CARDIAC VALVE DISEASE

Pathology MITRAL STENOSIS - RHD MITRAL REGURGE - RHD - IE - Ischaemic regurge 1. Echo measures - dilated LV (DD = 60mm SD = 45mm) 2. Symptoms are late - SOB AORTIC STENOSIS - RHD - IE - Congenital bicuspid valve 1. Symptomatic (LCOP) - blurred vision - easy fatigability - fainting 2. Complicated - cardiac arrest - left HF 3. Echo measures - gradient over aortic valve > 50 mmHg AV replacement AORTIC REGURGE - RHD - IE - Marfan syndrome - Dissecting aneurysm 1. Echo measures - dilated LV (DD = 60mm SD = 45mm) 2. Symptoms are late - SOB TRICUSPID VALVE DISEASE - Functional TR dt PHTN pt w/ MV disease - Drug addicts (right heart endocarditis)

Indication of surgery

Type of surgery

1. Symptomatic - SOB 2. Complicated - hemoptysis - Thrombo-embolic manifestations 3. Echo measures - MVA < 1.5 cm - MVG > 10 mmHg - LA > 40 mmHg 1. CMC *obsolete 2. OMC 3. MV replacement

1. MV repair & mitral ring annuloplasty (in case of rupture chordae, leaflet prolapse) 2. MV replacement (in severely diseased valve) MECHANICAL VALVE

AV replacement

1. Annuloplasty (De Vega or ring) - functional TR 2. Commisurotomy (organic TS) 3. TV replacement (severely diseased)

Types: - Cage ball valve (Starr-Edwards) - Monoleaflet tilting disc valve (Medtronic) - Bileaflet valve (St Jude, Carbomedic) Advantage: durable Disadvantage: 1. Need long life anticoagulant w/ INR measurement - coagulation problems (thrombosis of valve (stuck valve), thromboembolism causing CVA, bleeding over coagulation,valve failure) 2. Prosthesis valve endocarditis 3. Paravalvular leak 4. Arrhythmias Indications: People who can deal safely w/ anticoagulation - educated young men, compliant to Rx, nearby medical facilities

Autograft Excision of native pulmonary valve - implanting it in the aortic position of the same patient

TISSUE VALVE Homograft Human cadaveric valve, usually aortic which is sewn into aortic root of the patient

Xenograft i) Pigs aortic valve (Carpentier-Edwards) ii) Bovine pericardium (Hancock) - mounted on a stent OR stenless

No need for anticoagulation - No bleeding - No thrombosis - No thrombo-embolic manifestations

1. Lasts 10-15 years need reoperation 2. Prosthesis valve endocarditis 3. Paravalvular leak 4. Arrhythmias

People in whom anticoagulation is not recommended - young ladies in child bearing age - non compliant to Rx - professionals w/ violent jobs - pt away from medical facilities

Types

Treatment

VSD *commonest CHD i) Perimembranous (Infracristal) *commonest type ii) Inlet (canal) iii) Outlet (supracristal, subpulmonic) iv) Muscular *swiss-cheese type - Patch (Dacron/Gore-tex) closure thru right atriotomy or ventriculotomy - If pt cant withstand open cardiac procedure pulmonary artery banding (to protect against PHTN) followed later by debanding & patch closure of VSD

ASD i) Secundum *commonest type ii) Primum iii) Sinus venosus - Catheter device closure - Patch (autologous pericardium/ synthetic as Dacron or Gore-tex) - in the presence of MR (dt cleft in ant mitral leaflet) interrupted suture are used to approximate the defect ( to reduce the regurge) PS ii)Subvalvular

PDA Failure of closure of ductus arteriosus

- Device closure - Surgical ligation, clipping or division & suturing *mind LRLN! - VATS

Treatment

Coarctation = narrowing of the proximal descending thoracic aorta, adjacent to the site of ductus arteriosus * collaterals develop below & above coarctation - Resection & end-to-end anastomosis - Resection & tube graft interposition - Patch aortoplasty (Dacron / Gore-tex) - Subclavian flap aortoplasty - Catheter balloon dilatation (for post-op recurrence) F4 *most common CYANOTIC heart defect VSD + PS + overriding of aorta + RVH ( + ASD = pentalogy of Fallot)

i) Valvular

iii) Supravalvular

AS i) Valvular ii)Subaortic iii) Supravalvular

- Balloon pulmonary valvuloplasty - Open pulmonary valvotomy

-Resection of hypertrophied muscle

- Placing a wide Dacron patch across the stenosis to enlarge the aorta

Vascular ring abnormality in aortic arch & great arteries forming a ring that surrounds the trachea & oesophagus Thoracotomy & division of the ring

