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| '''For the WikiPatient page for this topic, click [[Mitral valve surgery (patient information)|here]]'''
| | #redirect:[[Mitral regurgitation surgery]] |
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| {{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@perfuse.org]; {{CZ}}; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.
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| [[Image:250px-Diagram_of_the_human_heart_(cropped).svg.png|right|frame|Anterior (frontal) view of the opened heart. White arrows indicate normal blood flow. (Mitral valve labeled at center right.)]]
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| [[Image:250px-Gray495.png|right|frame|Base of ventricles exposed by removal of the atria. (Bicuspid (mitral) valve visible at bottom left.)]]
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| ==Overview==
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| [[Mitral valve]] surgery is surgery that can either repair or replace the mitral valve in the heart.
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| Blood that flows between different chambers of your heart must flow through a valve. One such valve is called the mitral valve. It opens up enough so blood can flow from one chamber of your heart (left atria) to the next chamber (left ventricle). It then closes, keeping blood from flowing backwards.
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| In open surgery, the surgeon makes a large cut in the sternum to reach the heart.
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| [[Minimally invasive]] mitral valve surgery is done through much smaller surgical cuts than the large cuts needed for open surgery.
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| ==Anatomy and pathophysiology==
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| The mitral valve is typically 4–6 cm² in area. It has two cusps, or leaflets, (the anteromedial leaflet and the posterolateral leaflet) that guard the opening. The opening is surrounded by a fibrous ring known as the mitral valve annulus <ref name="pmid1539731">{{cite journal| author=Shinoda H, Stern PH| title=Diurnal rhythms in Ca transfer into bone, Ca release from bone, and bone resorbing activity in serum of rats. | journal=Am J Physiol | year= 1992 | volume= 262 | issue= 2 Pt 2 | pages= R235-40 | pmid=1539731 | doi= | pmc= | url= }} </ref>. The anterior cusp protects approximately two-thirds of the valve (imagine a crescent moon within the circle, where the crescent represents the posterior cusp). Note that although the anterior leaflet takes up a larger part of the ring and rises higher, the posterior leaflet has a larger surface area. These valve leaflets are prevented from prolapsing into the left atrium by the action of tendons attached to the posterior surface of the valve, chordae tendineae.
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| The inelastic chordae tendineae are attached at one end to the papillary muscles and the other to the valve cusps. Papillary muscles are fingerlike projections from the wall of the left ventricle. Chordae tendineae from each muscle are attached to both leaflets of the mitral valve. Thus, when the left ventricle contracts, the intraventricular pressure forces the valve to close, while the tendons keep the leaflets coapting together and prevent the valve from opening in the wrong direction (thus preventing blood to flow back to the left atrium). Each chord has a different thickness. The thinnest ones are attached to the free leaflet margin, whereas thickest ones are attached quite away from the free margin. This disposition has important effects on systolic stress distribution physiology <ref name="pmid10901521">{{cite journal| author=Nazari S, Carli F, Salvi S, Banfi C, Aluffi A, Mourad Z et al.| title=Patterns of systolic stress distribution on mitral valve anterior leaflet chordal apparatus. A structural mechanical theoretical analysis. | journal=J Cardiovasc Surg (Torino) | year= 2000 | volume= 41 | issue= 2 | pages= 193-202 | pmid=10901521 | doi= | pmc= | url= }} </ref>.
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| During left ventricular diastole, after the pressure drops in the left ventricle due to relaxation of the ventricular myocardium, the mitral valve opens, and blood travels from the left atrium to the left ventricle. About 70-80% of the blood that travels across the mitral valve occurs during the early filling phase of the left ventricle. This early filling phase is due to active relaxation of the ventricular myocardium, causing a pressure gradient that allows a rapid flow of blood from the left atrium, across the mitral valve. This early filling across the mitral valve is seen on doppler echocardiography of the mitral valve as the E wave.
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| After the E wave, there is a period of slow filling of the ventricle.
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| Left atrial contraction (left atrial systole) (during left ventricular diastole) causes added blood to flow across the mitral valve immediately before left ventricular systole. This late flow across the open mitral valve is seen on doppler echocardiography of the mitral valve as the A wave. The late filling of the LV contributes about 20% to the volume in the left ventricle prior to ventricular systole, and is known as the atrial kick.
