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Mitral valve repair

AORN Journal, Jan, 2007 by Margo Winters, Pam Obriot

* DISEASES THAT AFFECT the mitral valve include mitral regurgitation, mitral stenosis, rheumatic heart disease, and cardiomyopahy.

* THE RESULTS OF DIAGNOSTIC procedures are used to identify and confirm mitral valve disease, evaluate the patient's anatomy, and determine the severity of the disease.

* AFTER THE PATIENT IN PREPARED for surgery, the surgeon performs an intraoperative trans-esophageal echocardiogram and the patient is placed on cardiopulmonary bypass.

* A REPAIR PROCEDURE (eg, annuloplasty, slidingplasty, chordal repair/transfer/replacement, valve replacement) is performed depending on the patient's specific anatomical abnormalities. AORN J 85 (January 2007) 152-166. (c) AORN, Inc, 2007.

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The first treatment for mitral valve disease came shortly after the invention of the heart-lung bypass machine. (1) Direct visualization of the mitral valve made replacement surgery possible. The negative aspects of mitral valve replacement, however, include possible thromboembolism, hemolysis, and infection. This led cardiothoracic surgeons to search for other methods to treat mitral valve disease. As physicians began to understand the complex function and geometry of the mitral valve and the subvalvular apparatus, repair techniques evolved, and mitral valve repair soon became the gold standard in mitral valve treatment. (1)

The number of mitral valve repair cases has increased during the last decade as new knowledge and increased experience has offered new treatments for valvular repair. (2) This article describes typical mitral valve repair procedures performed on a daily basis at the University of Michigan Health System, Ann Arbor, Mich. Table 1 provides definitions of common medical terms associated with mitral valve repair.

MITRAL VALVE DISEASE PROCESSES Two types of disease processes (ie, geometric and valvular) affect the mitral valve. The type of disease process determines the appropriate type of repair.

GEOMETRIC DISEASE. Geometric disease, also referred to as ventricular disease, is mitral regurgitation originating within the left ventricle. In geometric mitral disease, the left ventricle has dilated so much that the mitral annulus has stretched and the mitral valve leaflets can no longer coapt (ie, come together).

Geometric disease can be ischemic or nonischemic in origin. The most common form of ischemic heart failure is myocardial infarction. In the presence of coronary artery disease, narrowing or obstruction of an artery causes decreased myocardial perfusion. (3) Occlusion of the artery can be caused by platelet aggregation, thrombotic embolism, dislodged calcium plaque, or coronary artery spasm. This ischemia leads to necrosis of the myocardial tissue. Persistent necrosis interferes with myocardial function and eventually can produce large areas of akinetic tissue (ie, tissue that has lost the ability to move). (3)

There are many causes of nonischemic heart disease, but the heart's decreased ability to pump effectively ultimately results in cardiomyopathy. Some causes of nonischemic heart disease are hypertension and infections such as endocarditis. (3)

The most common cause of geometric disease is dilated cardiomyopathy. In geometric mitral disease, the valve and subvalvular apparatus are all normal. The problem is within the ventricle, which has become dilated to the extent that the normal function of the valve is disrupted.

VALVULAR DISEASE. Valvular mitral disease is a process in which the leaflets and/or the annulus have become calcified and stiff or fused. In addition to calcification, valvular disease also may include chordal shortening, which may lead to mitral stenosis or regurgitation. In the United States, valvular disease most commonly is caused by rheumatic endocarditis. (4) Whatever the etiology, most patients will have some degree of dilation in the mitral annulus that must be repaired. (5)

MITRAL VALVE ANATOMY AND PHYSIOLOGY

The bicuspid (ie, two leaflet) mitral valve is located between the left ventricle and left atrium. The valvular complex consists of the annulus, leaflets, chordae tendineae, and papillary muscles (Figure 1), and in a sense, the left ventricle is the mitral valve. The annulus, a fibrous band of tissue from which the leaflets originate, is considered the "hinge line" of the valve leaflets. (6) Continuing out from the annulus, the two leaflets (ie, anterior and posterior) are pale yellow, thin, fibroelastic membranes whose anterior surfaces are relatively smooth. The posterior or ventricular surfaces are slightly irregular because of the attachments to the chordae tendineae.

[FIGURE 1 OMITTED]

The anterior leaflet is also known as the anteromedial, septal, or aortic leaflet. (4) The posterior leaflet, also known as the mural leaflet, is further divided into three cusps commonly known as P1, P2, and P3. The three posterior cusps do not have separate functions; they have been named purely for ease of describing mitral valve anatomy and locations of regurgitation jets (ie, flashes of backward blood flow).

Health Care Industry

Mitral valve repair

AORN Journal, Jan, 2007 by Margo Winters, Pam Obriot

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