4 SURGERY II 3A - Acquired Cardiac Diseases

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Surgery 4.3a

ACQUIRED CARDIAC DISEASESDr. Villanueva

November 10, 2014

*Sample Case at the appendix

UTLINE

Cardiac Assessment

a. Cardiac Function Disability

b.

Diagnostics and Ancillary Procedures

Coronary Artery Disease

a.

Coronary Anatomy

b.

Coronary Angiography

c. Viability Studies

d.

Revascularization

Valvular Heart Diseasesa. Mitral Valve Diseases

i.

Mitral Stenosis

ii. Mitral Regurgitation/Insufficiency

iii.

Mitral Valve Operative Techniques

b.

Aortic Valve Diseases

i. Aortic Stenosis

ii.

Aortic Regurgitation/Insufficiency

c. Tricuspid Valve Disease

i.

Tricuspid Stenosis and Insufficiency

ii. Multivalve Disease

Most of the things discussed here are from Schwartz and powerpoint

CARDIAC ASSESSMENT

Symptoms

o

Chest discomfort, fatigue, edema, dyspnea, palpitations, syncope.Family history

Past medical history

Personal habits

Functional capacity

Review of systems

Physical examination – foundation for evaluation with acquired cardiac

diseases (ACD) requiring surgical intervention.

Appropriate diagnostic studies

CARDIAC FUNCTION DISABILITY

NEW YORK HEART ASSOCIATION (NYHA) FUNCTIONAL CLASSIFICATION

Class I

Patients with cardiac disease but WITHOUT resulting

limitation of physical activity. Ordinary physical activity does

not cause undue fatigue, palpitation, dyspnea, or angina pain.

Class II

Patients with cardiac disease resulting in SLIGHT limitation of

physical activity. They are comfortable at rest. Ordinary

physical activity results in fatigue, palpitation, dyspnea, or

angina pain.

Class III

Patients with cardiac disease resulting in MARKED limitation of

physical activity. There are comfortable at rest. Less than

ordinary physical activity causes fatigue, palpitation, dyspnea,

or angina pain.

Class IV

Patients with cardiac disease resulting in an INABILITY to carry

on any physical activity without discomfort. Symptoms of

cardiac insufficiency of the angina syndrome may be present

even at rest. If any physical activity is undertaken, discomfort is

increased.

Used to determine the functional capacity of the patient

Used for evaluating patient’s severity of disability, in comparing

treatment regimens, and in predicting operative risk

The NYHA is the most widely used classification system in categorizing

patients based on their functional status.

CANADIAN CARDIOVASCULAR SOCIETY (CSS) ANGINA CLASSIFICAT

Class

I

Ordinary physical activity, such as walking or climbing sta

DOES NOT CAUSE angina. Angina may occur with strenuous

rapid or prolonged exertion at work or recreation.

Class

II

There is SLIGHT limitation of ordinary physical activity. Ang

may occur with walking or climbing stairs rapidly, walk

uphill, walking or stair climbing after meals or in the cold

the wind, or under emotional stress, or walking more than t

blocks on the level, or climbing more than one flight of staunder normal condition at a normal pace.

Class

III

There is MARKED limitation of ordinary physical activ

Angina may occur after walking one or more blocks on

level or climbing one flight of stairs under normal condition

a normal pace.

Class

IV

There is INABILITY to carry on any physical activity with

discomfort. Angina may be present at rest.

Grading system for patients with ischemic heart disease

Mainly referred for surgery of coronary artery disease

Used to incorporate angina symptoms into the functional asses

for prognostic value.

DIAGNOSTIC AND ANCILLARY PROCEDURES

ELECTROCARDIOGRAM AND CHEST X-RAY

ECG

o Summary of electrical impluses generated by the heart

o Used to check for rhythm disturbances, heart block, vent

strain, signs of atrial and ventricular enlargement, and si

ischemia

Stress ECG- requires a patient to exercise to a target rate t

diagnose ischemic pathologies

Chest X-ray

o

detect pulmonary pathology, sequelae of heart failure, as w

hardware from previous procedures (e.g. prosthetic valves)

a) PA view

Cardio-thoracic ratio of >0.5= cardiac enlargement

Lung pathology such as pleural effusion and congestion

b)

Lateral view

Substernal fullness = right ventricular enlargement

Retrocardiac fullness= left atrial enlargement

Figure 1. The PA (left) and Lateral views (right)

ECHOCARDIOGRAPHY (TTE/TEE/DOBUTAMINE STRESS ECHO)

Utilizes reflected sound waves to image the heart.

Evaluate structural diseases of the heart.

