CARDIAC SURGERY - valve disease - aortic dissection - atrial fibrilation Petr Fila [USEMAP] Dear students, welcome to second part of commented presentation from cardiac surgery. In this part I will talk about valve disease, aortic dissection and atrial fibrilation in context of surgical correction. Valve diseases - history - 1950 - Bailey – closed aortic valvulotomy 1952 - Hufnagel – descending thoratic aortic valve 1956 - Murray – descending thoratic aortic homograft end of 50th – Hurley, Kirklin – open valvulotomy 1960 - Harken, Starr – AVR with aortic ball valve 1962 - Barratt-Boyes – AVR with homograft 1965 - Binet – AVR with bioprothesis 1967 – Ross procedure 1991 - David, Yacoub – aortic valve sparing surgery Starr Monoleaflet SJMbileaflet [USEMAP] We start with something from history of heart valve surgery. First AVR was performed in 1960 withaortic cage ball valve. You see on picture. The other generation was tilting disk prosthesis. Hoping to improve haemodynamics, a rigid bileaflet was developed. This design produces three flow areas through the valve orifice, with a more uniform and laminar central flow. Better haemodynamics was associated with less blood stagnation and the lower profile allowed easier implantation. The sewing ring and the external profile were modified to further increase the effective orifice area. Anatomy of heart valves - Atrio-ventricular valves (Mi,Tri) - leaflets - anulus - chords - papillary muscles - left /right ventricle Ventriculo-arterial valves - leaflets - anulus - root - ST junction [USEMAP] Basics functional parts of AV valves (mitral and tricuspid) are leaflets attached to annulus, papillary musceles witch chords attached to the leaflets. And also left or right ventricle is important funcitonal parts of AV valves. In VA valves (mainly aortic), there are no chords, but leaflets are attached to the annulus. And with STJ they are parts of aortic root. This is important for understanding to function and etiology of disease and it´s important for correction (mainly for reconstruction surgery). Anatomy of heart valves - localization - Superior view of the heart showing the four heart valves open and closed https://upload.wikimedia.org/wikipedia/commons/thumb/9/94/Heart_anterior_ventricles_valves.jpg/656p x-Heart_anterior_ventricles_valves.jpg [USEMAP] On this picture you see very close localization between heart valves. Pathological process (endocarditis) can affect more than one valve. It´s important to know during surgery. Aortic valve disease - stenosis - most often AS risk factors bicuspid - 2% turbulent flow aortic root dilatation! + Mi valve Etiology - degenerative - congenital - post-rheumatic 062001B 062001C 062001D 062001A [USEMAP] Now we start with aortic valve disease. AoS is the most often disease of valves. There are three basic ethiologic types of AoS. On first picture you see normal valve leaflets. The second is degenerative AS with calcification. On third picture you can see bicuspid valve (for about 2% of population has bicuspid valve). In bicuspid aortic valve degeneration, calcification and stenosis can occur in early age. Also aortic root dilatation in this cohort is more often than in other population. Fourth picture - post-rheumatic aortic stenosis – fusion of leaflets - rare diagnosis (in rare of rheumatic fever) in this part of world – often with mitral stenosis. Aortic valve disease – stenosis – indication for surgery (AVR) - aortic valve stenosis (on ECHO) symptoms (chest pain, dyspnea, syncope) surgery symptoms …. LV function? (↓EF, LV dilatation) surgery http://www.hexdoctor.de/upload/image/Syg%20Vejrtr.jpg [USEMAP] Important for AoS indication for surgery are symptoms. ECHO diagnosis is on first place but for you is important…SYMPTOMS (chest painangina, shortness of breathe, syncope) If there are no symptoms we detect LV function. If there is LVEF bellow 50% and/or LV dilatation – surgery is indicated. If not, during regulary follow up we check the patienzt with AoS. Aortic valve disease - regurgitation - acute x chronic Etiology - post-rheumatic - endocarditis - congenital - degenerative - annulus/root/STJ dilatation https://columbiasurgery.org/sites/default/files/styles/large/public/aortic_enlarged_aorta.gif?itok= cY1ZH-dx [USEMAP] AoR can be acute or chronic. Etiology… As I said abou functional part of VA valve Sometimes there are normal leflets, no patology on leaflets. And due to annulus, root , STJ dilatation, there is no coaptation and AoR developed. Mitral valve diseases - Stenosis Etiology - post-rheumatic - degeneration (calcification) Indication for surgery - symptoms (dyspnoa) - MV ≤ 1,5cm2 - atrial fibrilation - pulmonary hypertension Regurgitation (acute, chronic) Etiology - myxomatous degeneration (leaflet prolaps, chords rupture…) - post-rheumatic - endocarditis - ischemic (MI, LV dysfunction) Indication for surgery - symptoms - RV > 40ml, RF > 40%, https://i0.wp.com/thoracickey.com/wp-content/uploads/2018/12/m_cardsurg5_ch37_f001-1.png?w=960 [USEMAP] MiS – postrheumatic or mitral valve calcification due to degenmeration Regurgitation – acute (after MI – papilary muscle rupture, ot IE) chronic – tissue degeneration (leaflet prolaps, chordal rupture), post rheumatic or due to LV dysfunction – LV dilatation Tricuspid valve disease - Stenosis Etiology - post-rheumatic - carcinoid syndrom Indication for surgery - gradient > 2-3mmHg Regurgitation Etiology - relative…annulus dilatation - endocarditis Indication for surgery - TriR grade III-IV [USEMAP] Tricuspid valve stenosis can be cused by rheumatic fever, or by carcinoid syndrom. More often is tricuspid valve regurgitation, ussualy due to annular dilatation. Tricuspid valve endocarditis is uncommon in ths region. However, recent global data indicate growing trends related to drug abuse. Heart valve surgery - 1. Valve sparing – if it‘s possible X risk of failure valve sparing surgery → redo surgery 2. Valve replacement X risk of valve prosthesis [USEMAP] Basic decision-making in heart valve surgery 1. We can spare the valve, repair the valve if it is possible, but there is risk of... 2. On the other side we can replace the valve but there is risk of artefitial valve complication (Risk of anticoagulation therapy (in case of mechanical prothesis), risk of thrombebolism, risk of prosthetic) endocarditis Anatomy of heart valves - Ventriculo-arterial valves - leaflets - anulus - root - STJ [USEMAP] We can make correction on every functional parts of valve. In VA valves on leaflets... Aortic valve sparing surgery - Leaflets \\192.168.249.7\Zalohy CKTCH\DrOndrášek\foto\MMCTS_2006_001958_s9.gif \\192.168.249.7\Zalohy CKTCH\DrOndrášek\foto\MMCTS_2006_001958_s10.gif D:\USB_backup_021011\Kardio\Medici\Foto medici\AVP.JPG G:\Kardio\david\111025_Potěšil_AVP\DSCN4982.JPG [USEMAP] During AVS surgery on leaflets – plication of free edge, replacement of pathologic part of leaflet (calcification) with percardial patch. Aortic valve sparing surgery - Annulus Výřez obrazovky Výřez obrazovky C:\Users\Jan Vojacek\Desktop\CB-prednasky\VS\obrazky\AnnularStitchInside.jpg C:\Users\Jan Vojacek\Desktop\CB-prednasky\VS\obrazky\AnnularStitchOutside.jpg [USEMAP] Second: in case of annular dilatation we can diminish annulus by special stitch, by annular ring (coroneo) on required diameter. Aortic valve sparing surgery - D:\USB_backup_021011\Kardio\Medici\Foto medici\David4.JPG Root [USEMAP] In case of root dilatation we can replacemet root by vascular prothesis with sparing of valve. You see replacement dilated aortic root with aortic valve reimplantation into the prosthesis. Anatomy of herat valves - localization - Atrio-ventricular valves (Mi,Tri) - leaflets - anulus - chords - papillary muscles - limited - left/right ventricle - limited [USEMAP] It´s similar in mitral valve reconstruction surgery… On papillary muscles and ventricle – possibility for correction is very limited. Mitral valve reconstruction surgery - Leaflets http://www.bbraun.com/images/Nanosites/indication_valverepair_graphic02.gif [USEMAP] But we can correct