Mitral Valve Prostheses

Abstract

Mitral valve surgery is one of the most technically demanding aspects of cardiac surgery, owing both to the valve’s location and to its complicated structure. Overall cardiac surgical performance is gauged by the rate of successful mitral valve repair. Typically, the best short-term and long-term outcomes are achieved by surgeons who have a subspecialized interest in mitral valve surgery and perform large numbers of repairs in high-volume centers. A repair is usually preferred over a replacement, owing to both longevity and the avoidance of anticoagulation, but repair is not always technically feasible if the valve is stenotic, calcified, significantly thickened, or morphologically unsuitable. A good replacement is always better than a poor repair, which may lead to premature redo surgery. Mitral valve repairs typically involve plication of the posterior leaflet and insertion of an annuloplasty ring. An Alfieri stitch is sometimes included to optimize leaflet coaptation. Mitral valve replacements can be both bioprosthetic and mechanical. Individualized factors including the patient’s age, suitability for anticoagulation, and plans for future pregnancies are all important to consider when deciding on the best approach. Robotic mitral valve surgery with femoral cannulation via a mini-thoracotomy is now providing an alternative to traditional approaches via a median sternotomy. Percutaneous valve replacement or repair using various clip devices is now a viable alternative for some patients [see Chap. 6]. Valvuloplasty may be adjunctively performed as a temporizing bridge to surgery or a more palliative procedure in the setting of significant mitral stenosis, although factors such as valve and subvalvular thickening and calcification will ultimately govern suitability for this procedure.

Keywords

Prosthetic valve Annuloplasty ring Alfieri stitch 

Supplementary material

Video 11.1

A 3D image of a normally functioning, trileaflet, Biocor bioprosthetic mitral valve replacement viewed from the left atrium. High image resolution enables the leaflets, annulus, and even sutures to be clearly demonstrated. The 3D image is conventionally orientated with the aortic valve at the 12 o’clock position, thereby allowing consistency of image description and better ease of interpretation (AVI 1528 kb)

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Video 11.2 A parasternal long-axis view demonstrates the repaired mitral valve, with the aortic valve replacement in situ (AVI 2992 kb)
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Video 11.3 Slight angulation of the probe demonstrates a parasternal long-axis view of the mitral valve at the position of the Alfieri stitch. This appearance may be mistaken for mitral stenosis. The annuloplasty ring in short axis can be best appreciated at the posterior aspect of the annulus (AVI 2244 kb)
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Video 11.4 A parasternal short-axis view at the left ventricular base demonstrates the double-orifice mitral valve with the Alfieri stitch joining the middle aspects of both mitral valve leaflets and improving overall leaflet coaptation (AVI 3100 kb)
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Video 11.5 The mitral valve is viewed from an apical four-chamber view. The Alfieri stitch can be seen joining the leaflet tips centrally. The annuloplasty ring is appreciated laterally. The posterior leaflet appears small and somewhat restricted, consistent with the known repair and plication of the middle posterior scallop (AVI 2712 kb)
Video 11.6

Transesophageal echocardiogram (TEE) at 0°, demonstrating severe thickening and tethering of both mitral valve leaflets (predominantly involving the leaflet tips). This appearance is typical for rheumatic heart disease (AVI 4855 kb)

Video 11.7

TEE at 0° demonstrating moderate (2–3+) regurgitation at baseline. A septostomy has been performed in preparation for the valvuloplasty, and the catheter can be seen traversing the interatrial septum (AVI 1992 kb)

Video 11.8

A 3D image of the mitral valve viewed from the left atrium. The leaflets are thickened, with commissural fusion and a resultant reduced valve area (AVI 1077 kb)

Video 11.9

Balloon inflation within the mitral valve at the time of valvuloplasty (AVI 6410 kb)

Video 11.10

After valvuloplasty, biplane color Doppler imaging through the mitral valve demonstrates no significant increase in severity of mitral regurgitation from baseline (AVI 1806 kb)

Video 11.11

A 3D image of the mitral valve (viewed from the left atrium) after valvuloplasty shows that leaflet mobility has improved, with a reduction in commissural fusion and an increased valve area (AVI 1272 kb)

Video 11.12

TEE at 50° demonstrates an eccentric paravalvular leak originating at the anterolateral aspect of the mitral annulus (AVI 1485 kb)

Video 11.13

With 3D reconstruction of the mitral valve, orientated with the aortic valve at the top of the image, the small paravalvular defect can be seen adjacent to the valve annulus at the 6 o’clock position (AVI 845 kb)

Video 11.14

Color 3D imaging clearly demonstrates the small paravalvular leak (AVI 953 kb)