STANDARD TRANSTHORACIC ECHOCARDIOGRAPHY (TTE)

Excellent non-invasive screening test to evaluate cardiac size

motion, and valvular pathology

Used for viewing LV enlargement and thickening, nature of

cardiac valves, any fluid accumulation, ascending aorta and the

root



SURGERY 4.3A

Parasternal Long Axis View

Cuts the areas of the heart longitudinally

Figure 2. Parasternal Long Axis View

Parasternal Short Axis View

A series of views from apex to the pulmonary artery may be

obtained by tilting and shifting along the line of the long axis

gure 3. Parasternal Short Axis view (top left); Parasternal Short Axis view at

the level of the aortic valve (top right); Parasternal Short Axis view at the

level of the papillary muscles. It is used to check for weakness of the

myocardium, as well as thickening or thinning of the cardiac muscle walls

(bottom)

Apical 4-Chamber View

Useful window for visualizing all four cardiac chambers

simultaneously as well as the tricuspid and mitral valves.

Figure 4. Apical 4-Chamber view

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE)

Invasive test used when more precise imaging is required or wh

diagnosis is uncertain after a transthoracic study

Better used for viewing posterior structures of the heart

Probe inserted via the mouth and it goes behind the heart to che

structures near the esophagus like the left atrium and the mitral

3D ECHO

Useful in the evaluation of mitral regurgitation

STRESS ECHO

For patients with signs of ischemia and cardiac dysfunction

RADIONUCLIDE STUDIES (THALLIUM SCAN/PET SCAN)

Thallium Scan

Currently the most widely used myocardial perfusion scre

study to assess myocardial ischemia.

The amount of uptake at both rest and stressed state

compared to assess ischemia and viability of myocardium

Initial uptake of thallium into myocardial cells is dependent

myocardial perfusion while delayed uptake depend

myocardial viability

PET Scan

o

Used to assess myocardial viability in underperfused areas

heart

o More sensitive than thallium scan

o Most useful in determining whether patients with CHF

improve with operative revascularization

MRI

Delineates the transmural extent of MI

Distinguishes bet. reversible and irreversible myocardial ischemic

Useful in the assessment of patients with myocardial scarrin

ventricular aneurysms when ventricular remodelling surgery

option

Use of gadolinium can enhance scar tissue and are very use

viability assessment

CARDIAC CATHETERIZATION

Measures intercardiac pressures and cardiac output

Localizes and quantifies intercardiac shunts

Determines internal cardiac anatomy and ventricular wall mot

cineradiography

Determines coronary anatomy by coronary angiography

o Coronary angiography = primary diagnostic procedur

determining degree of coronary artery disease

CT CORONARY ANGIOGRAPHY

Less invasive imaging of coronary anatomy

Extremely sensitive in detecting coronary stenosis

CORONARY ARTERY DISEASE (CAD)

Multifactorial disease in which the primary etiology is atheroscler

Risk factors include hyperlipidemia, smoking, diabetes, hyperte

obesity, sedentary lifestyle, male gender, and elevated levels

reactive protein, lipoprotein A, and homocysteine.

Most important factor in long term treatment is the modificat

risk factors such as immediate cessation of smoking, cont

hypertension, weight loss, and reduction of serum cholesterol.

Myocardial ischemia from CAD may result in angina pectoris, M

cardiac arrhythmias, and sudden death.

Angina pectoris (periodic substernal chest pain that typically ap

with exertion and may radiate to the left upper extremity) is the

common manifestation.



SURGERY 4.3A

Myocardial infarction is a serious consequence of CAD occurring when

ischemia results in myocardial necrosis.

Pre-operative evaluation includes complete history and PE, chest X-ray,

ECG, and baseline ECG.

Patient’s functional status is of importance because quality of life

improvement and symptomatic relief are both goals of therapy.

Cardiac catheterization (coronary angiography) is the GOLD

STANDARD. Shows coronary anatomy and degrees of stenosis are

delineated allowing for planning of surgical revascularization.

CORONARY ANATOMY

HEART

Base lies opposite the middle thoracic vertebra

Apex at 5th

intercostal space, 10 cm from the midline

Measures 12 cm in length, 8 cm in width, and 6 cm in thickness

Weighs 280 grams

FIgure 5. The coronary artery and its branches.

RIGHT CORONARY ARTERY

Arises from the anterior/right coronary aortic sinus

Runs forward between the pulmonary trunk and right atrium.

Descends in the right coronary sulcus to reach right (acute) cardiac

order and continues posteriorly.

Does not reach crux of heart (junction of interatrial and interventriculargrooves) in 20%, reaches cruz and extends slightly beyond in 60%, and

may reach left heart border in 20%.

BRANCHES:

1.

Atrial branches

o Supply the anterior and the lateral surface

of the right atrium

o One branch supplies the posterior surface of both left and

right atria

2. Right anterior ventricular branches

o Usually 2 to 3 branches

3.

