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Yeah. Hello, everyone. Welcome to this evening's Webinar. Were really great to we're delighted to be starting are undergraduate surgical teaching series again this year after its success last year, and the SS undergraduate surgical teaching series games to cover a range of surgical topic topics at the level expected of clinical year students. So largely years four and five. Um, and the content is specifically relevant to Edinburgh Medical School curriculum. But we'll also apply to medical schools both nationally and internationally as well. And the aim is for the information to be really useful for exams. And we've tried to pick topics that are particularly challenging that students find they would appreciate going over again. So we hope you find this session useful also. And these sessions will run throughout the year roughly once a month, Um, and will consist of a presentation followed by small group case discussions. So this evening, we are delighted to have Mr Peter Lang, who will be talking on the topic of heart valve disease, and Mr Long will talk for about half an hour, and then we'll split into break out rooms. Um, Mr. Lang graduated from Imperial College, London and did foundation training in London, and subsequently he completed course surgical training in Brighton. And currently Mr Lange's in his last year of cardiothoracic training in Glasgow. And his interests include valve surgery, intensive care and echocardiography. So I'll hand over to Mr Lang shortly. But just before I do, I will mention that in order to create our break out rooms, um, it helps us to know what stage of medical school or medical training you're at. So we will be putting a pole in the chat. So at some point in the next half an hour would appreciate if you could fill that in also. But without further ado, I'll hand over to Mr Lang. Thanks, Beatrice. Hello, everybody. I'm Peter. Um, So I'm going to talk to you about heart valve disease, and, uh, we're gonna have a particularly clinical relevance to that. Please do feel free to interrupt me via Beatrice or Lucas if you have any burning questions in the middle of the presentation. So I'm going to try and get you to develop a structure for the management of any kind of adult valvular heart disease. Uh, it's not that difficult. We're going to revise some of the key things that you probably have already learned at some point about each valve. And we're gonna have a focus on surgical anatomy and pathology, talk a bit about operating and also touch upon some special situations. So when I was a medical student, uh, this is how I felt about learning and understanding about valve heart disease. Um, this I won't spoil anything for those of you who haven't but plan to watch the original Star Wars trilogy. But in the words of, uh, Luke Skywalker, that's impossible, is how I felt. Um, so we're just going to try and simplify simplify things. It's not actually that difficult, Uh, so as you know, obviously the heart usually has four chambers were talking about non congenital heart has four sets of great vessels, and there are four valves, and basically you have two valves that connect the ventricles to their arteries and two valves that connect the patriot to their ventricles. And each valve can either be leaky and also the nose, and we'll talk about what happens when those things occur. When you have pathology, you usually have a murmur, which is due to turbulent flow either regurgitation or stenotic. You then have consequences on the chamber before and the chamber after in terms of pressure and your volume loading. And then in order to treat it, you can use medication, catheter based therapy and surgery. So it's quite simple in principle. Uh, Beatrice, can you hear me? Okay. Yes, I can hear you. Fine. Okay. Great. Thanks. Okay, So So bear in mind that each valve has a unique anatomy. When I was a medical student, I thought all the valves were the same. Four valves, some leaflets. You know, it can't be that hard. It isn't that hard, but they do have unique characteristics. Um, the fiber skeleton of the heart is something that's not really well taught in medical school. And that encompasses it connects the micro aortic and tricuspid valves. We'll talk about that more in a moment. As I said, there are physiological consequences of anatomical abnormalities. Uh, they're usually assessed by echocardiography, and then you offer intervention. When the murmur the lesion becomes severe and or symptomatic. Any kind of cardiac surgery is for prognostic and or symptomatic benefits. So you will only offer cardiac surgery if it will prolong life and or offer a better quality of life and effective and ineffective endocarditis is a special situation, and you have to watch out for that because it can present in weird ways. So for each valve, we're going to talk about the anatomy, and we're going to go through how to clinically assess, uh, for valvular disease. We're going to talk a bit about echocardiography, and then we're going to talk about those, um, interesting and special situations. Okay, so anatomy. So as you all know, the heart lies in the chest. In between the two lungs, it's slightly to the left. The apex is usually leftward pointing, and the most anterior structure