Is the aortic valve (AV) typically removed or intervened on during mitral valve (MV) repair?

Aortic Valve Is Not Typically Removed During Mitral Valve Repair

The aortic valve is not removed or directly intervened upon during standard mitral valve repair procedures, as these are anatomically distinct structures with separate surgical approaches.

Anatomical Relationship Between Mitral and Aortic Valves

The mitral and aortic valves are adjacent cardiac structures separated by the intervalvular fibrous body (also known as the aortic-mitral curtain). While they are in close proximity, surgical procedures on one valve do not typically require removal or direct manipulation of the other valve unless there is specific pathology affecting both valves.

Key Anatomical Considerations:

• The mitral valve is accessed through the left atrium or through a left atriotomy
• The aortic valve is accessed through the ascending aorta
• The intervalvular fibrous body connects these structures but allows for separate surgical approaches

Standard Surgical Approaches

When performing mitral valve repair:

• The surgeon accesses the mitral valve through the left atrium
• The mitral valve leaflets, annulus, and subvalvular apparatus are repaired as needed
• The aortic valve remains intact during this procedure

Scenarios When Both Valves May Be Addressed

There are specific clinical scenarios when both valves might require intervention, but these are distinct from standard mitral valve repair:

1. Combined valve disease: When a patient has both mitral and aortic valve disease requiring intervention 1

   • This requires separate procedures on each valve
   • The decision to replace or repair each valve is made independently

2. Extensive endocarditis or calcification: When infection or calcification involves the intervalvular fibrous body 2

   • In these complex cases, reconstruction of the intervalvular fibrous body may be required
   • This is not standard mitral valve repair but a more extensive procedure

3. Functional mitral regurgitation with aortic valve disease: When aortic valve replacement is performed, concurrent functional mitral regurgitation may sometimes improve without direct mitral intervention 3

   • This is based on hemodynamic improvement after aortic valve replacement
   • The decision to address the mitral valve depends on specific patient factors

Evidence-Based Approach to Combined Valve Disease

When both valves require intervention, the guidelines recommend:

1. For severe aortic disease with mitral disease:

   • Surgery is indicated for patients undergoing CABG or surgery of the ascending aorta or another valve 1
   • When feasible, mitral valve repair with aortic valve replacement is superior to double valve replacement 4

2. For functional mitral regurgitation with aortic disease:

   • The decision to address moderate functional MR during AVR should be individualized based on specific risk factors 3, 5
   • Patients with specific risk factors (left atrial diameter >5 cm, low aortic gradient, atrial fibrillation) may benefit from combined procedures

Common Pitfalls to Avoid

1. Unnecessary combined procedures: Performing mitral valve surgery when functional MR might improve after isolated aortic valve replacement

2. Missing associated pathology: Failing to recognize when both valves require intervention due to shared pathology (e.g., endocarditis affecting both valves)

3. Underestimating surgical complexity: Combined valve procedures carry higher risk than single valve operations and should be performed at experienced centers

In conclusion, the aortic valve is not removed during standard mitral valve repair procedures. These are anatomically distinct structures that can be approached separately, though in specific clinical scenarios, intervention on both valves may be warranted.