Right marginal branch

o Considered by some to be the largest anterios right

ventricular artery often reaching the apex

o

Size often reciprocal to that of other anterior ventricularbranches

4. Posterior descending (or interventricular) artery

o

Supplies both ventricles

o Anastomoses with the anterior interventricular branch of the

left coronary artery

5.

Atrioventricular nodal artery

o Arises from the right coronary artery in 80-85% of patients

(right-dominant)

LEFT CORONARY (MAIN) ARTERY

Passes forward between pulmonary trunk and left atrium

Varies from a few mm to a few cm in size

Usually has no branches

Occasionally gives rise to an atrial branch

Rarely gives rise to sinoatrial artery

Supplies the major part of the heart, including the greater part

left atrium, left ventricle and ventricular septum

LEFT CORONARY ARTERIES

Larger than the right coronary artery

Arises from the left posterior (left coronary sinus)

Enters the anterior interventricular groove and divides into an

descending and circumflex arteries.

In 30% of cases, there is a 3

rd branch called ramus intermedius

LEFT ANTERIOR DESCENDING ARTERY

Runs towards the apex in the anterior interventricular groove

Sometimes embedded in or crossed by bridges of myocardium (5

Passes around the apex 2/3 of the time, traversing 1/3 to ½ of pos

interventricular septum to anastomose with the PDA

Anterior ventricular branches

o Diagonal branches

Septal branches

o Anterior septal branches supply ventral 2/3 of intervent

septum

o

Posterior septal branches supply posterior septum a vdistance from apex

LEFT CIRCUMFLEX ARTERY

Following the atrioventricular groove, it winds around the left m

of the heart and anastomoses with the right coronary artery

BRANCHES:

1.

Left marginal branches

2. Anterior ventricular branches

o Usually 2 to 3

o Course parallel to diagonal artery and replace it when a

3. Atrial branches

4.

Artery to sinus node (35%)

o Passes over and supplies the left atrium

o

Encircles the superior vena cava, supplying the SA nodthe right atrium

5.

Artery to AV node (20%)

o When left circumflex artery provides posterior

ventricular branch

CORONARY ANGIOGRAM

Figure 6. Coronary Angiogram

In this invasive technique, the coronary arteries are approached

catheters inserted via the femoral artery or the radial artery

selective Judkins Left/Right coronary catheters used in this tec

have pre-formed curvatures such that when the catheter is insert

tip will lodge in the ostium of the left/right coronary artery.

In this procedure the coronary arteries are filled up wit

introduced via the catheters.

Hypodense areas or irregularities seen are those portions in the

vessels which some dye or none at all can pass through. The

irregularities signify partial or complete obstruction of the a

with calcifications



SURGERY 4.3A

SELECTIVE JL4 CATHETER

Judkins Left coronary catheter (JL4) have special pre-shaped double

curve and end-hole tip

The size of the segment between the primary and secondary curve

determines the size of the catheter (3.5, 4.0, 5.0, 6.0)

The size of JL is selected depending on the length and width of the

ascending aorta (small person needs JL 3.5 while a large person or

dilated asceding aorta needs 5.0 or 6.0)

JL4 fits most patients

Technique for cannulation is simple: catheter tip follows ascendingaorta border and falls into left main coronary ostium (should happen

without an abrupt jump)

Figure 7. JL4 catheter

SELECTIVE JR4 CATHETHER

Is sized by the length of the secondary curve and it comes in 3.5, 4.0

and 5.0

JR is advanced into ascending aorta (usually LAO projection) with the

tip directed caudally

Cannulating right coronary artery:

o

Advance into right coronary cusp and rotate 45° to 90° clockwise

while the tip is pulled back -3cm

o JR tip is advanced 2-4 cm above the valve and rotated clockwise

45o to 90

o, with tip rotating downward

o JR4 does not use contralateral wall support

o Nylon vs polyurethane catheters feels different

Figure 8. JR4 Catheter

ote: Judkins LEFT catheter = LEFT coronary artery

Judkins RIGHT catheter = RIGHT coronary artery

ABLE STUDIES (discussed above):

Thallium Scan

PET Scan

MRI

REVASCULARIZATION

Prolong life and reduce major cardiovascular events

Improve the quality of life and functional status

o

Decrease the possibility of a heart attack in the future

o Symptoms like chest pain will disappear in 80-90% of cases

Refer to appendix for guidelines for revascularization w/ percutaneous

ronary intervention & coronary artery bypass grafting in patients

/angina

OPTIONS FOR REVASCULARIZATION

Surgical (CABG)

o Conventional ON-pump coronary artery bypass

o Off-pump coronary artery bypass

o MIDCAB – minimally invasive direct coronary artery bypass

o TECAB – total endoscopic coronary bypass

PCI (angioplasty) – percutaneous coronary intervention

Others

o TMR – transmyocardial laser revascularization

o Biomolecular therapy and tissue engineering

Figure 9. Grafts in CABG

ACCESS: MEDIAN STERNOTOMY

In coronary artery bypass grafting, the entire chest is opened

suprasternal notch to xiphoid process, then cut by using a stern

to split open the sternum. And then a retractor is placed to sethe sternum.

