https://www.mitraltherapies.com/new-index daily 0.75 2020-02-08 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1579963530059-9O28NBZDDZAS2S65RS0U/DSC_0287.jpeg SITE INDEX https://www.mitraltherapies.com/surgeons-lounge daily 0.75 2020-02-19 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1582144792935-WXETFYA4MEWW8X716OM3/IMG_7372.jpg Surgeon's Lounge https://www.mitraltherapies.com/surgeons-lounge/management-of-the-p2-flailprolapse monthly 0.5 2020-02-19 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1582134683920-50C0EJN2NVLD978CRYDQ/P2+flail+with+wm.PNG Surgeon's Lounge - Management of the P2 flail/prolapse P2 FLAIL https://www.mitraltherapies.com/surgeons-lounge/management-of-the-a2-flailprolapase monthly 0.5 2020-02-19 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1582134625626-J58O7H7LA18HMCL6Z6TT/Anterior+lefalet+flail.jpg Surgeon's Lounge - Management of the A2 flail/prolapase A2 FLAIL https://www.mitraltherapies.com/surgeons-lounge/commissural-leaflet-flailprolapase monthly 0.5 2020-02-19 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1582144732584-O7HBCN7SELWIEVBOIAOL/Commissural+flail.png Surgeon's Lounge - Commissural Leaflet Flail/Prolapase COMMISSURAL FLAIL https://www.mitraltherapies.com/surgeons-lounge/management-of-the-myxomatous-valve monthly 0.5 2020-02-20 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1582134368395-P0KJLMFNZ7T1H5736FXG/IMG_0691.PNG Surgeon's Lounge - Management of the Myxomatous Valve BARLOW’S DISEASE https://www.mitraltherapies.com/surgeons-lounge/management-of-mitral-annular-calcification monthly 0.5 2020-02-19 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1582134838504-YJGLNM8DCZL4KW8FWCET/IMG_0687.jpg Surgeon's Lounge - Management of Mitral Annular Calcification MITRAL ANNULAR CALCIFICATION https://www.mitraltherapies.com/new-cover-page daily 0.75 2020-09-07 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580917278425-F1ATHITQB2CDEK5V8SBS/icon.jpg For Heart Surgeons https://www.mitraltherapies.com/home daily 1.0 2021-11-13 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1578629022808-WS0LPHVPNZ2YI1O2EZAK/operative%2Bmitral.jpg MitralTherapies.com Homepage - The mitral valve A picture of the mitral valve as seen by the surgeon at the time of minimally invasive mitral valve repair. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1579389817040-GA6N2SF1M7YAM0NXK84F/IMG_0591.jpg MitralTherapies.com Homepage https://www.mitraltherapies.com/what-we-do daily 0.75 2020-09-22 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1581100398157-F8MITHDKTIA8UKVJ2V1Z/R%26M.jpg ABOUT THE AUTHORS Rochus Voeller, MD (left) and Mario Castillo-Sang, MD (right) Two Heart Surgeons and friends who trained together at Washington University in Saint Louis/Barnes-Jewish Hospital looking to positively impact the public’s knowledge on mitral valve disease and the therapeutic options available to them across the United States. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1579486731078-8KM7A9DO4MF8QJYMH9EN/DSC_0935.jpg ABOUT THE AUTHORS https://www.mitraltherapies.com/new-murmur daily 0.75 2021-01-11 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1579481892541-M3RJYQ1YE10DYFCO1PQQ/DSC_0078.jpg A NEW MURMUR https://www.mitraltherapies.com/leaking-valve daily 0.75 2020-02-21 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1581014596766-3E0Q6UVBPL61RQJGIWIL/IMG_0694.PNG THE LEAKING DEGENERATIVE MITRAL VALVE Above is a spectrum of mitral valves within the category of degenerative mitral valve disease. The common denominator to this category is a damage to the valve tissue itself including the chords. Fibroelastic tissue disorder of the mitral valve may present as the simple rupture or stretching of the chords that hold the leaflets in place (prevent them from flopping backwards and causing leakage). In more advanced forms the material from which the leaflets or flaps are made stretch and become redundant, as the process progresses over the years the valve appears more redundant and more damaged. A severe form of this disease is characterized the most abundant amount of tissue with stretched-out chords or even ruptured chords, this form is known as Barlow’s disease. The entire complex of problems leading this form of mitral regurgitation are often referred to as “Degenerative” mitral valve disease. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580231920729-RUZL7FYXB7YUBV4TT03H/medial+commisure+surgery.png THE LEAKING DEGENERATIVE MITRAL VALVE This picture taken at the time of mitral valve repair minimally invasive shows the medial or right sided commissure leaking from ruptured chords of the P3 segment. This valve was repaired. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580580837126-QEL4J1Q83AL1FQCYLOIB/IMG_0691.PNG THE LEAKING DEGENERATIVE MITRAL VALVE A drawing of a mitral valve affected by Barlow’s disease. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1578618694395-V8JYCOLJ5ALYU0URNYXD/anterior+second+case+tee+3d.png THE LEAKING DEGENERATIVE MITRAL VALVE - Anterior leaflet flopping (leaflet flaiL) This 3 dimensional image of the mitral valve at the time of a transesophageal echocardiogram clearly shows the ruptured chord on the top and middle of the picture (finger-like projection) and the elevation of the tissue at the top of the picture. The blood will leak under the raised flap, this is mitral regurgitation. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580517008669-MYLPYAWRCJR9ZF10VL31/IMG_0688.PNG THE LEAKING DEGENERATIVE MITRAL VALVE Damage to the corner flap, in this case P3 third posterior segment. This damage was caused by ruptured chords which lead to leakage. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580585847851-XFVG6TJFE0NHXOLOGAT4/Anterior+leaflet.png THE LEAKING DEGENERATIVE MITRAL VALVE - Anterior leaflet flopping (leaflet flaiL) This is the image of an anterior flap of the mitral valve that is flopping upwards. There is also a perforation or hole on the anterior leaflet. One can see the ruptured chords of the anterior flap (lower center). https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1581081988255-DAPDCWG1Q7XHDE9GP5CY/Anterior+lefalet+flail+wm.PNG THE LEAKING DEGENERATIVE MITRAL VALVE Anterior leaflet of the mitral valve with ruptured chords. This is and example of degenerative mitral valve disease. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1582311950998-WM947LAM4GO824PYH0TC/bileaflet+damage+with+perforation.png THE LEAKING DEGENERATIVE MITRAL VALVE https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580232144143-KSX2MWZPRQ3C6QL4J1MA/medial+commissure+color.png THE LEAKING DEGENERATIVE MITRAL VALVE This same mitral valve on transesophageal echocardiogram showing the flow of blood from the left to the right top corner through the gap created at the corner segment. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580321396535-M2GMEMUGOBGA9V1G4V8W/IMG_0669.jpg THE LEAKING DEGENERATIVE MITRAL VALVE https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580321147254-03F4H2PVZJ0TSJ8TBHRY/P2+ruptured+2.png THE LEAKING DEGENERATIVE MITRAL VALVE https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580321451426-R1FLT0PHPI65EA5I4QBM/IMG_0676.jpg THE LEAKING DEGENERATIVE MITRAL VALVE https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580321134468-FVOSZUTZJKUXX2Y0KDPN/p2+ruptured.png THE LEAKING DEGENERATIVE MITRAL VALVE https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580321432501-OTPS9PRKTEEMUOJELFAW/p2%252Bflail%252Bsurgery.jpg THE LEAKING DEGENERATIVE MITRAL VALVE https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580517277528-O9HFNKJ1C7TKWABWO06S/medial%2Bcommisure%2Brepaired.jpg THE LEAKING DEGENERATIVE MITRAL VALVE The same mitral valve from the prior pictures with a right sided commissure repaired through a minimally invasive approach. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580232124156-BVOCIVOASYRNMA72E2JN/medial+commisure+flail+TEE.png THE LEAKING DEGENERATIVE MITRAL VALVE A tranesophageal echocardiogram showing the left ventricle on the right side with the corner flap riding higher than the anterior flap (see gap). https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1581081813414-47O52OZHPO56BV39FM0R/P2+flail+with+wm.PNG THE LEAKING DEGENERATIVE MITRAL VALVE The most common form this form of degenerative disease of the mitral valve is when chords rupture or elongate in the posterior leaflet of the valve in the P2 segment. The second most common form is when both leaflets (anterior and posterior) show either elongated or ruptured chords. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1578619113035-LJ0P8316OF4RAINERCT2/anterior+second+case+TEE.png THE LEAKING DEGENERATIVE MITRAL VALVE - Anterior leaflet flopping (leaflet flaiL) This two-dimensional echocardiographic picture shows the two flaps of the mitral valve: the anterior is to the left of the picture and the posterior is to the right. The anterior leaflet is flail or flopping in upwards above the level of the posterior flap (right). https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580230654590-FTXE2A58WIV06HZS69LM/IMG_0658.PNG THE LEAKING DEGENERATIVE MITRAL VALVE https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580320546352-K3E5BO6P97J9HFEZGUYX/Mitral%2Bapparatus%2Blabeled.jpg THE LEAKING DEGENERATIVE MITRAL VALVE A cut-out of the mitral valve apparatus. To the lower right are the two papillary muscles that anchor the mitral chords to the leaflets or flaps of the valve. There are two flaps, one anterior and one posterior. Together all these structures are called the mitral valve apparatus. The papillary muscles are susceptible to ruptured and scarring from heart attacks, while the chords are susceptible to ruptured or stretching in some circumstances. The entire apparatus is susceptible to damage from bacterial infections and to the buildup of calcium. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1579479914806-EMQWTCZDDBZPKCL1LJB5/DSC_0994.jpeg THE LEAKING DEGENERATIVE MITRAL VALVE https://www.mitraltherapies.com/heart-anatomy daily 0.75 2020-02-17 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580078637087-ODW0H20ARAKSUSX3C9UM/IMG_0658.PNG HEART ANATOMY - THe mitral valve as a parachute The two flaps of the mitral valve called the anterior and posterior leaflets touch each other and seal the valve preventing blood from abnormally going upwards when the heart pumps. This is like the canopy of a parachute opening with air and being held down by the strings (chordae or chords in the mitral valve). https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580078783917-Q8HLUGVXMAMHEGTJIWYW/IMG_0660.PNG HEART ANATOMY - The open mitral valve The mitral valve is a one way valve. When the valve closes the two flaps touch each other and prevent the blood from going upwards or leaking. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580135815056-TBGZJ5AHAPXFGJR1ZB1V/Mitral+apparatus+labeled.PNG HEART ANATOMY - The mitral valve Apparatus The mitral valve apparatus, as it is understood in medicine, consists of the valve leaflets or flaps (two: anterior and posterior), the chordae tendineae or simply chords, and the papillary muscles that act as anchoring points of the chordae to muscle of the heart. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580078660278-51CKP1W2A5XBFJW4RR8S/IMG_0662.PNG HEART ANATOMY - The mitral valve as a set of french doors The mitral valve functions similar to a set of french doors. The image to the left shows in pink what is known as the annulus which would be the frame of the valve. The two leaflets or flaps of the valve would be the doors. These flaps should open only in one direction and the chords prevent them from flopping like saloon doors. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580074098547-CQ6FRAFK3K72FGT908SM/IMG_0637.PNG HEART ANATOMY - The mitral valve The mitral valve as seen by surgeons as studied in the medical field. There are two leaflets of flaps to the valve, one anterior and one posterior. The valve is divided by imaginary lines into three anterior and three posterior segments. The frame surrounding the valve to which the leaflets attach is called the annulus. The leaflets are held anchored to the muscle of the heart through the papillary muscles. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580313253059-76AIVQ7L6SEJ69W5FHOC/IMG_0675.PNG HEART ANATOMY - This is the Human Heart The human heart seen on the inside with front cut out. The four chambers of the heart are shown. Two top and two lower ones. To the right of the screen are the left sided structures including the mitral valve, papillary muscles, left ventricle and left atrium. To the left of the screen are the right sided structures including the right atrium, right ventricle, tricuspid valve and superior vena cava. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580078598148-XFUW0TYPL4QYTVMHML0A/IMG_0655.PNG HEART ANATOMY This image of the left lower portion of the heart or left ventricle show a normal mitral valve. The shape of the ventricle is still normal, different to the globular shape in some forms of mitral valve disease. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580312474433-J4SPCC3R4S397AVURIDH/IMG_0668.jpg HEART ANATOMY The cardiovascular system has veins (above in purple) and arteries (above in red). Arteries carry the blood away from the heart to the different organs including brain, kidneys and heart itself. Veins return the blood from different organs back to the heart’s right atrium. The large artery leaving the heart is called the aorta. The largest veins arriving at the heart are the superior and inferior vena cava. Both arteries and veins can be quickly accessed in the groin through a small incision. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1579475498881-2VY4DD3LYZ8NQE17KLTQ/DSC_0899.jpg HEART ANATOMY https://www.mitraltherapies.com/ischemic-mitral-valve-disease daily 0.75 2020-02-07 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1581020959961-HIZVGYL7TPJ9N72O5SRQ/IMG_0697.PNG ISCHEMIC MITRAL VALVE DISEASE In ischemic mitral regurgitation or leakage from damage after a heart attack the lower left part of the heart or left ventricle is damaged and then scars causing retraction or pulling of the chords that hold the posterior flap (seen to the right of the image with arrow pointing to the direction of pull). https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1578673654048-SX2ML4L2F5O97SKHB2O3/ruptured+pap+muscle+1.png ISCHEMIC MITRAL VALVE DISEASE This is a picture of the muscle that holds the chords belonging to the mitral valve including the flap of the mitral valve itself. A massive heart attack led to the destruction of the muscle which later one ruptured. This is the most extreme form of what we call “ischemic mitral regurgitation” or leakage caused directly by coronary blockages. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580350708117-74SBH7KS3P3G9MTAVLQK/IMG_0684.jpg ISCHEMIC MITRAL VALVE DISEASE Another example of ischemic mitral leakage. This problem originates with a heart attack, in this case at the tip of the heart which leads to scarring and ballooning of the tip of the heart or apex of the heart. This will in turn pull outwards the papillary muscles (two finger-like muscles inside the heart that hold the chords of the mitral valve) and this will splay open the valve causing leakage. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580132605480-XE1UV41FKNVPMZF5JAKG/IMG_0635.PNG ISCHEMIC MITRAL VALVE DISEASE An inside view of the heart after a heart attack. The area in tan-grey represents the area of the heart attack. The muscle inside affected includes the papillary muscle which holds the chords for the mitral valve. If the heart attack is large enough and goes untreated, the muscle can rupture and lead to fulminant mitral leakage, a life threatening condition. If the infarction is not that severe the muscle, in time, will scar and retract, pulling on the chords and flap of the valve. This is called ischemic mitral valve regurgitation or leakage. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1578673659703-GM6NHOL0DYS8TG9JZBTH/ruptured+pap+muscles+2.png ISCHEMIC MITRAL VALVE DISEASE Another view of how the muscle in the heart can die after a heart attack and lead to mitral leakage. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580350780492-C9AXB5YGCUAL9PZQ2S4F/IMG_2678.jpg ISCHEMIC MITRAL VALVE DISEASE https://www.mitraltherapies.com/functional-mitral-valve-disease daily 0.75 2020-02-17 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1578675569704-1W41IKDV7TEMYYBBT1PG/functional+dilated+mr+operative.png FUNCTIONAL MITRAL VALVE DISEASE This is a picture of the same valve seen on the picture to the left at the time of minimally invasive mitral valve surgery done with a 2 inch incision on the right chest. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580132722548-TXAKOHZ3TQIVMTX5ZQ9Z/Dilated%2Bcardiomyopathy%2Blabeled.jpg FUNCTIONAL MITRAL VALVE DISEASE This image of the left ventricle and mitral valve shows the lower part of the heart with a more globular or balloon shape (rounded), this means it has enlarged or dilated and the annulus of the valve (black line around the mitral valve) has dilated and the two flaps of the valve are pulled apart. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1578675564285-XUZYKHQUH9SERHXYV0M7/functional+dilated+tee.png FUNCTIONAL MITRAL VALVE DISEASE This trans esophageal echocardiogram shows the multiple leaking jets of mitral regurgitation. This leakage was brought on by the dilation of the annulus or “frame” that holds the two flaps of the valve. An analogy to a set of french doors is valid with the frame enlarging, but the leaflets or doors staying the same size. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1579491266416-GADCPCXO2NS9XIMSC11X/DSC_0547.jpg FUNCTIONAL MITRAL VALVE DISEASE https://www.mitraltherapies.com/infectious-mitral-valve-disease daily 0.75 2021-11-13 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1578759604177-MOCAOFTC7OPYJAK1V6D0/endocarditis+damage.png INFECTIOUS MITRAL VALVE DISEASE (ENDOCARDITIS) Another image of the same mitral valve showing the posterior flap damage from the bacterial infection. Both these pictures are from a minimally invasive mitral valve repair through a 2 inch incision on the right chest. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1578759598277-ER6EYQL7ED29S7AYJLQD/endocarditis+2.png INFECTIOUS MITRAL VALVE DISEASE (ENDOCARDITIS) This image shows a mitral valve that has been damaged by a bacterial infection. The posterior leaflet or posterior flap is damaged and is seen as the rugged/reddish area. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1578759612889-8V1W43A0ENRVVBPS9ZSN/endocarditis+repaired.png INFECTIOUS MITRAL VALVE DISEASE (ENDOCARDITIS) - repaired infected valve This operative image shows the mitral valve after bring repaired. This is the same valve shown above. The infected portions were resected and the tissue cleaned and then the valve was repaired. The circular material is a bioprosthetic ring used to stabilize the frame of the valve or mitral annulus. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580581289163-1NQBFUHCOF4N1NJAY4ZW/Endocarditis%2B.jpg INFECTIOUS MITRAL VALVE DISEASE (ENDOCARDITIS) Another example of a mitral valve damaged by a bacterial infection. This operation was performed minimally invasive through 2 inch incision and the valve was repaired. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1581020355198-XFI10WBXGQTG5BIY9130/IMG_9600.jpg INFECTIOUS MITRAL VALVE DISEASE (ENDOCARDITIS) https://www.mitraltherapies.com/rheumatic-mitral-valve-disease daily 0.75 2021-11-13 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580233913157-X4DH4LGOZAF9JGWI8IS3/image.jpg RHEUMATIC MITRAL VALVE DISEASE This is an image of a rheumatic mitral valve showing clear signs of thickening and stiffness. There are also signs of heavy calcium deposit in to the left of the screen. This valve was leaking, but was also very tight. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1578675149317-X9NGLEMBRVWOQ3STVP9W/mitral+stenosis+swirl.png RHEUMATIC MITRAL VALVE DISEASE - the stenotic or tight mitral valve Mitral stenosis is usually from rheumatic heart disease. This is often accompanied by leakage. Two problems in one. This transesophageal echocardiogram shows the swirling pattern of the blood in the top part of the picture. This denotes the difficulty of the blood crossing the mitral valve and therefor higher pressure in the left atrium or top chamber. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1578674624569-MO8J4BDISPFFE563T9ZX/rheumatic+operative.png RHEUMATIC MITRAL VALVE DISEASE A picture of a rheumatic mitral valve at the time of minimally invasive mitral valve surgery. The valve is seen as a light yellow color in the center with some calcium deposits on it as well as thickened tissue. