What is the optimal surgical approach for patients requiring multiple heart valve replacements due to myxomatous degeneration?

Optimal Surgical Approach for Multiple Heart Valve Replacements Due to Myxomatous Degeneration

For patients requiring multiple heart valve replacements due to myxomatous degeneration, valve repair should be prioritized over replacement whenever technically feasible, particularly for the mitral valve, with decisions guided by a multidisciplinary Heart Team assessment of valve anatomy and surgical expertise. 1

Preoperative Assessment

Imaging Evaluation

• Comprehensive transesophageal echocardiography (TEE) is essential to:
  • Determine the extent of myxomatous degeneration across valves
  • Assess valve anatomy and repair feasibility
  • Evaluate for concomitant cardiac pathologies 1
• 3D echocardiography provides superior assessment of complex leaflet geometries in myxomatous disease 2

Surgical Risk Stratification

• Consider:
  • Left ventricular function (patients with EF <25% require special consideration) 1
  • Pulmonary hypertension (systolic PAP >70 mmHg increases surgical risk) 1
  • Right ventricular function (dysfunction increases mortality risk) 1

Surgical Approach for Mitral Valve

Mitral Valve Repair Techniques

• For myxomatous mitral regurgitation, repair techniques include:
  1. Non-resection techniques using polytetrafluoroethylene neochords for leaflet flail or bileaflet prolapse 1
  2. Focal triangular resection with annuloplasty ring for posterior leaflet flail 1
  3. Sliding leaflet valvuloplasty with annuloplasty ring for diffuse myxomatous disease 1

Repair vs. Replacement Decision

• Repair is strongly preferred for mitral valve myxomatous disease, with 99% success rate for ≤mild MR at discharge 3
• Repair has demonstrated excellent outcomes with very low operative mortality (0.9%) 3
• Replacement should only be considered if repair has been attempted and was unsuccessful 1

Surgical Approach for Aortic Valve

Aortic Valve Management

• Aortic valve replacement is typically required for myxomatous degeneration causing aortic regurgitation 4
• Bioprosthetic valves may be preferred in older patients
• Mechanical valves may be preferred in younger patients requiring lifelong anticoagulation

Combined Valve Procedures

Operative Strategy

• For combined mitral and aortic valve disease:
  • Prioritize repair of the mitral valve when feasible
  • Consider the impact of cardiopulmonary bypass time on outcomes
  • Ensure adequate myocardial protection with frequent cardioplegia redosing, especially for right ventricular protection 1

Technical Considerations

• Intraoperative TEE is essential to:
  • Guide repair decisions
  • Assess repair results immediately after cardiopulmonary bypass
  • Evaluate for residual regurgitation, systolic anterior motion, or restriction 1
• Representative loading conditions may need to be created with volume or vasopressors to fully assess valve function 1

Special Considerations

Minimally Invasive Approaches

• Port-access approaches may be considered for isolated mitral valve procedures in selected patients 1
• Complex multiple valve procedures due to myxomatous degeneration may be less amenable to minimally invasive approaches 1

Surgical Expertise

• Patients with complex myxomatous disease involving multiple valves should be referred to high-volume centers with experienced valve surgeons 1
• Surgeon experience significantly impacts repair success and durability, particularly with complex pathology 1

Postoperative Management

Anticoagulation

• For mechanical valves: Lifelong warfarin with target INR based on valve position and risk factors 1
• For bioprosthetic valves: Short-term anticoagulation followed by antiplatelet therapy 1
• For patients with both mechanical and tissue valves, anticoagulation regimen should follow the requirements for the mechanical valve 1

Follow-up

• Regular echocardiographic assessment to monitor valve function
• First follow-up at 3-6 months, then annually thereafter 1

Pitfalls and Caveats

• Underestimation of MR severity under general anesthesia may lead to inadequate treatment decisions 1
• Failure to recognize complex repair requirements may result in suboptimal outcomes 1
• Inadequate myocardial protection during prolonged multiple valve procedures can lead to right ventricular dysfunction 1
• Systolic anterior motion of the mitral valve after repair requires immediate recognition and correction 1

By following this structured approach with emphasis on valve repair when feasible, particularly for the mitral valve, outcomes for patients with myxomatous degeneration requiring multiple valve interventions can be optimized.