CARDIOPULMONARY BYPASS/HEART-LUNG MACHINE

MYOCARDIAL PROTECTION (not discussed)

Cardioplegia was developed as a protective solution to induce both

asystole and protect the myocardium from ischemic injury.

When infused through the coronary circulation, cold high-pot

cardioplegic solution produces diastolic arrest and slows metabolic a

protecting the heart from ischemia.

The arrested heart allows the surgeon to work precisely in the heamotionless, bloodless field.

OPERATIVE TECHNIQUES

Bypass Conduit Selection

o The most important criterion in conduit selection is graft pat

Internal thoracic artery - conduit with the highest p

rate which is commonly left attached proximally t

subclavian artery and anastomosed distally to the

coronary artery.

o Arterial grafts: internal thoracic a., internal mammary a. ra

R gastroepiploic a., free inferior epigastric a., splenic a.

o Venous grafts: greater saphenous v., lesser saphenous v.

Figure 10. Heart-lung machine. Diagrammatic llustration of blood

coming from right pumped back to the aorta. After it is

oxygenated will go through roller pump and brought to aorta. In a

heart lung machine, there are lines to drain the blood and a line to

pump the blood back to the patient .



SURGERY 4.3A

o Indications: chronic angina, unstable angina, post-infarction

angina, asymptomatic patients with atypical symptoms who have

easily provoked ischemia during stress testing

Conventional Coronary Artery Bypass Grafting (CABG)

o Performed with median sternotomy, cardiopulmonary bypass, and

cardioplegia/myocardial protection.

o Proximal anastomoses are then performed directly onto the

ascending aorta or onto pre-existing grafts.

o The left internal thoracic artery to left anterior descending graft is

frequently performed to avoid kinking or disruption of the bypass.

Off-pump Coronary Artery Bypass (OPCAB)

o To avoid the adverse consequences of cardiopulmonary bypass.

o With OPCAB the heart is left beating

o Requires use of myocardial stabilization devices which help

portions of the epicardial surface to remain relatively immobile

while anastomoses are being performed.

o Creative maneuvers have been developed, including repositioning,

opening the right pleural space to allow for cardiac displacement

in exposing various surfaces of the heart.

o Temporary proximal occlusion of the coronary artery being grafted

is necessary to provide a bloodless target.

On-pump CAB- uses cardiopulmonary bypass

Figure 11. Off-pump Coronary Artery Bypass (OPCAB) (left) Involves

erforming coronary bypass surgery on a beating heart, without the use of a

cardiopulmonary bypass. The use stabilization devices (right) allows the

surgeon to make precise anastomoses while the heart remains beating.

Minimally Invasive Direct Coronary Artery Bypass (MIDCAB)o An extension of the off-pump coronary revascularization

technique.

o Performed using a left anterior mini-thoracotomy through which

mobilization of the left internal thoracic and direct in situ

anastomosis to the left anterior descending artery

o

Applicable to single-vessel disease.

Other operative techniques

o Total Endoscopic Coronary Artery Bypass

o Hybrid Coronary Revascularization

o Transmyocardial Laser Revascularization

o Regenerative Medicine and Tissue Engineering

VALVULAR HEART DISEASE

Figure 12. Valves of the heart

Age-associated and acquired conditions represent the primary

of valvular heart disease.

The most common screening method for valvular heart dise

cardiac auscultation, with murmurs classified based primarily o

timing in the cardiac cycle, but also on their configuration, locatio

radiation, pitch, intensity and duration.

Although auscultation may provide initial evidence of valvular d

associated signs and symptoms may help narrow the diagnosis.

Several diagnostic/imaging examinations to evaluate valvular dise

o

Electrocardiogramo PA and L view X-ray

o Transthoracic echocardiography (gold standard)

Regardless of etiology, valvular heart disease can produce a my

hemodynamic drangements.