leaflets - pathologic part (if there is i.e. prolaps) can be cut of and edges are sewn together. Mitral valve reconstruction surgery - http://www.annalsthoracicsurgery.org/cms/attachment/2005504847/2024144896/gr6.jpg http://www.annalscts.com/article/viewFile/2895/html/13169 Papillary muscles Chords [USEMAP] If the problems is on chords – we can replaced prolonged or ruptured chord by new gore-tex chords implant. Mitral valve reconstruction surgery - http://www.themitralvalve.org/mitralvalve/admin/uploads/Videos/Ischemic/CombineImg1.jpg Annulus [USEMAP] Almost in all cases of mitral valve renstructions annulus diameter is decreased and shape is remodelated with special ring. As you see on picture. Tricuspid valve reconstruction surgery - Bicuspidalization DeVega Annulus Leaflets (chords) C:\My Documents\Dačice\Dr. Piler\Dscn1409.jpg [USEMAP] In basic is the same in case of Tri valve. Surgery on leaflets and chords is less frequently. An annuloplasty is made with tri ring, lvery rare with stitches. Valve replacement - mechanical - Starr Monoleaflet SJMbileaflet [USEMAP] If the valve sparing or reconstruction is impossible, than we replace the valve. We can use echanical: First historic picture – cage ball valve, second - The other generation was tilting disk prosthesis. Hoping to improve haemodynamics, a rigid bileaflet was developed. Valve replacement - biological - C:\Dokumenty\Obrázky\Mi\SAV220[1].jpg http://www.heartvalvebank.info/wordpress/wp-content/uploads/2008/02/allograft.gif Související obrázek Výsledek obrázku pro perimount magna valve [USEMAP] Second main type are biological valves – porcine or from bovine pericardium. New valve are also so called suturesless. In special indication we can use allofraft, so calle homograft from tissue bank. On last picture you see aortic homograft , we can use that homograft for example in case of endokarditis to avoid placement of any prosthetic materiál. Aortic valve replacement - video - AVR-short.mp4 [USEMAP] Aortic valve replacement – sutureless bioprosthesis - ministernotomie- Náhrada aortální chlopně bezstehovou chlopní z ministernotomie MIAVR Sutureless LivaNova Perceval.mp4 [USEMAP] Mechanical vs. biological valves - Mechanical - advantages - long-term durability - disadvantages - need of anticoagulation Biological - advantages - no anticoagulation - disadvantages - limited durability H:\Kardio\Foto\Kalcifikace biochlopně\DSCN2881.JPG [USEMAP] There are adventages and disadventages of both mechanical and biological valves ...(text)... Mechanical – younger patients less than 60 years because the long term durability Biological – older, because durability is limited by degeneration. Nowadays there is trend to use biological valve more often and in younger patients. Complications after valve replacement - - thrombembolism - bleeding - valve dysfunction (pannus, thrombus) - prosthetic endocarditis 2 - 4% per year Mortality 1% per year [USEMAP] General complications after valve replacement are trombembolic events, bleeding complications, artifitial valve dysfunction, prosthetic endokarditis in both types. TAVI – transcatheter aortic valve implantation - Apogee6Revised (2) [USEMAP] Modern trend in valve replacement (especially in aortic valve replacement) is co called TAVI – trancatheter aortic valve implantation. Transfemoral – from groin, catheter with baloon and valve, or transapical - from small thoracotomy, open the pericardiom and across the LV apex, on beating heart without C-P bypass. TAVI - transfemoral - [USEMAP] TAVI - transapical - [USEMAP] TAVI - http://d3hjf51r9j54j7.cloudfront.net/wp-content/uploads/sites/5/2014/06/SAP3.jpg http://www.dicardiology.com/sites/daic/files/field/image/X0000_Medtronic_corevalve_sideview_1.JPG G:\Kardio\Medici\Foto medici\TAVI-thorakotomie3.JPG G:\Kardio\Medici\Foto medici\TAVI-TA.JPG G:\Kardio\Medici\Foto medici\TAVI2.JPG [USEMAP] Two most udes valves for TAVI Pictures from Transapical approach using minithoracotomy – LV apex, using the TEE and X-ray imaging for navigation on