2009 Heart Valve Summit: The Repaired Mitral Valve Leaks: Now What?
So the first case, a 54 year-old man presents with a 10 year history of heart murmur, gradual onset of dyspnea; and a 6-month history of increased palpitations. His echo reveals severe MR due to bileaflet prolapse. The patient is referred for elective surgery.
Here is a Barlow's case. You cannot really appreciate that with the ventricle full. You notice when the ventricle, just make one point for surgeons, when you decompress the ventricle and your clamp is on and then you fill the ventricle you do not see the same degree of prolapse. You really have to fill the ventricle because now the ventricle is relaxed, you have a lot of excess tissue so valves often will not leak, that is why when you have a little bit of AI, you can really distend the ventricle because the valves will not leak as often times when you do not have that systolic pressure. Well I did a valve sliding plasty you saw that the sliding plasty typical Carpentier type repair and this was the echo afterwards. They called me back to the room. I thought the valve looked okay and they call me back a few minutes later and they said, "come in here and look at this echo, Dave, see what you think." There is no bleeding. The pericardial well is completely dry. They want to know whether they should give protamine or what to do. So let us let the panel think about that and then I will ask the question too. So here is the question.
Q: Did you look behind the heart?
Dr. Adams: I have looked behind the heart and I do not see anything.
Q: You do not see a big hematoma.
Dr. Adams: I do not see a hematoma, and I do not see any blood.
Q: Intramural hematoma back there?
Dr. Adams: I do not see anything behind the heart. I see literally just what I have showed to you.
Q: Did you decalcify the annulus?
Dr. Adams: I did not. Straight sliding plasty. It could not have been a more routine.
Dr. Martin: Can you go back just for a second?
Dr. Adams: Sure.
Dr. Martin: So play it again, can you play the images there. Because you have clearly got MR, okay, that looks like it is coming around the side of the ring.
Dr. Adams: Yeah.
Dr. Martin: You got a lot of that. You can see the ring there. The ring looks a little funny to me, but I am you know.
Dr. Adams: Well watch again. This is tricky. See I have got, I agree that we have a systolic jet and it is at the ring.
Dr. Martin: I mean that you got.
Dr. Adams: I am trying to sort out what the heck has happened here.
Steve: Did you rupture into the coronary sinus?
Dr. Martin: That is what you are wondering about?
Dr. Adams: That is what we were thinking about. What I am thinking about is something going on.
Dr. Martin: Although when you show us the coronary sinus, the flow there is blue.
Dr. Adams: Looks pretty good.
Dr. Martin: Yeah coming toward us.
Dr. Adams: The other thing you notice is there is something odd.
Dr. Martin: What did you? You left a sickle in the left atrium there?
Steve: No, I think...
Dr. Adams: Okay guys.
Steve: I think it is the left atrium. I think the left atrium is that little thing.
Dr. Martin: Not only that the color was sort of, you had a dropout, so it is likely to.It is not now, but you have got a space there. You have got some kind of big space. If you watch the color.Turn the color on again David. See the color, it is interrupted, so you have got some kind of space-occupying lesion and the color is actually going around it. Now, looking back there posteriorly, you look like you have got a.I agreed with Steve, it looked like he had a hematoma or something posteriorly. Alright.
Howie: Dave was he instrumented with a Swan before the surgery?
Dr. Adams: Yup, all patients get a Swan.
Howie: I mean, it was obviously done blindly and typically those catheters are soft but, you know, it is very easy to miss and get into the coronary sinus and cause mischief with the catheter.
Steve: I think they are little things. That is the posterior of the LA wall push forward.
Dr. Adams He did have one in and he does have it in now. So here we go. What would you recommend next ? Re-institution of cardiac pulmonary bypass. Now we are going to vote; valve replacement; reinstitution of cardiopulmonary bypass and valve re repair; give protamine and observe carefully in the operating room; consultation with an interventionalist for possible device closure.
Steve: In the OR?
Dr. Adams: It is true para-ring leak, I might do that. Give protamine and plan on repeat echo in 24 to 48 hours. What do you guys think? I was trying to come up with 5 instead of 4.
Steve: Somehow, you got to take a look back in there again.
Dr. Adams: We are just ready to wean from bypass. He looks rock stable. When I showed you that, we had just put our clamp on and the heart is working great. Everything looks perfect. This guy looks good. He has got a funny looking echo.
Dr. Martin: Let us go ahead and vote.
