 But thank you for inviting me here today to talk about the surgeon's perspective on both aortic and mitral valve. I'm going to kind of cover the ways we think through it and the ways that we look for leadership from our echocardiographers and cardiologists in order to figure out the best treatment plan for a patient. So let's start with where it all began. Aortic and mitral valve repair really started with Alain Carpentier from Paris when he gave an honored presidential guest address at the AATS meeting back in 1983. He called it the French Correction. What he really focused on was the pathophysiologic triad of aortic and valvular disease, the etiology, which is what causes the disease, the lesions. That's what results from the disease and the dysfunction, which is what results from the lesions. Let's start with the aortic valve. We have to understand the functional anatomy before we can talk about ways to repair it. The functional aortic annulus includes the aortic annulus itself, which is the ventricular aortic junction, plus through to the sinus tubular junction above the corners. It includes the leaflets, the commissures, the sinus of val salva, and some aortic wall itself. The dysfunction can be classified into three discrete types of abnormalities. Number one, normal leaflet motion. That is with sinus tubular junction or aortic annulus dilatation pulling the valve apart. Excess of a leaflet motion, which can be due to CUSP prolapse or some sort of commissural disruption or even a perforation. And restricted leaflet motion, which is commissural fusion or valve thickening or calcification. We're going to focus on the first two types in regards to repair. What are the triggers for surgery in regards to aortic regurgitation? Well, the progression is slow and the symptoms develop late. So we need to look for signs of progressive left ventricular overload and adaptive chamber dilatation. If a patient is symptomatic, that's obviously an indication. But an asymptomatic patient whose ejection fraction has fallen or has left ventricular dilatation is also the person to consider a valve repair. Exercise testing can show a decrease in ejection fraction and left ventricular dilatation with exercise. And a patient has moderate aortic regurgitation and is undergoing another cardiac surgery. There was an excellent study from Oxford looking at cardiac MRI and predicting which patients would need surgery. If the regurgitant fraction was over 33%, then 85% of those patients progressed to surgery within three years or symptomatic. Left ventricular endiastolic volume measured greater than 246 milliliters also improved the predictive capability of the MRI. So aortic valve replacement, classically. Low morbidity and mortality, excellent late durability, especially in older patients. And it's applicable for all patients with aortic regurgitation. But aortic valve repair, what about that? Well, you can avoid anticoagulation. It can be appropriate for selected patients, but which patients will talk about that. And it requires a dedicated approach. L. Corey from Brussels came up with a functional classification of aortic regurgitation depending on what was causing the problem. One A, B, and C are dependent on the aortic itself with normal leaflets, dilation of the sinotubular junction above the valve pulling it apart, dilation of the sinotubular junction and aortic analyst as you've seen in Marfan syndrome or just dilation of the aortic analyst pulling the leaflets away from co-optation. One D is a special type of mechanism and that is perforation of one of the cusps and I'll show you a couple of examples of that. Type two is cusp prolapse where the aorta itself is normal and type three is cusp restriction. Here we see a normal aorta and sinotubular junction. The type one A is again dilatation of the sinotubular junction pulling the leaflets apart. Type one B, like you see in a Marfan syndrome and type one C, just the aortic analyst itself with a normal sinotubular junction. Here's cusp perforation. This was a traumatic cusp perforation on one D and then you can see cusp prolapse. Type two with generally causing an eccentric jet of regurgitation and cusp restriction as we see in radiation injury, rheumatic disease or calcific disease. So what are the principles of aortic valve repair? Well, one is to, the overarching goal is to create and support an optimal surface for co-optation of the leaflets. We can remodel and stabilize the proximal distal ends of the functional aortic annulus in types one A through one C and then we have to repair abnormal cusps and restore their normal geometry in types one D and two. Here's type one A, sinotubular junction dilatation pulling the tricuspid aortic valve apart causing a central jet because it's a symmetrical dilatation of the aorta above the valve. In this patient, what we did was ascending aortic replacement only with a 34 millimeter Dacron graph and we were able to pull the sinotubular junction back to a normal anatomy. There was no involvement of the root and you can see on the postoperative TEE there's no good co-optation with no regurgitation. Here's a type one B. This is what we see with Marfan syndrome or annual aortic ectasia. There's normal cusp motion but they're pulled apart at both areas and generally again yield a central jet of severe regurgitation. In this patient, we did a valve sparing aortic replacement and you can see we re-implant the valve inside of the tube, preserving the leaflets. We've been doing this since Tyrone David first presented it back in 1993 and we can have excellent results and excellent long-term results. Before I left WashU, I put together my series of 177 patients who had a valve