hybrid OR. Aortic dissection - tear in the inner wall of the aorta causes blood to flow between the layers of the wall of the aorta and force the layers apart → true and false lumen - acute (< 2 weeks) - chronic Marfan_MRI_Type_B_Dissection type-a-dissection-ct ANd9GcQ1L0Q26r_L2CAAKJnCGbqHRJ3np-wys-UpKGUmS4QG31uWhJj1 [USEMAP] Let‘s talk about severe acute diagnosis as aortic dissection realy is. Acute aortis dissection is acute condition that needs emergent diagnosis and treatment. It is caused by tear in the inner wall of the aorta. Blood flows between the layers. So we can ditinguish so called true and false lumen. According time of symptoms we differenciate acute (less than 2 weeks) and chronic. Aortic dissection - Splitting tunica media Weakening of the walls of the false lumen Impaired flow of aortic branches Tamponade Malperfusion – brain, myocardial, visceral, extremity Risk of rupture [USEMAP] During acute dissection tunica media of aortic wall is splited. So there is weaking of the wall and increases risk of rupture. On the other hand flow in the banches of aorta can be impaired. There is danger of i.e. pericardial tamponade (in case of rupture to pericardium) or risk of malperfusion according to localization – myocardial, brain, visceral extremity malperfusion Aortic dissection - -hypertension -connective tissue disorders (Marfan, Ehlers-Danlos, Turner) -degenerative or inflamatory disease of aortic wall -iatrogenic injury -atherosclerosis -bicuspid aortic valve -aortic dilatation -trauma -polycystic kidney disease -coarctation of the aorta -… [USEMAP] The most often risk factors for aortic dissection are…. Aortic dissection - classification - [USEMAP] There are two basic types of classification…De Bakey And frequently used Stanford classification – type A – dissection of ascending aorta (also possible of descending) and type B – only descending aorta (after the origin of left subclavian artery). Survival of untreated pts with type A aortic dissection - days post dissection event - 50 % (36–72 %) of untreated pts with acute type A dissection die within 48 hours - mortality rate 1 % / hour - the survival rate without treatment at 1 month is approximately 5% - after 3 weeks approx. 90 % [USEMAP] This is very important slide that shows that the acute aortic type A dissection has to be treated quickly. Because fifty percent of untreated pts with acute type A dissection die within 48 hours. Mortality rate is 1% per one hour. Mortality after 3 weeks without surgery is around 90%. Aortic dissection - symptoms - PAIN!!! -pre-shock symptoms (sweating, hypotension, tachycardia) - -malperfusion (peripheral or splanchnic ischemia) - CAVE: ALWAYS CONSIDER AORTIC DISSECTION IN CASE OF ISCHEMIC EXTREMITY ! -neurological signs (stroke) - -no another symptoms (some patients are only complaining chest pain) [USEMAP] The main symptom of acute dissection is pain. The others are… In case of ischemic extremity is important to think about acute dissection Sometimes the pain is only one symptom. The others can be neurolocical symptoms or no other symptoms Aortic dissection - diagnosis - WITHOUT DELAY !!! ECHO CT-angio (MR) Diss. A CT 0000F782GrawöWorkstation ABA78158: Graphic [USEMAP] Because hight mortality we have to diagnose dissection quickly, without any delay! Most accurate tools for aortic dissection evaluation is CT- angio. The others are ECHO and MRI You see echo picture – intimal flap in aortic root, across aortic valve causing aortic regurgitation. Aortic dissection - therapy - Initial analgetics ANTIHYPERTENSIVE THERAPY (vasodilatation, betablockers) Definitive type A - surgery !!! type B - no surgery - intervention (stentgraft) : rupture malperfusion pain progresive dilatation >10mm/30 days failure of hypertension treatment management [USEMAP] Initial therapy of aortic dissection is antihypertension therapy, and analgetics. Final solution in case of type A AA is surgery – only!!!. In type B – conservative treatment is prefered (no surgery), follow-up. Intervention is