Dr. Adams: Why don't we vote?
Steve: He has got to have an intramural hematoma back there. Everyone should take a look.
Dr. Martin: I like the 1% called for Howie.
Dr. Adams: Okay, well, I think the main message and you notice the title of my little 5-minute or 8-minute clips here is, you know, the valve leaks, what do you do. We have some perivalvular systolic jet. We are not completely sure to be honest with you about what is going on here but we know we are not going to leave that behind. Fortunately, it is not going outside the heart; it is inside the heart. Let me just go to the next slide. And that is what we found. And so what we had was, is we had a tear. This is the hematoma. Now that we saw an intraatrial hematoma in the left atrium, we took the repair back down, I had to literally start all over, take the ring out, redetach the leaflets that had been slid along the annuloplasty and sure enough, one of these sutures that was used to tie the ring in had torn the atriaventricular groove and instead of rupturing out, we ruptured back into our left atrium.
Dr. Martin: You know, that was the point I was making about the color. The color was, you had a significant amount of leak but it was interrupted by this shadow and that had to be a hematoma or something around it.
Dr. Adams: And so, at any rate, we took it all down, I used a couple of pledgeted sutures to repair that defect and we re-repaired the valve, put it all back together again and you can see where the X is, where now this cavity is thrombosed. The patient went home and did fine but I think it is an interesting case, certainly one we have not seen before. Of course, we have had a lot of fun kidding our chief resident about that case but I think it shows a good example of things you do not understand after valve repair, or mitral surgery, you need to look at and the reason you need to look at is because things are under systolic pressure.
Dr. Martin: So the guy did okay.
Dr. Adams: The guy did fine and again I think the key there I think from the surgeon's standpoint is it is not just re-replacement and actually it was quite a simple thing to do but to get there, you have to take it down and be thinking about looking at the annulus when you see that. I will show two other real quick ones. Again, it is a promise that they are just for interest sake. This guy is 54 years old, he has dyspnea, he has an echo. Again, this is the intraoperative TEE. The MR is downgraded a bit. You can see this QLAB analysis suggests there is some prolapse around the posterior commissure. And so, here is his valve and he is interesting for the surgeons here that you will notice that he has a, it takes me a while to figure this valve out too. He has got again a posterior commissural leaflet. So he has a freestanding posterior commissure leaflet that is not P3 that is a posterior commissure leaflet. That is what is prolapsing. I make the decision as you can see in this picture to make it, to attach it to the anterior leaflet because I do not want to leave this free standing. It just had some chordal elongation, so I have attached that to the anterior leaflet and you can see my saline test, I am pretty satisfied with that. The ventricle looks watertight. And here is the postop echo, and they called me back by the way and said it leaks some. I think everybody wants me to go to the next room. I am of course distraught because I am looking and thinking about the picture of the saline test and very happy in seeing that. So, anybody have any ideas what is happening here? Randy? I think one good point you can make Randy is that you agree that is inside the ring this time. Last case outside the ring.
Q: Yeah, that looks fairly inside the ring and David I cannot see it well enough to say.
Dr. Adams: And I know I am just showing one view but I think the message here is that there might be one case or two cases you might accept something like that, I do not know.
Dr. Martin: No, that is a lot of MR.
Dr. Adams: But not in degenerative disease. I am saying may be it is reop, it is calcified, you have done a valve replacement, you have calcium you cannot get rid of. Sometimes we accept paravalvular
Dr. Martin: By suturing them together, have you restricted the motion or have you done something to distort even though that looks like it is at the P, you know, at the posterior P1.
Dr. Adams: I was cursing myself honestly, as soon as I saw that echo because I had known the mistake that I had made because I thought about it. First of all just the question is obvious this time, reinstitution of valve replacement, valve re-repair, or protamine. I think everyone should re-repair that valve or at least go back and look at it again and the mistake I have made is right there. See when I close the septal, when I attach the commissural leaflet, in this particular case, I thought that my indentation would close and it closed with saline, but under systole I had this leak at the base of that and I needed to put two sutures in there to close that, so by going back on for literally 15 minutes, putting two interrupted sutures there and doing a careful interrogation of the rest of the valve, you see the difference in the echo. And the message is again, you just do not accept these kind of jets and always focus on those deep indentations because you do not want to close all of them, particularly in smaller rings because you will limit motion but if you see a leak like that, that is the thing to do. The last case I will show you.
