1. Valve Surgery V.Rohn

2. 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

3. Valve Surgery History With ECC 1960 – Harken – aortic valve replacement with the „ball and cage“ valve 1960 – Starr – replacement of the mitral valve

4. 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

5. Aortic Valve Stenosis Etiology –degenerative –congenital (bicuspid valve) –rheumatic Symptoms –angina pectoris –syncope –dyspnea

6. Aortic valve Anatomy

9. 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

11. Aortic valve regurgitation Etiology –multiple Symptoms –None - very long time –angina pectoris –dyspnea

12. 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

13. Aortic valve Replacement

15. Aortic root enlargement – Manougian, Nicks

19. Allograft, Pulmonary autograft

20. Percutaneous or transapical implantation – 1965 Davies Lancet 1965;62:926—9.

21. Endovascular or transapical AVR

22. 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

23. Aortic Valve Repair

24. 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

25. Mitral stenosis percutaneous balloon valvuloplasty „closed“ commissurotomy „open“ commissurotomy replacement

26. Mitral stenosis – open commissurotomy

27. Mitral stenosis – closed commissurotomy

28. Mitral regurgitation Etiology rheumatic Degenerative mitral regurg. (fibroelastic, myxomatous, Barlow disease) Ischemic symptoms –dyspnea –a.fib., embolization

29. 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

30. Mitral valve - anatomy

32. Mitral valve repair – Valve Exposure

34. Mitral valve repair- quadrangular resection of the posterior leaflet

38. Chordal transfer

39. Ischemic Mitral Regurgitation

41. Undersized Annuloplasty

42. Tricuspid valve

43. 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

44. 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.

45. De Vega plasty

46. Rings and Bands

47. Tricuspid valve repalcement

48. Valve Prosthesis biological mechanical homograft autograft

49. Mechanical vs biological lifelong anticoagulation therapy degeneration

51. ESC guidelines 2007