 Hi, I'm Mark Moon. I'm the professor-in-chief of the Division of Cardiothoracic Surgery here at Baylor College of Medicine and also the chief of cardiac surgery at the Texas Heart Institute and Baylor St. Luke's Medical Center. Today, my topic is going to be to discuss the strategic assessment of mitral valve disease, how we as surgeons look at echocardiograms and interpret the results to come up with a treatment plan for our surgical patients. It all began in 1983 when Dr. Elan Campantier was an honored guest speaker at the American Association for Thoracic Surgery when he presented the French Correction, a whole new way to address mitral valve disease. And many of the images I'm showing, or some of them, will be from his most recent summary of reconstructive techniques. We start with the pathophysiological triad. That involves the etiology, which is the cause of the disease. The lesions, which are what results from the disease, and dysfunction, which is what results from the lesions. Campantier classified mitral regurgitation as one of three different types of mitral valve disease. Number one, normal leaflet motion. That's where you have a dilation of the annulus of the mitral valve pulling the leaflets apart, but they move normally. Number two, excessive leaflet motion, which would be either prolapse or rupture of a cord or portion of a leaflet. Three is restricted leaflet or cord motion. Three A is with rheumatic disease, whereas three B is ischemic disease where the back portion of the heart doesn't work well, the inferior wall, and the posterior leaflet is stiff. So, looking at the functional anatomy of the valve, we're going to start with the annulus and work down from there. Lesions of the annulus can include either dilation or calcification. A dilation can be either symmetrical, completely dilating the entire posterior portion. The anterior portion usually does not dilate because it's fibrosis in that region. There's fibrosis that keeps its structure. There's asymmetrical dilatation as shown in the right lower bottom if it's ischemia that affects one region more so than another. And the images you can see demonstrate heavy calcification of the annulus in the bottom image and a dilated annulus in the upper image. Here's a case of a dilated annulus in a 64-year-old man with atrial fibrillation, severe mitral agurgitation, normal leaflets. He underwent simple mitral valve repair with a downsizing band and a maze procedure, which you can see in the postoperative images, completely eliminated his mitral agurgitation. When you do a mitral valve repair, it's generally accepted that some sort of buttressing support should be done to prevent annular dilatation in the future. This can involve a rigid ring or a flexible band, and there's also semi-rigid rings and bands. Some sort of support. There are various reasons to use one or the other, which are probably beyond the scope of what I can talk about today. Next, let's look at the leaflets and cordy tendiniae. Leaflet lesions include cleft or tear of the leaflet. They can include vegetations or perforations that you can see from endocarditis most often. They can be thickening or commissural fusion, which we might see with rheumatic disease or radiation injury, and calcification, of course. The cordy tendiniae can become elongated or rupture. There can also be thickening fusion and shortening, as we see with rheumatic disease. The degenerative disease generally involves changes in both the leaflets and the cordy tendiniae. Let's first talk about non-pathologic clefs. There are natural clefs between P1 and P2 and between P2 and P3. These are supportive i-cords that function like commissures to facilitate a wide opening of the valve. They don't extend to the annulus, though. They're only partially into the leaflet. Then we have pathologic clefs. Here we can see in the upper image an anterior cleft that is generally congenital, and also the pathologic cleft in the posterior leaflet you can see below, which is between P2 and P3 creating severe regurgitation. You can see the image on the right at the bottom demonstrates putting a suture in to start the repair and close that cleft. Vegetations or perforations can occur from endocarditis, rarely trauma in the mitral valve position, but here you can see a vegetation that we excised and did a patch reconstruction with a piece of bovine pericardium or native pericardium. Again, with rheumatic disease we can get thickening or commissural fusion. The left picture demonstrates anterior lateral fusion, or it can occur in both commissures. If the leaflet's repliable otherwise, this is a patient we could do a repair in. There's also techniques for peeling off some rheumatic disease that's not too common in the United States, but we do this occasionally in other countries. Here we have a leaflet fibrosis. This is a restricted posterior leaflet. You can see the image on the left at posterior leaflet doesn't hardly move, and you can see that the anterior leaflet in the middle image of the 3D does not come all the way back down to the bottom annulus to close the regurgitating cavity. So in this patient you can see the restricted posterior leaflet was second, but the anterior leaflet was normal caliber. So what we did was put in a downsizing annula-plasty band and were able to eliminate the regurgitation. The spectrum of degenerative disease extends from fibroelastic deficiency to fibroelastic efficiency plus, which means normal leaflet size, normal scallop sizes, however, ruptured cord. Then you get that, and as it expands, you get to the fibroelastic deficiency plus. The form-frust involves more than just one segment of the posterior valve, and the Barlow's valve is the most extreme version affecting both the anterior and posterior leaflet. Here's a pre-op image of a flail mitral valve in an 87-year-old gentleman with congestive heart failure and a ruptured P2. You can see the jet is anteriorly directed behind the anterior leaflet. Here, fibroelastic deficiency, basic. We do a triangular resection of the area of the ruptured cord and can reconstruct, and we get no regurgitation postoperatively, also supported with a 29-millimeter band to prevent any future dilatation of the annulus that could be a cause for recurrent regurgitation. Here's a flail P3, similar, 38-year-old gentleman. He had anteriorly directed jet, but you can see the 3D image demonstrates that that area of the abnormal leaflet was on the P3, P2 region. And we did a limited triangular resection of this patient, and also put a supporting suture, an A3P3 Gore-Tec