Innovative Approaches to Mitral Valve Repair and Replacement Flashcards
What is the definition of minimally invasive valve surgery?
Any procedure to replace or repair a heart valve without a full sternotomy
It involves various techniques and technologies aimed at minimizing surgical trauma.
List some types of access used in minimally invasive valve surgery.
- Partial upper or lower sternotomy
- T or J transection of the sternum
- Mini-thoracotomy approaches
These techniques may use videoscopic or robotic assistance.
What are some reported advantages of minimally invasive valve surgery compared to open surgery?
- Shorter hospital stays
- Less postoperative pain
- More cosmetically acceptable incisions
- Lower infection rates
- Less use of blood products
- Better postoperative respiratory function
- Rapid return to baseline functional status
- Greater patient satisfaction
- Lower hospital costs
These advantages are similar to those seen in other minimally invasive techniques.
What are some concerns associated with minimally invasive valve surgery?
There is a tradeoff of limited exposure against surgical outcomes
This concern is particularly relevant with complex cardiac procedures.
What recent technologies have been developed for mitral valve procedures?
- Transcatheter mitral valve replacement
- Transcatheter mitral valve repair
- Micro-invasive procedures
These technologies aim to minimize invasiveness while addressing the complexities of the mitral valve.
Who was the first to successfully use cardiopulmonary bypass (CPB), and when?
John Gibbon in 1953
This advancement allowed for the correction of complex cardiac anomalies in a bloodless field.
What was the first documented minimally invasive approach to mitral valve disease?
A right parasternal incision attributed to Cosgrove and colleagues in 1996
This marked a significant advancement in minimally invasive heart surgery.
What are some techniques to establish CPB in minimally invasive valve surgery?
- Central aortic cannulation
- Peripheral cannulation via femoral, subclavian/axillary, or jugular vessels
- Hybrid cannulation strategies
These techniques may be used on an arrested, fibrillating, or beating heart.
Name a significant disadvantage of peripheral arterial cannulation.
Elevated incidences of vascular complications and stroke
However, some studies show similar outcomes between central and peripheral cannulation.
What is a recent advancement in visualization techniques for mitral valve surgery?
The use of 2-D and 3-D video thoracoscopic assistance
These advancements improve visualization and depth perception during surgery.
What is the most common surgical approach to the mitral valve?
Right mini-thoracotomy in the fourth or fifth intercostal space
This approach is preferred for its balance of invasiveness and exposure.
What preoperative assessments are important for minimally invasive mitral surgery?
- Complete history and physical exam
- Computed tomography (CT) imaging
These assessments help identify comorbidities and anatomical considerations.
What are some comorbidities of concern before minimally invasive mitral surgery?
- Significant lung disease
- History of chest trauma
- Peripheral vascular disease
- Aortic aneurysmal disease
- Coronary artery disease
Each of these can impact the safety and feasibility of the procedure.
True or False: Aortic calcification is a definitive contraindication to minimally invasive mitral surgery.
False
While it presents challenges, it does not definitively contraindicate the procedure.
Fill in the blank: The only definitive contraindication to a less-invasive approach is the inability to _______.
cannulate the patient safely
This highlights the importance of vascular accessibility in minimally invasive procedures.
What is a relative contraindication to minimally invasive mitral surgery?
Mitral annular calcification
This condition can complicate surgery and is difficult to repair even for experienced surgeons.
What is a relative contraindication in the context of mitral valve surgery?
A complication of atrioventricular disruption associated with mitral annular calcification that is difficult to repair.
What imaging techniques can identify features of mitral valve pathology?
Preoperative echocardiography and CT angiography.
Which additional valve disease is particularly important to consider in mitral valve surgery?
Aortic regurgitation.
What are the challenges associated with robotic mitral valve surgery?
More technically challenging and takes longer to learn.
What is the purpose of intubating the trachea with a double-lumen tube in robotic mitral valve surgery?
To facilitate ventilation management.
What is the standard patient positioning for robotic mitral valve surgery?
Right chest elevated with scapula roll, right arm hanging off the table.
Where is the endoscope port placed during robotic mitral valve surgery?
In the fourth intercostal space, 2–3 cm lateral to the nipple.
