Mitral Valve Repair in Children
Mitral Valve Repair in Children
Mitral Valve Repair in Children
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<strong>Mitral</strong> <strong>Valve</strong> <strong>Repair</strong> <strong>in</strong> <strong>Children</strong><br />
S. Buz, R. Hetzer<br />
Deutsches Herzzentrum Berl<strong>in</strong>, Germany<br />
DHZB-cw/ 2009
Deutsches Herzzentrum Berl<strong>in</strong><br />
4/1986 – 6/2009<br />
All valve operations 21.723<br />
mech. biol. repair<br />
Aortic valve surgery 4.651 7.240 724<br />
<strong>Mitral</strong> valve surgery 2.090 1.855 3.820<br />
Tricuspid valve surgery 80 103 1.314<br />
Pulmonary valve surgery 17 604 240<br />
Multiple valve operations <strong>in</strong> 1041 cases<br />
S<strong>in</strong>ce 2007 Transfemoral PVR (Melody ®) 35<br />
S<strong>in</strong>ce 2008 Transapical AVR (Sapien ® )<br />
125<br />
Transfemoral + transapical, t.axillary 11<br />
(Sapien ® , Corevalve ® )<br />
DHZB-cw/ 2009
DHZB Guidl<strong>in</strong>e MVR<br />
►Any mitral valve reconstruction must lead to a primarily<br />
optimal result with an expected durability of at least 10 to 15<br />
years.<br />
►Excepted t d from this rule are children and patients t with active,<br />
<strong>in</strong>fectious endocarditis.<br />
►In all cases where there is doubt about the result of a<br />
reconstruction, prosthesis must be preferred.<br />
►Patients t can benefit from less traumatic, ti „m<strong>in</strong>imal i <strong>in</strong>vasive“<br />
i operations, if no compromise has to be made concern<strong>in</strong>g the<br />
orig<strong>in</strong>al goal of the operation.<br />
►In chronic or <strong>in</strong>termittent atrial fibrillation endo-atrial<br />
ablation is added as a rule.<br />
DHZB-cw/ 2009
Heart <strong>Valve</strong> Surgery – The Biological Concept<br />
Pr<strong>in</strong>ciples of <strong>Mitral</strong> <strong>Valve</strong> <strong>Repair</strong><br />
►Primary repair should be reached by sutures only. The<br />
pericardial strip should not lead to further anulus<br />
shorten<strong>in</strong>g, however, should stabilize the suturedependent<br />
repair and <strong>in</strong>crease the height of the posterior<br />
leaflet coaptation counterpart. This is particularily<br />
important <strong>in</strong> ischemic mitral <strong>in</strong>competence<br />
►Secure anchorage of runn<strong>in</strong>g sutures, pericardial<br />
pledgets and pericardial strip by additional sutures<br />
DHZB-cw/ 2009
Criteria for <strong>Mitral</strong> <strong>Repair</strong><br />
positive +/- negative<br />
Tender Leaflet Body ++<br />
Reduced d Mobility PML +<br />
AML ++<br />
Calcium Commissure +<br />
Leaflet Body +<br />
Post. Anulus +<br />
Chordal Rupture PML ++<br />
AML +<br />
Leaflet Perforation +<br />
DHZB-cw/ 2009
<strong>Mitral</strong> valve surgery –<br />
the approaches<br />
DHZB-cw/ 2009
DHZB-cw/ 2009
M<strong>in</strong>imal-<strong>in</strong>vasive <strong>Mitral</strong> Surgery<br />
DHZB-cw/ 2009
DHZB-cw/ 2009
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DHZB-cw/ 2009
DHZB-cw/ 2009
<strong>Mitral</strong> valve repair –<br />
some risks and some precautions<br />
DHZB-cw/ 2009
Ruptured Chordae of Posterior Leaflet<br />