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1578674644632-1KPSR4E6UJX89296I0V7/rheumatic+tee+color.png RHEUMATIC MITRAL VALVE DISEASE This is a trans esophageal echocardiogram of a mitral valve (white/grey structure around the blue color) with rheumatic disease. The opening of the valve is very small and leads to pressure backing up above it in the left atrium. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580235926757-1E9YM39MZMJYISDVGCY5/Rheumatic%2B3.jpg RHEUMATIC MITRAL VALVE DISEASE Rheumatic valve disease is secondary to prior untreated infections by streptococcus, a bacteria. The valve in time thickens and many of the thin chords transform into what appear to be very thick pillars. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1581019054464-3R8KPGP02OPWRPZLISNI/IMG_0284.jpg RHEUMATIC MITRAL VALVE DISEASE https://www.mitraltherapies.com/other-surgeons daily 0.75 2022-04-15 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1581978945178-PG4U6LZ8YQ8NHP65MINU/ralph+damiano.jpg MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - Ralph J.Damiano, MD Dr. Damiano is the Evarts A. Graham Professor, Surgery Chief, Division of Cardiothoracic Surgery at Washington University School of Medicine in Saint Louis/Barnes-Jewish Hospital. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1583372818486-NVN3NMXTZ6QL6FYW0GLE/Ross%2C+Scott-31.png MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - SCott Ross, MD Dr. Ross is Director of the Structural Heart Program at Roper Saint Francis Hospital in downtown Charleston, SC. He specializes in minimally invasive valve surgery and mitral valve repair. His program is the longest standing minimally invasive heart surgery program in South Carolina. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1581962484890-WUTQES0O2ZLXO64DPH6F/joseph+lamelas.jpg MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - Joseph Lamelas, MD Dr. Lamelas is a pioneer in minimally invasive mitral valve surgery and all forms of minimally invasive cardiac surgery. He is the Chairman of Cardiac Surgery at the University of Miami. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/09a7a2b8-9277-4dea-a40e-cca85c29b933/ECS+Club.png MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - Make it stand out The Endoscopic Cardiac Surgery Club Members perform complex minimally invasive valvular surgery. The group represents surgeons based out of Europe and Asia with some North American Members. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1582640168653-HYJYVXC2PN9R3BPTX9T2/Gorav+ailawadi2.jpg MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - Gorav Ailawadi, MD Dr. Ailawadi is Chair of the Department of Cardiac Surgery and co-director of the Frankel Cardiovascular Center and Professor of cardiac surgery. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1583805526588-NFYQGMGZDUP1KE1ILUI3/peter+knight2.jpg MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - Peter A. Knight, MD Dr. Knight is a minimally invasive mitral valve surgeon and is the Marjorie B. Morris Endowed Professor in Cardiac Surgery at the University of Rochester in New York. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1582072968490-WHZUWRNDZVK6Z4K94KTX/goldman_scott_m_Person_Thumbnail.jpg MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - SCott Goldman, md Dr. Goldman is a cardiac surgeon at Lankenau Hospital with extensive experience with treatment of valvular heart disease. Pioneer in minimally invasive and trans catheter therapies. He is system Chair, Department of Surgery, Main Line Health and Clinical Professor of Surgery, Jefferson Medical College https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1582073786649-2FBU9IGAJ1EOZ4YSLLM6/tom-nguyen.jpg MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - Tom Nguyen, MD Dr. Nguyen specializes in minimally invasive valve surgery, complex adult cardiac surgery, and mitral repair. He is the Chief of the Division of Adult Cardiothoracic and Charles Schwab Distinguished Professor of Surgery in the Department of Surgery at the University of California, San Francisco. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1578764222534-IHDA0KZMF27S0WQK2NRC/Rochus+Voeller.jpg MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - Rochus Voeller, MD Dr. Voeller is the director of minimally invasive heart surgery at the University of Minnesota in Minneapolis/Saint Paul. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1582684890412-0UEDDCCDXIE15YDG9OIF/Mark+Anderson.jpg MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - Mark B. Anderson, MD Dr. Anderson is a minimally invasive mitral valve surgeon in Hackensack, New Jersey with interests in the surgical management of heart failure and mechanical circulatory support, minimally invasive and robotic heart surgery as well as heart valve replacement and repair. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1582639662727-AVSTWISIOJSSWCUZB753/Gillinov_Marc_531091.jpg MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - Marc Gillinov, MD Dr. Gillinov is the Chair of the Department of Thoracic & Cardiovascular Surgery at the Cleveland Clinic. He is an expert in minimally invasive mitral valve repair and replacement. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580248969342-3O5MQDSGRNEOQ0BJ5SPN/IMG_0571.jpg MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1582640249250-5KARL971G8Q08NNBWDKF/Tobias+deuse+2.jpg MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - Tobias Deuse, M.D. Dr. Deuse is Professor & Interim Chief Division of Adult Cardiothoracic Surgery The Julien I.E. Hoffman, M.D. Endowed Chair in Cardiac Surgery Director, Minimally-invasive Cardiac Surgery Surgical Director, Transcatheter Valve Program at the University of California San Francisco. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1590111717865-7TK8RBM1L2984AL61JZR/Joseph+Woo+Photo.jpg MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - Joseph Woo, md Dr. Woo is the Norman E. Shumway Professor and Chair, Department of Cardiothoracic Surgery at Stanford University School of Medicine. He is an expert minimally invasive mitral valve surgeon who specializes in mitral valve repair. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1612024348601-D7QHJ6XFFWCRFS53WRR5/DSC_1288.jpg MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - Mario Castillo-Sang,MD Dr. Castillo-Sang is director of mitral valve and heart failure surgical therapies at Saint Elizabeth Healthcare in Edgewood, Kentucky. He specializes in minimally invasive mitral valve surgery with complex valve repair and advanced heart failure surgery. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1588450314554-QVLB05S11SBZB25IFRRO/sabik-joseph-surgery-19-500x600.jpg MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - Joseph F. Sabik III, MD Dr. Sabik is an expert minimally invasive mitral valve surgeon in Cleveland, Ohio. He is the University Hospital Cleveland Medical Center Vice President for Surgical Operations and Chairman of the Department of Surgery. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1588776577617-V05DYPSGXZ9XNNVQ7V3U/donald-d-glower-jr-md.jpg MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - Donald D. Glower Jr., MD Dr. Glower is Professor of Surgery at Duke University Medical Center in Durham North Carolina. He is an expert in minimally invasive mitral valve surgery including mitral valve repair. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1598315960172-LH3OZO4N22BWOTXIB0R7/Marc+Gerdisch.JPG MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - Marc W. Gerdisch, MD Dr. Gerdisch is Chief of Cardiothoracic Surgery at Franciscan Health in Indianapolis and specializes in minimally invasive valve surgery. Dr. Gerdisch has expertise in valve repair and complex multi-valve and redo cardiac surgery. In addition, he has developed a comprehensive program for rapid recovery following heart surgery. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1582121237178-WO38JMLJ2J0VJCYJWO0O/Lenny+lee.png MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS - Leonard Y. Lee, M.D. Dr. Lee is a cardiothoracic surgeon with expertise in minimally invasive mitral valve surgery. He serves as the James W. Mackenzie, M.D. Professor and Chair for the Department of Surgery at the Robert Wood Johnson Medical School. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1579390585832-P605BYTKBRZ795IX72L0/DSC_0348.jpg MINIMALLY INVASIVE MITRAL VALVE EXPERT SURGEONS https://www.mitraltherapies.com/links daily 0.75 2020-08-07 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1581176917209-1I4SGB1URZK7I39CYPC4/DSC_0979.jpg HELPFUL LINKS https://www.mitraltherapies.com/contact daily 0.75 2020-02-05 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580759204816-0SGVRON00ZLONWKKDTXB/DSC09034.jpg Contact Us https://www.mitraltherapies.com/the-tight-mitral-valve daily 0.75 2020-02-07 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580236034725-6G3G5DZSXSVWSHL3I584/image.jpg THE TIGHT MITRAL VALVE A picture of a specimen rheumatic mitral valve with severe tightening . This valve was affected by rheumatic disease and one can see that should have been thin chords hold the flaps are thickened like “spaghetti” the tissue of the flap or leaflet is thickened too. The operation to replace this mitral valve was performed minimally invasive with a 2 inch incision on the right chest. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580236061707-AQ39ZC22YRIU3WV5MJHJ/Rheumatic%2Bmitral%2B2.jpg THE TIGHT MITRAL VALVE A rheumatic mitral valve specimen showing heavy thickening of the valve with calcification. This valve was removed during a minimally invasive mitral valve replacement. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1579287724651-B7CDFWSRW5HQ5ODCYI8R/mitral+stenosis+swirl.png THE TIGHT MITRAL VALVE - Mitral STenosis This echocardiogram pictures shows top right the blood stagnated inside the left atrium causing a pattern of swirls and the two flaps of the valve mid right screen that barely open. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1579487377689-YIS5OYH4I8PJB7UGHMGX/DSC_0985.jpg THE TIGHT MITRAL VALVE https://www.mitraltherapies.com/mitral-valve-repair daily 0.75 2021-11-13 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580134318811-QLD5OGPQ2ZEC85734KII/IMG_0641.PNG REPAIR FOR LEAKING MITRAL VALVE - Completed Leipzig techinque A repaired mitral valve using a respect technique and new gortex chords to the posterior flap to re-anchor the flail flap. This repair can be performed minimally invasive with a 2 inch incision on the right chest. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580314771488-KGMIGGVMP3YIJPVDV7M3/IMG_0669.PNG REPAIR FOR LEAKING MITRAL VALVE - THe REspect repair The mitral valve can often times be repaired without cutting out portions of eat, but using gortex sutures to recreate the natural anatomy of the valve as shown in this image with chords anchored (green) on the muscle of the heart and then to the posterior flap of the valve. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580134281706-D9ECBJJN35GSA3OVY2IN/IMG_0642.PNG REPAIR FOR LEAKING MITRAL VALVE - Leipzig technique A mitral valve with a posterior or back leaflet (flap) flail from a ruptured chord (degenerative disease). https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580134119505-7LRMOJ0FWE3IWX41WPT2/IMG_0650.PNG REPAIR FOR LEAKING MITRAL VALVE A repaired mitral valve using a resection technique. The flail portion of the flap is resected or cut and then sewn back together. This repair can be performed minimally invasive with a 2 inch incision on the right chest. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1578769431292-F66JIV670OV1NII313UV/Table+AHA+ACC.png REPAIR FOR LEAKING MITRAL VALVE This table summarizes the American Heart Association and American College of Cardiology as well as Society of Thoracic Surgeons recommendations for mitral valve repair in cases of patients with severe mitral leakage. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1581176772443-DF5SJ2765DP5Z1VL7LDW/DSC_0759.jpg REPAIR FOR LEAKING MITRAL VALVE https://www.mitraltherapies.com/mitral-valve-replacement daily 0.75 2021-11-13 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580314953817-WJMSSWRM0FKJPBVSY7ND/IMG_0671.PNG Mitral valve replacement The bottom part of the heart seen from above. To the left in light blue is the mitral valve with typical C shape configuration and to the right is the tricuspid valve. Between the two large valves at the top is the aortic valve and above it the pulmonic valve. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580475578749-HZSGZZ39KCI4KGKO8SJ4/TAVR-mAC.jpg Mitral valve replacement This is the picture of the final product of a TAVR in MAC. The valve seen in place is a transcatheter aortic valve balloon expandable. This was implanted within the calcium of the mitral annulus. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1579279839050-WZ42Y9VGU628Z2SWAFM4/mitral%2Bvalve%2Breplacement%2B2.jpg Mitral valve replacement Images of mitral valve replacements. To the left a bioprosthetic valve made of the heart sack of a cow (bovine pericardium) and to the right a mechanical valve form graphite. The choice to replace a mitral valve is made only after the determination that a repair is not possible or that it would lead to a less than durable repair. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580475742564-8UO8T1V5F0FGNOJ3RIF2/MAC.jpg Mitral valve replacement An intraoperative picture of the mitral valve with two things happening. First it has a clip in the middle holding the two flaps together. Second, it has severe MAC or mitral annular calcification from the top left corner to the top right corner of the image. This calcium makes it difficult and risky to replace the valve in the conventional fashion. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1579563089962-EZ0KNRHA8Y5P3QT4YZO2/DSC_0578.jpg Mitral valve replacement https://www.mitraltherapies.com/overview daily 0.75 2020-03-06 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1581083565734-RQNIE4J9MYC28DZBIF7G/IMG_0669.PNG Treatment Overview https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580520404932-3MASAC1PA4G2Q9J6Y122/IMG_0646.PNG Treatment Overview A right minithoracotomy incision for a minimally invasive mitral valve operation. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580314588504-E4XQ8T6IQH8IGZ86JQJN/IMG_0676.PNG Treatment Overview https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1579113831324-WM9LVMMDTOW97RVEIR5A/Table%2BAHA%2BACC.jpg Treatment Overview This table summarizes the American Heart Association and American College of Cardiology as well as Society of Thoracic Surgeons recommendations for mitral valve repair in cases of patients with severe mitral leakage. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1581082746511-AWHCCZU1MZF22ASXQN7W/DSC_1362.jpg Treatment Overview https://www.mitraltherapies.com/new-page daily 0.75 2021-11-13 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580311727759-PGRH7L6MIHCK85TAQ5OV/IMG_0673.jpg THE MINI MITRAL APPROACH Positioning in the operating room for a minimally invasive mitral valve operation. Both repairs and replacements can be performed with this approach as well as as combined valve operations like mitral valve repair and tricuspid valve repair simultaneously. Other operations that can be performed with this approach are resection of cardiac tumors, cardiac ablations for atrial fibrillation (Maze procedures) and closures of holes in the heart or atrial septal defects. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580132834352-AV4BJ82NTN7CPGEBIQ0X/IMG_0645.PNG THE MINI MITRAL APPROACH A right minithoracotomy approach in a woman. The right minithoracotomy approach has 1-2 5mm incisions (if done with a 5mm fiberoptic camera 2, if with a head camera 1). There is a 2 inch incision on the right chest through which the surgeon works. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580311563721-NFE9HDY2GUEPV9NDMFP5/IMG_0668.jpg THE MINI MITRAL APPROACH https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580132952783-NR3YMPHK2ACYV1VESPSB/IMG_0644.PNG THE MINI MITRAL APPROACH Robotic assisted mitral valve surgery typically has a series of 8mm port incision between the ribs and often times a larger 1.5-2 inch incision on the right chest. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580311819358-BJFNHZA478SCIDWJWGY9/IMG_0672.jpg THE MINI MITRAL APPROACH This is a common setup for minimally invasive mitral valve surgery in the operating room. At the center is the patient; to the left of the image is the surgical assistant and the perfusionist (person who runs the heart lung machine). To the right is the surgeon and the scrub technician. At the top of the image is the anesthesiologist who is also operating the transesophageal echocardiogram, a modern standard in cardiac surgery monitoring. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580132896352-RAR68P0G6QRRDTOF23NV/IMG_0646.PNG THE MINI MITRAL APPROACH A right minithoracotomy approach in a man. The right minithoracotomy approach has 1-2 5mm incisions (if done with a 5mm fiberoptic camera 2, if with a head camera 1). There is a 2 inch incision on the right chest through which the surgeon works. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1579285582306-N3OIJBWEG7RGC4WJUP2S/CT%2BScan%2Bwhy%2Bright%2Bmini.jpg THE MINI MITRAL APPROACH A three dimensional computerized axial tomography illustration showing the location of the heart and the approach via the right minithoracotomy. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580246919832-7U3NJO4WQNO2J30YQ6ER/Minimitral%2Binstruments.jpg THE MINI MITRAL APPROACH Minimally invasive mitral valve surgical instrumentation. These instruments can be 12 to 14 inches in length and using them relies on a different set of skills than those using standard open heart instruments. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580312215685-1WIFPTR8UVSI1C6ERCAD/IMG_0674.jpg THE MINI MITRAL APPROACH Typical positioning of the patient a the time of minimally invasive mitral valve surgery. The incision is shown in black and below it is the chest drain. In the neck is the monitoring IV line called a Swan Ganz catheter. The right groin shows a small incision for the heart lung machine. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1579484987124-0NYOP73ZLII0ZBOQFLW4/IMG_2023.jpg THE MINI MITRAL APPROACH https://www.mitraltherapies.com/what-are-the-symptoms daily 0.75 2020-02-20 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1582206543697-0VZ7DB8D5CU5J5928P43/Graph.png SYMPTOMS OF MITRAL DISEASE The progression of symptoms in patients with severe mitral valve leakage often starts with no symptoms, slight shortness of breath and fatigue on activity. As times passes the symptoms are more obvious with less activity and ultimately even at rest. The changes to the heart may not show up until the patient has developed symptoms. Although the changes above often happen in the order described, some persons may not present them all or in this order. The final outcome is loss of heart power and congestive heart failure. Notice the enlargement of the lower left chamber of the heart (left ventricle) as the disease progresses, while the ejection fraction (EF) percentage drops signaling the weakening of the left ventricle. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580313552186-LHAFFDS3CHGQDM268NB0/IMG_0676.PNG SYMPTOMS OF MITRAL DISEASE A mitral valve showing ruptured chords on the posterior leaflet or flap. This is an example of degenerative mitral valve disease. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1579476550554-2BA54D4K4K8N7FC6KWDC/DSC_0299.jpg SYMPTOMS OF MITRAL DISEASE https://www.mitraltherapies.com/does-mitral-leakage-need-treatment daily 0.75 2020-02-03 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1579479856470-O53X6MPU2XHQ57JTPX9F/IMG_2640.jpg DOES MITRAL LEAKAGE REQUIRE TREATMENT? https://www.mitraltherapies.com/terms-of-use daily 0.75 2020-02-08 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580162843483-PXPUT1ARL59WTJCJC00I/DSC_0866.jpeg Terms of use https://www.mitraltherapies.com/mac daily 0.75 2021-11-13 https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580480845494-GPTM15OICM2EQ2BALHWG/IMG_0687.PNG MAC - Mitral Annular Calcification Mitral Annular Calcification or MAC is a significant problem when it involves the majority of the annulus (frame of the mitral valve) posteriorly. This calcium accumulation is more than the deposition of calcium particles, it is the replacement of the muscle and materials that make the heart in that area with heavy calcium deposits. https://images.squarespace-cdn.com/content/v1/5e17371a94011e6cccb91757/1580759058967-U4P3YUKXPGKSNQ6GKTH4/IMG_7895.jpg MAC - Mitral Annular Calcification