Mitral kapak tamir secenekleri dr. cengiz koksal
Transcript of Mitral kapak tamir secenekleri dr. cengiz koksal
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Dr. Cengiz KöksalKartal Koşuyolu Eğitim Araştırma Hastanesi
MİTRAL KAPAK TAMİR
SEÇENEKLERİ
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Neden tamir??
Çünkü ideal prostetik kapak yok!!!
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Mitral Kapak Tamirinin Avantajları
Antikoagulan kullanımının gerekmemesi
Kapak tromboz ve yapısal disfonksiyon riski
olmaması
Prostetik kapak İnfeksiyonu riski olmaması
Ameliyat mortalitesi daha düşük
Geç dönem sağ kalım daha iyi
Paravalvüler kaçak (ring dehishence??)
Sol ventrikül fonksiyonlarının daha iyi korunması
A-V groove yırtığı
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“The patient with a mitral prosthesis
is a patient for life”
Dr. Robert W.M. Frater-1962
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“A leaking but repaired mitral valve is
worse than a functional prostetic mitral
valve insertion”
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2014 AHA/ACC
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2014 AHA/ACC
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Carpentier’in altın kuralları
Leaflet patolojisini düzelt
Geniş koaptasyon yüzeyi oluştur (8-15 mm)
Anulusu stabilize et
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Mitral kapak tamir teknikleri
The French Correction: Alain Carpenteir 1983
“Anormal veya fazla dokunun rezeksiyonu, kordal
transfer, kordal kısaltma ve remodeling
anuloplasti”
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Mitral kapak tamir teknikleri
Respect Rather than Resect (RRR): Non
resection teknik
(Neokorda+ring anuloplasti)
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Mitral kapak tamir teknikleri
Edge-to-edge (double orifice) (Alfieri tekniği)
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BAŞARILI VE UZUN ÖMÜRLÜ
MİTRAL KAPAK TAMİRİ…
AMA NASIL?
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Başarılı ve uzun ömürlü mitral tamir
Kapak patolojisinin tipi
Cerrahi ekip
Operatif kriterler
İntraoperatif TEE’de max. eser MY (+1?)
5-8 mm. Uzunluğunda ve düzgün bir koaptasyon hattı
(boyama)
Zayıf kordaların desteklenmesi
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Mitral Kapak Tamirinde EKO
Preoperatif değerlendirme
-Tamir için doğru hasta seçimi
-Tamir için yol haritası
İntraoperatif değerlendirme
Postoperatif değerlendirme (1. hafta, 3. ay)
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Mitral Kapak Tamirinde EKO
Tamir için yol haritası
-Romatizmal MY (posterior restriksiyon?)
-İskemik MY
-Dejeneratif MY
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Mitral Kapak Tamirinde EKO
Dejeneratif MY
-Primer lezyon nedir?
-Ek leaflet patolojileri
-Bikom. ve AP anulus çapı
-SAM riski
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SAM riski
Posterior leafletin uzun olması
C-septal mesafe<2.5 cm
Mitral anulus çapının küçük olması
Aorto-mitral açı<120 derece
Septal hipertrofi
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Mitral Kapak Tamirinde EKO
Preoperatif değerlendirme
-Tamir için doğru hasta seçimi
-Tamir için yol haritası
İntraoperatif değerlendirme
Postoperatif değerlendirme (1. hafta, 3. ay)
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Uzun soluklu ve başarılı tamir için istiyorsanız iyi
intraop. TEE
-Sabırlı olun ve bekleyin
-TEE yapan kişiyi serbest bırakın
-Optimum şartlar için 10 dk. bekleyin
-Mutlaka koaptasyon mesafesini ölçtürün (min.
6. mm)
-MY varsa sorunu saptayın geriye dönmekten
korkmayın (max. eser MY)
-Kapak altı korunarak yapılmış MVR, kaçıran
tamir edilmiş kapaktan daha iyidir
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Tamir ama Nasıl?