Valvular heart diseases:

o Mitral stenosis, mitral insufficiency, aortic stenosis,

insufficiency, tricuspid stenosis and insufficiency, multivalve

MITRAL VALVE DISEASES

MITRAL STENOSIS

ETIOLOGY

o Rheumatic Heart Disease/Rheumatic fever (60% of ca

acquired mitral stenosis)

o

Other causes: Left atrial myxoma

Ball valve thrombus

Mucopolysaccharidosis

Previous chest radiation

Severe annular calcification

CLASSIFICATION

o Normal Mitral Valve Area: 4 -6 cm2(Schwartz 4-5 cm

2)

o

Mild MS: 1.6 – 2.5 cm2

Begin experiencing symptoms upon exertion

o Moderate MS: 1 – 1.5 cm2

Symptoms may begin at rest

o Severe MS:



SURGERY 4.3A

o Advanced MS can cause pulmonary arterial hypertension and

subsequent right heart failure, manifested as:

Jugular Venous Distention (JVD)

Hepatomegaly

Ascites

Ankle edema

o Auscultatory triad: best heard at the apex

opening snap 2o to immobility of chordate

apical crescendo diastolic rumble due to rapid entry of blood

into left ventricle

increased 1st

heart sound due to rapid closing of MV

o Atrial fibrillation

May develop as left atrial pathology worsens, causing atrial

stasis and subsequent thromboembolism.[4]

DIAGNOSTICS

o Electrocardiogram (ECG) – atrial fibrillation, left atrial enlargement

(P mitrale large P wave), right axis deviation

o

Chest X-ray

“double density” sign behind the right atrial shadow (Left

Atrial Enlargement on PA view)

The overall heart size may be normal but the

enlargement of the left atrium and the pulmonary

artery may obliterate the normal concavity between the

aorta and the left ventricle, thus, producing a “straight”left border of the heart.

Calcification

Pulmonary congestion

Basal interstitial edema with engorgement of lymphatics

(Kerley B lines)

o 2D Echocardiogram

TEE- diagnostic tool of choice

Left atrium enlargement

Elevated mitral valve gradient (pressure gradient being

produced when the left atrium pushes blood into the orifice)

Significantly reduced mitral valve area (8mm)

Extensive

thickening &

shortening of all

chordal

structures

extending down

to papillary

muscles

Extensive

brightness

throughout

much of leaflet

tissue

Total score can range from 4 to 16

Treatment based on total score:

o

8 and below – PBMV or repair

o 8 and above – replace mitral valve

Score of ≤8 = more favorable candidate for balloon valvuloplasty

MITRAL REGURGITATION/INSUFFICIENCY

ETIOLOGY:

o Myxomatous degeneration

o

Rheumatic Fevero Ischemic heart disease

o Infective Endocarditis

o Congenital abnormalities

o Dilated Cardiomyopathy

o Others: Trauma, collagen vascular diseases, previous

radiation, hypereosinophilic syndrome, carcinoid diseas

exposure to certain drugs.

CARPENTIER FUNCTIONAL CLASSIFICATION:

Focuses on the functional anatomic and physiologic characte

of the MV pathology, and proposes three basic types of di

valves based on the motion of the free edge of the leaflet r

to the plane of the mitral annulus.

Table 2. Carpentier Functional Classification

Type IAnnular dilatation or leaflet perforation with n

leaflet motion

Type II

Leaflet prolapsed or ruptured chordae tendinae

increased leaflet motion, typically occurring in pa

with degenerative disease

Type III

Restricted leaflet motion with leaflets not reachi

proper plane of closure during systole; occurs

rheumatic patients and (b) chronic ischemic insuffic

PATHOPHYSIOLOGY:

Basic pathophysiologic abnormality: retrograde flow o

portion of the LV stroke volume into the left atrium during s

due to an incompetent MV or dilated MV annulus.

Acute severe MR can result from ruptured chordae tend

papillary muscle, or infective endocarditis, and causes a s

volume overload on both the left atrium and ventricle.

Chronic MR has indolent course, with increasing volume ov

of the left atrium and ventricle as the effective valve orific

becomes larger.

As the left atrium becomes more dilated, the developm

AF becomes more likely, disrupting atrioventricular syn

and predisposing to thrombus formation

Chronic volume overload may lead to LV cont

dysfunction

The changes herald LV decompensation and heart failur

indicate significant injury to the ventricular myocardium

CLINICAL MANIFESTATIONS: o

Exertional dyspnea

o Decreased exercise capacity

o Orthopnea

o CHF

o Apical holosystolic murmur with radiation to axilla

In cases of acute severe MR, patients are often very sympt

and present with pulmonary congestion and reduced fo

stroke volume.

In cases of chronic MR, patients may remain asymptoma

long periods of time due to the compensatory mechanisms

remodeled LV. However, once the LV begins to fail, pa

become increasingly symptomatic.



SURGERY 4.3A

In general, the direction of the mitral valve regurgitant jet is opposite

the leaflet involved.

DIAGNOSTIC:

o 2D Echocardiogram (TTE/TEE)

Left atrium ≥5 – 6 cm --> AF

Propensity for atrial fibrillation is greatly increased when the

left atrial size is >4.5 – 5.0 cm

Coronary angiography must be performed preoperatively in

hemodynamically stable patient rhythm status and the degree of

pulmonary congenstion.