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| The mitral annulus changes in shape and size during the cardiac cycle. It is smaller at the end of atrial systole due to the contraction of the left atrium around it, like a sphincter. This reduction in annulus size at the end of atrial systole may be important for the proper coapting of the leaflets of the mitral valve when the left ventricle contracts and pumps blood <ref name="pmid12578332">{{cite journal| author=Pai RG, Varadarajan P, Tanimoto M| title=Effect of atrial fibrillation on the dynamics of mitral annular area. | journal=J Heart Valve Dis | year= 2003 | volume= 12 | issue= 1 | pages= 31-7 | pmid=12578332 | doi= | pmc= | url= }} </ref>.
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| The closing of the mitral valve and the tricuspid valve constitutes the first heart sound (S1). It is not actually the valve closure which produces a sound but rather the sudden cessation of blood flow caused by the closure of the mitral and tricuspid valves. The mitral valve opening is normally not heard except in mitral stenosis (narrowing of the valve) as the opening Snap. Flow of blood into the heart during rapid filling is not normally heard except in certain pathological states where it constitutes the third heart sound (S3).
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| Chronic mitral regurgitation can be divided into three stages; compensated, transitional, and decompensated stage. The stage depends on the left ventricular (LV) chamber size and function.
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| *In '''the compensated stage'''; the left ventricular (LV) end-diastolic dimension is less than 60 mm, and the end-systolic dimension is less than 40mm (Dimensions measured by echocardiography)
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| *'''The transitional stage''' left ventricular (LV) dimensions is not precisely defined, but most studies indicates that surgery at this stage has a very good results.
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| *'''The decompensated stage''' defined on the basis of decompensated ventricular function. At this stage; the patients are at risk for a poor results of valve replacement. Markers for decompensated ventricular function include LV end-diastolic dimension greater than 70 mm, LV end-systolic dimension greater than 45 to 47 mm, or a left ventricular ejection fraction (LVEF) less than 50 to 55 percent.
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| Knowing the stage of chronic mitral valve surgery enables the clinician to predict the LV function, so he or she can decide if the patient could get benifit from the surgical treatment. Usually, a corrective surgery for mitral valve regurgitation should be performed before the transition to the decompensated stage of the disease, in this situation the corrective surgery (and continued medical therapy) may provide symptomatic relief, but chamber enlargement and a low LVEF usually persist even with successful surgery.
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| ==Indications for Procedure==
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| You may need surgery if your mitral valve does not work properly.
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| *A mitral valve that does not close all the way will allow blood to leak back into the left atria. This is called [[mitral regurgitation]].
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| *A mitral valve that does not open fully will restrict blood flow. This is called [[mitral stenosis]].
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| *A valve defect that you have had since birth is called [[mitral valve prolapse]].
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| You may need open-heart valve surgery for these reasons:
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| *Changes in your mitral valve are causing major heart symptoms, such as [[angina]] (chest pain), shortness of breath, fainting spells ([[syncope]]), or heart failure.
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| *Tests show that the changes in your mitral valve are beginning to seriously affect your heart function.
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| *Your doctor may want to replace or repair your mitral valve at the same time as you are having open-heart surgery for another reason.
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| *Your heart valve has been damaged by [[endocarditis]] (infection of the heart valve).
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| *You have received a new heart valve in the past, and it is not working well, or you have other problems such as blood clots, infection, or bleeding.
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| ==Treatments for (the disease)==
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| Many of these patients exhibit characteristics of a dilated cardiomyopathy with increased LV afterload and depressed myocardial contractility. Their initial management includes aggressive medical therapy with digitalis, diuretics, and vasodilators.
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| ==Preoperative preparation==
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| Cardiac catheterization and coronary angiography should be performed in preparation for surgery.
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| Always tell your doctor or nurse:
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| *If you are or could be pregnant.
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| *What drugs you are taking, even drugs, supplements, or herbs you bought without a prescription.
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| You may be able to store blood in the blood bank for transfusions during and after your surgery. Ask your surgeon how you and your family members can donate blood (autologous donation).