CPB
Kapağın iyi görülebilmesi
Kapağın iyi değerlendirilmesi
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Kapağın İyi Görülmesi
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Kapağın İyi Görülmesi
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Kapağın İyi Görülmesi
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Mitral Kapak Yetmezliği
Dejeneratif MY: Primer kapak
hastalığı
Romatizmal MY: Primer kapak
hastalığı
Fonksiyonel MY: Primer myokardiyal
hastalık
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“Dejeneratif mitral yetmezlik için
kapak tamiri gold standart”
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Dejeneratif Mitral Yetmezlik
Miksamatöz infiltrasyon
Fibroelastik eksiklik
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Dejeneratif Mitral Yetmezlik
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DEJENERATİF MİTRAL YETMEZLİK
İzole P2 prolapsus
Anterior leaflet prolapsusu
Bileaflet prolapsus (Barlow)
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P2 prolapsus tamir teknikleri
Triangular rezeksiyon
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P2 prolapsus tamir teknikleri
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P2 prolapsus tamir teknikleri
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P2 prolapsus tamir teknikleri
Quadrangular rezeksiyon
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P2 prolapsus tamir teknikleri
Sliding Plasty
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P2 prolapsus tamir teknikleri
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P2 prolapsus tamir teknikleri
E2E (double orifice-Alfieri tekniği)
Asla ilk tercih değil
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P2 prolapsus tamir teknikleri
Butterfly tekniği
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P2 prolapsus tamir teknikleri
Non-resection technique
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Anterior leaflet prolapsus
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Anterior leaflet prolapsus
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Robert W.M. Frater
-Replacement of pericardial chordae-1964
-Neochordae with PTFE suture-1986
“The rest is history”
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Neokorda
PTFE dikiş CV-5 veya CV-4
Papiller kasın 1 cm ucundaki fibröz kısımdan
Anterior ve posterior prolapsusta
Pledget leaflet üzerinde veya papiller kas
seviyesinde bırakılabilir.
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ROMATİZMAL MİTRAL KAPAK PATOLOJİLERİ
Komisural fibrozis
Kordal fibrozis ve kısalma
Leafletlerde fibrozis ve kısalma
Leaflet kalsifikasyonu
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Romatizmal Mitral Yetmezlik???
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Fonksiyonel (iskemik) MY
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İskemik Mitral Yetmezlik
Orta-ileri MY Cerrahi müdahale
Mitral Kapak Tamiri veya MVR (kapak altı
koruma)
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İskemik MY’de tamir
Ring undersize (m:30; f:28) E2E
Sekonder korda rezeksiyonu
Leaflet augmentasyonu
Dıştan kalbe destek (CorCap)
ve komplet revaskularizyon!!!
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İskemik MY (tamir veya replasman)
Rekürrens için risk faktörleri
Tenting alanı>2.5 cm2
Tenting mesafe>1 cm
Distal anterior leaflet açısı>25
Posterior leaflet açısı>45
Anulus çapının küçük olması
Multiple regürjitan jetlerin varlığı
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LVEDÇ>65 mm, LVESÇ>50 mm (ileri sol ventrikül
dilatasyonu ve kontraktil reserve olmaması)
Canlı doku araştırması (reverse remodeling)
İleri yaş
Uzun süreli kalp yetmezlik bulgularının olması
(hastalığın geç safhası)
Alternatif? Kapak altı aparey tam korunarak
yapılan MİTRAL KAPAK YERLEŞTİRME
(Biyoprotez)
İskemik MY (tamir veya replasman)
Rekürrens için risk faktörleri
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MİTRAL ANULOPLASTİ
RİNGLERİ
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MİTRAL ANULOPLASTİ RİNGLERİ
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MİTRAL ANULOPLASTİ RİNGLERİ
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Mitral Kapak tamir kontraendikasyonları
Yaygın anuler kalsifikasyon!!!
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SAM riski
Posterior leafletin uzun olması
C-septal mesafe<2.5 cm
Küçük ring
Aorto-mitral açı<120 derece
Küçük anulus
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TOOLBOX
Triangular rezeksiyon
Neokorda
E2E
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Teşekkür ederim……