is the right ventricle. So it's actually, although it's named left and right. The right is in the front and the left is in the back. And the most posterior structure of the heart are the pulmonary veins, which, of course, brain into the left atrium. So if you just bear that in mind, if you were to cut the heart at the level of the valves, then you would get this and you have your two semilunar valve so called because of the shape of the cusps, which your your ventricular arterial valves and your to atrioventricular valves. The atrioventricular valves are open during diastole and closed during systole. That's ventricular systole, and your ventricular arterial valves are open during systole. I mean, that's quite obvious, but the reason, I reiterate that is because it will help to understand the pathology more clearly in a moment. So I mentioned the fiber skeleton of the heart. That's the picture on the right that is basically a structure that allows for electrical insulation of the heart so that the electrical conduction passes from the S a note to the HIV node and then down the his bundles rather than jumping from place to place in a chaotic manner. And the fiber skeleton of the heart is anchored to the ventricular wall and provides stability for the three valves that it connects. The micro tried hospital and aortic valves. The pulmonary valve is not connected to the fiber skeleton. Clinically, it's relevant because if you have a pathology like infective endocarditis, or if you do, if you make a mistake and I acrogenic mistake, whether that's in surgery or fire a transcatheter technique, you can when you're intervening on one valve, you can damage another valve, which is in the local area. So this is on the left is just a reminder of how the electrical conduction of the heart is processed. The pathways from the essay node, uh, which is at the cave. Oh, atrial junction on the right. The the impulses passed through Bachmann's bundles two left and right, and through to the Navy node, which is at the floor of the right atrium. More on that later and then down the Hispanic needles into the ventricles. And the fiber skeleton allows that ordered pathway to occur and prevents chaotic electrical conduction from jumping from one place to another. Okay, so if you're ever asked in real life or in an exam, how to manage anything, not just talking about heart disease? Um, you should have a kind of structure to it, and a simple structure that you can use is the following. So how did you manage a patient with aortic stenosis where I would take a focused cardiovascular history? I would conduct a full cardiovascular respiratory examination. I would carry out basic and advanced investigations, formulate a differential diagnosis and then come up with a treatment plan and then follow up the patient. That's how you can answer any question about any kind of management for anything and that applies, uh, to valvular heart disease. Okay, so history of examination you will have been taught a lot of this by my very expert medical colleagues, so I won't bore you too much about it. But for a cardiovascular history, you want to focus on certain things if you're faced with a potential cardiac surgery patient, so obviously you need to delve into history presenting complaint. The most common cardiac complaints are shortness of breath, chest pain and tiredness, shortness of breath. As you know he's created by the New York Heart Association. Classification 1 to 4 Chest pain by the Canadian Cardiovascular Society Classification and tiredness is a very common symptom of valvular heart disease. You have other symptoms. You want to really classify the severity of the symptoms to see if they're in heart failure. Because if somebody has heart failure and valvular heart disease, that's bad, and you need to do something about it. If you can. You look at cardiovascular risk factors, so smoking, hypertension, hypercholesterolemia, diabetes, family history, you know all of that, and you need to know about their previous cardiovascular problems. Premorbid function is very important. That basically means What can you do? If we were to rewind a year ago, before all of these symptoms of shortness of breath started, how much activity can you do? And the reason that is important is because you're assessing their fitness for intervention, particularly surgery. The rest of it, you know, past medical history, drug history, social history, alcohol in particular. So that's the basics of a cardiovascular history, which you know but focused on somebody who's who might present for cardiac surgery. So examination. Why bother? Why bother to put your stethoscope on somebody's chest when you can just get an echocardiogram these days? Well, sometimes you can't get an echocardiogram immediately if you're in a very busy and the and the patients about to crash. So you want to detect abnormal heart sounds because you won't know to order an echocardiogram. If you can't detect the heart sounds in the first place, you need to assess for heart signs of heart failure, as we said and you need to evaluate for fitness for surgery, you'll be surprised at the number of patients who we, whom we take for surgery for infective endocarditis who have lingered for months in the medical system because