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| For the 2-week period before surgery, you may be asked to stop taking drugs that make it harder for your blood to clot. These might cause increased bleeding during the surgery.
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| *Some of these drugs are [[aspirin]], [[ibuprofen]] (Advil, Motrin), and [[naproxen]] (Aleve, Naprosyn).
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| *If you are taking [[warfarin]] (Coumadin) or clopidogrel (Plavix), talk with your surgeon before stopping or changing how you take these drugs.
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| Prepare your house for when you get home from the hospital.
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| The day before your surgery, shower and shampoo well. You may be asked to wash your whole body below your neck with a special soap. Scrub your chest two or three times with this soap. You also may be asked to take an [[antibiotic]] to guard against infection.
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| During the days before your surgery:
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| *Ask your doctor which drugs you should still take on the day of your surgery.
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| *If you smoke, you must stop. Ask your doctor for help.
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| *Always let your doctor know if you have a cold, flu, fever, [[herpes]] breakout, or any other illness in the time leading up to your surgery.
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| On the day of the surgery:
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| *You will usually be asked not to drink or eat anything after midnight the night before your surgery. This includes chewing gum and using breath mints. Rinse your mouth with water if it feels dry, but be careful not to swallow.
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| *Take the drugs your doctor told you to take with a small sip of water.
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| *Your doctor or nurse will tell you when to arrive at the hospital.
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| ==The procedure==
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| Before your surgery, you will receive general [[anesthesia]]. This will make you asleep and pain-free during the entire procedure.
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| *Your surgeon will make a 10-inch-long cut in the middle of your chest.
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| *Next, your surgeon will separate your breastbone to be able to see your heart.
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| *Most people are connected to a [[heart-lung bypass machine]] or bypass pump. Your heart is stopped while you are connected to this machine. This machine does the work of your heart while your heart is stopped.
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| *A small cut is made in the left side of your heart so your surgeon can repair or replace the mitral valve.
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| If your surgeon can repair your mitral valve, you may have:
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| *Ring annuloplasty -- The surgeon repairs the ring-like part around the valve by sewing a ring of metal, cloth, or tissue around the valve.
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| *Valve repair -- The surgeon trims, shapes, or rebuilds one or more of the three leaflets of the valve. The leaflets are flaps that open and close the valve.
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| If your mitral valve is too damaged, you will need a new valve. This is called replacement surgery. Your surgeon will remove your mitral valve and sew a new one into place. There are two types of mitral valves:
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| *Mechanical -- made of man-made (synthetic) materials, such as a metal like titanium. These valves last the longest, but you will need to take blood-thinning medicine, such as [[warfarin]] (Coumadin) or [[aspirin]], for the rest of your life.
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| *[[Biological]] -- made of human or animal tissue. These valves last 10 to 12 years, but you may not need to take blood thinners for life.
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| Once the new or repaired valve is working, your surgeon will:
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| *Close your heart and take you off the [[heart-lung machine]].
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| *Place [[catheters]] (tubes) around your heart to drain fluids that build up.
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| *Close your breastbone with stainless steel wires. It will take about 6 weeks for the bone to heal. The wires will stay inside your body.
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| You may have a temporary [[pacemaker]] connected to your heart until your natural heart [[rhythm]] returns.
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| Your surgeon may also perform [[coronary artery bypass surgery]] at the same time, if needed.
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| This surgery may take 3 - 6 hours.
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| ==Recovery==
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| Expect to spend 4 to 7 days in the hospital after surgery. You will wake up in the [[intensive care unit]] (ICU) and recover there for 1 or 2 days. Two to three tubes will be in your chest to [[drain]] fluid from around your heart. They are usually removed 1 to 3 days after surgery.
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| You may have a flexible tube (catheter) in your bladder to drain urine. You may also have intravenous (IV, in the vein) lines to get fluids. Nurses will closely watch monitors that show information about your [[vital signs]] (pulse, temperature, and breathing).
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| You will be moved to a regular hospital room from the ICU. Your nurses and doctors will continue to monitor your heart and vital signs until you are stable enough to go home. You will receive pain medicine to control pain around your surgical cut.