TGA - PA arises from LV & aorta from RV

Tricuspid Atresia Atresia of tricuspid orifice + ASD

Truncus Arteriosus Both aorta & main PA arise as common trunk from the heart *generally associated with VSD - Close VSD so that the trunk is included in the LV - Interpose a conduit between RV & the pulmonaries which are disconnected from the common trunk

Treatment

i) Palliative shunt - modified Blalock-Taussig Shunt (MBTS) by interposing a tube graft (Gore-tex) between subclavian artery (rt/lt) & pulmonary artery (rt/lt) - thru rt/lt thoracotomy or sternotomy ii) Total correction An open cardiac procedure to: 1. Close VSD by a patch (Gore-tex) to correct aortic overriding in the same time 2. Correct PS (as mentioned above). This improves RVH

i) Palliative percutaneous atrial septostomy (to create/enlarged VSD) *Rashleinds+ ii) Arterial switch (in neonates) iii) Atrial switch in (pt presenting later)

Glenns shunt (SVC to Rt pulmonary) followed by univentricular repair (Fontains operation)

TAPVD 4 PV drain into RA or its systemic tributaries (SVC, ICV, coronary sinus) * ass w/ VSD Surgical redirection of pulmonary veins to left atrium + closure of VSD

Eisenmengers synd. Reversed shunt

- Close defect early before PHTN develops *with established syndrome, closure of defect alone is contraindicated! - Medical treatment + heart lung machine or a lung transplant w/ repair of the defect

Patholog y

CARDIAC TUMOR MYXOMA - benign - most common cardiac tumor - smooth, firm, spherical, encapsulated mass or loose gelatinous material - pedunculated - attached to septum in the LEFT ATRIUM

CONSTRICT. PERICARDITIS Common cause - idiopathic (50%) - TB (15%) Fibrosed & thickened pericardium + obliteration of pericardial space uniform restriction of diastolic filling of all heart chambers + calcium deposition contribute to stiffening of the pericardium

PERICARDIUM PERICARDIAL EFFUSION Malignant (75%) - metastases (lung, breast) - direct invasion of mediastinal tumor Benign (25%) - infection - trauma - uremia

AORTA AORTIC DISSECTION = tear in intima of aortic wall allowing blood to enter and flow in a false channel Complications 1. weaken aortic outer wall rupture/ aneurysm 2. progress & occlude aortic branches MI, stroke, renal failure, paraplegia, limb ischaemia 3. disrupt aortic valve annulus valvular insuff., HF Standford classification Type A Type B Proximal Distal dissection, beyond left dissection subclavian artery Ascending aorta Descending aorta Staging Acute Subacute Chronic st st nd 1 2 weeks 1 2 months After 2 month 5Ps : pain, pallor, pulselessness, parasthesia, paralysis CXR : broad mediastinum Echo CT, MR, aortography

AORTIC ANEURYSM = an area of bulging in the wall of aorta - weakened by AS, degenerative disease as Marfan synd, syphilis or trauma Type: - saccular - diffuse

Rapid accumulation of fluid CVP + diastolic filling + SV + cardiac tamponade + cardiogenic shock Pulsus paradoxus Becks triad - distended NV - muffled HS - hypotension

Investiga tion

Echocardiography

Treatme nt

Surgical excision of the tumor w/ the attached interatrial septum + patch closure of the atrial septal defect

CXR - normal / mildly enlarged cardiac silhouette - calcification of pericardium Echo: thickened pericardium CT, MRI *better Pericardiectomy - midsternotomy/left thoracotomy - w/ or w/o CP bypass

Echocardiography - pericardial fluid - compression of right atrium & ventricle - paradoxical septal motion

CXR Echo CT MRI Aortography Replacement w/ Dacron tube graft when the diameter is over 5-6 cm

1. No hemodynamic compromise - treat underlying condition - Echo-guided pericardiocentesis 2. Impending/acute tamponade - volume expansion diastolic filling - Echo-guided pericardiocentesis, subxiphoid 3. Surgical decompression Indications : - clotted blood, trauma, purulent pericarditis, loculated effusion - pericardial biopsy Technique : resection of a portion of pericardium (create pericardial window to drain pericardial fluid) Approach : subxiphoid/ VATS/ Left anterior thoracotomy

Type A: IMMEDIATE SURGERY - ascending aorta tube graft replacement (sternotomy) - aortic valve annulus resuspension of aortic cusps / aortic valve replacement - coronary ostia implanted into tube graft (Bentalls operation) Type B: STABILIZED MEDICALLY! May not require immediate surgery - sedation, analgesia - vasodilator (IV nitrates) lower BP 90-100 mmHg - BB (propranolol) or CCB (verapamil) slow the pulse & make the beat less forceful - *if not stabilized medically EXCISION & TUBE GRAFT replacement @ upper thoracic aorta (left thoracotomy)