10. MItral Valve Repair Flashcards
Benefits of Mitral Repair vs Replacement
- Preservation of LV function through preservation of chordal attachments
- Low rates of thromboembolism and endocarditis
- Lack of requirement for anticoagulation
- Excellent durability
Indications to repair Mitral Stenosis
- NYHA Class 3 or 4 + AVA <1.5cm^2
2. NYHA Class 2 + severe stenosis
Indications to repair Mitral Regurgitation
- NYHA Class 2 or greater + severe MR
2. Asymptomatic + severe MR + LV dysfunction
Repair of structural MR
- Type 2 lesions (excessive motion) most amenable to repair
- P2 prolapse, small anterior defects easiest
- Multiple segment prolapse and restricted motion make repair less favorable
- Ruptured papillary muscle 2/2 MI is rarely repairable
Repair of functional MR
- Majority are ischemic (post MI)
- Combined CABG/MVR significantly increases mortality vs CABG alone
Arguments for intervention
- MR may hinder proper LV remodeling
- even mild MR a negative prognostic indicator in setting of CHF or post MI
- repair of structural MR in similar patients is of great benefit
Outcomes of repair of structural MR
- Best results with isolated posterior leaflet prolapse repair + ring
- Residual 2+ or more MR at end of case decreases durability or repair
Outcomes of repair of functional MR
- Severe ischemic MR should be addressed at time of CABG
- Unknown if repair of 3+ MR or less should be repaired
- Similar outcomes vs no repair
- Increased hospital mortality of CABG/MVR
Normal mitral annulus diameter
3.0 - 3.8 cm in five-chamber view
> 4cm = dilated
Risk of SAM s/p MV repair
Higher risk if:
Anterior leaflet/Posterior leaflet length <2.5cm
- Sliding leaflet procedure repair will minimize this risk
Isolated MV P2 prolapse repair
- Often quadrangular resection
- Best lesion to repair
MV Anterior leaflet prolapse repair
- Resection not reliable unless very small lesion
- Usually requires chordal transfer, chordal-shortening or artificial chord placement
MV Bileaflet prolapse repair
- Combines quadrangular resection with chord transfer/shortening
MV Papillary muscle rupture repair
- Papillary muscle can be moved to adjacent tissue, but if necrotic, valve must be replaced
Repair of non-ischemic MR
- Can be repaired with small ring, forcing dilated and restricted leaflets to coapt
- Best repair controversial
- Often requires replacement
- Unresolved if repair is better than replacement in ischemia MR (unlike non-ischemic MR)
Risks of calcified mitral annulus
- ventricular rupture
- damage to circumflex artery
- postoperative perivalvular MR