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Video 11.15 TEE at 60° demonstrating the mechanical mitral valve with normally functioning leaflets. A small paravalvular region of defect can be seen adjacent to the lateral aspect of the valve (AVI 8981 kb)
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Video 11.16 The same 60° TEE view demonstrates a small jet of flow through the paravalvular defect on color Doppler imaging (AVI 1539 kb)
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Video 11.17 Rotating the TEE probe to 90° demonstrates the paravalvular leak adjacent to the lateral aspect of the valve, perpendicular to the orifice of the left atrial appendage (AVI 1689 kb)
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Video 11.18 3D imaging of the mechanical mitral valve demonstrates a normally functioning, well-seated bileaflet prosthesis (AVI 1277 kb)
Video 11.19

Transesophageal long-axis view demonstrating a normally functioning bioprosthetic mitral valve replacement (AVI 4234 kb)

Video 11.20

Transesophageal long-axis view with a moderate (2+) paravalvular leak anteriorly on color Doppler imaging (AVI 2679 kb)

Video 11.21

3D left atrial view of the mitral valve, atypically orientated with the aortic valve at 3 o’clock and the anterior paravalvular defect at the 9 o’clock position (AVI 745 kb)

Video 11.22

3D left ventricular view of the mitral valve, with the anterior paravalvular defect now visible at the 3 o’clock position (AVI 755 kb)

Video 11.23

TEE imaging of the bioprosthetic mitral valve replacement at 38°, demonstrating the large pseudoaneurysm adjacent to the valve annulus and left atrium laterally (AVI 4606 kb)

Video 11.24

The addition of color Doppler imaging demonstrates regurgitant flow directly from the left ventricle into the pseudoaneurysm via a communication located just below the level of the valve annulus laterally (AVI 2413 kb)

Video 11.25

Transesophageal biplane view of the bioprosthetic mitral valve replacement at 0 and 90°, demonstrating the large lateral pseudoaneurysm, which expands during systole, when there is retrograde flow into the cavity (AVI 3898 kb)

Video 11.26

3D reconstruction of the mitral valve viewed from the left atrium. The large pseudoaneurysm can be seen adjacent to the lateral aspect of the valve and left atrium (AVI 1886 kb)

Video 11.27

TEE imaging of the bileaflet mechanical mitral valve prosthesis at 58°. The valve appears well seated, with normal leaflet opening. A large left atrial appendage can be seen laterally to the right of the image. Between the appendage and the valve is a small cavity demonstrating expansion during systole. This dynamic appearance is suggestive of a pseudoaneurysm (AVI 4572 kb)

Video 11.28

Color Doppler imaging, in the same 58° TEE plane, demonstrates three separate jets of systole flow. There is a moderate (2+) valvular regurgitant jet, a moderate (2+) paravalvular jet originating laterally with flow directed into the left atrial appendage, and a small amount of systolic flow going directly from the left ventricle into the pseudoaneurysm (AVI 1335 kb)

Video 11.29

A 3D reconstruction of the mitral valve prosthesis from the left atrial aspect. The valve appears well seated, with normal motion of both leaflets. The large left atrial appendage can be seen adjacent to the valve laterally to the left of the image. Between the appendage and the valve ring is a small slit-like annular defect (9 o’clock position), which represents the cause of the paravalvular leak (AVI 927 kb)

Video 11.30

Parasternal long-axis view on transthoracic echocardiography (TTE), demonstrating dehiscence of the mitral annuloplasty ring, which can be seen partially hanging below the native valve within the left atrium (AVI 4432 kb)

Video 11.31

The same parasternal long-axis view with color Doppler imaging shows a severe paravalvular regurgitant jet (AVI 1942 kb)

Video 11.32

An apical four-chamber transthoracic view also shows the partially dehisced annuloplasty ring hanging below the native valve annulus in the left atrium (AVI 9310 kb)

Video 11.33

Color Doppler imaging of the same four-chamber view confirms a severe paravalvular jet laterally (AVI 2219 kb)

Video 11.34

Biplane imaging of the mitral valve at 40 and 130° on TEE also demonstrates a moderate central jet of valvular regurgitation (AVI 896 kb)

Video 11.35

3D transesophageal imaging of the mitral valve demonstrates severe dehiscence of the annuloplasty ring, involving nearly 50 % of its circumference (AVI 1046 kb)

Video 11.36

3D transesophageal imaging with color Doppler demonstrates the severe paravalvular regurgitation associated with the annuloplasty ring dehiscence (AVI 1533 kb)

Video 11.37

Transesophageal view (at 91°) of the repaired mitral valve with an annuloplasty ring in situ, taken immediately after the original valve surgery. There is good leaflet coaptation without restriction of leaflet movement (AVI 4700 kb)

Video 11.38

Another transesophageal view (at 139°) taken immediately after the original valve surgery, showing good leaflet coaptation without restriction of leaflet movement (AVI 4752 kb)

Video 11.39

Color Doppler imaging at the same transesophageal 139° view immediately after the original valve repair confirms that there was no residual regurgitation (AVI 1148 kb)