somebody thought they had a malignancy because they had weight loss and fevers. And actually, when the F one put the stethoscope on the chest, they hear a murmur and the process begins. So, clinical examination. Hopefully you know most of this, but I'll just go through the essentials. So, General inspection Uh, look at mobility. Look at their frailty. There are frailty scores. Bm i These are all indicators of fitness for surgery. Vital signs, obviously BP, heart rate sats, respiratory rate temperature. Look at the hands for the posts and signs of effective endocarditis or other valvular heart disease. JVP uh huh. And face mouth, eyes and then onto the precordium inspection palpations or rotation percussion all the rest. You know that chest, abdomen and then peripheries. So for cardiac consultation, there are four basic areas, and these areas correspond to where the jet of blood usually travels, not actually where the heart valves are located. So for the aortic valve, that's usually the second intercostal space on the right by the by the sternal edge. And that's because the jet of aortic stenosis is usually going that way. Aortic regurg is Herbs Point, which is fourth intercostal the space left parasternal edge pulmonic valve, which we won't talk about today. That's more a congenital thing, but I'm happy to talk about that at another point. If you wish opposite, try to spit further down fifth or sixth intercostal space on the left and then Mike Rowe at the apex, usually at the apex or by the midclavicular line. So often you hear a mitral murmur loudest at the apex because that's the direction in which the regurgitate jet is going okay, echocardiography, the one of the most useful investigations in the entire specialty of cardiovascular medicine and surgery. We'll talk about that in a moment, um, basic investigations first. So if you are asked to talk about basic investigation for everybody, there is a useful pneumonic, which you may already know, which is you, Becks. Urine, blood CCG, chest X ray and then for cardiac surgery patients. Advance investigations include echocardiography coronary angiogram. If you think they might have coronary disease or CT, and then consider lung function tests if they have a smoke heavy smoking history, history of COPD and karate doctors if they have risk factors for stroke. Okay, so echocardiography is basically an advanced form of ultrasound. Ultrasound, as you know, is produced by piezoelectric crystals oscillating at a high frequency. The sound wave travels through either a solid or liquid medium and then gets reflected back to the probe, and that gives you information about the structure so it can be used to assess the morphology of valves and using Doppler ultrasound. The Doppler effect, which is where you hear the ambulance changing in pitch as it moves further away from you because of the change in frequency of the sound waves. So using Doppler, you can actually have. You can see color flow, and you can assess for gradients across the valve so you can use doctor in for velocity. And then you can use formula to calculate pressure gradients from the velocity. It's an extraordinarily useful form of investigation. Okay, so on to the cardiac surgery stuff. So whenever you're asked about operative strategy for any surgical specialties, split it up into pre intro and postoperative management. Um, it can often be overwhelming for anybody thinking about how to conduct an operation, and this is really what you need to do. Break it down into the basics. So for heart surgery for the setup for most cardiac surgery, that's via a median sternotomy. We do have minimally invasive access routes. We can talk about that another time, but usually we do a median sternotomy so through the sternum, and then you need to connect the patient up to the heart lung bypass machine. Stop the heart, turn off the lungs and the way that you connect them up to the heart lung bypass machine is you have a cannula that takes oxygenated blood into the systemic circulation. You then have a cross clamp below that I a proximal to that. And then you have a cardioplegia line to give potassium based solutions to stop the heart and perfumes the coronaries, and you have a venous return. Can you learn? Or can you really usually draining from either the KV or the right atrium to bring deoxygenated blood to the machine? So that's the set up for most cardiac surgery operations. This is a simple way to simplify this diagram of the heart lung bypass machine Basically, you have an inflow cannula, arterial cannula, which, as I said, brings the oxygenated blood and, uh, deoxygenated outflow cannula, venous return cannula. And then you have a heater cooler. Which heat or warmth or blood and various suction pumps that take blood from the operative field. That's what it looks like. That's how it was in the old days. Took up half a room with a bubble oxygenated that basically blew air into the column of blood. Very primitive back in those days, but that has already changed. Now, this is basically what happens during this set up for heart surgery. So I can't play the video for some reason. Um, okay, So for the cardiac surgical plan, if you're planning a heart operation, you basically have a team brief with your team. You think about how to position