Read It, Code It, See It

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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

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Disclosure

• Nothing to Disclose

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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.

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Mitral Valve Replacement

1. No

2. Annuloplasty only

3. Replacement

4. Reconstruction with annuloplasty

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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

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Annuloplasty only

1. No

2. Annuloplasty only

3. Replacement

4. Reconstruction with annuloplasty

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Mitral Anatomy

_{Subaortic curtain}

_{Aortic leaflets}

_{AV node position}

_{Coronary Sinus}

_{Circumflex Artery}

Preservation of

Preservation of ““surroundingsurrounding”” anatomic integrityanatomic integrity essential for successful mitral repair

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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.

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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

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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.

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Reconstruction without annuloplasty

1. No

2. Annuloplasty only

3. Replacement

4. Reconstruction with annuloplasty

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Complex mitral repair

Alfieri

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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.

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Reconstruction with annuloplasty

1. No

2. Annuloplasty only

3. Replacement

4. Reconstruction with annuloplasty

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1968 2005 1980

Edwards acquires manufacturing and distribution rights

1983 CE Classic inner changes from steel to titanium 1993 Limited launch CE Physio ring 1993 Limited launch of Cosgrove-Edwards Band 2001 Launch of the MC3Tricuspid 2004

Launch of the IMR ETlogix Ring Professor Carpentier

introduces CE Classic manufactured by Rhone-Poulenc at the Hospital Broussais

1970 Introduction CE Classic Tricuspid

Launch of the GeoForm Ring

Edwards Heart Valve Repair

Portfolio

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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….

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1. NO

2. Replacement

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Replacement with Aortic Annular

Enlargement

Aortic Annular Enlargement

1. Yes

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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

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Root Reconstruction with Valve

Sparing

1. NO

2. Replacement

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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).

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Root Reconstruction with Valve

Conduit

1. NO

2. Replacement

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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.

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Repair

1. NO

2. Replacement

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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…..

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Resuspension Aortic Valve with

Replacement of Ascending Aorta

1. NO

2. Replacement

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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

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Replacement +Aortic Graft Conduit

1. NO

2. Replacement

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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.

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Resuspension Aortic Valve without

Replacement of Ascending Aorta

1. NO

2. Replacement

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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

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Resection of Sub-Aortic Stenosis

1. NO

2. Replacement