-often seen w AVCD (ref 30)
Anatomy
-cleft of the anterior leaflet is seen w partial AVCD; in a complete AVCD a cleft is made as part of the repair - the cleft is the most common site of regurg
-central MR in dilated vlvs w poor central apposition of the mural/ant leaflets
-regurg causes more regurg bc of the vol load..., and it can cause 2y cahnges to the leaflets- thick and rolled edges...
-MR can be bc of structurally abNl vlv- dysplastic and retracted, thick/short cords/paps
-other structural Abnlies- isolated cleft of ant MV leaflet' leaflet prolpase fr cordal elongation or rupture (usually w CT disorder/Marfans) or bc of leaflet perf or injury fr endocarditis
Path & Sx
--> incr LA P--> phtn
--> vol load on LV in addition to P load on RV
-CHF Sx...
Dx
-echo is Dx- quantify degree of MR w width of MR jet at level of leaflets, check fr multiple jets
Rx Tx
-CHF Tx...
-afterload reduction
Surgical Indications
-less stringent than for MS bc of the increased likelihood surg will help
-if you delay surg to the pt of 2y changes --> harder to repair, less success
-rare to need to replace the vlv w the 1st surgery
Surgical Mgt
-CP Bypass, hypothermia, cardioplegia...
-Assess the vlv
-TEE, 3D echo
-infuse cold cardioplegia into the LV w a fine rubber tube, avoid frothing as it can cause LV dysfx postop. ____
-when LV has been distended w cardioplegia solution, then study the regurg jet, note relative positions of the vlv leaflets, espec at level of the cleft if present
Cleft Closure
-continuous sutures at cleft edges, but this might make for more difficulty in accurately aligning the margins, so may want to use interrupted sutures w pericardial pledgets if the leaflet is fragile
Annuloplasty for Central Regurg
-if see regurg centrally after closing the cleft, then must do an annuloplasty
-don't use annuloplasty rings in kids bc --> restrict growth
-place commissuroplasty sutures at one or both commissures
-lateral commissure is safer bc further fr the conduction bundle
-but do it on the one from which the jet is coming from...
-remember that the circumflex cor art lies close to the annulus post and laterally
Chordal shortening, chordal transfer
-for rheumatic MV dz and degen vlvr dz, rarely used in kids w congen xx
Repeat Testing of the Valve
-after each step, reassess the vlv w infusion of cardioplegia solution into LV, goal is complete elimination of regurg given you are in a low P setting
MV Replacement for MR
-same technique as for MS (see other page w notes)
-but note that annulus is likely relatively large so shouldn't need supra-annular positioning
Surgical Results
-ref 35- 1999 study - 56 pts, 36 MV repairs and 30 MV repalcements
-2 hospital deaths, 2 late deaths in MV repair group
-re-op in 4 pts - 3 of which had MV replacement bc of residual MR after a repair
-no hosp death in MV replacement pts
-6 pts had 10 thrombotic episodes at prosthetic vlv, all Tx w thrombolytic Tx w urokinase
-mean 78 months for re-replacement of a MV prosthesis
-survival and freedom fr cardiac events at 10 yrs was 87% & 73% for MV repair, and 90% and 67% for MV replacement
-ref 36- 1999 study- 49 pts w commissural plication annuloplasty in Tokyo
-69% pts had chordal anomalies as cause of MR
-16% pts had annular dilation
-14% pts had leaflet anomalies
-88% had commissural plication annuloplasty
-11 had modified Devega procedures
-5 had cleft closure
-3 had plication of ant leaflet
-combined techniques in 19 pts
-86% free fr re-op at 13 yrs
-ref 37- 30 pts w congen MV dz
-87% had calve repair, rest replacement
-3 pts needed late vlv replacement, rest had great fx at f/u echo