sparing replacement and we presented this at one of our national meetings. What we found predicted recurrence over time or the presence of regurgitation over time was how much effective height we had. The effective height is how we put the distance from the top of the co-optation down to the annulus and if we had effective height greater than 11 millimeters or greater than 10 millimeters, that was protective against aortic valve re-intervention. Let's look at type one C. That's dilatation of the aortic annulus. There have been various techniques to address this. Some more successful than others. Suture annular plasty has been attempted to pull the annulus together. That doesn't usually have great long-term results. An external aortic ring can be combined with a valve sparing procedure to bring the annulus back to a normal diameter. Subcommon chiral plasty is an older technique that has some benefit but not overwhelming if there's truly dilatation of the annulus. The new geometric internal ring, I'm gonna show a video of how that's implanted in a minute. So type one D is cuff perforation or vegetation. This is a patient of my friend years ago that had just a vegetation present on one of the leaflets. We were able to reconstruct that leaflet with some glutaraldehyde tan pericardium and get a good long-term result. And non-infectious perforations, obviously, this one was after a minimally invasive mitral valve repair where one of the guide wires for a balloon occluder went through the leaflet and we were able to fix that with a patch as well. Let's look at leaflet prolapse. Here's a tricuspid valve on the left. You can see this one has isolated right-cornery cusp prolapse. There's three margin elongation and there's a transverse fold causing discontinuity of the normal curvature of the cusp as it's supposed to go down. The other two leaflets are actually normal. And then a biocuspid valve, you can, there are three different types I'll show you in a minute, but prolapse is the most common cause of irregular agitation with a biocuspid valve. How can we repair vals that have prolapse? Well, we can do free margin resuspension. That's if there's like a commissure tear, we can do this and the leaflet's gotten too long on its free margin. We can do free margin plication, which is what's demonstrated in that picture and I'll show you a video of how we do that in a more complex case. And cleft closure, that's how we bring the conjoined tendon, I mean the conjoined leaflet of the biocuspid valve up to the right height because it's essentially the leaflets are falling down and not staying up high enough. And so we have to raise the height. Patch repair for perforation I showed you an example of the other ones are a bit more complex. So here's a case of the commissural disruption. This is a patient, we took to the operating room 42 year old gentleman new murmury at all the criteria on MRI. And what we did was took a very fine Gore-Tex suture, did a double layer on that one leaflet and we're able to pull it up to the right height and repair that gentleman's aortic regurgitation. Here's a biocuspid prolapse case. The aortic annulus and the synod tubular junction were not doubted. This was only a valvular problem. And you can see the prolapse of the leaflets on the non-color imaging and then the very severe eccentric jet of aortic regurgitation this 39 year old gentleman had. So here's the classification system. A type two severs is essentially there's no RAFE. It's just two leaflets. The type one severs has a RAFE with the conjoined leaflets and a type two is essentially a unicuspid type valve. And again, Hans Joachim Schafer has written a lot on aortic valve repair. And he reported that in aortic repair alone, similar to what we found with valve sparing root replacement that the effective height was important to prevent recurrence. So let's look at this geometric internal ring. This is something very new that we can use to support a repair. Otherwise the leaflet had to be support, the leaflet itself had to be repaired and you had to count on a normal aortic annulus in order to support that repair. We're gonna talk about cleft closure of the conjoined tendon and you can see in the far right example, that's what we're gonna demonstrate. So here's a case, it's about three minutes long showing you how we do this aortic valve repair. We size with a Hagar dilator and you can see the bicuspid valve. And this is the sizing apparatus for this ring that measures the commissure to commissure length so that we get the right size. What we do is mark the spot below the commissure where we're going to secure the geometric ring and we put some sutures around the commissure. This will be two different sutures because there's two struts to the device and you'll see it here in a short second. These sutures are felted but they're not a standard felt. You would see in the operating room, these are special felt that do not interact or cause fibrosis. So here comes the ring down into position. We secure one of the struts underneath one of the commissures and then we're gonna secure the other strut. This is a horizontal mattress suture that we place into the strut and bring it through the other side of the commissure underneath the valve so we don't disrupt the valve and then we're able to secure the ring. And so it's a double suture technique and you would think, well, is that gonna hold this thing in place? Well, not in and of itself. It gets it into the right position and I'll show you what we need to do in order to make sure it doesn't rock around after repair. So we get it down into position in the outflow track and it's actually elliptical. The shape of the outflow