the patient, how to access, which, as I said, is mainly through median sternotomy. You think about how to cannulate for bypass and connect them up to the heart lung bypass machine. And then you think about how to stop the heart perfused the brain. And then only then do you think about your technical steps in terms of where to cut and which bits to sew together. And then, after all of that, you think about how to separate the patient from the heart lung bypass machine. How to wean for all any cardiac operation? As I said, the reason that you're doing that is to prolong life and improve symptoms. Nothing else. If you can prolong life or improve symptoms, you don't offer the operation. You have to balance that with the risks. And those are risks to life and risk of stroke and organ failure and other risks, like bleeding, infection and all of that stuff. You can calculate the risk, estimate the risk using evidence based risk scores. Um, but the most important thing is to consider what the patient's priorities are. This comes from Montgomery from Lanarkshire, which is basically what the patient's priorities are in terms of. You're consenting process, so you have to weigh the risks and benefits of any surgical operation. As with any surgery, okay, so that's kind of the basics. Before we even talked about any valves. We've talked a bit about anatomy a bit about how to clinically manage any valvular condition a bit about how to investigate valvular conditions, how to set up the heart surgery. And now we're gonna talk about individual valves. Any questions? So far, Beatrice or Lucas? Not yet. Although if anyone has any questions, please do put them in the chat. Okay, great. So let's start with the So this is the valve that, as you know, lies in the left ventricular outflow tract. It connects the left ventricle to the aorta. So all of the oxygen in the blood from the heart is going through this valve. So the aortic valve is part of the aortic route, which is a specific, complex complex. The aortic root has a basil ring, which is where the ventricle meets the left ventricular outflow tract. The valve is contained here and then whether it was it ends is the sign a tubular junction. You whether Bogle a bit bulbous tip it meets the tubal a bit. And the tubular bit is the ascending aorta proper rather than the aortic route. And the leaflets of the valve basically come up when they open during diastole, they come up during Systole. Rather, they come up to meet the Sinotubular junction. The aortic valve doesn't actually have an analyst. As such, we as surgeons, we invent the analysts, and we take it to be the basal point of where the leaflets attached to the left ventricular outflow tract. And that's where we. So that's where we put our stitches for doing an aortic valve replacement. If you look at the left ventricular in flow out shows, if you slice the heart down longitudinally, you will see that the the aortic and mitral valves are actually next to each other. So when I was a medical student, I I just used to think it went in this one way and went out another way, and they were totally separate. That's actually not the case at all. Your pulmonary veins drain into the left atrium. Blood goes through the mitral valve, and then it takes a sharp curve to go out of the aortic valve. So this is really important. These two valves can affect each other in a lot of pathologies, including infective endocarditis, and the aortic valve is in fibrous continuity with the mitral valve. We'll talk about that in a moment, but they are. They are really close to each other. This is the surgeons view. If you if you were to slice the aorta open, which is what we do during surgery with the transverse aortotomy, the surgeon you're standing in the non coronary cusp, so called because there are no coronary arteries coming out of it. On your left is the left coronary cusp, which is where the left main stem usually arises. Sometimes you have a brain anatomy and the right coronary cusp is on your right hand side, and that's where the right coronary artery comes from. Okay, so when you're doing aortic valve or aortic root surgery, these are the structures at risk. So if you're standing in the non coronary cusp, then your mitral valve. The anterior leaflet of your mitral valve is in fibrous continuity, with half of the non coronary cusp and half of the left coronary cusp. And actually, if you look down, if you put your head down through that hole and you were to look there during surgery. If if the surgeon has placed a micro valve prosthesis, particularly a micro valve replacement, you will see that prosthesis poking out through the whole of the aorta, and that is weird. But that's actually how close the valves are together. Your so obviously your coronaries are here. Your member in the septum, which is very thin, lies between the junction of the non and the right coronary cusps If you damage that with your sutures, you cause, uh, VSD and your conduction tissue is here to your bundle branch and your A V node is further down. So again, if you take too thick bites in the membrane septum, you will cause heart block left bundle branch block at the least, but also heart block if you go really deep. So those are the structures. So that was quite surprising for me to know as