DHZB-cw/ 2009
Gerbode Plasty – Coronary K<strong>in</strong>k<strong>in</strong>g<br />
DHZB-cw/ 2009
Hazard of Coronary K<strong>in</strong>k<strong>in</strong>g <strong>in</strong><br />
Lateral Annuloplasty<br />
DHZB-cw/ 2009
Hazard of Coronary K<strong>in</strong>k<strong>in</strong>g <strong>in</strong><br />
Lateral Anuloplasty<br />
DHZB-cw/ 2009
DHZB-cw/ 2009
Mechanism of SAM <strong>in</strong> Excessive Annular Shorten<strong>in</strong>g<br />
DHZB-cw/ 2009
<strong>Mitral</strong> valve repair <strong>in</strong> childhood<br />
DHZB-cw/ 2009
<strong>Mitral</strong> <strong>Valve</strong> <strong>Repair</strong> <strong>in</strong> <strong>Children</strong> (Personal Series)<br />
DHZB 06/1987 – 05/2009<br />
130 children<br />
<strong>Children</strong> age range<br />
1 mo. – 17 yrs.<br />
Mean age<br />
6.8 yrs.<br />
Mdi Median age<br />
60 6.0 yrs.<br />
Male n = 67<br />
Female n = 63<br />
≤ 30 days mortality = 4 / 130 = 3.0%<br />
DHZB-cw/ 2009
<strong>Mitral</strong> <strong>Valve</strong> Lesions <strong>in</strong> Childhood<br />
►Congenital n = 83 ►Acquired n = 47<br />
Cleft 38<br />
Parachute 11<br />
Hammock 8<br />
Bland-White-Garland-Syndr Syndr. 4<br />
Membrane 5<br />
MV-Dysmorphy y 5<br />
Marfan-Syndrome 5<br />
Annular Dilation 3<br />
S<strong>in</strong>gle AV-<strong>Valve</strong> 1<br />
MV Stenosis 1<br />
Floppy <strong>Valve</strong> Syndrome 2<br />
HOCM 14<br />
Endocarditis 11<br />
Rheumatic fever 12<br />
DCM 7<br />
After chest trauma 1<br />
Leaflet et perforation o 1<br />
Rupture of Chordae 1<br />
DHZB-cw/ 2009
Hetzer R, Delmo-Walter E, Hübler M, Alexi-Meskishvili V, Weng Y, Nagdyman N, Berger F.<br />
Annals of Thoracic Surgery 2008;86(2):604-13.<br />
DHZB-cw/ 2009
Annular Dilatation<br />
before Reconstruction<br />
DHZB-cw/ 2009
Modified Kay-Wooler annuloplasty<br />
for annular dilatation <strong>in</strong> small <strong>in</strong>fants<br />
DHZB-cw/ 2009
Modified Gerbode plication plasty<br />
for ruptured chordea of posterior leaflet<br />
DHZB-cw/ 2009
Video 2 m<strong>in</strong><br />
DHZB-cw/ 2009
Modified Paneth Plasty<br />
(Hetzer R, <strong>in</strong> Borst HG (ed) Herzchirurgie 1991 )<br />
DHZB-cw/ 2009
Modified Paneth Annuloplasty<br />
for dilated annulus<br />
Posterior annulus<br />
shorten<strong>in</strong>g plasty<br />
Re<strong>in</strong>forcement with<br />
autologous pericardial<br />
strip (Hetzer modification)<br />
Completed repair<br />
DHZB-cw/ 2009
Video 2 m<strong>in</strong><br />
DHZB-cw/ 2009
Video<br />
DHZB-cw/ 2009
MVR-Paneth+autologous autologous pericardial strip, left auricula occlusion,<br />
Maze operation<br />
DHZB-cw/ 2009
Recurrent <strong>Mitral</strong> Incompetence 8.4 years after<br />
<strong>in</strong>itial iti Paneth Suture <strong>Repair</strong> at 2.1 years of age<br />
DHZB-cw/ 2009
Repeat Paneth and Pericardial Strip Plasty<br />
DHZB-cw/ 2009
Hammock valve<br />
Absence of papilary muscle<br />
DHZB-cw/ 2009
<strong>Repair</strong> of Hammock valve<br />
Before repair<br />
Splitt<strong>in</strong>g of a<br />
papillary muscle<br />
After repair<br />
DHZB-cw/ 2009
Hypertrophic obstructive cardiomyopathy<br />
and<br />
the mitral valve<br />
DHZB-cw/ 2009
HOCM: Parasternal long axis view<br />
Preoperative<br />