track, most of us think, oh, that's a circle. Well, it's not a circle, it's an ellipse. And so this device is designed specifically to accommodate that ellipse. So here you can see a suture being placed underneath the ring. You can see the ring below the leaflet and we're gonna take that suture and we're gonna essentially wrap it around that strut or that bottom ring to secure it in place. You can see the suture wrapping around and we put about seven or nine of those sutures depending on the size of the ring. So we tie those down. And also there's a specific thing we do with the knots. We take a suture and move the knot out laterally so that the ends of the sutures, the tips of the sutures after tying and cutting are away from the leaflet so they can't poke a hole in it. So we do that and secure the ring in place. Now we're gonna do the leaflet repair. And this is the non-conjoined leaflet, the one without a rep bay, but it was prolapsing as well. So what I'm gonna do is put a placation suture and on one side of the leaflet and we're gonna do it on the other side of the leaflet in order to get it to the height we want. Remember, it's all about height. You know, when I first started thinking about the regurgitation, I thought there was just too much leaflet and that was the problem. But the problem is that the leaflet goes low. Now here's the pseudo-RFA in the conjoined leaflet and what we're going to do then is again a placation suture and that's gonna be the start of our cleft closure. But what we're gonna do is put a series of these in order to again elevate the leaflet to the appropriate height. And these patients do ideally have a gradient to their valve. It's like most bicuspid patients will have some gradient but ideally we're shooting for about 12 millimeters of mercury. So I'm looking still that leaflet is a little bit low. So we're gonna put one more suture to close the cleft again and bring the leaflet to the appropriate height. And the portion of the leaflet that's repaired is going to be outside of co-optation. So it's not going to injure the other leaflet. The two portions of the leaflet that are going to co-opt together. Hopefully for this 39-year-old gentlemen for the next 50 years are just smooth leaflet tissue. So here's the echocardiogram and you can see in the middle image you can see nicely where the placation sutures are and you can see obviously there's no regurgitation. Restricted leaflet motion fibrosis that calcified bicuspid valves and unicuspid valves these generally are not ones to repair the durability is not long in that regard. And here's a patient with a combined lesion he had both 1A and 2. So he had dilatation of a Sanitubio junction and bi-leaf prolapse. He was a 23-year-old gentleman. We really want to put a valve in him. No, not if we can avoid it. So here's another minute or so of a video. I just want to show you how we do this without a ring. You don't have to put a ring in if the aortic annulus is a normal diameter we can just do a leaflet repair and hope that the aortic annulus won't dilate with time which it doesn't generally. If it's not dilated at the time of repair it generally doesn't dilate over time. So here we are at doing a clef closure trying to get to the appropriate height on that leaflet. Again, with multiple sutures on that conjoined leaflet and then we're running a suture down the repair to buttress it. So we have now that leaflet repaired and we'll check the height to make sure it's correct. It doesn't need another suture. And you can see I put application on the other leaflet as well like we did in the previous case. We can see it looks quite good and a water test. Then we put a tube graph to replace the dilated ascending aorta because remember this was a type 1A and a type 2. And then we have a nice result and the echocardiogram shows no regurgitation. You can see the placation points but again, that's not causing traumatic co-aptation because all that hyper echogenic portions of the repair are outside co-aptation, not along the co-aptation point. So let's talk about the mitral valve now. It's again the same thing. Pathophysiologic triad of etiology the cause of the disease lesions what results from the disease and dysfunction which is what results from the lesions. The functional anatomy of the mitral valve is a little bit more complex. We have the annulus, the leaflets, chorded tendinia papillary muscles and left ventricular wall. And I'm gonna talk about the abnormalities in all of those and how we address them. Annual lesions can be caused by dilatation as you can see a dilated annulus in that upper right or a calcific annulus which can restrict the capability of the leaflet to close. And you can have some symmetrical dilatation as you see in dilated cardiomyopathy or prolonged periods of atrial fibrillation or asymmetric dilatation as in figure C which occurs with ischemia. This is all the pictures of this point where it from St. Louis but here's a patient of Dr. Georges who had meortic regurgitation. She had a dilated annulus and you can see the leaflets on the 3D image are just not co-acting causing quite severe regurgitation. This patient also though had a dilatation of the tricuspid annulus causing at least moderate if not severe regurgitation. And it's important to remember in the tricuspid valve that it's the portion of the anterior leaflet and the posterior leaflet that dilates the septal leaflet portion generally doesn't dilate and that means we don't have to put sutures down there all the way across the septal leaflet because that's where we can get into more trouble with heart block. So in this patient we put a 28 millimeter semi-rigid mitral valve band and a 28 