a medical student and you're tricuspid valve. Also, it's far away, but it's actually over here somewhere. Okay, so those are your structures, your your muscular septum. Your muscular ventricular septum is along the line of the right coronary cusp. So again, if you take too thick bites here, you might cause a muscular VSD. But that's very hard to do. Um, aortic valves do vary a lot. Bicuspid aortic valve is a common congenital abnormality. In a lot of cases, nothing happens, but in some cases you can have an associated aortopathy e aortic aneurysm disease. And more commonly, you get earlier degenerative disease. So the bicuspid valve is wear out sooner, and the patients come to you for surgery at a younger age. As you know, this is the motion of the aortic valve, the normal motion. So it's not just an opening and closing of the leaflets. The whole of the aortic root moves I/O, and it's a very dynamic process. Okay, so aortic stenosis. So, uh, etiologies degenerative is the most common in the Western world. You can also have rheumatic or congenital, as we just said from a bicuspid valve. The pathology is basically pressure loading, so you have a tight valve. The heart works harder to push the blood through this tight valve. Your LV muscle hypertrophy is you get concentric hypertrophy that increases after load so the heart has to work even harder. And then later on you get acquired. Von Willebrand factor deficiency because all of your your factors are getting sheered and your platelets are getting shared as they pass through the stenotic aortic valve. And some patients develop Haider's syndrome, which is a combination of gastrointestinal angiodysplasia, aortic stenosis and von Willebrand acquired von Willebrand Factor deficiency because those things are getting shared as they pass through the severely stenotic valve. Patients can get angina in the absence of coronary artery disease simply because the LV is so hypertrophied and he's taking up all the blood. Clinically, you get a slow, rising, low volume pulse with a narrow pulse pressure, and later on you can get a heaving and even laterally displaced Apex. That's later on. But you have an ejection systolic murmur, loudest in the aortic area. Second intercostal space, right parasternal edge, and that radiates to the carotids. And if you get an obscured second heart sound, then that's that's usually a sign of severe aortic stenosis. Um, back in the very old days, in between the two World wars before the advent of open heart surgery, people followed up patients with severe aortic stenosis, and when they developed symptoms, they found that basically their survival was on average, five years if they had angina three years if they had syncope and two years if they had signs of heart failure. So once you get into the territory of severe symptomatic aortic stenosis, it's definitely it becomes a life limiting disease, and you need to offer therapy. How do we investigate it? We use echocardiography, and basically, because the jet of blood is going fast through the narrow valve, you get an increase in velocity and increasing pressure, and you can detect that on echo. Sometimes if the heart is poor, the velocity might be slow, and you might need to challenge the heart by giving it dobutamine to make it pump harder. You need to do coronary angiography for almost all patients undergoing heart valve surgery. If they're above the age of 50 because they might have coronary disease, they might need a concomitant CABG. And the risk factors for degenerative aortic stenosis in the Western world are the same as for coronary disease. So the two diseases do InterNAP. Um, so when you intervene, as I said, if they're severe and symptomatic or if they're asymptomatic, But they have physiological signs of impairment, either impairment of LV function, um, positive exercise, tolerance test or very severe parameters and other signs on CT, we use TV. Um, that's that's exponentially rising Now. Tavi is transcatheter aortic valve implantation and in the UK is offered for basically elderly patients high risk patients and failed patients. But there's increasing evidence that it can be offered to moderate and low risk patients without any um, increasing risk as compared to surgery. However, the downside of TV is that there is an increased risk of paravalvular leak because you're putting a new valve inside the old valve, which is calcified, and you're not cutting out the old valve. So you get a little gaps where your new valve is sitting, so that can leak. And that can be associated with decreased life expectancy. And you get an increased risk of permanent pacemaker because when you deploy your new valve, it might squash the Navy nodes or the bundle branch, which we saw in the previous slide on anatomy. However, in the short term, there are few risks than surgery, so there are pros and cons, so essentially, it's probably a better short term option, particularly in elderly and high risk patients. But we don't know the long term data on TV. Are we okay for Beatrice? I'll be okay for time. Sorry. Probably need to speed up tonight. That's no problem. Just another seven minutes. Okay. All right. Okay. So, um for a surgical aortic valve replacement. Um, what you basically do is you go through everything that we just