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Video 11.40 A TEE image (0°) obtained 2 years later showed that the mitral annulus was severely thickened circumferentially, with laminated echogenic material extending from the annulus onto both leaflet bodies. This thickening restricted leaflet opening and resulted in a small, stenotic valve orifice (AVI 3941 kb)
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Video 11.41 TEE view at 60°, also obtained 2 years later, showing thickening of the mitral annulus (AVI 5445 kb)
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Video 11.42 TEE view at 90°, also obtained 2 years later, showing thickening of the mitral annulus (AVI 5005 kb)
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Video 11.43 TEE view at 120°, also obtained 2 years later, showing thickening of the mitral annulus (AVI 3815 kb)
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Video 11.44 3D imaging of the mitral valve demonstrated a significant reduction in valve orifice area related to the smooth, laminated echogenic material overlying the annuloplasty ring and extending onto the leaflet bases. Severe associated valve leaflet thickening was also evident (AVI 681 kb)
Video 11.45

Normal TEE (119° long-axis view) of the first bioprosthetic valve immediately after replacement (AVI 7356 kb)

Video 11.46

Standard TEE (0° view) demonstrating extensive multiple mobile echodensities attached to the left atrial aspect of the valve leaflets and annulus (AVI 8015 kb)

Video 11.47

Standard TEE (61° view) demonstrating extensive multiple mobile echodensities attached to the left atrial aspect of the valve leaflets and annulus (AVI 6522 kb)

Video 11.48

Standard TEE (94° view) demonstrating extensive multiple mobile echodensities attached to the left atrial aspect of the valve leaflets and annulus (AVI 6563 kb)

Video 11.49

Biplane 0/90° view demonstrating orthogonal views of the mitral valve prosthesis with multiple mobile echodensities attached (AVI 4399 kb)

Video 11.50

3D reconstruction of the mitral valve prosthesis with multiple mobile echodensities attached to the valve annulus and leaflets (AVI 1340 kb)

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Video 11.51 Repeat TEE after the redo bioprosthetic mitral valve replacement also demonstrated small, mobile echodensities adherent to the left atrial aspect of the prosthetic valve annulus (AVI 7291 kb)
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Video 11.52 Repeat TEE after the redo bioprosthetic mitral valve replacement also demonstrated small, mobile echodensities adherent to the left atrial aspect of the prosthetic valve annulus (AVI 3147 kb)
Video 11.53

3D reconstruction of the mitral valve immediately after initial implantation, demonstrating a normal, functioning valve (AVI 996 kb)

Video 11.54

Two days after surgery, while the patient was on arteriovenous extracorporeal membrane oxygenation support, TEE (0° view) demonstrated severe biventricular dysfunction and severe mitral valve dysfunction. Both leaflets demonstrated very poor mobility and were severely restricted by overlying thrombus, which extended into the left atrium. Swirling sludge could be seen throughout the left atrium. The left atrial appendage had been ligated at the time of the original surgery (AVI 7260 kb)

Video 11.55

TEE (138° view) performed at the same time as Video 11.54 also demonstrated severe biventricular dysfunction and severe mitral valve dysfunction. Both leaflets demonstrated very poor mobility and were severely restricted by overlying thrombus, which extended into the left atrium. Swirling sludge could be seen throughout the left atrium (AVI 7232 kb)

Video 11.56

Color Doppler imaging demonstrated only a small jet of turbulent forwards flow across the severely stenotic mitral valve (AVI 2125 kb)

Video 11.57

3D reconstruction of the mitral valve showed a severely stenotic valve with only a slit-like valve orifice remaining (AVI 1136 kb)

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Video 11.58 After the thrombectomy, leaflet mobility improved, but a degree of restricted leaflet excursion persisted because of residual thrombus on the valve leaflets and annulus. Biventricular function remained severely impaired (AVI 3627 kb)
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Video 11.59 Zoomed view of Video 11.58 (AVI 5439 kb)
Video 11.60

(a) TEE (0° view) showing that the lateral prosthetic valve leaflet is relatively fixed because of overlying thrombus, which also extends onto the annulus (AVI 6167 kb)

Video 11.60

(b) Zoomed view of Video 11.60a (AVI 8609 kb)

Video 11.61

Color Doppler imaging demonstrated significant turbulence in the flow across the valve, suggestive of valvular stenosis. Trivial regurgitation was noted (AVI 2146 kb)

Video 11.62

3D imaging of the trileaflet, bioprosthetic mitral valve prosthesis viewed from the left atrium. Significant restriction of lateral leaflet is noted, with relatively preserved excursion of the other two leaflets (AVI 1227 kb)

References

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    Acker MA, Parides MK, Perrault LP, Moskowitz AJ, Gelijns AC, Voisine P, et al. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med. 2014;370:23–32.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  1. 1.Department of Cardiovascular MedicineCleveland ClinicClevelandUSA

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