Mitral valve repair or replacement - Revision history

Zining2023: References section completed

2026-03-03T15:00:17Z

References section completed

← Older revision		Revision as of 08:00, 3 March 2026
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	* Elderly patients		* Elderly patients
	* High or prohibitive surgical risk		* High or prohibitive surgical risk
	* Frailty or hostile chest		* Frailty or hostile chest<ref>{{Cite journal\|last=Otto\|first=Catherine M.\|last2=Nishimura\|first2=Rick A.\|last3=Bonow\|first3=Robert O.\|last4=Carabello\|first4=Blase A.\|last5=Erwin\|first5=John P.\|last6=Gentile\|first6=Federico\|last7=Jneid\|first7=Hani\|last8=Krieger\|first8=Eric V.\|last9=Mack\|first9=Michael\|last10=McLeod\|first10=Christopher\|last11=O’Gara\|first11=Patrick T.\|date=2021-02-02\|title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines\|url=https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923\|journal=Circulation\|language=en\|volume=143\|issue=5\|doi=10.1161/CIR.0000000000000923\|issn=0009-7322}}</ref>

	=== Surgical procedure<!-- Briefly describe the major steps of this surgical procedure. --> ===		=== Surgical procedure<!-- Briefly describe the major steps of this surgical procedure. --> ===
	Most commonly performed via median sternotomy, but minimally invasive approaches exists.		Most commonly performed via median sternotomy, but minimally invasive approaches exists<ref>{{Citation\|last=Yandrapalli\|first=Srikanth\|title=Minimally Invasive Mitral Valve Surgery\|date=2025\|url=http://www.ncbi.nlm.nih.gov/books/NBK567730/\|work=StatPearls\|place=Treasure Island (FL)\|publisher=StatPearls Publishing\|pmid=33620807\|access-date=2026-03-03\|last2=Sharma\|first2=Sanjeev\|last3=Kaplan\|first3=Jason}}</ref>

	After systemic heparinization (ACT > 480 seconds), cardiopulmonary bypass is established with aortic and right atrial (or bicaval) cannulation. Aortic cross-clamp is applied, and myocardial protection is achieved through cold blood cardioplegia delivered either through aortic root (antegrade) and/or coronary sinus (retrograde).		After systemic heparinization (ACT > 480 seconds), cardiopulmonary bypass is established with aortic and right atrial (or bicaval) cannulation. Aortic cross-clamp is applied, and myocardial protection is achieved through cold blood cardioplegia delivered either through aortic root (antegrade) and/or coronary sinus (retrograde).
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	{\| class="wikitable wikitable-horizontal-scroll"		{\| class="wikitable wikitable-horizontal-scroll"
	\|+		\|+<ref>{{Cite book\|title=Kaplan's cardiac anesthesia: perioperative and critical care\|date=2024\|publisher=Elsevier\|isbn=978-0-323-82924-3\|editor-last=Kaplan\|editor-first=Joel A.\|edition=8th edition\|location=Philadelphia, PA\|editor-last2=Augoustides\|editor-first2=John G. T.\|editor-last3=Gutsche\|editor-first3=Jacob T.}}</ref><ref>{{Cite book\|last=Bartels\|first=Karsten\|title=Hensley's Practical Approach to Cardiothoracic Anesthesia: EBook Without Multimedia\|date=2024\|publisher=Wolters Kluwer Health\|others=Amanda A. Fox, Andrew D. Shaw, Kimberly Howard-Quijano, Robert H. Thiele\|isbn=978-1-9752-0910-0\|edition=7th ed\|location=Philadelphia}}</ref>
	!		!
	!Minimally invasive		!Minimally invasive