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| Your nurse will help you slowly resume some activity. You will be asked to begin a physical therapy program to make your heart and body stronger.
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| ==Surgical outcome==
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| Mechanical heart valves do not fail often. They last from 12 to 20 years. However, blood clots develop on them. If a blood clot forms, you may have a stroke. Bleeding can occur, but this is rare.
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| Biological valves tend to fail over time. But they have a lower risk of blood clots.
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| ==Possible complications==
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| Risks for any surgery are:
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| *Blood clots in the legs that may travel to the lungs.
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| *Blood loss.
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| *Breathing problems.
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| *Infection, including in the lungs, kidneys, bladder, chest, or heart valves.
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| *Reactions to medicines.
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| Possible risks from having open-heart surgery are:
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| *[[Heart attack]] or stroke.
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| *Heart [[rhythm]] problems.
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| *Infection in the cut, which is more likely to happen in people who are obese, have [[diabetes]], or have already had this surgery.
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| *Memory loss and loss of mental clarity, or "fuzzy thinking."
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| *[[Post-pericardiotomy syndrome]], which is a low-grade fever and chest pain. This could last for up to 6 months.
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| ==Videos==
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| *'''Minimally invasive mitral valve surgery - Right thoracotomy approach video'''.
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| <youtube v=EnJQh_W3r3A/>
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| ==External links==
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| ==References==
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| <references/>
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| ==Indications for Surgery in Chronic Mitral Regurgitation==
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| Indications for surgery for chronic mitral regurgitation include signs of left ventricular dysfunction. These include a [[left ventricular ejection fraction]] ([[LVEF]]) of less than 60% and a left ventricular end systolic dimension (LVESD) of greater than 45 mm.
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| <table border="1" cellpadding="5" cellspacing="0" align="left">
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| <caption>'''Indications for surgery for chronic mitral regurgitation'''<ref name="pmid9809971">{{cite journal |author= |title=ACC/AHA guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association. Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease) |journal=[[Journal of the American College of Cardiology]] |volume=32 |issue=5 |pages=1486–588 |year=1998 |month=November |pmid=9809971 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735109798004549 |accessdate=2011-03-16}}</ref>
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| <tr>
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| <th style="background:#efefef;">Symptoms</th>
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| <th style="background:#efefef;">LV EF</th>
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| <th style="background:#efefef;">LVESD</th>
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| </tr>
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| <tr><td>[[New York Heart Association Functional Classification|NYHA II - IV]]</td><td>> 60 percent</td><td>< 45 mm</td></tr>
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| <tr><td>Asymptomatic or symptomatic</td><td>50 - 60 percent</td><td>≥ 45 mm</td></tr>
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| <tr><td>Asymptomatic or symptomatic</td><td colspan=2>< 50 percent or ≥ 45 mm</td></tr>
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| <tr><td colspan=3>[[Pulmonary artery]] systolic pressure ≥ 50 [[mmHg]]</td></tr>
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| </table>
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| ==Dysfunction with a Dilated Ventricle==
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| The patient with severe LV dysfunction (an LVEF < 30% and/or a left ventricular end-systolic dimension greater than 55 mm poses a higher risk but may undergo surgery if chordal preservation is likely.
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| ==Overview==
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| Mitral valve surgery is indicated when the [[mitral regurgitation]] is severe or when the patient is symptomatic. | |
| Valve repair or replacement are the two types of surgeries available to treat these conditions. Decision between valve repair or valve replacement is made based on the type and severity of damage to [[mitral valve]].