performed in case of risk of rupture, malperfusion... - Dissektionslammelen.jpg 00003BEFGrawöWorkstation ABA78158: Dissektion Typ A.jpg 00003BEFGrawöWorkstation ABA78158: D:\USB_backup_021011\Kardio\Medici\Foto medici\dissekce.JPG D:\USB_backup_021011\Kardio\Medici\Foto medici\disekce3.JPG Dissektionslammelen.jpg 00003BEFGrawöWorkstation ABA78158: [USEMAP] Typical pictures of dissection ascending aorta with blood effufion. Pericardial tamponade can occurs.. After incision you can see two layers of wall with thrombus. Here is aortic valve and entry of dissection close to aorticc valve. Aortic dissection - surgery - !DISSAAA [USEMAP] Acording to range the type of surgical procedures is made. -Ascending aorta replacement with tubular vascular prothesis -Replacement of aortic valve and all ascending aorta with prothesis Aortic dissection - surgery - [USEMAP] You see replacement ascending aorta and part of aortic arch (so called hemiarch procedures) with aortic valve sparing and coronary artery reimplantation on first picture. Aortic dissection - surgery - ElephantBypassMidA_RGBmd without TAG ElephantBypassPostA_RGBmd soft transition [USEMAP] We can replace also aortic arch with origin of aortic braches or with redirection of supraaortic vessels. In case of dissection or aneurysm on descending aorta cathether intervention after surgery is indicateted using so called stentgraft. Endovascular therapy of aortic type B dissection - Tassoni 2° controllo VR [USEMAP] You see using of stentgrafts for descending aorta catheter intervention – for type B dissection or descending aorta aneurysms. Aortic dissection type B - surgery - [USEMAP] Surgery in aortic type B dissection is not indicated initially. In case of surgical treatment descending aorta, main branches have to be reimplanted (larger intercostal arteries, truncus arteriosus, mesenteric arteries, both renal arteries) It is very large, dificult procedure with thoraco-freno-laparotomy incision. Aortic dissection therapeutic results - Prognosis without surgery type A - within 48 hours of the event - 50% mortality - survival rate at 1 month is approximately 5% Surgery survival early mortality 1 year 5 years Type A 10-25% 91% 75% Type B 20-50% 93% 82% stentgrafts 5-10% Conservative (no surgery) therapy Type B 10-20% [USEMAP] As I said – results w/o surgery... Results after surgery in type A – early mortality 10-25%. You can se differece betwen surgery and conservative therapy in type B (20-50% v.s. 10-20%). This is the reason why we prefer no surgical therapy in case of type B. Atrial fibrilation - - the most often SV dysrythmias - the most serious consequences - no mapping during surgery [USEMAP] The other indication for cardiac surgery procedure is AF. You know AF is the most often SV arhythmia. Atrial fibrilation – MAZE procedure - Lesions - transmural - continual Technique - surgical incision - cryo energy - radiofrequency energy [USEMAP] The so called maze procedure is a surgical treatment for atrial bribrillation. The surgeon can create pattern of scar tissue due to incisions, radio waves, freezing energy to create scar tissue.The leasions have to be transmural and without any gaps on left and right atrium. The scar tissue, which does not conduct electrical activity, blocks the abnormal electrical signals causing the atrial fibrilation. Atrial fibrilation – cryo MAZE - [USEMAP] So calle MAZE procedu is performed (ussually if there is indication for other cardiac surgery procedure -valve surgery, revascularisation...) . We use cryo maze…cryo energy. You se cryo probe Atrial fibrilation – radiofrequency MAZE - [USEMAP] …or radiofrequency maze procedure Thoracoscopic MAZE procedure - [USEMAP] Several years ago we started with hybrid MAZE procedure. Why hybrid. We start with surgery – throracoscopic part, small incision. After Surgical part elecrofysiologic mapping with catheter in LA is performed. And if there are any gaps between the Surgical lesions, the catheter ablation is completed. Petr Fila petr.fila@cktch.cz [USEMAP]