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Valvular Heart Disease > Innovative Approaches to Mitral Valve Repair and Replacement > Flashcards

Innovative Approaches to Mitral Valve Repair and Replacement Flashcards

1
Q

What is the definition of minimally invasive valve surgery?

A

Any procedure to replace or repair a heart valve without a full sternotomy

It involves various techniques and technologies aimed at minimizing surgical trauma.

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2
Q

List some types of access used in minimally invasive valve surgery.

A
  • Partial upper or lower sternotomy
  • T or J transection of the sternum
  • Mini-thoracotomy approaches

These techniques may use videoscopic or robotic assistance.

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3
Q

What are some reported advantages of minimally invasive valve surgery compared to open surgery?

A
  • 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.

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4
Q

What are some concerns associated with minimally invasive valve surgery?

A

There is a tradeoff of limited exposure against surgical outcomes

This concern is particularly relevant with complex cardiac procedures.

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5
Q

What recent technologies have been developed for mitral valve procedures?

A
  • 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.

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6
Q

Who was the first to successfully use cardiopulmonary bypass (CPB), and when?

A

John Gibbon in 1953

This advancement allowed for the correction of complex cardiac anomalies in a bloodless field.

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7
Q

What was the first documented minimally invasive approach to mitral valve disease?

A

A right parasternal incision attributed to Cosgrove and colleagues in 1996

This marked a significant advancement in minimally invasive heart surgery.

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8
Q

What are some techniques to establish CPB in minimally invasive valve surgery?

A
  • 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.

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9
Q

Name a significant disadvantage of peripheral arterial cannulation.

A

Elevated incidences of vascular complications and stroke

However, some studies show similar outcomes between central and peripheral cannulation.

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10
Q

What is a recent advancement in visualization techniques for mitral valve surgery?

A

The use of 2-D and 3-D video thoracoscopic assistance

These advancements improve visualization and depth perception during surgery.

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11
Q

What is the most common surgical approach to the mitral valve?

A

Right mini-thoracotomy in the fourth or fifth intercostal space

This approach is preferred for its balance of invasiveness and exposure.

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12
Q

What preoperative assessments are important for minimally invasive mitral surgery?

A
  • Complete history and physical exam
  • Computed tomography (CT) imaging

These assessments help identify comorbidities and anatomical considerations.

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13
Q

What are some comorbidities of concern before minimally invasive mitral surgery?

A
  • 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.

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14
Q

True or False: Aortic calcification is a definitive contraindication to minimally invasive mitral surgery.

A

False

While it presents challenges, it does not definitively contraindicate the procedure.

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15
Q

Fill in the blank: The only definitive contraindication to a less-invasive approach is the inability to _______.

A

cannulate the patient safely

This highlights the importance of vascular accessibility in minimally invasive procedures.

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16
Q

What is a relative contraindication to minimally invasive mitral surgery?

A

Mitral annular calcification

This condition can complicate surgery and is difficult to repair even for experienced surgeons.

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17
Q

What is a relative contraindication in the context of mitral valve surgery?

A

A complication of atrioventricular disruption associated with mitral annular calcification that is difficult to repair.

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18
Q

What imaging techniques can identify features of mitral valve pathology?

A

Preoperative echocardiography and CT angiography.

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19
Q

Which additional valve disease is particularly important to consider in mitral valve surgery?

A

Aortic regurgitation.

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20
Q

What are the challenges associated with robotic mitral valve surgery?

A

More technically challenging and takes longer to learn.

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21
Q

What is the purpose of intubating the trachea with a double-lumen tube in robotic mitral valve surgery?

A

To facilitate ventilation management.

22
Q

What is the standard patient positioning for robotic mitral valve surgery?

A

Right chest elevated with scapula roll, right arm hanging off the table.

23
Q

Where is the endoscope port placed during robotic mitral valve surgery?

A

In the fourth intercostal space, 2–3 cm lateral to the nipple.

24
Q

What technique is used for aortic occlusion in robotic mitral valve surgery?

A

Endoaortic balloon catheter.

