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1 Read It, Code It, See It Richard L. Prager, M.D. University of Michigan Ann Arbor, Michigan Dorothy Latham, R.N. Port Huron Hospital Port Huron, Michigan

2 Nothing to Disclose Disclosure

3 Preoperative diagnosis: Mitral stenosis Operative procedure: The left atrium was opened via the interatrial groove and the mitral valve was inspected. It was characterized by commissural fusion, chordal shortening and annular calcification. The existing valve was excised and replaced with a 25mm Mosaic valve using 0 Ethibond pledgetted supra-annular mattress suture technique.

4 Mitral Valve Replacement 1. No 2. Annuloplasty only 3. Replacement 4. Reconstruction with annuloplasty 5. Reconstruction without annuloplasty

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6 Preoperative diagnosis Mitral regurgitation and atrial fibrillation Operative procedure The left atrium was opened via the interatrial groove, and the mitral valve was inspected. It was characterized by annular dilatation and insufficiency. The valve was repaired by annular reshaping. Annuloplasty was performed using a 26mm Physio ring and 2-0 Ethibond annular mattress suture technique.

7 Annuloplasty only 1. No 2. Annuloplasty only 3. Replacement 4. Reconstruction with annuloplasty 5. Reconstruction without annuloplasty

8 Mitral Anatomy Subaortic curtain Aortic leaflets AV node position Coronary Sinus Circumflex Artery Preservation of surrounding anatomic integrity essential for successful mitral repair

9 Mitral Repair - more stitches!

10 Preoperative diagnosis Aortic insufficiency, endocarditis Operative procedure The aorta was opened and the aortic valve was inspected. It was characterized by leaflet vegetation, destroyed non coronary cusp with large hole in the right cusp. The existing valve was excised and replaced with a 27 mm Magna valve using 2-0 Ethibond pledgetted sub-annular mattress suture technique.

11 Replacement 1. NO 2. Replacement 3. Repair/reconstruction 4. Root Reconstuction with valve conduit 5. Replacement with aortic graft conduit 6. Root Reconstruction with valve sparing 7. Resuspension Aortic valve with replacement of ascending aorta 8. Resuspension Aortic valve without replacement of ascending aorta 9. Resection subaortic stenosis

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13 Edwards Magna Valve

14 Preoperative diagnosis Mitral regurgitation Operative procedure The left atrium was opened via the interatrial groove and the mitral valve was inspected. It was characterized by annular calcification. The valve was repaired by Alfieri stitch.

15 Reconstruction without annuloplasty 1. No 2. Annuloplasty only 3. Replacement 4. Reconstruction with annuloplasty 5. Reconstruction without annuloplasty

16 Complex mitral repair Alfieri

17 Pre-operative diagnosis Mitral regurgitation Operative procedure The left atrium was opened via the interatrial groove and the mitral valve was inspected. It was characterized by posterior leaflet prolapse, annular dilatation and insufficiency. The valve was repaired by posterior leaflet resection, sliding-plasty and annuloplasty. Annuloplasty was performed using a 27mm SJM Tailor ring and 2-0 Ethibond annular mattress suture technique.

18 Reconstruction with annuloplasty 1. No 2. Annuloplasty only 3. Replacement 4. Reconstruction with annuloplasty 5. Reconstruction without annuloplasty

19 Mitral Valve Repair

20 Edwards Heart Valve Repair Portfolio Professor Carpentier introduces CE Classic manufactured by Rhone-Poulenc at the Hospital Broussais 1983 CE Classic inner changes from steel to titanium 1993 Limited launch of Cosgrove-Edwards Band 2004 Launch of the IMR ETlogix Ring Launch of the Limited launch MC 3 Tricuspid Edwards acquires Introduction CE Physio ring manufacturing Launch of the CE Classic Tricuspid and distribution rights GeoForm Ring