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| ==Indications==
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| '''[[Mitral valve repair]]''' is recommended in following:
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| *Limited damage to certain areas of the mitral valve leaflets or [[chordae tendineae]]<ref name="pmid12830055">{{cite journal| author=Gillinov AM, Faber C, Houghtaling PL, Blackstone EH, Lam BK, Diaz R et al.| title=Repair versus replacement for degenerative mitral valve disease with coexisting ischemic heart disease. | journal=J Thorac Cardiovasc Surg | year= 2003 | volume= 125 | issue= 6 | pages= 1350-62 | pmid=12830055 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12830055 }} </ref>
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| *Limited calcification of the leaflets or annulus
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| *[[Mitral valve prolapse|Prolapse]] of less than one-third of either leaflet
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| *Pure annular dilatation
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| *Valvular perforations
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| *Incomplete [[papillary muscle rupture]]
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| '''[[Mitral valve replacement]]''' is recommended in following:
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| *Extensive calcification or degeneration of a leaflet or annulus
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| *[[Mitral valve prolapse|Prolapse]] of more than one-third of the leaflet tissue
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| *Extensive chordal fusion, calcification, or [[papillary muscle rupture]]
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| *Extensive damage of mitral valve secondary to [[endocarditis]]
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| ==Clinical trial data==
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| *Multiple studies have shown that there are better outcomes in terms of left ventricular function and survival with mitral valve repair compared to valve replacement.<ref name="pmid3769948">{{cite journal| author=Krayenbuehl HP| title=Surgery for mitral regurgitation. Repair versus valve replacement. | journal=Eur Heart J | year= 1986 | volume= 7 | issue= 8 | pages= 638-43 | pmid=3769948 | doi= | pmc= | url= }} </ref><ref name="pmid7850937">{{cite journal| author=Enriquez-Sarano M, Schaff HV, Orszulak TA, Tajik AJ, Bailey KR, Frye RL| title=Valve repair improves the outcome of surgery for mitral regurgitation. A multivariate analysis. | journal=Circulation | year= 1995 | volume= 91 | issue= 4 | pages= 1022-8 | pmid=7850937 | doi= | pmc= | url= }} </ref><ref name="pmid10612761">{{cite journal| author=Yau TM, El-Ghoneimi YA, Armstrong S, Ivanov J, David TE| title=Mitral valve repair and replacement for rheumatic disease. | journal=J Thorac Cardiovasc Surg | year= 2000 | volume= 119 | issue= 1 | pages= 53-60 | pmid=10612761 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10612761 }} </ref><ref name="pmid9918527">{{cite journal| author=Tribouilloy CM, Enriquez-Sarano M, Schaff HV, Orszulak TA, Bailey KR, Tajik AJ et al.| title=Impact of preoperative symptoms on survival after surgical correction of organic mitral regurgitation: rationale for optimizing surgical indications. | journal=Circulation | year= 1999 | volume= 99 | issue= 3 | pages= 400-5 | pmid=9918527 | doi= | pmc= | url= }} </ref>
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| *In a 6 year follow-up study<ref name="pmid16293530">{{cite journal| author=Kouris N, Ikonomidis I, Kontogianni D, Smith P, Nihoyannopoulos P| title=Mitral valve repair versus replacement for isolated non-ischemic mitral regurgitation in patients with preoperative left ventricular dysfunction. A long-term follow-up echocardiography study. | journal=Eur J Echocardiogr | year= 2005 | volume= 6 | issue= 6 | pages= 435-42 | pmid=16293530 | doi=10.1016/j.euje.2005.01.003 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16293530 }} </ref> of 45 patients with isolated non-ischemic [[mitral regurgitation]] and [[EF]] ≤50%, who underwent either valve repair(27 patients) or replacement(18 patients) following results were observed:
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| ::*5 patients and 6 patients died in repair group and replacement group respectively.
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| ::*2 patients underwent valve replacement due to failure of valve repair while 1 patient in valve replacement group underwent re-operation due to [[prosthetic valve endocarditis]].
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| ::*Incidence of [[atrial fibrillation]] was similar between both groups.
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| ::*Left ventricular end diastolic dimension(LVEDD), [[velocity time integral]] and [[ejection fraction]](EF) improved with valve repair while LVEDD and EF worsened in valve replacement patients.