25
Q

What is a key difference in the setup for endoscopic mitral valve surgery compared to robotic surgery?

A

Rib spreading with an intercostal rib retractor is avoided.

26
Q

What is the role of carbon dioxide in endoscopic mitral valve surgery?

A

To facilitate evacuation of air from the heart.

27
Q

What is the purpose of transesophageal echocardiography (TEE) during mitral valve surgery?

A

To assess mitral valve size, left ventricular function, and atherosclerotic disease.

28
Q

Fill in the blank: The preferred access site for cannulation in minimally invasive mitral valve surgery is the _______.

A

femoral platform.

29
Q

What is the recommended technique for femoral venous cannulation?

A

Seldinger technique.

30
Q

Which patient demographic shows significant benefit from minimally invasive mitral valve surgery?

A

Higher-risk patients, including those over 75 years old and those with chronic obstructive pulmonary disease (COPD).

31
Q

What is the most common valvular disorder worldwide?

A

Mitral valve disease.

32
Q

What are the two classifications of mitral regurgitation?

A

Primary (organic) and secondary (functional).

33
Q

What is the most common cause of primary mitral regurgitation?

A

Degenerative diseases.

34
Q

What condition is referred to as Barlow disease?

A

Myxomatous degeneration of the mitral valve.

35
Q

What is the significance of the ‘forme fruste’ of Barlow disease?

A

Recognizes the spectrum of lesions in mitral valve pathology.

36
Q

What is the primary surgical approach for treating mitral valve disease?

A

Surgical repair and replacement.

37
Q

True or False: Medical therapy is the mainstay of treatment for mitral valve disease.

A

False.

38
Q

What is the estimated incidence of new cases of severe mitral regurgitation per year?

A

250,000 new cases.

39
Q

Which patients are often deemed too high risk for surgical correction of severe mitral regurgitation?

A

Patients with age, comorbidities, or severe left ventricular dysfunction.

40
Q

What is Barlow disease characterized by?

A

Diffuse chordal elongation and rupture

Carpentier described a “forme fruste” of Barlow disease, recognizing the spectrum of lesions.

41
Q

What causes fibroelastic disease leading to degenerative mitral regurgitation (MR)?

A

Deficiency of connective tissue

This results in a deficiency of collagen, elastins, and proteoglycans, causing leaflet thinning.

42
Q

What are some additional causes of primary MR?

A
  • 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.

43
Q

What is the primary cause of secondary or functional MR?

A

Ventricular dysfunction due to dilation, diffuse hypokinesis, or segmental damage

This is often secondary to ischemic disease or dilated cardiomyopathy.

44
Q

What anatomical changes occur in the ventricle that cause functional MR?

A

Displacement of papillary muscles in an outward and/or apical direction

This causes tethering of the leaflets, restricting closure.

45
Q

What is the structure of the mitral valve (MV) apparatus composed of?

A
  • Annulus
  • Leaflets
  • Chordae tendineae
  • Papillary muscles

Understanding the structure is crucial for surgical and percutaneous approaches to MV repair and replacement.

46
Q

What are the components of the MV leaflets?

A
  • Anterior leaflet
  • Posterior leaflet

The anterior leaflet has greater length but a narrower base than the posterior leaflet.

47
Q

What does Carpentier’s classification of leaflet dysfunction include?

A
  • 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).

48
Q

What is a common cause of functional MR with preserved left ventricular function?

A

Left atrial remodeling from atrial fibrillation

This leads to annular enlargement and MR.

49
Q

What is the significance of grading the degree of MR?

A

It has limitations; a comprehensive process using multiple imaging techniques is essential

Techniques include transthoracic echocardiography (TTE), TEE, and Doppler color flow imaging.

50
Q

What imaging technique provides better spatial resolution for assessing MR?

A

Transesophageal echocardiography (TEE)

TEE allows for more accurate MR quantification and 3-D visualization of the valve.

51
Q

Why is it important to obtain an echocardiogram while the patient is not under anesthesia?

A

Loading conditions of the heart are not altered

This prevents the degree of regurgitation from being underestimated.

Valvular Heart Disease (13 decks)

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