In chronic MR, ECG and chest X-ray are performed to assess

FUNCTIONAL MITRAL REGURGITATION

o Mitral regurgitation secondary to ventricular dysfunction with

structurally normal valve leaflets and subvalvar apparatus.

o Underlying pathology: LV dyssynchrony , annular dilatation, LV

distortion

o Classification:

Ischemic Functional MR (IMR)

Pure Functional MR (FMR)

o Treatment:

Repair – complete semi-rigid or rigid ring

Replacement

+ CABG

LESIONS IN THE MITRAL VALVE

Figure 13. Parts of the Mitral Valve

PART LESION

Leaflets Fused, thickened, calcified, redundant

Chords Elongated, shortened, ruptured,

Papillary Muscle Fused

Annulus Dilated, calcified

MITRAL VALVE OPERATIVE TECHNIQUES

Performed in an arrested heart with median sternotomy/minimally

invasive incisions (mini-thoracotomy or partial sternotomy) and the

assistance of cardiopulmonary bypass

MV is commonly exposed through a left atrial incision placed posterior

and parallel to the intra-atrial groove, or through a right atriotomy withtransseptal incision.

Indications for surgery:

o Development of pulmonary hypertension

o Mitral valve area is



SURGERY 4.3A

Edge-to-edge Repair

Also called “double-orifice” repair for MR

Involves taking the free edge of the anterior leaflet to the

opposing free edge of the posterior leaflet giving the valve

a double-orifice “bow tie” configuration.[4]

Used for anterior leaflet pathology, ischemic insufficiency,

endocarditis, and dilated cardiomyopathy

Late result not well established

o

Robotic MV Surgery Da Vinci Robot

Good results but a disappointingly high early valve repair

failure rate

o Newer techniques:

Pericardial patch augmentation

Tricuspid autographs

o

Advantages over MV Replacement:

Preservation of the patient’s native valve & subvalvular

apparatus

Better (lower) operative mortality

Better postoperative function and survival

Better functional outcomes

Better long-term survival (Degenerative)

Avoidance of complications related to lifelong anticoagulationor systemic thromboembolism

Lower prosthetic valve failure after surgery

MITRAL VALVE REPLACEMENT

o watch out for the left circumflex artery

o Indication: dense calcification of leaflets or subvalvular apparatus

or with significant mitral regurgitation

o To preserve left ventricular function, the chordate and posterior

leaflet of native valve must be preserved.

o Procedure:

1. Expose the valve, make an incision in the anterior mitral leaflet

at approximately the 12 o’clock position, and excise leaflet

tissue as needed.

2. The papillary muscles are reattached to the annulus and, if

possible, the posterior leaflet along with its associatedsubvalvular structures are preserved.

3. The annulus is subsequently sized, and an appropriate mitral

prosthesis is implanted using pledgeted horizontal mattress

sutures.

4. The annular sutures may be placed from the atrial to the

ventricular side, seating the valve intra-annularly, or from the

ventricular to the atrial side, seating the valve in a supra-

annular position.

5. When placing the mattress sutures, care must be taken to stay

within the annular tissue may cause injury to circumflex

coronary artery posterolaterally, the atrioventricular node

anteromedially, or the aortic valve anterolaterally.

6. Sutures are subsequently placed through the sewing ring, and

the valve prosthesis is lowered onto the annulus, where it is

secured.

Factors associated with increased operative risk for MV

replacement include:

Age

Left ventricular function

Emergent procedure status

NYHA functional status

Previous cardiac surgery

Associated coronary artery disease

Concomitant disease in another valve

NOTE: in the management of mitral stenosis, try the less in

procedures first such as PBMV before you move on to the

invasive procedures.

SURGICAL OPTIONS FOR VALVE REPLACEMENT

Valve repair is increasingly indicated, especially in aortic, mit

tricuspid insufficiency, valve replacement may be necessary in c

patient populations.

Valve replacement can be accomplished with either mechan

biological prostheses. Choice of valve depends many patient-specific factors includin

health status, desire for future pregnancy, indicatio

contraindications to anticoagulation therapy.

Mechanical valves

o Highly durable

o Ex. Ball-in-cage valve, Tilting disk

(monoleaflet/bileaflet)

o

Require permanent

anticoagulation therapy (lifelong)

and careful monitoring of the

International Normalized Ratio

reduces the risk of thromboembolic events and hemor

complications

o

High risk of valve thrombosis and thromboembolic sequelaeo Not advisable to young women who is planning to have

pregnancies due to use of anticoagulant.

o Patient with indications for systemic anticoagulation may b

from mechanical valves.

o For patients with renal failure, on hemodialysis, or

hypercalcemia.

o Preferred in patients with expected long life spans wh

candidates for anticoagulation therapy and patients in AF

Tissue Valves

o One implanted from another

species, such as porcine xenograft,

bovine, or equine pericardium

o Stented valves are the most

commonly implanted and the mostpopular valve in the U.S> is stented

bovine pericardial valve.