discussed in terms of set up. And then what you do is you stop the heart. You cut the aorta open, you drop out the old valve, you size a new valve, and then you put your sutures your annual sutures, which run all the way around the so called Angeles, which, as we said, doesn't really exist. It's a surgeon. He invented structure, and then you join those sutures onto your prosthesis, and usually you parachute it down. There are various techniques, but that's the most common technique. You then tie your uterus, and your new valve sits nice and snug in the position. You then have to basically close the aorta. Get rid of the air that you've just been trained in the heart and then take the patient off bypass so that that's the basics for aortic valve replacement. We can talk about that more in detail later if you wish. In terms of valve prosthesis choice. Basically, there is no ideal valve substitute, particularly in younger patients, But basically, if you're replacing the valve for an elderly patient with degenerative aortic stenosis. Your two main choices are a tissue valve or a mechanical valve. Tissue valves last about 10 to 15 years. Max, but you do not have to take warfarin. Mechanical valve last a very long time as long as you look after yourself. But there is a bleeding risk of about 1% every year, and that goes up more as you passed the age of 75. So you have to consider patient preference and lifestyle. There are other options in younger patients, which we can talk about, including the Ross Procedure, where you basically take the patient's pulmonary valve and put it in the aortic valve position. And then you get a dead person is pulmonary valve and put it in that patients pulmonary valve position. Okay, aortic regurg is usually degenerative or related to connective tissue disorders such as Marfan. There's lots and lots of wonderful signs because basically, you get a column of regurgitant blood flowing back down the aorta during diastole. Um, so you you get clarity pulsation Corrigan sign. You get nail bed per station. I haven't actually seen that before. Uh, you can get the muscle sign, which is the head nodding. You can get a little uvula. You get murmurs in the families because of regurgitant flow. Uh, so tribes, And do you see a sign you don't always see? Many of these, until it's very late, have seen most of these, but not all of them. Um, nowadays, we tend to detect valvular heart disease quite early, so what you will see is a water hammer pulse. As you lift the arm up, you will definitely get a wide pulse pressure. You have an early diastolic murmur, and you may hear an Austin faint murmur, which is basically where the jet of aortic regurg strikes the anterior mitral valve leaflets, which we said is right next to the aortic valve, causing turbulent flow through the mitral valve. And you can see that on echocardiography very nicely, and basically the heart dilates and then basically, eventually decompensates. So it's a volume overload, as opposed to a pressure overload in aortic stenosis. Assessment is also via echocardiography. Indications of surgery are basically severe. Symptomatic they are, or if it's severe, a are but asymptomatic. But you're doing other cardiac surgery or the heart is impaired or the aorta is dilated, so those are basically indications your options are to repair in some select cases and in some select centers most people would replace Um, as I mentioned, you can do the Ross procedure in young adults, but that's a complex procedure only done in expert centers. And you can do other things, such as replace the valve with autologous autologous pericardium, which is also a complex procedure. And if your aortic root is dilated, you can replace that either with a with the Bentyl, which is where you replace the valve with the route or do a valve sparing replacement. So you resuspend the valve by its commercials, but replace the root only very interesting procedure. Okay, that's aortic valve, so I'm going to talk about Michael now. Briefly, the micro is a fascinating valve. It's the left atrioventricular valve. In adults, it has to leaflets and anterior, which takes up two thirds of the visible surface area, and the posterior, which takes one third or less of the visible surface area. There's a smiley face, which is the coaptation line, and it's divided up. There are two commercials which are the corners and anterolateral, so this is the surgeons view anterolateral, which is left lateral left, that's easy to remember and posture and medial. And then the posterior leaflet is scalloped. It has little indentations which don't go all the way to the Angeles, and there are usually three of them. So there are three scallops, P one p to Pee three and the anterior leaflet. Although it does not have scallops, it is divided into segments which correspond to the opposite counterparts on the posterior leaflet. It's a fascinating valve because the mitral valve complex doesn't just consist of the leaflets. It consists of the analysts, the Chordee tendon me, the papillary muscles and the LV wall, and abnormalities in any of these areas at any level can cause mitral valve dysfunction. And the way that we classify mitral valve dysfunction is by cut twenties classification. Uh, 20 was a famous French, is a famous French