Steve: Can I make a point about you know, when you come off bypass, people ask me, when you come off bypass, how much MR do you accept? Well, I sort of think of a factor of 2 so if they had 1+, they are going to walk around with 2+. If they had 2+, they are going to walk around with 4+. The amount of regurgitation you had the first time coming off was pretty analogous to what you started with so, I mean, it is pretty downgraded, so I agree with you, I would not have accepted that. And the other point is we have that same feeling that when you move something over, you may open up a cleft more than you think and you may have to put those things together.
Dr. Adams: I think that is a good point is that one thing about you and in triangular resection can be that too. You can separate an adjacent indentation so that is almost always the most common source of a recurrent or a residual leak after a valve repair is something very simple along the margin line which is why I think re-exploration in almost everyone is a right answer. I will show you one last case.
Kevin: When you go back to look at the valve it is hard because it is out of the level plane of how your used to looking at it and when you put the stitch in the ring. Is that the way you put a valve stitch in? You pull the valve up?
Dr. Adams: Yeah, I am sorry, yeah, you can see that.
Kevin: Because otherwise it is hard to evaluate it.
Dr. Adams: Yeah. Guys, what Kevin is bringing up which is an excellent point is that whenever you need to do something fine after you have done an annuloplasty, what the ring now has let the valve rotate almost flat; it is not pulled up like it was when you had your annular sutures in. So you see, the first step we always do is put a ring, we would normally used to implant the ring, an Ethibond stitch into the ring and retract it toward the drape and that rolls the valve toward us, so now we can look at the plane in the annulus again so that is an extremely important trick and it is useful not just like in a case like this but also at the end of the case when you are just not quite happy with your saline test, that is the way to roll it up and really look at your edge.
Dr. Adams: Yeah, you are right. I should have made that point. I think it was intuitive. These cases, you have got to have great intuition because your saline test is normal and I really distend ventricles, a lot of you guys have visited me before, I really let the ventricle get distended. I want to see a watertight valve repair so you do always have a little bit of consternation when you have to go back on because you do not have saline now to guide you because we normally will not close with that abnormal saline test. But this is an intuitive thing, like Steve said; just keep it in mind when you close segments together, if you have adjacent indentations or clefts, that is almost always a source of recurrent leak.
Steve: This is a good point that the saline test, David, is not foolproof, that the left ventricular pressure you get when you fill it up with a bulb syringe of saline is about 45. So unless that patient is an amphibian you know they could have possible mitral regurgitation. You just cannot get it tense enough to fill it up. So the real proof in the pudding is unfortunately the TEE. So you really have to think about how you have done that, you know, have you opened it up, you know, we do a sliding plasty sort of rob peter to pay paul , we pulled the P1, P2 cleft or P2, P3 cleft open, do we need to do something than that.
Howie: Do you guys use 3DT here to assess these things? so that, it would seem to me you would be able to tell more quickly what the problem is without having to go before you open up in a more physiologic state if you had 3D.
Dr. Adams: Yeah, I think how 3D is in my experience, 3D is best for QLAB in telling you position of leaflets in the annular plane. I think it is less precise in terms of locating the actual, you know, sort of regurgitation, I think it locates regurgitation in quadrants but I am not sure it can show you the specific.
Dr. Martin: Well, Howie, there are lots of technical problems that you have to overcome. I mean, you can make clefts appear, you can have all sorts of stuff.
Howie: We use it a lot to figure out for e-valve, mechanism of MR if you are unsure sometimes.
Dr. Martin: No, I think there is. He is saying that, I mean, he is saying that but on the fly it is a little bit more difficult.
Steve: I think that where 3D is going to be really important while we see it as an enabling technique to make people more comfortable doing mitral repair increasing the ability of everybody to do mitral repair. What we see, is, you know, I get in there,the first time I look at the valve is when the cross-clamp is on its cardioplegia and I do not really have an understanding. If somebody sends me a 3D you know, 2 weeks ahead of time, I can really think about that and see. And that is exactly what we do. I think it is a great technique to think about the valve ahead of time.
Dr. Martin: It is different than in the interventional lab where I think that the evaluation makes a difference.
Steve: Even ahead of time we use it to figure out whether we think, you know, what
Question at the mic?
Q: I just wondered how much mitral stenosis do you accept when you do these kind of repairs.
