PREOPERATIVE DIAGNOSIS: Mitral Regurgitation

OPERATION: Complex Barlow Mitral Valve Repair (Size 36 Physio Ring Annuloplasty; Posterior Leaflet Resection with Commissure to Commissure Sliding Plasty, Gap Closure P2, P3; Correction of Anterior Leaflet Prolapse with Posterior Leaflet Flip Technique x 2; Gap Closure P2, P3)

SURGEON: David Adams, M.D.

Arrhythmic mitral valve prolapse has been identified as a potential cause of sudden cardiac death among some patients with primary mitral regurgitation. What are critical indications and possible mechanisms?

PREOPERATIVE DIAGNOSIS: Mitral Valve Regurgitation

OPERATION: Mitral Valve Repair (Fibroelastic Deficiency with Ruptured Chordae and P2 Prolapse; Quadrangular Resection with Vertical Plication and True Size 36 Physio-Ring Annuloplasty)

SURGEON: David Adams, M.D.

INDICATIONS FOR SURGERY: The patient is a 69 year old man who had severe mitral valve regurgitation with mild pulmonary hypertension here for elective intervention.

In this discussion we review a six-year study of over 53,000 patients that reveals the extraordinary safety and durability of mitral valve repairs among patients with primary mitral regurgitation.

In this video we review a challenging case of a 48-year-old woman presenting with chest pain. We explore the role of Echo, CT, and MRI imaging, and highlight how surprising and dramatic results led to a diagnosis of a Left Ventricular Pseudoaneurysm (LVPA). Using excellent intraoperative surgical video, we also explore the best surgical approach to treating LVPA.

PREOPERATIVE DIAGNOSIS: Mitral Regurgitation

OPERATION: Complex Mitral Valve Repair (Bileaflet Prolapse; Triangular Resection of P2; Gap Closure of P2, P3; True Size 32mm Physio II Ring; Gore-Tex Chord x 1 to Correct A2 Prolapse due to Chordal Elongation)

SURGEON: David Adams, MD

INDICATIONS FOR SURGERY: The patient is a 55-year-old gentleman with a 5-year history of mitral valve prolapse with severe mitral valve regurgitation referred for elective intervention.

Secondary mitral valve regurgitation increases the dangers of heart failure, and the two conditions are often encountered together.

PREOPERATIVE DIAGNOSIS: Barlow's Mitral Valve Disease

OPERATION: Complex Barlow's Mitral Valve Repair (Bileaflet Prolapse; Posterior Leaflet Quadrangular Resection; Vertical and Horizontal Compression followed by Sliding Plasty; Magic Suture x 1 to Posterior Commissure; Chordal Transfer x 1 to Correct A2 Prolapse; Gore-Chord x 1 to Correct A2-A3 Prolapse; Gap Closure A2-A3; True Size 36 mm Physio II Ring)

SURGEON: David Adams, MD

Mitral Annular Calcification (MAC) is a complex and increasingly common syndrome. In this discussion we review Mount Sinai’s proven algorithm for determining the best treatment for MAC, as well as imaging and intraoperative videos.

PREOPERATIVE DIAGNOSIS: Mitral Regurgitation

OPERATION: Complex Mitral Valve Repair (Anterior Leaflet and Posterior Commissural Prolapse; Gore-Tex Chords x 3: 2 to A2, 1 to the Posterior Commissure; Magic Sutures x 2 to Posterior Commissure; True Size 28mm Physio II Ring)

CO-SURGEONS: David Adams, MD and Joanna Chikwe, MD

Reviewing surgical video from a case study, we explore the complexity of diagnosing mitral valve endocarditis, especially when there is a risk of embolism.

This Mitral Foundation Teaching Library case is going to highlight the first U.S. implantation of the Edwards Lifesciences Physio II Annuloplasty Ring.

In Part 2 of our discussion on the risk of sudden cardiac death from arrhythmic mitral valve prolapse, a case study offers new insights into properly identifying, diagnosing and treating high-risk patients. Topics include:

Undetected or untreated, aortic aneurysms can be fatal. New guidelines from the American College of Cardiology and American Heart Association suggest earlier intervention to help patients who typically go undiagnosed or untreated.

There are a variety of repair strategies that are useful for anterior leaflet prolapse. In this video, we're going to show a technique of single suture PTFE, placed in the tip of the papillary muscle and passed through the free edge, with final height adjustment during saline testing; a functional height adjustment, as opposed to geometric adjustment.

Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is caused by blood clots in the lung arteries and may be a common cause of pulmonary hypertension that can in turn cause heart failure, and often goes undiagnosed. 

Triangular resection is a simple technique. It's designed to correct prolapse at the margin of the leaflet. As demonstrated in this case, adjusting the width and depth of the triangular resection will allow you to tailor the body of the leaflet to the correct height and deal with myxomatous degeneration that may be present.

When a patient’s aortic valve is irreparably damaged, either because it has calcified and narrowed (Aortic Stenosis) or because it is leaking (Aortic Regurgitation), one proven therapy is the Ross procedure.

This Mitral Foundation Teaching Library case is going to demonstrate sliding leaflet plasty in combination with annular plication to treat a patient with a Barlow's malformation.

Our main strategy for treating patients with excess posterior leaflet tissue is sliding leaflet plasty. We follow Carpentier's rules, usually performing a limited quadrangular resection. We do resect less tissue today than we did historically, and then we reattach the leaflet along the annulus. Annular plication is sometimes used to narrow the orifice and take tension off the leaflet.

The complex physiology and function of the aorta make the successful diagnosis and treatment of aortic regurgitation a highly nuanced endeavor.

This Mitral Foundation Teaching Library case is going to demonstrate teaching points in the repair of multi-segment Barlow's mitral valve disease.

Systolic anterior motion occurs after mitral valve repair due to an excess of leaflet tissue versus the anterior lateral height of the orifice of the mitral valve. The posterior leaflet pushes the anterior leaflet into the outflow tract. There are two principal causes for this. One is excess height of the posterior leaflet after reconstruction. The second one is a ring size that is too small for the available leaflet tissue.

High velocity jets after mitral valve repair strongly suggest leaflet perforation. They're usually simple lesions to re-repair. And if patients are stable and have good ventricular function, it's usually worth a second look on bypass to identify them. They can be dynamic and they can also happen from a pressurized ventricle and when you see them, you shouldn't just trust the sailing test, you should go back on and reexamine the valve.

In this video we show an example of a reconstruction of Barlow's valve disease in a patient that has calcification of the annulus. The key steps we'll show are a detachment of the leaflet with a targeted de-calcification of the annulus and then reconstruction of the posterior leaflet and finally ring annuloplasty.

The key teaching points that we show in this video is patch augmentation is the primary strategy for a perforation, whether that's healed or acute in the anterior leaflet.