cardiac surgeon who basically invented many of the principles of modern day mitral valve surgery, and he divided up micro valve dysfunction into a very simple 33 type classification. So Type one is normal leaflet motion, So if you have a hole in your leaflet from endocarditis, but your leaflets are moving normally you'll get mitral regurgitation if you have excessive leaflet motion. That's usually from degenerative mitral valve disease. Uh, for example, because of a ruptured Corti 10 called a tendon. Uh, that will cause, uh, excessive leaflet motion and, like mitral regurgitation. Or, if you have type three, which is restricted leaflet motion, which is usually either mitral stenosis from rheumatic disease or ischemic cardiomyopathy. So a dysfunction at the LV level, those can all cause mitral valve dysfunction. Um, and it's a fascinating valve because you have not just interesting anatomy, but also many structures to watch out for which can be damaged during surgery. So your culinary Sinus runs out the back here. Your left circumflex usually runs laterally on the left and the back, so you don't want to take too deep bites when you're here and your bundle of hisses over here by your posture and medial common shore, and you can cause heart block. And as you know, as we just said before, your aortic valve is here closely related to the anterior micro valve leaflets via half of the left and half of the non coronary cusps. This area, this fibrous continuity is known as the auto mitral curtain. Okay, so the murmur of mitral regurg is a pan systolic murmur. It's allowed us at the apex, and it radiates to the axilla. That's basically all you need to know for the for the exams. Um, it's mostly degenerative. That's the cause. Um, you have primary MRI, which is the most common, which is because of organic structural heart disease. And surgery is preferred, preferably repaired rather than replacement. Because the life if you repair a micro valve, as long as the patient looks after themselves, their life expectancy can be restored to the age match. General populations Normal secondary MRI is because of a functional problems such as ischemic cardiomyopathy. Um, and that's usually treated medically. First, Uh, this is this is, uh, principles of mitral repair. But basically what you're aiming to do is number one restore normal leaflet motion to make sure the leaflets come together nicely. Coaptation ensure good surface of cooptation where they come together, good surface area and stabilize the analysts with a ring. Those are basically the three principles of any microvalve repair mitral stenosis less common, but we see a lot of it in Glasgow, certainly, and that's mainly rheumatic. You can have that because of media son or irradiation and other things, but it's mainly rheumatic, and you get your typical signs. You get a flush, you get him a Texas and you get chest pain. And these are actually not that common until late. Um, in a very enlarged left atrium that can compress local structures such as the recurrent laryngeal nerve. So you got a horse voice, the esophagus, dysphagia and even the left main bronchus, and you get left lung collapse. These are very late signs. You don't really see these in textbooks. Um, you get a mid diastolic murmur, her best at the at the apex with the patient lying on their left, and sometimes you can hear a grain still murmur, which is a murmur of pulmonary regurge. As a result of this, I've actually never heard that before. Um, mitral. So rheumatic disease starts at the leaflet tips and what works its way towards the analysts. Degenerative disease is the other way around, starts at the analysts and the leaflet body and then works its way towards the tips. Um, rheumatic disease basically affects the throat I think that there's an old saying which it says it looks. The throat burns the joints and then scars the heart. And that's basically the the time, the temporality of it. So you get as you know, some kind of a strep like throat infection. Then you can get joint disease, and then later on, much later on 2025 years later, you then get valvular disease, which is usually stenosis, Usually stenosis interventions are usually percutaneously balloon if suitable, and then surgery if not suitable or if fails. And surgery is usually mitral replacement. Beatrice, how are we doing? Can I say one more? One more. Can I talk about one more valve? Yes, Absolutely. Okay. So any burning questions so far before we talk about the tricusp it otherwise known as the forgotten valve? Is it? Is it all making sense? Beatrice and Lucas? Yes, it is. Thank you. And no questions currently. Okay. Okay. The tricuspid valve. This is the right side of the valve in adults. Um, and this is known as the forgotten valve because people didn't used to respect it. Unfortunately, in the old days, although to be fair, a lot of tricuspid valve disease is secondary. So, as I said, primary means organic. So you know you've got a problem with the leaflets or you've got something wrong with the analysts. Something is going on. So there's an organic pathology. Secondary means that usually the leaflets are morphologically okay, but something else is going on. And that's usually ventricular or atrial disease. Um, interest Hospital. That's mainly secondary tr