Dr. Adams: Well, in degenerative disease, it is extremely uncommon to get a gradient so that is very different than when you are downsizing in ischemic cases because in degenerative disease we are true sizing the annulus as some patients do have a size 24 or a size 26 normal size annulus in relation to the leaflet surface area but it is very uncommon to get mitral stenosis, even functional stenosis after degenerative valve repair.
Steve: Yeah, I agree in degenerative we do not really see stenosis, you know, you accept a gradient of 3 or 2 or 4, it depends on what their heart rate is and what the cardiac output is. I think it is very hard in degenerative disease to provoke mitral stenosis.
Dr. Martin: You want to go forward?
Dr. Adams: I will show one last case. So here is the last case I will show you and it looks like a simple prolapse of the posterior leaflet. Of course there are a lot of ways to fix this and, let's see, here is I just show you quickly what we did. It is sort of tall P2, a quadrangular resection is a good choice in this particular thing I thought maybe we will do a triangular resection. We had a hypoplastic P1 closure line, so far so good, and that is the postoperative echo.
Dr. Martin: So you got a little SAM?
Dr. Adams: This is really after the, and you notice we do not have a lot of MR guys. This is after, I'm sorry we didn't rotate this probe we didn't leave it on long enough. We have optimized it. You know, we are not on epinephrin. We tilt the ventricle up. We obviously do the usual hemodynamics sort of optimization and we have got a gradient in the outflow tract and minimal MR and a young patient, you know, sure, you could always give me a 90 year-old or some reason I would not do it but let us just assume it is the usual 60 year-old or 54 year-old and we have a high gradient in the outflow tract with no MR. And the question is again, what should we do.
Dr. Martin: Are you going to give us a choice?
Dr. Adams: Reinstitution of bypass and valve replacement. Reinstitution of bypass and valve re-repair. Give protamine and optimize.
You know whatever you are going to do is only going to take a couple of minutes because the other thing, almost all these reinterventions are very quick. The first case was very unusual, an annular disruption. These sort of cases are going to be quick and I would go back on and fix this because we have already done our optimization. Keep in mind that there are a lot of these that are created by our friends in anesthesia when they are trying to sort of, especially the younger the anesthesiologist and the quicker they are to go to epinephrin regardless of what is going on with the patient, you can easily create SAM in perfect valve repair. So you do have to be patient, come back to the room, make sure that all the conditions are optimized and often times, I will just give Levophed and give the beta-blocker and if it resolves then I never worry. As soon as you see an echo where it has gone, it is going to go away. I think, you know, almost variably it goes away eventually. I will still leave the room with some if I can make it perfect by filling with volume, slowing the heart rate down and raising the pressure, I am always happy it is going to be resolvable. If it looks like what I just showed you, even though there was no MR in that case, I would actually go back on as well and I will show you what the mistake I made was.
Steve: Dave, can I ask you a question?
Dr. Adams: Sure.
Steve: You think that the height of the P2 was still too high?
Dr. Adams: That was the mistake. Well you see, I made 2 mistakes here. One was the anterior leaaflet was a little bit triangular in shape; it was a little bit taller than the size of the ring and I thought I had a displacement of closure line and I was not worried but you can see what I did there, Steve, was I did a small tip triangular resection and I used a Gore-Tex cord to displace the posterior leaflet lower in the ventricle to make room for the anterior leaflet to come up so again, very simple re-repair you can see, Kevin, that suture you always correctly pointed it out, always here to help me see everything but I think that systolic anterior motion is another process that you will see occasionally when you do valve repair and it is not just in Barlow;s disease; it can be in this sort of intermediate size ring and tall leaflet segment and I think that one thing, you know, Randy, I will say in closing is that one thing what would really help us in the future, you know Carpentier has talked about closing angles of aortic mitral valve and Roberto mentioned that earlier but I wish we could get more sophisticated in preoperatively predicting which patients are sort of at higher risk versus a lower risk for this because we spent a lot of time worrying about it and sometimes you have that exact same case and you come off and for whatever reason the balance is still far away but at any rate, when you do see it, I think the best thing to do is, is take your medicine and go back on and we used to make a horizontal incision in the leaflet and shorten it; now I think leaflet displacement. That is why I never get too frozen because even though I do not do primary leaflet displacement as my first routine without some resection, I learned from Fred Moore and others that Gore-Tex displacement is extremely useful in this sort of setting when you are trying to optimize your closure line if you have left it too tall, just tying it a little bit lower so effectively, the margin in that leaflet acts like cord, is a very simple trick and takes very little time.