up Echo 08/05/10 – Apical 2C

30. Follow-up Echo 08/05/10 – Apical 4C

31. Follow-up Echo 08/05/10

32. Before & After MV Repair

33. References DeWitt, S. 2009, Echocardiography...From a Sonographer's Perspective (6 th Edition), Camden Printing, St. Marys, GA Drugs.com, “Prescription Drugs, Information, Interactions and Side Effects.” http://www.drugs.com Accessed 24 October 2010 http://www.drugs.com MedicineNet.com, “Health and Medical Information.” http://www.medicinenet.com Accessed 24 October 2010 http://www.medicinenet.com Wikipedia, “The Free Encyclopedia.” http://www.wikipedia.org/wiki/Mitral_valve; http://wikipedia.org/wiki/File:Heart_short_axis_view_papillary.jpg Accessed 22 October 2010 http://www.wikipedia.org/wiki/Mitral_valvehttp://wikipedia.org/wiki/File:Heart_short_axis_view_papillary.jpg Pick, A., “The Patient's Guide to Heart Valve Surgery.” http://www.heart-valve-surgery.com/heart-valve-repair-valvuloplasty-annuloplasty.php Accessed 29 October 2010 http://www.heart-valve-surgery.com/heart-valve-repair-valvuloplasty-annuloplasty.php Mitral Valve Repair Center at The Mt. Sinai Hospital. http://www.mitralvalverepair.org Accessed 30 October 2010 http://www.mitralvalverepair.org University of Maryland Medical Center, “Mitral Valve Repair Surgery.” http://umm.edu/heart/mitral.htm Accessed 31 October 2010 http://umm.edu/heart/mitral.htm Cleveland Clinic, “Heart and Vascular Health.” http://my.clevelandclinic.org/heart/disorders/valve/mvrepair.aspx Accessed 30 October 2010 http://my.clevelandclinic.org/heart/disorders/valve/mvrepair.aspx E-cardiography Journal, “Vena Contracta.” http://rwjms1.umdnj.edu/shindler/venacontracta.html Accessed 1 Novermber 2010 http://rwjms1.umdnj.edu/shindler/venacontracta.html