Zining2023: Procedural variants section

2026-03-03T14:10:16Z

Procedural variants section

← Older revision		Revision as of 07:10, 3 March 2026
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	\|+		\|+
	!		!
	!~~Variant 1~~		!Minimally invasive
	!~~Variant 2~~		!MVR+MAZE
			!MVR+CABG
			!Redo
			!Commando
	\|-		\|-
	\|Unique considerations		\|Unique considerations
	\|		\| -Peripheral cannulation
	\|		-Lung isolation
			\| -Possible LAA closure
			\| -Higher ischemic risk
			-More inotropes need
			\|Blood in room before incision
			\| -Prolonged bypass, vasoplegia
			-Massive transfusion

			-Mechanical circulatory support
	\|-		\|-
	\|~~Indications~~		\|CPB complexity/time
	\|		\|Higher
	\|		\|Higher, longer
	\|-		\|Higher, longer
	~~\|Position~~		\|Very high
	\|		\|Extremely high
	\|
	\|-
	\|~~Surgical time~~
	\|
	\|
	\|-		\|-
	\|EBL		\|EBL
	\|		\|Lower
	\|		\|Similar
	\|-		\|Higher
	~~\|Postoperative disposition~~		\|Higher
	\|		\|Very high
	\|
	\|-
	~~\|Pain management~~
	\|
	\|
	\|-		\|-
	\|Potential complications		\|Potential complications
	\|		\|<nowiki>-Full sternotomy conversion</nowiki>
	\|
			-Less wound complications
			\| -Atrial arrhythmia
			-Heart block
			\|LCOS, bleeding
			\| -Re-entry injury
			-Transfusion
			\| -Pacemaker dependence
			-Very high bleeding, vasoplegia

			-Mortality risk
	\|}		\|}

Zining2023: Finished postop management section

2026-03-03T13:17:05Z

Finished postop management section

← Older revision		Revision as of 06:17, 3 March 2026
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	* Vasopressors (norepinephrine, vasopressin)		* Vasopressors (norepinephrine, vasopressin)
	* Pacing (temporary wires placed)		* Pacing (temporary wires placed)
			*Pulmonary vasodilators

	Common issues:		Common issues:

	* ~~LV dysfunction~~		* Systolic anterior motion (SAM)
	* RV dysfunction		* Pulmonary HTN
	* Residual gradient		*RV dysfunction
			* Residual gradient
	* Paravalvular leak		* Paravalvular leak
	* ~~Complete heart block~~		*Atrial arrhythmias

	TEE assessment:		TEE assessment:
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	=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===		=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===

			* Cardiac ICU

	=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===		=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===

			* Parasternal block
			* Multimodal analgesia

	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===

			* Atrial arrhythmias (large left atrium, surgical manipulation, MAZE procedure)
			* Heart block (requiring pacing)
			* Vasoplegia (CPB induced inflammatory state with low SVR despite normal EF)
			* Low cardiac output syndrome (can be from ischemia, LV dysfunction, afterload mismatch, prosthesis-patient mismatch)
			* Bleeding/re-exploration
			* Stroke/neurological deficits (air embolism from LA opening)
			* Acute kidney injury

			Mechanical valve is more durable but carries higher bleeding risk and requires lifelong anticoagulation

	== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==		== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

Zining2023: Finished intraop section

2026-03-02T17:31:53Z

Finished intraop section

@@ Line 158: / Line 158: @@
 === Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
 === Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
 === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
 === Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
 === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
 == Postoperative management ==

Zining2023: Finished preop management

2026-03-02T16:58:07Z

Finished preop management

← Older revision		Revision as of 09:58, 2 March 2026
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	\|-		\|-
	\|Airway		\|Airway
	\|		\| -Prior sternotomy may limit neck mobility
	\|-		\|-
	\|Neurologic		\|Neurologic
	\|		\| -History of stroke, TIA, cognitive baseline
	\|-		\|-
	\|Cardiovascular		\|Cardiovascular
	\|		\| -Severity assessment (MS vs MR)
			-LV size and systolic function

			-LA size

			-RV function

			-Pulmonary HTN (RV risk post bypass)

			-CAD (concomitant CABG)

