Mitral valve repair Prof Alain Carpentier is considered the modern day father of MV repair. His publication in the 1980’s called the French correction changed the way surgeons treated mitral valve disease. The aim is to repair a valve rather than replace it if at all possible and this talk is just to show you in short what can be done. Prof Carpentier is a famous French surgeon and also the first to implant an total artificial heart into a human in Europe.

Anatomy Situated between the left atrium and left ventricle. This valve opens to let blood through from the atrium to the ventricle and when the heart contracts the mitral valve closes to let the blood through the aortic valve into the aorta and then flow to the body. Close relation to the aortic valve.

Consists of 1) Annulus 2) Leaflets 3)subvalvular apparatus Disease cause stenosis, incompetence or combination.

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 > 12mmHg.

Attacks all parts of the valve.

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 3a- Restricted leaflet movement. ( Rheumatic) Type 3b- Ischaemic leaflet retraction

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

Type 1: Annulus dilatation The aim is to restore the annulus into as normal shape as possible by using an annuloplasty ring, like this one.

Remodelling annuloplasty The ring reduces the annular size so that the leaflets can oppose better that makes the valve competent.

That is what it looks like in real life.

Type 2 – Valve prolapse To much thickened leaflet. Stretched out chordae. Elongated papillary muscles. Leaflet prolaps. Barlow's disease is common in this group. It causes thickened and floppy valve leaflets that do not close properly and cause the valve to leak.

Mitral valve segments Any part of the valve leaflets can be involved.

Quadrangular excision repair In this case it is the p2,or middle part of the post leaflet. This is fixed by the quadrangular excision of the affected area, sewing up of the resected area and putting in a annuloplasty ring.

This is a similar case that we did at Vergelegen This is a similar case that we did at Vergelegen. These are TEE pictures of the mitral valve before surgery.

TEE- Post repair So we did exactly the same repair as described earlier and got a excellent competent valve.

This is a picture of the same repair with a 3-d echo This is a picture of the same repair with a 3-d echo. This is some of the latest echo technology that we have available at Vergelegen

Triangular excision repair There are many other repair technics as demonstrated here. I will show you only a few.

Artificial chordoplasty This is a repair of elongated or ruptured chordae. Artificial chordae is made with gortex sutures. This is placed from the papillary muscle to the free edge of the leaflet.

Artificial chordoplasty and cleft repair

Type 3a- Rheumatic valves This is unfortunately by far the most common valve problem we see in S.A. It looks like there are more problems than solutions. Unfortunately less than 20% of these valves can be repaired and so the majority needs replacement.

Type 3 b- Ischaemic incompetence Valve dysfunction because of impaired coronary blood flow. Posterior leaflet retraction. (P3 area) Needs to be fixed > moderate incompetence. Remodelling annuloplasty.

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

Mechanical prosthesis The patient needs to take warfarin,( which is a blood thinning agent) for the rest of their lives. But this valve can potentially last a lifetime.

Tissue prosthesis This can be either a bovine or porcine valve. No warfarin is needed with this type of valve, but this valve can calcify like the native valve over time and is only considered in patients over the age of 60.

Mechanical mitral valve replacement Surgical mortality 2% - 4% Bleeding risk 1%/year Thrombo-embolism 1%/year Endocarditis 0.1%/year

Clotted mitral valve

Pannus ingrowth

Minimally invasive mitral surgery This is a new technique to do mitral valve surgery. The incision is small and on the side of the chest instead of a normal midline incision. This TECHNIQUE CAN NOT BE USED FOR ALL PATIENS.

The future- Robotic surgery This is called the Da Vinci system. Don’t worry the patient is asleep .The idea is that the surgeon performing the procedure does not have to be in the theatre. He is doing the op via remote control of these robotic arms . Although this is a reality it is still not widely used mainly because it is time consuming (that could be bad for the patient), and certainly not cost effective yet.