Disadvantage: smaller effective orifice area especiall

small prosthetic valve area

o Stentless minimizes the limitations in flow characteristics s

patients with small prosthetic valve.

o Less thrombogenic

o Recommended for patients averse to systemic anticoagu

therapy and for patients >65 years old

o Recommended for women planning pregnancy

o More prone to degeneration especially in the mitral position

Increased degeneration in patients in renal f

hemodialysis, or with hypercalcemia

o

Preferred in patients without other indications for anticoagu

therapy

>60 years of age for aortic position

>70 years for mitral position

Homografts

o From human cadavers, also known as allografts

o Have been used for aortic valve replacement and pulmonary

o Risk of thromboembolic complications with homograft is low

o Systemic anticoagulant is not required

o Have been shown to have some advantages in patients

endocarditis

o Uncertain long-term durability in the face of tissue degenera



SURGERY 4.3A

Autograft

o The diseased aortic valve is replaced using the patient’s native

pulmonary valve graft as an autograft. (Ross Procedure)

o Particularly beneficial in children

AORTIC VALVE DISEASES

AORTIC STENOSIS

Calcific aortic valve disease, also known as senile or degenerative

disease, is an age related disorder characterized by lipid accumulation,

proliferative, and inflammatory changes, oxidative stress, upregulationof angiotensin enzyme infiltration of macrophages, and T lymphocytes.

ETIOLOGY:

o Acquired/Degenerative Calcific Disease – most common, affecting

older patients particularly >70 years old – 50%

o Bicuspid Aortic Valve – 30%

o Rheumatic Disease – common in developing countries – 10-15%

CLASSIFICATION OF AORTIC STENOSIS:

o Normal Aortic Valve Area: 2.5 – 3.5 cm2

o Mild AS: >1.5 cm2

o Moderate AS: 1 – 1.5 cm2

o Severe AS: 50 mmHg

o Critical AS: 2/6, a single second hear sound, or symptoms charact

of AS

o Cardiac Catheterization and Coronary Angiography

Since the symptoms of AS oftentimes mimic tho

ischemic disease, these may be necessary at the

evaluation in patients with AS.o Stress-echocardiography

May be useful in the asymptomatic patient with AS in

to elicit exercise-induced symptoms, or abnorm

responses during exertion.

Also useful in the evaluation of low-gradient AS in p

with depressed LV function.

Contraindicated in patients with ischemic heart disease

COMPLICATIONS:

o A-S-C survival in 5-3-2 years (angina, syncope, CHF)

TREATMENT:

o Valve Replacement

Based on the severity of AS and the overall physical con

of the patient, aortic valve replacement ma

recommended for the treatment of AS.

In patients with severe calcific AS, this is the only eff

treatment.

Indicated for all symptomatic patients experiencing exe

dyspnea, decreased exercise capacity, heart failure, a

and syncope.

o Ross Procedure

Better outcome

Involves replacing the diseased AV with the patient’s

pulmonary valve as an autograft, which is in turn re

with a homograft in the pulmonic position. The autogra

be implanted in the aortic position directly with resusp

of the valve commissures, or in association with a

replacement, which requires reimplantation of the co

ostia.(See Appendix for illustration)

The primary benefit compared to traditional AV surge

low risk of thromboembolism without the need for sy

anticoagulation.


10/15


11/15up 14 | QUIJANO, QUIMBO, QUITOY, RAMIREZ Page 11 of

SURGERY 4.3A

CLINICAL MANIFESTATIONS:

o Asymptomatic

o Dyspnea on exertion

o Decreased exercise capacity

o Palpitations

o

Left ventricular heaveo High-pitched decrescendo diastolic blowing murmur 3

rd left ICS

sternal border

Diastolic murmur may be short and/or soft because the left

ventricular and aortic pressures often equalize before the end

of diastole.[4]

o Wide pulse pressure

Causes a sensation of pounding in the patient’s head and

peripherally causes a forceful, bounding and quickly

collapsing pulse (Corrigan’s or water-hammer pulses)

o S3 gallop heart failure; may be indicative of late disease

ble 4. Common Signs of Aortic Insufficiency

ustin Flint Murmur

Low-pitched rumbling heart murmur which is best

heard at the cardiac apex (midsystolic rumble atthe apex that stimulate mitral stenosis)