			-Rhythm (atrial fibrillation)
	\|-		\|-
	\|Pulmonary		\|Pulmonary
	\|		\| -Restrictive lung physiology (HF/sternotomy)
			-COPD (prolonged vent weaning)
	\|-		\|-
	\|Gastrointestinal		\|Gastrointestinal
	\|		\|<nowiki>-Dysphagia, esophageal/GI tract surgeries (TEE)</nowiki>
	\|-		\|-
	\|Hematologic		\|Hematologic
	\|		\|<nowiki>-Anticoagulation use, blood products available</nowiki>
	\|-		\|-
	\|Renal		\|Renal
	\|		\| -Baseline Cr, kidney disease (CPB AKI risk)
	\|-		\|-
	\|Endocrine		\|Endocrine
	\|		\|<nowiki>-DM</nowiki>
	\|-		\|-
	\|Other		\|Other
	\|		\|<nowiki>-Endocarditis (longer CPB)</nowiki>
	\|}		\|}
			'''Echocardiography'''

			Severe Mitral Stenosis - Valve area < 1.0 cm2, mean gradient > 10mmHg, PAP > 50mmHg

			Severe Mitral Regurgitation - EROA > 0.4cm2, regurgitant volume > 60mL, regurgitant fraction > 50%, vena contracta > 7mm

	=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===		=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===

			* CBC, CMP, PT/PTT
			* T&C pRBC FFP
			* TTE/TEE, cardiac cath, EKG, CXR

	=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===		=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===

			* Have at least 5-8 channels for infusions
			** Epinephrine, norepinephrine, carrier, insulin (some institutions use phenylephrine in place of norepi)
			** Consider TXA, ketamine, dexmedetomidine, cefazolin
			* Drugs:
			** Emergency medications (bolus):
			*** epinephrine, atropine
			*** Other bolus vasopressors (e.g. vasopressin, phenylephrine, norepinephrine)
			*** +/- esmolol, nicardipine, and nitroprusside
			** Heparin, protamine, calcium
			** +/- Magnesium
			* Perfusion technician should be available along with cell saver
			* Fluid warmer
			* Triple transducers primed and zeroed
			* Internal defibrillator/pacer available in room
			* TEE machine with appropriately sized probe

	=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===		=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===

			* Continue beta blockers, statins, antianginals
			* Hold ACE inhibitors/ARBs and DOACs per protocol

	=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===		=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===

			* Pre-Op: Erector Spinae Plane Block
			* Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence

	== Intraoperative management ==		== Intraoperative management ==

Zining2023: Finished surgical procedure overview section

2026-03-02T15:28:39Z

Finished surgical procedure overview section

← Older revision		Revision as of 08:28, 2 March 2026
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	-Pulmonary HTN, RV function		-Pulmonary HTN, RV function
	-Chronic atrial fibrillation		-Chronic atrial fibrillation
	-~~Thromboemoblism~~ risk (LA thrombus)		-Thromboembolism risk (LA thrombus)
	-Concomitant procedures (CABG, MAZE, multi valves)		-Concomitant procedures (CABG, MAZE, multi valves)
	\| considerations_intraoperative = -Hemodynamic goals (MS vs MR)		\| considerations_intraoperative = -Hemodynamic goals (MS vs MR)
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	=== Surgical procedure<!-- Briefly describe the major steps of this surgical procedure. --> ===		=== Surgical procedure<!-- Briefly describe the major steps of this surgical procedure. --> ===
			Most commonly performed via median sternotomy, but minimally invasive approaches exists.

			After systemic heparinization (ACT > 480 seconds), cardiopulmonary bypass is established with aortic and right atrial (or bicaval) cannulation. Aortic cross-clamp is applied, and myocardial protection is achieved through cold blood cardioplegia delivered either through aortic root (antegrade) and/or coronary sinus (retrograde).

			Left atriotomy (via interatrial groove or transseptal approach) is performed and mitral valve is directly inspected to determine mechanism of pathology.

			Repair techniques include annuloplasty ring placement, leaflet resection, chordal replacement, or commissurotomy (MS).