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23 Preoperative diagnosis Aortic stenosis Operative procedure The aorta was opened and the aortotomy was performed. The valve was visualized and appeared to be heavily calcified. The leaflets of the aortic valve were excised sharply and the annulus was debrided back sharply. After the valve was excised we irrigated with saline. The size of the annulus was too small to appropriately accommodate a size 19 valve. Feeling a size 17 valve was not appropriate, we extend the aortotomy through the remnant of the noncoronary cusp in modified Manouguian Nicks fashion. Valve sutures were placed at the apex of the incision and an eliptical Hemashield patch was sewn into the defect created in the subaortic anterior leaflet of the mitral valve. We placed 2-0 Tycron sutures with pledgets on the aortic side at the level of the annulus. A 19 Magna valve was seated easily into good tissue.

24 1. NO 2. Replacement 3. Repair/reconstruction 4. Root Reconstuction with valve conduit 5. Replacement with aortic graft conduit 6. Root Reconstruction with valve sparing 7. Resuspension Aortic valve with replacement of ascending aorta 8. Resuspension Aortic valve without replacement of ascending aorta 9. Resection subaortic stenosis

25 Replacement with Aortic Annular Enlargement Aortic Annular Enlargement 1. Yes 2. No

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27 Preoperative diagnosis Type A aortic dissection Operative procedure Inspection of the aorta revealed an aortic dissection. The aortic valve was characterized by insufficiency. The aortic sinus tissue and ascending aorta were inspected and replaced with a 30 Vascutek conduit. The conduit was secured to the LV outflow tract using 2-0 Prolene sub-annular mattress sutures placed in the horizontal plane at the level of the nadir of the annulus. Coronary perfusion was restored by coronary ostial button reimplantation.

28 Root Reconstruction with Valve Sparing 1. NO 2. Replacement 3. Repair/reconstruction 4. Root Reconstuction with valve conduit 5. Replacement with aortic graft conduit 6. Root Reconstruction with valve sparing 7. Resuspension Aortic valve with replacement of ascending aorta 8. Resuspension Aortic valve without replacement of ascending aorta 9. Resection subaortic stenosis

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36 Preoperative diagnosis Aortic stenosis Operative procedure Inspection of the ascending aorta revealed aortic stenosis. The aortic valve was characterized by bicuspid morphology, commissural fusion, calcification and stenosis. The aortic valve and ascending aorta were inspected and replaced with a 23 mm Prima valve conduit. The valve was secured to the annulus using 2-0 Ethibond simple technique. Coronary perfusion was restored by ostial reimplantation (modified Bentall technique).

37 Root Reconstruction with Valve Conduit 1. NO 2. Replacement 3. Repair/reconstruction 4. Root Reconstuction with valve conduit 5. Replacement with aortic graft conduit 6. Root Reconstruction with valve sparing 7. Resuspension Aortic valve with replacement of ascending aorta 8. Resuspension Aortic valve without replacement of ascending aorta 9. Resection subaortic stenosis

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41 Preoperative diagnosis Aortic insufficiency Operative procedure The aorta was opened and the aortic valve was inspected. It was characterized by stenosis. The existing valve was repaired using 3-0 Ethibond commissuroplasty suture technique.

42 Repair 1. NO 2. Replacement 3. Repair/reconstruction 4. Root Reconstuction with valve conduit 5. Replacement with aortic graft conduit 6. Root Reconstruction with valve sparing 7. Resuspension Aortic valve with replacement of ascending aorta 8. Resuspension Aortic valve without replacement of ascending aorta 9. Resection subaortic stenosis

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44 Preoperative diagnosis Ascending aortic aneurysm Operative procedure The aorta was transected at the level of the right pulmonary artery. We then dissected the aorta down to the sinotubular junction and transected at the sinotubular junction. The leaflets appeared normal. We put 4-0 Ethibond sutures in the commissural post, measured the annulus at 28. We took a 28 Hemashield graft, trifurcated it and placed 4-0 Prolene sutures through the commissural post and up through the trifurcation markers of the graft. We used felt for reinforcement. We slid the graft down onto the sinotubular junction, tied down the stitches and sutured the sinotubular junction from post to post to the graft..