millimeter semi-rigid tricuspid valve band. We also did a left atrial ligation with a clip as her left atrial appendage was quite large and left atrium was large and we got a good result with no regurgitation. She's going home today. The rings can be either a rigid ring that's the classic original that Carpentier developed. A flexible band is also an option and I like to use bands preferentially because remember I've said in the tricuspid valve the septal portion doesn't dilate. Well in mitral valve the portion between the trigones in the anterior leaflet doesn't dilate. So supporting a repair can be done with a band alone. If you have ischemia though that's one I would use a full rate. Let's look at the leaflets in Cordy tendinia. Leaflet lesions can be cleft hair or tear, vegetation perforation, thickening, commissure fusion or calcification. Cordy tendinia can be elongated, ruptured or as we see with rheumatic disease thick and fused and shortened. First we have to define non pathologic clefts. These are clefts that are natural in the valve. They're between P1 and P2 and between P2 and P3. They're supported by cords. They essentially function like commissures to open the valve and facilitate opening wide. They don't extend to the annulus. That's what makes them non pathologic. A pathologic cleft can occur in the anterior leaflet like the picture above and that's congenital abnormality. And you can also see one in the posterior leaflet down below causing severe regurgitation. And there's an image of us putting a stitch, the first stitch into that cleft which we'd run all the way down to the annulus to complete the repair. Vegetations and perforations. Here's a vegetation that I had previously and what we did was that involved a portion of the leaflet and we were able to resect out that portion of the leaflet. And the other image is a patient here in the hospital that we're operating on soon after some other workup that we should be able to do a repair on as well. Interior lateral fusion or double commissural fusion occurs with rheumatic change or calcification and commissurotomy is what we would do to address this. Or we can get fibrosis of the leaflet. There's a restricted posterior leaflet and a 52 year old gentleman in stage renal disease that caused quite severe regurgitation. But while the posterior leaflet was fibrosis, patient's anterior leaflet was quite normal. So we put in a downsizing band and we're able to eliminate that gentleman's regurgitation which is great in a patient with in stage renal disease because then we didn't have to put in a tissue valve or a deal with anticoagulation from a mechanical valve. The spectrum of degenerative disease goes from fibroelastic deficiency to fibroelastic deficiency, plus to the formfrost to a full blown Barlow's which involves both leaflets. And I'm gonna show you examples of all these. Here's a flail mitral valve at an 87 year old gentleman, P2 ruptured cord. Essentially it was a cord that was ruptured but the leaflet itself was not enlarged. So what can we do in that patient? We can do a triangular resection of the portion. There are other ways to repair it but this is what I classically do, a triangular resection of the portion with the flail cord and then reconstruct the leaflet back together and support it with a ring. We always support it with a ring just to prevent, just to improve co-optation because there's always some annular dilapidation with prolonged regurgitation. So here's a good result post-operatively. It can also be not necessarily just P2. Here's a P3 flail in a 38 year old gentleman with ruptured cord causing quite eccentric jet. And in him, we did a limited triangular resection. P3 needs a little bit more support usually than P2 as there's not as many surrounding cords. So we did a A3 P3 alfieri stitch which carpentry used to call a magic stitch where we just re-approximate the leaflets, an edge to edge and we put it in a band to support. Anti-leaflet prolapse is something that for surgeons when you're starting to learn how to do repairs, you generally start with ring-onlies, then you start with P2s, then you can go to other portions of the posterior leaflet. Anti-leaflet is kind of the last area to address because it's the most complex. Here's an anti-leaflet flail in a 54 year old gentleman. He had ruptured A2 cord. And for this gentleman, we put three neocords and also put in a band to support and we're able to get that anti-leaflet to the appropriate height and no longer prolapsing. Here's an 83 year old woman. Here's five of elastic deficiency plus. That's where not only do you have an abnormality of the cord, but you have leaflet abnormality, excessive height or width or bulk of the leaflet itself. So in this case, we have to take more than just a limited triangular resection. In this patient, we did a quadrangular resection, re-approximated the annulus to do application and then reconstructed the leaflet itself, post-op no regurgitation. Here's a form-frust. Here's a 62 year old woman with dyspnea exertion. This is a patient from here that we took care of a week or two ago with severe regurgitation and a very abnormal valve. Interoperatively on the 3D echo, we saw both P1 and P2 were involved. You can see on the intraoperative image, the excessive width in both P1 and P2. So not only can we, do we need to resect P2, like we did with the other patient, but the height of P1 is too high. So what we've got to do is lower the height of that leaflet. And so what we do is called a sliding plastic, where we cut below the leaflet edge so that we can move it over and then re-approximate the valve leaflets the way we had did before. And we get a patient with no