			Replacement involves native valve excision (preserving posterior leaflet, if possible, to maintain ventricular geometry). Mechanical or bioprosthetic valve is then implanted. Sutures are placed circumferentially around the annulus. Preservation of subvalvular apparatus reduces postoperative LV dysfunction.

			Concomitant MAZE procedure frequently performed in patients with chronic atrial fibrillation and involves surgical ablation lines created in atria. This can be combined with left atrial appendage ligation or excision.

			De-airing is critical due to open left atrium and TEE guidance before cross-clamp removal. After reperfusion and rewarming, patient is weaned from CPB.

			Temporary epicardial pacing wires are routinely placed due to risk of conduction disturbances. After protamine administration and hemostasis, chest closure is performed.

	== Preoperative management ==		== Preoperative management ==

Zining2023: Added TMVR comparison in indications section

2026-03-02T15:12:13Z

Added TMVR comparison in indications section

← Older revision		Revision as of 08:12, 2 March 2026
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	}}		}}

	Mitral valve repair or replacement is performed for severe mitral regurgitation (MR), mitral stenosis (MS), or mixed disease. Repair is preferred when possible because it preserves annular-ventricular continuity, maintains LV geometry, improves long-term survival, and avoids prosthetic complications. Replacement is performed when repair is not durable or technically feasible (severe calcifications, rheumatic disease, extensive endocarditis).		Mitral valve repair or replacement is performed for severe mitral regurgitation (MR), mitral stenosis (MS), or mixed disease. Repair is preferred when possible because it preserves annular-ventricular continuity, maintains LV geometry, improves long-term survival, and avoids prosthetic complications. Replacement (SMVR) is performed when repair is not durable or technically feasible (severe calcifications, rheumatic disease, extensive endocarditis).

	== Overview ==		== Overview ==
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	=== Indications<!-- List and/or describe the indications for this surgical procedure. --> ===		=== Indications<!-- List and/or describe the indications for this surgical procedure. --> ===

	* Symptomatic severe primary MR		* Symptomatic severe primary (degenerative) MR
	* Severe secondary MR with persistent symptoms despite GDMT		*Symptomatic severe MS
	* Severe MS with ~~symptoms~~ or ~~pulmonary hypertension~~		* Severe secondary (functional) MR with persistent symptoms despite GDMT
			* Severe MR with LV dilation or LV dysfunction
			*Recurrent MR after primary repair
	* Endocarditis with structural destruction		* Endocarditis with structural destruction
	* Concomitant need during CABG or other valve surgery		* Concomitant need during CABG or other valve surgery
			Unlike Transcatheter mitral valve repair/replacement, SMVR allows:

			* Complete annular debridement
			* Abscess debridement
			* Annular enlargement
			* Leaflet resection and chordal reconstruction
			* Preservation of subvalvular apparatus
			* Concomitant procedures like MAZE, left atrial appendage excision, tricuspid repair, or CABG
			* Durability advantage in primary MR in low risk patients

			Transcatheter mitral valve repair/replacement (TMVR) is preferred in:

			* Elderly patients
			* High or prohibitive surgical risk
			* Frailty or hostile chest

	=== Surgical procedure<!-- Briefly describe the major steps of this surgical procedure. --> ===		=== Surgical procedure<!-- Briefly describe the major steps of this surgical procedure. --> ===

