Reconstructive Valve Surgery, From Valve Analysis to Valve Reconstruction

Reconstructive Valve Surgery, From Valve Analysis to Valve Reconstruction, written by Drs Carpentier, Adams, and Filsoufi, is an outstanding cardiac surgical textbook. Dr Carpentier has been both a major innovator and a leader in the rapidly advancing field of reconstructive cardiac valve surgery. This book represents the culmination of nearly 5 decades of surgical experience in reconstructing heart valves. It is not just for surgeons, but will interest cardiologists and cardiac anesthesiologists who are integral to the care of patients with complex valvular disease. The book begins with a section on valve analysis, which the authors describe as critical to successful reconstructive valve surgery. Proper valve analysis is a process of evaluating a valve with a “pathophysiological triad.” This triad identifies first the disease, then the specific valve lesions, and finally the valve dysfunction. It is followed by mitral, tricuspid, and aortic valve reconstruction; disease-specific approaches; and finally, transfer of knowledge. In this final paragraph, the authors discuss how surgeons in the past and in the future will teach other surgeons the techniques of valve reconstruction. Although all surgical textbooks rely on illustrations of anatomy and surgical techniques, the illustrations in this book are of the highest quality.

Reconstructive Valve Surgery, From Valve Analysis to Valve Reconstruction contains a novel addendum at the end of each chapter. This includes a separate discussion section in which Drs Adams and Filsoufi pose questions to Dr Carpentier. The purpose of these discussions is to address practical issues and alternative therapies in valve analysis and reconstruction. I found these discussions to be very helpful and informative because I have had many of the same questions while performing mitral valve reconstructive surgery on my own patients.

Chapter 2 describes Dr Carpentier's “functional classification.” It begins with the basis of valve analysis, the pathophysiological triad. The triad begins with valve type, which leads to valve lesion, which in turn leads to valve dysfunction. Detailed descriptions of valve types and lesions are provided. The chapter ends with a succinct description of Dr Carpentier's functional classification of valve dysfunction. Type I is valve dysfunction with normal leaflet motion; type II is valve dysfunction with excess leaflet motion; and type III is valve dysfunction with restricted leaflet motion. The reader has to understand this chapter to gain the most information from the remainder of the book.

Chapters 3 and 4 deal with perioperative and intraoperative management issues. These 2 chapters are very basic, and would help a non–cardiac surgeon understand the basics of safe cardiac surgery.

Chapter 5 is a wonderful chapter on surgical anatomy and physiology. As stated, the illustrations in this chapter are beautifully constructed and make very clear the anatomy of each heart valve and the relationship between heart valves. There are several tables on valve dimensions that are critical for successful reconstruction of cardiac valves. Chapter 6 describes preoperative valve analysis, including echocardiographic still images coupled with drawings of specific valve pathologies. The chapter ends with a summary of surgical indications for mitral valve stenosis and regurgitation. Surgical pearls are highlighted by a blue box with italicized text. Chapter 7 is essential for surgeons, because it describes valve exposure, intraoperative valve analysis, and reconstruction. Mitral valve exposure can be very difficult, and even experienced surgeons can learn from the techniques described in this chapter.

Chapter 8 starts with a superb illustration of the history of mitral annular repair. Sizing of the mitral valve is critical to the outcome of these procedures. This chapter illustrates the proper way to size a mitral valve for a ring annuloplasty. Also noted are the different mitral rings that Drs Carpentier and Adams have used over the years. The placement of sutures in the mitral annulus is also critical to the success of the repair. The illustrations in this chapter perfectly show the correct placement of these annular sutures. Page 83 shows sketches by Dr Carpentier of arches, parachutes, and a sailboat. These graphic drawings truly elucidate his surgical foresight and brilliance.

Chapter 10 illustrates the reconstructive techniques in anterior leaflet prolapse of the mitral valve. This condition is a challenging one for the reparative surgeon. This chapter describes 3 techniques for repair of chordal elongation to the anterior leaflet: papillary muscle sliding plasty, chordal shortening, and papillary muscle shortening. These techniques are technically challenging, and are well illustrated here. The next chapter includes techniques for posterior leaflet prolapse. This condition is most commonly seen in patients with nonischemic mitral insufficiency. The illustrations of a sliding leaflet plasty after resection of the P2 segment clarify this technique beautifully. In the discussion section of this chapter, Dr. Carpentier addresses the use of the “Alfieri stitch,” although he uses the term “edge to edge.” Many mitral repair surgeons now use the edge-to-edge technique. Dr Carpentier has significant concerns about this technique, which he describes in this section.

Chapters 13 and 14 include reconstruction of type III functional classification lesions. This type of mitral stenosis and insufficiency is encountered less commonly; therefore, individual surgical experience is limited. For this reason, these 2 chapters are especially helpful in understanding the type of repair necessary for this complex valve condition.

Systolic anterior motion is a condition that can occur after mitral valve repair. This condition occurs when there is a discrepancy between the amount of leaflet tissue and mitral valve orifice area. It can lead to subaortic outflow obstruction and postoperative mitral insufficiency. Chapter 15 deals exclusively with this entity, including its cause, medical treatment, and finally, surgical correction. This chapter is essential for cardiologists and cardiac anesthesiologists. Understanding this condition is critical for good outcomes in reconstructive mitral valve surgery. This chapter is excellent in this regard.

Reconstructive techniques for the tricuspid valve are covered in chapters 17 through 19. Cardiac surgical treatment of tricuspid valve pathologies is increasing in frequency, and these chapters describe various techniques of repair.

The final major section of this book involves reconstruction of the aortic valve. Chapter 20 has beautifully detailed anatomic illustrations of the aortic root and valve, including dimensions and angles. Chapter 21 includes pathophysiology, valve analysis, and surgical indications. Again, type I, II, and III functional classification of valve pathology is described. Chapter 22 describes reconstructive techniques. Most surgeons replace the aortic valve, and therefore have little experience in reparative techniques. This chapter provides less experienced surgeons with multiple repair options for aortic valve repair.

Chapters 23 thru 28 involve disease-specific approaches to the mitral valve. Each disease is covered in a chapter. This section has operative photographs to illustrate the valve pathologies. It includes very infrequently encountered conditions, such as primary valve tumors and radiation-induced valvular lesions. These chapters will be invaluable to a surgeon about to embark on a repair for these rare conditions.

The final chapter describes the transfer of knowledge of reconstructive valve surgery. In this closing chapter, the authors discuss components of the team effort required for successful reconstructive valve surgery, including cardiologists, echocardiographers, anesthesiologists, and surgeons. Many surgeons, myself included, attended live videoconferences directed by Dr Carpentier (Le Club Mitrale). Now, with the advent of the Internet, both patients and physicians have immediate access to medical information that did not exist during the inception of Le Club Mitrale. There are some excellent aphorisms in this final chapter that all cardiac surgeons should remember. “Try to repair before deciding to replace” and “No residual leak over 1+ should be left without proceeding to a second look” are among the notable “pearls.”

• © 2011 American Heart Association, Inc.