regurgitation. She also had a maize procedure as well. And here's a form-frust with P1, P2, and P3 abnormalities. You can see essentially there's a functional double cleft on the 3D image and the 3D color image shows exactly that phenomenon. So what we did in this patient is we did a quadrangular resection to debulk P2, but then P1 and P3 were also too high. So we did a sliding plastic towards P1 and a sliding plastic towards P3 and we were able to bring the leaflets together in the middle and eliminate the regurgitation. The anterior leaflet was normal. But what if it's not? Here's a 50 year old woman with congestive heart failure, severe MR with multiple jets. Interoperatively we assessed the valve and essentially all of these segments of the both posterior and anterior leaflets were building. So we take it one step at a time. One lesion takes one technique to repair. We did a triangular P1 resection to downsize P1. We did a P2 sliding plastic. We closed the P2 P3 cleft. We put a P3 neocord. We did an A3 P3 alfieri stitch and put on a 33 millimeter band and we had a good result and we're able to repair that valve in that complex setting. Here's one more. 81 year old gentleman, congestive heart failure. He's actually a physician. He's actually waiting preoperative. He's got severe mitral regurgitation with multiple jets. He's got permanent persistent atrial fibrillation. You can see the anterior leaflet is prolapsing. The posterior leaflet is prolapsing. And you can see on the color images there's multiple jets coming out of that valve. So this is another one that's gonna take multiple techniques to get it repaired. But I'm optimistic we'll be able to get that valve repaired next week. Wish me luck. So you can see on his 3D images that the P2 is prolapsed, P1 is prolapsed. A2 and A3 look strange. And there's quite a wide jet in the middle. And he also has some tricuspid regurgitation as one might expect with longstanding mitral regurgitation. Let's look at the papillary muscles now. Here's a ruptured posterior medium papillary muscle. 62-year-old gentlemen of acute myocardial infarction. You can see it creates just a massive acute jet. This is a sick patient. These can't really wait. This is the one mitral valve operation you need to do in the middle of the night. But we were able to get that papillary muscle reconstructed and actually buttress it with some suture, Gore-Tex neocords, and we're able to get that valve repaired sparing that guy at a mitral valve replacement. Let's end up with the left ventricular wall. There's a couple of different things we have to address. One is restricted posterior motion with a chronic ischemic disease change. You can see on the pre-ambient image at the top, black and white, the posterior leaflet, it doesn't even look like he's got a posterior leaflet. And that's causing quite severe odd jet of regurgitation. But in this case, we put in a 28-millimeter, what's called an ischemic mitral regurgitation ring and that is asymmetrical in its shape. And we were able to eliminate his regurgitation as well. And then finally, systolic anterior motion. This is a patient from just this week, septal hypertrophy, 73-year-old woman, acute shortness of breath, coronary artery disease, paroxysmolyfib, left ventricular outflow, tract gradient greater than 50. This is a complicated situation physiologically, not only pre-operatively and intra-operatively, but post-operatively because not only is the septum thick but the whole ventricle is thickened and you can still get outflow tract problems post-operatively unless you have good control of the afterload and the endotropic state of the ventricle. So in this patient, we did a myectomy, put a true size band on the leaflets of the mitral valve were not normal, they were a bit abnormal but the regurgitation wasn't severe enough to warrant us replacing it. Pulmonary vein isolation, left atrial appendage ligation with the atroclip and bypass to her LAD. So you can see on the post-op images the left ventricle outflow tract, the septum would be inferiorly and you can see it staying out of the outflow tract and you can see the flow image demonstrating a nice wide open outflow tractoring systole. Now again, post-operatively, these patients if we let their blood pressure get low, that can lead again to collapse of the outflow tract and so it's important to maintain their vasoactive state and these were, this is intra-operatively but off pump measuring simultaneous aortic and left ventricular pressures and you can see that we have a peak-to-peak gradient of 13 which is what we're shooting for less than 15 to 25 ideally. So the principles for success in aortic and mitral valve repair, number one, the goal of that is to assess the valve. You gotta establish your precise diagnosis, pre-operative echo, then intra-operative echo, then visualization. Determine the most appropriate treatment option if you're a surgeon that doesn't do complex mitral valve repairs. Either please learn to do them or please consider transfer to a reference center because certainly a mitral valve repair, at least in my opinion, is much better for patient than a replacement. Now obviously patients need to have their valve replaced if they're fibrotic and scarred in, calcified annulus but I think most people are shifting towards repair whenever possible. You'd have to do a segmental valve analysis, localize and categorize all the dysfunction, do a complete inventory of the specific lesions. Sure, it may be complicated if you got P1, P2, A3, A2, all prolapsed but take them one at a time and address them one at a time, one lesion for one technique. So thanks again for inviting me to be here today. It's been a lot of fun.