Zining2023: Completed infobox

2026-03-02T14:58:24Z

Completed infobox

← Older revision		Revision as of 07:58, 2 March 2026
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	{{Infobox surgical procedure		{{Infobox surgical procedure
	\| anesthesia_type =		\| anesthesia_type = General
	\| airway =		\| airway = ETT
	\| lines_access =		\| lines_access = PIV, Arterial line, Central line, +/- PA catheter
	\| monitors =		\| monitors = Standard ASA, arterial line BP, CVP +/- PAP, TEE, NIRS
	\| considerations_preoperative =		\| considerations_preoperative = -Severity and mechanism of lesion (MS vs MR, primary vs secondary)
	\| considerations_intraoperative =		-LV size and systolic function
	\| considerations_postoperative =		-Pulmonary HTN, RV function
			-Chronic atrial fibrillation
			-Thromboemoblism risk (LA thrombus)
			-Concomitant procedures (CABG, MAZE, multi valves)
			\| considerations_intraoperative = -Hemodynamic goals (MS vs MR)
			-Full heparinization before CPB
			-Myocardial protection and de-airing
			-Conduction disturbances
			-Weaning from CPB: LV/RV function, valve seating, gradients
			\| considerations_postoperative = -RV failure
			-SAM
			-Atrial fibrillation
			-Low cardiac output syndrome
			-Bleeding
	}}		}}

Zining2023: General description and indications

2026-03-02T14:52:30Z

General description and indications

← Older revision		Revision as of 07:52, 2 March 2026
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	}}		}}

	~~Provide a brief summary here~~.		Mitral valve repair or replacement is performed for severe mitral regurgitation (MR), mitral stenosis (MS), or mixed disease. Repair is preferred when possible because it preserves annular-ventricular continuity, maintains LV geometry, improves long-term survival, and avoids prosthetic complications. Replacement is performed when repair is not durable or technically feasible (severe calcifications, rheumatic disease, extensive endocarditis).

	== Overview ==		== Overview ==

	=== Indications<!-- List and/or describe the indications for this surgical procedure. --> ===		=== Indications<!-- List and/or describe the indications for this surgical procedure. --> ===

			* Symptomatic severe primary MR
			* Severe secondary MR with persistent symptoms despite GDMT
			* Severe MS with symptoms or pulmonary hypertension
			* Endocarditis with structural destruction
			* Concomitant need during CABG or other valve surgery

	=== Surgical procedure<!-- Briefly describe the major steps of this surgical procedure. --> ===		=== Surgical procedure<!-- Briefly describe the major steps of this surgical procedure. --> ===

Zining2023: Created template

2026-02-26T19:14:48Z

Created template

← Older revision	Revision as of 12:14, 26 February 2026
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		{{Infobox surgical procedure
		\| anesthesia_type =
		\| airway =
		\| lines_access =
		\| monitors =
		\| considerations_preoperative =
		\| considerations_intraoperative =
		\| considerations_postoperative =
		}}

		Provide a brief summary here.

		== Overview ==

		=== Indications<!-- List and/or describe the indications for this surgical procedure. --> ===

		=== Surgical procedure<!-- Briefly describe the major steps of this surgical procedure. --> ===

		== Preoperative management ==

		=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
		{\| class="wikitable"
		\|+
		!System
		!Considerations
		\|-
		\|Airway
		\|
		\|-
		\|Neurologic
		\|
		\|-
		\|Cardiovascular
		\|
		\|-
		\|Pulmonary
		\|
		\|-
		\|Gastrointestinal
		\|
		\|-
		\|Hematologic
		\|
		\|-
		\|Renal
		\|
		\|-
		\|Endocrine
		\|
		\|-
		\|Other
		\|
		\|}

		=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===

		=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===

		=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===

		=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===

		== Intraoperative management ==

		=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===

		=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===

		=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===

		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===

		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

		== Postoperative management ==

		=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===

		=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===

		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===

		== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

		{\| class="wikitable wikitable-horizontal-scroll"
		\|+
		!
		!Variant 1
		!Variant 2
		\|-
		\|Unique considerations
		\|
		\|
		\|-
		\|Indications
		\|
		\|
		\|-
		\|Position
		\|
		\|
		\|-
		\|Surgical time
		\|
		\|
		\|-
		\|EBL
		\|
		\|
		\|-
		\|Postoperative disposition
		\|
		\|
		\|-
		\|Pain management
		\|
		\|
		\|-
		\|Potential complications
		\|
		\|
		\|}

		== References ==

		[[Category:Surgical procedures]]