Mitral Valve Repair

Case Study

Deborah Jeanne Warner November 10, 2010

Heart Valves-Four valves control the

direction of blood flow

-System of one-way doorsassure 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

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

Mitral Valve Anatomy

-Annulus: Fibrous ring

-Two leaflets: Valvular tissue

-Chordae tendineae

-Papillary muscles

Mitral Regurgitation

-Regurgitation/Insufficiency

-Result of incompetent valve-Doesn't close completely

-Blood leaks back into atriumduring systole

-MR increases the workload of the heart

-Complications-Cardiac arrhythmias -CHF-Irreversible heart damage

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

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

Diagnostic Studies

-Transthoracic Echocardiogram

-Transesophageal Echocardiogram

-Chest X-Ray

-EKG

-Holter monitor

-Cardiac Catheterization

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

Mitral Valve RepairAnnuloplasty

-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

Case StudyPatient Information

-Age/Gender: 76 year old male

-Hospital Admission on 5/27/10

-Current Symptoms:

-Dyspnea on exertion

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

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.

Patient History

-Medications at Admission:

-Aspirin 325 mg. daily

-Lotrel 5/10 one tablet daily

-Lipitor 20 mg. daily

Diagnostic StudyTransesophaegeal 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 venacontracta is 0.9 cm. No evidence of mitral stenosis.

Conclusions: Mitral valve appears repairable and annulus is dilated. MR is severe in several views.

Transesophageal Echo05/28/10

Transesophageal Echo05/28/10

Transesophageal Echo05/28/10

Diagnostic StudiesLeft 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

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

Pre and Post Op – TEE06/10/10

Pre and Post Op - TEE06/10/10

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)

Follow-upChest 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.

Follow-up Echo08/05/10

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.

Follow-up Echo08/05/10 - PLAX

Follow-up Echo08/05/10 – PSAX & MV Zoom

Follow-up Echo08/05/10 – Apical 2C

Follow-up Echo08/05/10 – Apical 4C

Follow-up Echo08/05/10

Before & After MV Repair

References DeWitt, S. 2009, Echocardiography...From a Sonographer's

Perspective (6th Edition), Camden Printing, St. Marys, GA

Drugs.com, “Prescription Drugs, Information, Interactions and Side Effects.”http://www.drugs.comAccessed 24 October 2010

MedicineNet.com, “Health and Medical Information.”http://www.medicinenet.comAccessed 24 October 2010

Wikipedia, “The Free Encyclopedia.”http://www.wikipedia.org/wiki/Mitral_valve; http://wikipedia.org/wiki/File:Heart_short_axis_view_papillary.jpgAccessed 22 October 2010

Pick, A., “The Patient's Guide to Heart Valve Surgery.”http://www.heart-valve-surgery.com/heart-valve-repair-valvuloplasty-annuloplasty.phpAccessed 29 October 2010

Mitral Valve Repair Center at The Mt. Sinai Hospital.http://www.mitralvalverepair.orgAccessed 30 October 2010

University of Maryland Medical Center, “Mitral Valve Repair Surgery.”http://umm.edu/heart/mitral.htmAccessed 31 October 2010

Cleveland Clinic, “Heart and Vascular Health.”http://my.clevelandclinic.org/heart/disorders/valve/mvrepair.aspxAccessed 30 October 2010

E-cardiography Journal, “Vena Contracta.”http://rwjms1.umdnj.edu/shindler/venacontracta.htmlAccessed 1 Novermber 2010