DK2985_C000 1..28 - AlSharqia Echo Club

Mitral Valve Replacement and Repair 435Prosthetic Mitral Valve DysfunctionE < 1.9E > 1.9PHT < 130 PHT > 130PHT < 130 PHT > 130Any Dysfunction 5%Regurgitation 5%Obstruction 0%Any Dysfunction 100%Regurgitation 0%Obstruction 100%Any Dysfunction 71%Regurgitation 69%Obstruction 2%Any Dysfunction 100%Regurgitation 5%Obstruction 95%Figure 18.28 Approach to the evaluation of prosthetic valve dysfunction using the early or E component of the transmitral flowDoppler velocities and the measurement of pressure half-time (PHT). The percentage corresponds to the incidence found in the studypopulation. [Adapted from Fernandes et al. (9).]ventricular ejection fraction 40% or systolic arterialpressure (SAP) 100 mmHg], stimulation with vasopressorssuch as phenylephrine should be considered to reevaluatethe severity of MR with higher loading conditions(see Chapter 17). Therefore, the evaluation of global andregional left ventricular function and review of thepatient’s hemodynamics should not be omitted.Significant extra- or periannular leaks are uncommonafter mitral valve repair but a search for their presenceand evaluation of their severity should systematically beperformed as with mitral valve replacement. In the longterm, annular dehiscence with periannular leak is aninfrequent condition and often results from degenerativedisease or endocarditis.Table 18.1Recommendations for Mitral Valve Repair for Mitral Stenosis Indication1. Patients with NYHA functional class III–IV symptoms, moderate or severe MS (mitral valve area ,1.5 cm 2 ), a and valve Imorphology favorable for repair if percutaneous Mitral balloon valvotomy is not available2. Patients with NYHA functional class III–IV symptoms, moderate or severe MS (mitral valve area ,1.5 cm 2 ), a and valve Imorphology favorable for repair if a left atrial thrombus is present despite anticoagulation.3. Patients with NYHA functional class III–IV symptoms, moderate or severe MS (mitral valve area ,1.5 cm 2 ), a and a Inonpliable or calcified valve with the decision to proceed with either repair or replacement made at the time of theoperation4. Patients in NYHA functional class I, moderate or severe MS (mitral valve area ,1.5 cm 2 ), a and valve morphology IIbfavorable for repair who have had recurrent episodes of embolic events on adequate anticoagulation5. Patients with NYHA functional class I–IV symptoms and mild MS IIIa The committee recognizes that there may be a variability in the measurement of mitral valve area and that the mean transmitral gradient, pulmonary arterywedge pressure, and pulmonary artery pressure at rest or during exercise should also be considered.Note: MS, mitral stenosis; NYHA, New York Heart Association.Source: Adapted from Bonow et al. (10).ClassTable 18.2Recommendations for Mitral Valve Replacement for Mitral StenosisIndication1. Patients with moderate or severe MS (mitral valve area ,1.5 cm 2 ) a and NYHA functional class III–IV symptoms whoare not considered candidates for percutaneous balloon valvotomy or mitral valve repair2. Patients with severe MS (mitral valve area ,1 cm 2 ) a and severe pulmonary hypertension (pulmonary artery systolicpressure .60–80 mmHg) with NYHA functional class I–II symptoms who are not considered candidates forpercutaneous balloon valvotomy or mitral valve repairClassIIIaa The committee recognizes that there may be a variability in the measurement of mitral valve area and that the mean transmitral gradient, pulmonary arterywedge pressure, and pulmonary artery pressure should also be considered.Note: MS, mitral stenosis; NYHA, New York Heart Association.Source: Adapted from Bonow et al. (10).