45 Resuspension Aortic Valve with Replacement of Ascending Aorta 1. NO 2. Replacement 3. Repair/reconstruction 4. Root Reconstuction with valve conduit 5. Replacement with aortic graft conduit 6. Root Reconstruction with valve sparing 7. Resuspension Aortic valve with replacement of ascending aorta 8. Resuspension Aortic valve without replacement of ascending aorta 9. Resection subaortic stenosis

46 Preoperative diagnosis Aortic insufficiency with a bicuspid aortic valve and six centimeter aneurysm of the ascending aorta Operation A standard hockey stick aortotomy was made exposing the bicuspid valve which demonstrated poor coaptation and with his known severe regurgitation it was felt most appropriate to replace the valve. Therefore, the valve was excised in total and using 2-0 pledgetted sutures, 14 in number, were placed around the annulus and a 25 mm. St. Jude aortic prosthesis was sutured and tied in place. The mechanical leaflets functioned normally and the aorta was closed in standard fashion. Attention was next directed to the ascending aorta. The aorta appeared normal to the sinotubular ridge, however above this area it was dilated and thin. Therefore, it was resected and a Hemashield tube graft sutured in placed resecting the entire aneurysmal and thinned area. The patient was then placed in the head down position and an aortic air needle placed in the graft and following rewarming the cross cramp was removed.

47 Replacement +Aortic Graft Conduit 1. NO 2. Replacement 3. Repair/reconstruction 4. Root Reconstuction with valve conduit 5. Replacement with aortic graft conduit 6. Root Reconstruction with valve sparing 7. Resuspension Aortic valve with replacement of ascending aorta 8. Resuspension Aortic valve without replacement of ascending aorta 9. Resection subaortic stenosis

48 Preoperative Diagnosis Severe aortic regurgitation Operation A hockey stick aortotomy was made and the aortic valve inspected. It was a three leaflet valve with what appeared to be inadequate central coaptation and an element of prolapse of the non and right coronary leaflets. In this setting it was elected to resuspend these leaflets 2-0 pledgetted sutures were placed at the highest commissural point just below the sinotubular ridge. Following this there appeared to be improved coaptation and the aortotomy was closed.

49 Resuspension Aortic Valve without Replacement of Ascending Aorta 1. NO 2. Replacement 3. Repair/reconstruction 4. Root Reconstuction with valve conduit 5. Replacement with aortic graft conduit 6. Root Reconstruction with valve sparing 7. Resuspension Aortic valve with replacement of ascending aorta 8. Resuspension Aortic valve without replacement of ascending aorta 9. Resection subaortic stenosis

50 Preoperative Diagnosis Asymmetric septal hypertrophy Operation The aorta was opened in the standard fashion and the aortic valve inspected. It was a three leaflet valve with no obvious abnormalities and with great care the leaflets were carefully retracted exposing the ventricular septum. It was obviously a hypertrophied septum impinging upon the left ventricular outflow tract. Transesophageal echo measurements preoperatively revealed the superior most portion of the septum was 22 mm. in thickness. With this noted, great care was taken to avoid the area of the conduction system and an angle handled 15 blade knife was utilized to resect subaortic muscle of approximately 1 cm. by 2.5 cm. starting on the assistant s side of the orifice of the right coronary artery. This was carried out without difficulty and the aortotomy closed in the standard fashion.

51 Resection of Sub-Aortic Stenosis 1. NO 2. Replacement 3. Repair/reconstruction 4. Root Reconstuction with valve conduit 5. Replacement with aortic graft conduit 6. Root Reconstruction with valve sparing 7. Resuspension Aortic valve with replacement of ascending aorta 8. Resuspension Aortic valve without replacement of ascending aorta 9. Resection subaortic stenosis