VALVE REPLACEMENT AND REPAIR

AORTIC STENOSIS (AS)

Indications for surgery
Symptomatic patients with valve gradient of > 50 mm Hg or valve area < 0.8 cm 2 (normal 3-4 cm2)
Asymptomatic patients with significant stenosis and LVH should also be considered
Moderate AS if other cardiac surgery is required (i.e. CABG)

Surgical options
Balloon valvuloplasty
For critically ill patients with end-stage AS as a "bridge" to aortic valve replacement
Also considered in pregnancy or if significant comorbidity and high surgical risk
50% recurrence of AS in 6 months

Decalcification/debridement
In patients with mild to moderate AS in whom the primary indication for surgery is
coronary artery disease
Commissurotomy
Useful in a small percentage of patients with aortic rheumatic valve disease with a tri-
leaflet valve and minimal to no calcification
Valve replacement
Practically all patients with severe AS require aortic valve replacement


AORTIC REGURGITATION (AR)
Indications for surgery
Acute AR with CHF
class III-IV symptoms
Endocarditis with hemodynamic compromise or recurrent emboli
Evidence of LV decompensation in the asymptomatic patient
EF <55%
End-diastolic dimension > 70 mm
End-systolic dimension > 55 mm

Surgical options
Valve repair
involves resection of portions of the valve leaflets and reapproximation to improve leaflet
coaptation (especially for bicuspid valves), often with a suture annuloplasty
valuable in younger patients
Valve replacement
practically all patients with AR require aortic valve replacement
Bentall procedure
a valve conduit is used if an ascending aortic aneurysm (annuloaortic ectasia) is also present


CHOICE OF AORTIC VALVE PROSTHESIS
The aortic valve can be replaced with either a valve (mechanical or porcine bioprosthetic tissue valve)
or graft (autograft or homograft)

Mechanical valve
Durable valves but require continuous anticoagulation with coumadin (contraindicated if previous
bleeding history), requiring patient to take daily medication and have periodic blood tests (to maintain
INR 2-3)
In carefully anticoagualate patients, the risk of hemorrhage is 1-2% per year, and the risk of
thromboembolic events is 1-3% per year
Preferred valve replacement if long life expectancy or if risk of reoperation is considered high
Preferred valve replacement if small aortic root (bioprosthetic aortic valve placement in a small aortic
orifice may result in obstruction and unacceptably high gradients)

Bio prosthetic valve
Low embolic rate in the absence of anticoagulation (1-2% risk of thromboembolic events)
Less durable than mechanical valves and require reoperation due to degeneration and structural
failure
However, structural degeneration of bioprosthetic valves is rare in elderly patients
Preferred valve replacement if life expectancy of patient is shorter than the known durability of the
bioprostheses
Also considered if potential for pregnancy (coumadin is teratogenic)

Pulmonary autograft
Ross procedure:
Replace the diseased aortic valve with the patient's own pulmonary valve and implant a semilunar valve
homograft (e.g. pulmonary valve homograft) in the pulmonary position
Pulmonary autograft failure is rare in carefully selected patients, but 20% will require reoperation at
10 years because of stenosis of the pulmonary homograft
Technically demanding operation
Ideal for children and young adults to avoid anticoagulation

contraindicated in patients with dilated aortic root (Bentall procedure recommended instead)

Aortic homograft
Particularly suitable for children, women of child-bearing age, and patients with active endocarditis
(e.g. aortic root abscess)
Durability is limited with 20% 10 year reoperation rate (higher in younger patients)
Procurement a problem: valves from donors older than 40 years of age are often not good

MITRAL STENOSIS (MS)
Indications for surgery
MV area < 1.5 cm 2 (normal is 4-6 cm 2 )
NYHA classes III-IV
NYHA class II when MV area < 1 cm 2 (critical mitral stenosis)
History of atrial fibrillation and/or systemic emboli (from left atrial thrombus)
worsening pulmonary hypertension

Surgical options
Percutaneous balloon mitral valvuloplasty
For young rheumatic patients with pure MS and good leaflet pliability, minimal chordal
thickening and good subvalvular mechanism
Also considered in pregnant patients with critical MS in whom CPB should be avoided
contraindicated if left atrial thrombus
open mitral commisurotomy
For patients with mild calcification and mild leaflet/chordal thickening +/other
coexistent diseased valves (e.g. aortic and/or tricuspid)
Technique involves incision of both commissures, incision/resection of fused chordae,
and occasionally incision into papillary muscle to increase mobility (if evidence of chordae shortening
from scarring and fibrosis)
50% of patients will require reoperation 8 years following initial commisurotomy due to
restenosis
Valve replacement
for moderate to severe calcification with severely scarred valve leaflets or subvalvular
apparatus


MITRAL REGURGITATION (MR
Indications for surgery
acute MR associated with CHF or cardiogenic shock
acute endocarditis with hemodynamic compromise or recurrent emboli
NYHA class III-IV
Class I-II symptoms with onset of atrial fibrillation or evidence of deteriorating LV function
EF < 55% end-diastolic dimension > 75 mm
end-systolic dimension > 45 mm
Surgical options
Valve repair
Applicable to more than 75% of patients with MR
The ideal pathology for mitral valve repair is myxomatous degeneration of the MV
Several techniques include annuloplasty rings, leaflet repairs, patch repair (for endocarditis), and
chordal transfers, shortening or replacement
Prolapse of the posterior leaflet is usually corrected by rectangular resection of the prolapsing
segment and plication of the annulus
Prolaspe of the anterior leaflet is corrected by transposition of chordae from the posterior leaflet (neo-
cordae)
chordal enlongation is corrected by invaginating the excess length of chordae into a trench in the
papillary muscle
A ring annuloplasty or Gortex is often used in MV repair to reshape the annulus to its normal elliptical
configuration and to maintain stability

Valve replacement
indicated only when satisfactory repair cannot be accomplished
most patients with MR due to ischemic heart disease, rheumatic heart disease or advanced
myxomatous disease need MV replacement
Replacement usually required if heavily calcified annulus or if papillary muscle rupture
chordal preservation of the posterior leaflet should be strongly considered for all MV replacements (to
improve ventricular function and minimize risk of posterior LV wall rupture) the advantages of repair vs.
replacement are the low rate of endocarditis and lack of need for long-term anticoagulation.

CHOICE OF MITRAL VALVE PROSTHESIS
The current choice for mitral valve replacements include
1. mechanical prostheses (e.g. ball valve, tilting disc, bileaflet, etc.) and
2. bio prosthetic valves the main factors affecting choice of prosthesis are anticoagulation, and the
attitude of the patient and surgeon regarding reoperation

Bio prosthetic valves
require anticoagulation only for first 3 months
lower durability and require reoperation due to degeneration and structural failure (20-40% fail by 10
years)
However, structural degeneration of bioprosthetic valves is rare in elderly patients
bioprosthetic valves in the mitral position are not as durable as in the aortic position
Preferred valve replacement if life expectancy of patient is shorter than the known durability of the
bioprostheses also considered if potential for pregnancy (coumadin is teratogenic)

Mechanical valves
require continuous anticoagulation (contraindicated if previous bleeding history)
In the setting of chronic A fib, patient is already anticoagulated, and therefore mechanical valve used
Preferred valve replacement if long life expectancy or if risk of reoperation is considered high