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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
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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.
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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
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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 .
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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:
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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.
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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
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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
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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.
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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
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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:
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Surgery 4.3a
ACQUIRED CARDIAC DISEASESDr. Villanueva
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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Surgery 4.3a
ACQUIRED CARDIAC DISEASESDr. Villanueva
November 10, 2014
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15/15
Surgery 4.3a
ACQUIRED CARDIAC DISEASESDr. Villanueva
November 10, 2014