The exposure of the mitral valve, the entire mitral valve apparatus is carefully examined. A detailed surgical valve analysis is performed to determine the functional type and the segmental localization. Valvular analysis will enable the surgeon to establish a comprehensive inventory of the lesions and the operative road map.
The presence of endocardial thickening or jet lesions is assessed. Jet lesions indicate a leaflet prolapse opposite to the side of the jet or a restricted leaflet motion on the side of the jet. The mitral valve annulus is examined to detect any annular dilatation and to assess its severity. The presence and the extent of annular calcification is carefully noted.
Mitral valve leaflets are examined using two nerve hooks to proceed to a functional analysis of all valvular segments. Leaflets motion is assessed using Carpentier's reference point technique. The free edge of P1 commonly serves as the reference point, as this segment is rarely affected by abnormal leaflet motion. This finding is particularly verifiable in patients with degenerative mitral valve disease. In this scenario, we first confirm the normal leaflet motion of P1 by pulling its free edge upward with a nerve hook. The free edge of P1 segment should not be prolapsing (it should not override the plane of the mitral annulus) nor be restricted. Using a second hook, other valve segments are examined in a systematic manner and compared to P1 to verify if they present with any abnormal leaflet motion. In the setting of type II dysfunction, the free edge of the prolapsing segment would be higher in the left atrium compared to the free edge of P1. In type III dysfunction, the mobility of the affected segment would be significantly reduced compared to P1. It is important to emphasize that type III dysfunction often affects all three segments of the posterior leaflet. Therefore, during intraoperative valve analysis the surgeon should compare the mobility of the posterior leaflet to that of the anterior leaflet. Echocardiographic valve analysis is of critical importance in patients with type III dysfunction.
Aortic Valve Replacement:
A significant number of clinical studies have investigated the long-term outcomes of mechanical valves and bioprostheses. Prosthetic heart valves are associated with several complications including structural valve deterioration, nonstructural dysfunction, valve thrombosis,embolism, bleeding event, endocarditis, and reoperation.The American College of Cardiology / American Heart Association Guidelines for Reporting Morbidity and Mortality After Cardiac Valve Interventions provide a precise definition of these complications.These guidelines represent a useful framework for investigating these events after heart valve surgery.Below we report the long-term results of mechanical and bioprosthetic aortic valve replacement. We have included clinical studies published during the last decade with a minimum follow-up of five years. If you click on each variable you will visualize the corresponding table. Each table can be reorganized according to the parameters included in the first row allowing the reader to analyze the data in a more personalized manner. References are provided and are linked to Pubmed.
He discussed several cases of double mitral and aortic valve diseases. He described the seat and characteristics of each murmur and emphasized the difficulty of diagnosis in this setting. This is a brief quotation from his comments on auscultation in double valve disease:
'...for the mitral valves may be so altered as that no murmur whatever shall be produced during the passage of blood through them; and again the murmur from the aortic opening may be so loud, and also propagated downwards into the ventricle, as to obscure the mitral murmur, even should it exist.'