Corrigan’s Pulse

A pulse characterized by a sharp rise to full

expansion followed by immediate collapse that is

seen in aortic insufficiency

Traube’s Sign A ‘pistol shot’ systolic sound heard over the

femoral artery

De Musset’s Sign Rhythmic nodding or bobbing of the head in

synchrony with the beating of the heart

Watson’s “Water-

hammer” Pulse

A pulse that is bounding and forceful, rapidly

increasing and subsequently collapsing as if it were

the hitting of a water hammer that was causing the

pulse

Hill’s Sign

A ≥20 mmHg difference in popliteal and brachial

systolic cuff pressures

Duroziez’s Sign

Consists of an audible diastolic murmur which can

be hear over the femoral artery when it is

compressed with the bell of a stethoscope

Quincke’s Sign Pulsation of the capillary bed in the nail

Mullers Sign Pulsation of the uvula

DIAGNOSTICS:

o Chest X-ray – cardiomegaly

o Electrocardiogram (ECG) – normal, LVH, sinus rhythm, atrial

fibrillation

o 2D Echo – primary diagnostic tool to evaluate chamber size, left

ventricular function, degree of insufficiency

TREATMENT:

o Aortic valve replacement

Performed more commonly

AV repair or replacement may be performed based o

morphology and severity of valve dysfunction.

Procedure:

Aortotomy is performed, extending medially

approximately 1 to 2 cm above the right coronary

and inferiorly into the noncoronary sinus, and the

is completely excised. The annulus is thoroughly debrided of calcium de

After the calcium has been removed, the ventr

copiously irrigated with saline. Annulus is sized a

appropriate prosthesis is selected.

Pledgeted horizontal mattress sutures are then

into the aortic valve annulus and subsequently th

the sewing ring of the prosthetic valve, taking c

avoid damage to the coronary ostia, the cond

system, and the MV apparatus.

o Aortic valve repair

The aneurysmal portion of the aortic root is excised, a

aortic valve is reimplanted inside a tubular Dacron graf

concomitant reimplantation of the coronary arteries.

Alternatively, the aneurysmal tissue and supravalvularcan be excised in their entirety, with subsequent implan

of the Dacron graft onto the superior aspect of the an

and the reimplantation on the coronary arteries.

o Ross Procedure

Poor Long-Term Outcome:

o Ejection Fraction 55 mm (30 mm/m2)

o Pre-operative end-diastolic/end-systolic volume



SURGERY 4.3A

TRICUSPID STENOSIS AND INSUFFICIENCY

ETIOLOGY:

o Organic : rheumatic fever, endocarditis, rarely trauma

o Functional : mitral valve disease, pulmonary HTN, right ventricular

failure

o Functional is more common than organic tricuspid insufficiency. It

results from dilatation of tricuspid annulus and right ventricle as a

result of pulmonary hypertension and right ventricular failure.

Cross-sectional area:

o

Normal tricuspid valve area: 7-9cm2

o Severe tricuspid stenosis:



Surgery 4.3a


November 10, 2014

APPENDIX

SAMPLE CASE

GENERAL INFORMATION

C.B.

56 y/o male

Taxi driver

Imus, Cavite

CC: DYSPNEA

HISTORY OF PRESENT ILLNESS

December 2005 December 2010

(+) Submandibular pain

and numbness 40 minutes

after a heavy meal

(+) Chest tightness with

radiation to the left arm

Admitted for 2 days

Prescribed ASA and ISMN x

1 month

Stopped smoking

Chest pain noted on exertion

Noted also at rest 2-3 times per

day, lasting for 10-15 minutes,

usually awakening him from

sleep

(+) Dyspnea on walking 200 m,

and 2 flights of stairs

September 2011 March 2012

(-) Chest pain

(+) Dyspnea on less than

ordinary activities;

orthopnea; PND; bipedal

pitting edema

(+) Palpitations and respiratory

distress

Admitted

Given Lanoxin and diuretics

incorporated into his chelation

medications

Decided to seek consult at PHC

REVIEW OF SYSTEMS

General : weight loss, loss of appetite

SHEENT : no rash, no visual dysfunction, no redness, no deafness, notinnitus, no discharge, no epistaxis, no postnasal drip, no bleeding

gums, no sores

Respiratory : no cough, no hemoptysis, dyspnea on minimal exertion

Gastrointestinal : no nausea, no vomiting, no abdominal pain, no

diarrhea, no hematemesis, no hematochezia, no melena

Genitourinary : no flank pain, no urinary frequency, no hesitancy, no

dysuria, no hematuria

Endocrine: no polyuria, no polydipsia, no polyphagia

Hematologic: no bleeding episodes

Neurologic: no headache, no seizure, no mental changes

Psychiatric: no anxiety, no depression

PAST MEDICAL HISTORY

(+) HPN (+) DM (2009)

o Metformin 500 mg/tab BID

(-) Asthma/allergy

PERSONAL/SOCIAL HISTORY AND ENVIRONMENTAL EXPOSURE

(+) 60 pack years smoker

(+) Occasional alcoholic beverage drinker

No illicit drug use

FAMILY HISTORY

(+) CAD

o Sister died of “heart attack” (



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