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| *In another study, lower operative mortality (2.6% vs 10.3%), greater increase in left ventricular [[EF]] and higher 10 years survival rate (68% vs 52%) were observed among patients who underwent valve repair compared to valve replacement.<ref name="pmid9323067">{{cite journal| author=Ling LH, Enriquez-Sarano M, Seward JB, Orszulak TA, Schaff HV, Bailey KR et al.| title=Early surgery in patients with mitral regurgitation due to flail leaflets: a long-term outcome study. | journal=Circulation | year= 1997 | volume= 96 | issue= 6 | pages= 1819-25 | pmid=9323067 | doi= | pmc= | url= }} </ref>
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| *A survival benefit with valve repair may not be seen in high risk patients with [[ischemic MR]].<ref name="pmid11726887">{{cite journal| author=Gillinov AM, Wierup PN, Blackstone EH, Bishay ES, Cosgrove DM, White J et al.| title=Is repair preferable to replacement for ischemic mitral regurgitation? | journal=J Thorac Cardiovasc Surg | year= 2001 | volume= 122 | issue= 6 | pages= 1125-41 | pmid=11726887 | doi=10.1067/mtc.2001.116557 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11726887 }} </ref><ref name="pmid11726886">{{cite journal| author=Grossi EA, Goldberg JD, LaPietra A, Ye X, Zakow P, Sussman M et al.| title=Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications. | journal=J Thorac Cardiovasc Surg | year= 2001 | volume= 122 | issue= 6 | pages= 1107-24 | pmid=11726886 | doi=10.1067/mtc.2001.116945 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11726886 }} </ref>
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| *Long term rates of re-operation appear to be similar in both valve repair and replacement.<ref name="pmid16928491">{{cite journal| author=Suri RM, Schaff HV, Dearani JA, Sundt TM, Daly RC, Mullany CJ et al.| title=Survival advantage and improved durability of mitral repair for leaflet prolapse subsets in the current era. | journal=Ann Thorac Surg | year= 2006 | volume= 82 | issue= 3 | pages= 819-26 | pmid=16928491 | doi=10.1016/j.athoracsur.2006.03.091 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16928491 }} </ref> However, among patients who underwent mitral valve surgeries between 1984 and 1997, 10 year rates of re-operation was shown to be lower with valve repair.<ref name="pmid12835220">{{cite journal| author=Thourani VH, Weintraub WS, Guyton RA, Jones EL, Williams WH, Elkabbani S et al.| title=Outcomes and long-term survival for patients undergoing mitral valve repair versus replacement: effect of age and concomitant coronary artery bypass grafting. | journal=Circulation | year= 2003 | volume= 108 | issue= 3 | pages= 298-304 | pmid=12835220 | doi=10.1161/01.CIR.0000079169.15862.13 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12835220 }} </ref>
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| ==Summary==
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| '''Advantages of [[Mitral valve repair]]:'''
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| #Improves left ventricular [[EF]] and function.
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| #Preserves native heart valve.
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| #Avoids long term use of [[anticoagulants]].
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| #Lower risk for [[endocarditis]].
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| #Has good overall outcome with good survival rates.
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| Based on above, '''ACC/AHA 2008 guidelines'''<ref name="pmid18848134">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 13 | pages= e1-142 | pmid=18848134 | doi=10.1016/j.jacc.2008.05.007 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18848134 }} </ref> recommend [[mitral valve repair]] rather than [[mitral valve replacement]] if the anatomy is appropriate, including patients with [[rheumatic]] mitral valve disease<ref name="pmid10612761">{{cite journal| author=Yau TM, El-Ghoneimi YA, Armstrong S, Ivanov J, David TE| title=Mitral valve repair and replacement for rheumatic disease. | journal=J Thorac Cardiovasc Surg | year= 2000 | volume= 119 | issue= 1 | pages= 53-60 | pmid=10612761 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10612761 }} </ref> and mitral valve prolapse<ref name="pmid11568020">{{cite journal| author=Mohty D, Orszulak TA, Schaff HV, Avierinos JF, Tajik JA, Enriquez-Sarano M| title=Very long-term survival and durability of mitral valve repair for mitral valve prolapse. | journal=Circulation | year= 2001 | volume= 104 | issue= 12 Suppl 1 | pages= I1-I7 | pmid=11568020 | doi= | pmc= | url= }} </ref> (Grade 1C). The procedure should be performed at experienced surgical centers.
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| ==References==
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| {{Reflist|2}}
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| [[Category:Cardiology]]
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| [[Category:Surgery]]
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| [[Category:Cardiac surgery]]
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| [[Category:Surgical procedures]]
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| [[Category:Overview complete]]
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| [[Category:Template complete]]
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| [[Category:For review]]
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