suture developed by Alfieri from Portugal, and put in a 32-millimeter band to, again, support the repair with no residual regurgitation. Here's anteriorly flipped prolapse, and this is a bit more complex, and this is the kind of patient that a surgeon who's not comfortable with mitral valve repair would consider transferring to a reference center. Here's one of our 54-year-old gentlemen with Nuonset congestive heart failure, a ruptured cord in the anterior leaflet in the A2. What we did was created an A2 neocord, and we put three of these in through the papillary muscle and then through the leading edge, or actually to the co-aptation edge of the anterior leaflet where we wanted the valve to co-ap, put, again, on a supporting band. We did not have to downsize extensively, and we had no regurgitation after repair. Here's cordial elongation in an 83-year-old woman with symptomatic mitral regurgitation. Here, this is, again, P2 prolapse, but this time without rupture. The cord was stretched, but there was excessive leaflet tissue as in FED+. So what we need to do in this case is decrease the excessive height of the middle scallop of the posterior leaflet. Here, we did a quadrangular resection with annular plication, and we're able to downsize that posterior annulus, and P1 and P3 were normal height so we could do a reconstruction with an annular plication and have no regurgitation. Here's a form-frust patient of 58-year-old women with dyspion exertion and palpitations, five-year history of a murmur, and mitral valve prolapse, with significant regurgitation and symptoms. Here we can see on the three-dimensional image that we had P1 and P2 prolapse with excess width and height, and you can see the intraoperative image of that leaflet. So what we're going to do was not only resect P2, because P1 was still going to be too big, so what we did was a sliding plastic cut underneath and unroofed the P1 segment, and we're able to move it over towards P3 and thereby decrease the height of P1 so that we can reconstruct the leaflet in normal fashion and put on a rigid band. No regurgitation after the procedure. Here's another form-frust with involvement of P1, P2, and P3. Essentially, you can see on the three-dimensional image to the right, there's a functional double cleft. There's the enlargement of all three leaflet segments. So in this case, we had to do bilateral sliding plastic, essentially. We resected P2, did a sliding plastic to P1, a sliding plastic to P3. We're able to bring them back together in the middle without an annular plication and then put on a 30-millimeter band with no regurgitation postoperatively. And finally, there's the bi-leaflet Barlow's disease, a 50-year-old woman with congestive heart failure with multiple jets of severe regurgitation and big leaflets throughout. We do an intraoperative segmental assessment to assess all the valve segments. Usually, we use P1 as a reference point, but because it's usually not affected, but in this patient, all of the segments of the valve are affected. Interoperatively, we did a triangular P1 resection. We did a P2 sliding plastic, a P2, P3 cleft, a P3 neocord, an A3-P3 alfieri stitch, and had no regurgitation after repair and supported it with a 33-millimeter band. It sounds complicated, but it's one technique for each lesion. Postoperatively, we had no regurgitation after that repair and we're very satisfied with the result. So what about the cord and leaflet fibrosis? Here's an example of a leaflet fibrosis that's stiffening and calcification. This is a 72-year-old woman with severe peripheral vascular disease, COPD. Her heart function was good, but she had severe pulmonary hypertension and she was quite frail and debilitated. The capability to repair a mitral valve depends on the pliability of the leaflets versus rigidity and also the involvement of the subvalvular apparatus. You can see on the left this patient had severe thickening of the cords, so the subvalvular apparatus was calcified and thickened and the leaflets were very rigid. So this, in the likelihood of repair, is not a patient we should repair and she did very, very well with a mitral valve replacement. So finally, next, the papillary muscles. We can have ruptured posterior menopapillary muscle from an acute myocardial infarction. You can see that papillary muscle moving around with a severe jet of acute regurgitation, making the patient quite sick. Introverted balloon pump was placed. We were able to reconstruct that papillary muscle, putting it back on the left ventricular wall with a good result. And finally, left ventricular wall aneurysms or dyskinesis that the inferior basal wall can cause the regurgitation due to limited motion of the posterior leaflet. Here's a restricted posterior leaflet in the 57-year-old gentleman due to ischemic area and circumflex. It was not bypassable, so we did a 28-millimeter ischemic mitral regurgitation ring that compensates for the asymmetrical dilatation and we were able to get an excellent result with long-term no regurgitation. And finally, you can have combinations of lesions. Here's a 76-year-old woman with severe mitral regurgitation who had a P2 prolapse. She had non-bypassable circumflex lesion, so we took her in to the P2 resection, a 31-millimeter band. But coming off pump, she still had 1 plus to 2 plus mitral regurgitation that I was not happy with. So I thought there must be something else, and it looked like we got other images and the inferior basal wall was not functioning well. So instead of leaving the true-sized flexible band that we put originally just to support the P2 repair, we placed a downsizing 28-millimeter, again ischemic MR ring, to reconstruct the asymmetrical annulus, and she had no regurgitation. We did not have to replace the valve. So the principles for success when analyzing the mitral valve are to, number one, understand the goals of valve assessment to establish a precise diagnosis preoperative echo then intraoperative echo, determine the most appropriate treatment option and consider reference center transfer if it's a complex lesion, or when the surgeon in your center or you, if you are the surgeon, are not comfortable with. Because almost all degenerative valves should be repaired these days in a reference center. And segmental valve analysis localize and categorize the dysfunction. For each lesion, do one repair. And do a complete inventory of the specific lesions you plan to repair and address them one by one, and it will simplify the procedure. So thank you very much. I'm glad you were able to join us today.