After surgery<br />
LVOT<br />
SAM<br />
DHZB-cw/ 2009
HOCM: Short axis view<br />
Bevor surgery<br />
After surgery<br />
30 mm<br />
11 mm<br />
DHZB-cw/ 2009
HOCM: Peroperative color Doppler<br />
Parasternal long axis view<br />
DHZB-cw/ 2009
Anterior leaflet retention plasty (ALRP)<br />
for HOCM and systolic anterior motion (SAM)<br />
A: Septal myectomy<br />
(aortic view)<br />
B: ALRP (Hetzer technique)<br />
C: completed repair<br />
(atrial view)<br />
D: <strong>Mitral</strong> <strong>in</strong>sufficiency <strong>in</strong><br />
HOCM and SAM (preop.)<br />
E: postoperative<br />
DHZB-cw/ 2009
HOCM and <strong>Mitral</strong> regurgitation<br />
DHZB-cw/ 2009
HOCM and <strong>Mitral</strong> regurgitation<br />
Myectomy<br />
DHZB-cw/ 2009
HOCM<br />
DHZB-cw/ 2009
HOCM<br />
DHZB-cw/ 2009
HOCM<br />
<strong>Mitral</strong> valve repair (ALRP)<br />
DHZB-cw/ 2009
HOCM<br />
<strong>Mitral</strong> valve repair (ALRP)<br />
DHZB-cw/ 2009
HOCM: Postoperative ECHO with CW Doppler<br />
DHZB-cw/ 2009
<strong>Mitral</strong> <strong>Valve</strong> <strong>Repair</strong> <strong>in</strong> Childhood<br />
Freedom from Reoperation<br />
DHZB-cw/ 2009
<strong>Mitral</strong> <strong>Valve</strong> <strong>Repair</strong> <strong>in</strong> Childhood<br />
Survival<br />
DHZB-cw/ 2009
<strong>Mitral</strong> <strong>Valve</strong> <strong>Repair</strong> <strong>in</strong> Childhood<br />
Survival by Age Group<br />
DHZB-cw/ 2009
<strong>Mitral</strong> <strong>Valve</strong> <strong>Repair</strong> <strong>in</strong> Childhood<br />
1. <strong>Mitral</strong> <strong>Repair</strong> is the preferred technique for any k<strong>in</strong>d of mitral<br />
disease <strong>in</strong> childhood<br />
2. This avoids the difficulty of valve replacement e <strong>in</strong> particular a <strong>in</strong><br />
<strong>in</strong>fants and small children <strong>in</strong> the face of complete lack of a<br />
prosthesis suitable for this age group<br />
3. Even when the primary repair result is not optimal, time can<br />
be ga<strong>in</strong>ed for later-on repeated repair until a def<strong>in</strong>ite adult<br />
size prosthesis can be implanted<br />
4. <strong>Repair</strong> allows for valve growth, no need of anticoagulation<br />
and has very little thrombotic risk<br />
DHZB-cw/ 2009
<strong>Mitral</strong> <strong>Valve</strong> <strong>Repair</strong> <strong>in</strong> Childhood<br />
5. This is best achieved by a spectrum of repair techniques<br />
applied <strong>in</strong>dividually and which avoid any k<strong>in</strong>d of prosthetic<br />
material<br />
6. Stabilisation of repair with autologous pericardial<br />
strip has rema<strong>in</strong>ed so far without re-operation<br />
7. <strong>Mitral</strong> valve area obviously grows along the anterior<br />
leaflet anulus<br />
DHZB-cw/ 2009
Thank you!!<br />
DHZB-cw/ 2009
DHZB-cw/ 2009
DHZB-cw/ 2009
<strong>Repair</strong> of Parachute ac <strong>Valve</strong><br />
DHZB-cw/ 2009
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Techniques of AV-<strong>Valve</strong> Reconstruction<br />
DHZB-cw/ 2009
Techniques of AV-<strong>Valve</strong> Reconstruction<br />
DHZB-cw/ 2009
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