What technique is used for aortic occlusion in robotic mitral valve surgery?
Endoaortic balloon catheter.
What is a key difference in the setup for endoscopic mitral valve surgery compared to robotic surgery?
Rib spreading with an intercostal rib retractor is avoided.
What is the role of carbon dioxide in endoscopic mitral valve surgery?
To facilitate evacuation of air from the heart.
What is the purpose of transesophageal echocardiography (TEE) during mitral valve surgery?
To assess mitral valve size, left ventricular function, and atherosclerotic disease.
Fill in the blank: The preferred access site for cannulation in minimally invasive mitral valve surgery is the _______.
femoral platform.
What is the recommended technique for femoral venous cannulation?
Seldinger technique.
Which patient demographic shows significant benefit from minimally invasive mitral valve surgery?
Higher-risk patients, including those over 75 years old and those with chronic obstructive pulmonary disease (COPD).
What is the most common valvular disorder worldwide?
Mitral valve disease.
What are the two classifications of mitral regurgitation?
Primary (organic) and secondary (functional).
What is the most common cause of primary mitral regurgitation?
Degenerative diseases.
What condition is referred to as Barlow disease?
Myxomatous degeneration of the mitral valve.
What is the significance of the ‘forme fruste’ of Barlow disease?
Recognizes the spectrum of lesions in mitral valve pathology.
What is the primary surgical approach for treating mitral valve disease?
Surgical repair and replacement.
True or False: Medical therapy is the mainstay of treatment for mitral valve disease.
False.
What is the estimated incidence of new cases of severe mitral regurgitation per year?
250,000 new cases.
Which patients are often deemed too high risk for surgical correction of severe mitral regurgitation?
Patients with age, comorbidities, or severe left ventricular dysfunction.
What is Barlow disease characterized by?
Diffuse chordal elongation and rupture
Carpentier described a “forme fruste” of Barlow disease, recognizing the spectrum of lesions.
What causes fibroelastic disease leading to degenerative mitral regurgitation (MR)?
Deficiency of connective tissue
This results in a deficiency of collagen, elastins, and proteoglycans, causing leaflet thinning.
What are some additional causes of primary MR?
- Connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome)
- Osteogenesis imperfecta
- Pseudoxanthoma elasticum
- Endocarditis
- Rheumatic disease
- Radiation- or drug-induced valvulopathy
Rheumatic disease is the most prevalent cause of primary MR in developing countries.
What is the primary cause of secondary or functional MR?
Ventricular dysfunction due to dilation, diffuse hypokinesis, or segmental damage
This is often secondary to ischemic disease or dilated cardiomyopathy.
What anatomical changes occur in the ventricle that cause functional MR?
Displacement of papillary muscles in an outward and/or apical direction
This causes tethering of the leaflets, restricting closure.
What is the structure of the mitral valve (MV) apparatus composed of?
- Annulus
- Leaflets
- Chordae tendineae
- Papillary muscles
Understanding the structure is crucial for surgical and percutaneous approaches to MV repair and replacement.
What are the components of the MV leaflets?
- Anterior leaflet
- Posterior leaflet
The anterior leaflet has greater length but a narrower base than the posterior leaflet.
What does Carpentier’s classification of leaflet dysfunction include?
- Type I: Normal leaflet motion
- Type II: Excessive leaflet motion
- Type III: Restricted leaflet motion
Type III has further subdivisions: IIIa (leaflet thickening/retraction) and IIIb (papillary muscle displacement/leaflet tethering).
What is a common cause of functional MR with preserved left ventricular function?
Left atrial remodeling from atrial fibrillation
This leads to annular enlargement and MR.
What is the significance of grading the degree of MR?
It has limitations; a comprehensive process using multiple imaging techniques is essential
Techniques include transthoracic echocardiography (TTE), TEE, and Doppler color flow imaging.
What imaging technique provides better spatial resolution for assessing MR?
Transesophageal echocardiography (TEE)
TEE allows for more accurate MR quantification and 3-D visualization of the valve.
Why is it important to obtain an echocardiogram while the patient is not under anesthesia?
Loading conditions of the heart are not altered
This prevents the degree of regurgitation from being underestimated.