secondary tricuspid regurge due to left sided heart disease. So the mitral valve, when it's diseased, affects the tricuspid valve not directly, but because of remodeling of the ventricles. So if you have severe mitral regurg, all that blood is going the wrong way, you then get pulmonary hypertension. You then get RV dysfunction, and then you get secondary tricuspid regurgitation. So that's why the mitral valve is so fascinating. Um, anyway, so tricuspid anatomy. So there are three leaflets tricuspid, although not all tricuspid valves are tricusp it. But most are. There's a septal leaflets. So the tricuspid valve is the right sided atrioventricular valve is the is the only valve out of the two that has a septal attachment. And so if you're in congenital surgery, that's one of the markers for telling which one is your right sided atrioventricular valve and which is your right ventricle, morphological right ventricle? Because obviously you have all sorts of more morphological abnormalities. So the tricuspid valve has a has an attachment to the interventricular septum, which is unlike the micro. The mitral obviously can't, because if it did, you would get left ventricular outflow tract obstruction because the atrial, aortic and mitral valves are next to each other, whereas the tricuspid and pulmonic valves are far away from each other. So that's a big difference between left and right anyway, acceptable. Leaflet, anterior. Leaflet on the left is surgeons view and posterior leaflet on the right structures at risk. Have a look at this. This is very interesting. So the floor of the right atrium is a very important structure. The coronary Sinus, which provides the main main venous drainage for the heart, empties into the floor of the right atrium and that forms the base of your triangle of cock K. O. C. H. One of the sides of the triangle is the tendon of Tomorrow, which is basically a fibrous um, tendon that basically extends from the eustation valve of the Ivc IV C is down here, so coronary Sinus tendon off tomorrow and septal defect of the tricuspid valve. So with the eye of faith, you can see a triangle. There. At the apex of that triangle lies the A V node, so you do not want to damage that during tricuspid surgery. So that means when you do tricuspid repair and you're putting in an annuloplasty ring a ring, all the rings have a gap along this area so that you don't go and Roger the A V node if you have to replace the tricuspid valve. Unfortunately, the ring has to be a complete ring, and therefore you do have a high risk of causing complete heart block. But sometimes you can try and take bites onto the leaflet and plicate the leaflet onto the annual so that your annual it sutures don't go too deep. But a lot of the times you will run into heart block, and therefore you have to place epicardial pacing leads prophylactically during surgery. The aortic valve quite close. As we said, there's fibers continuity between the two. If you get a fistula either acquired or congenital between the aorta and the right atrium that's known as a robot defect. G E r B o D E. Garbo defect, which can be acquired or congenital. You can get it in infective endocarditis, and you can get it iatrogenic li if you roger if you take too deep bites, either from this side or from this side. So your leaflets of your aortic valve that are related to the hospital are the right and the non the roof. As we said inside the right room, the roof is the sinoatrial node, and the floor contains the AP notes. So fascinating anatomy of the right atrial floor. That's your tricuspid valve annuloplasty ring. Okay, good stuff. Tricuspid regurge, As we said. Mostly secondary. Um, similar murmur two micro. But it's it's a bit. It's presystolic. Basically, it's a bit earlier. It's not pansystolic always, Um, basically your your your your criteria for intervention on secondary tricuspid regurge are is the left sided valve disease bad enough? And also is the tri tricuspid Angeles dilated enough. That is basically your criteria criteria rather for intervention. Okay, quick word about anti coagulation, and then we'll wrap up. I think, um, if you're putting in a tissue valve. You don't need long term anti coagulation, but most guidelines say to consider warfarin for three months because that allows the valve to bed down and that past that three months, your stitches are firmly bed it down into the tissue and your risk of thrombosis is low. If you have a mechanical aortic valve, you're on our needs to be 2 to 3, and for micro, it's 2.5 to 3.5. It's higher because the pressure in the left atrium is obviously lower, so the micro is at high risk of thrombosis, and also it has a much bigger surface area than the aortic valve with that smiley face. If you have combined valves, then usually you choose the higher iron are. But some guidelines say, to choose an even higher iron are than the micro, so 3 to 3.5 risk of bleeding. So any prostate valve has about 1% risk per year of prosthetic valve infective endocarditis, which is a nightmare 1% per year. Um, any valve on warfarin has a risk of about 1% per year of intracranial hemorrhage, and that goes up to about 4% for patients older than 75. And that's why, uh, for aortic valves. If you're younger than 65 then we would recommend a mechanical. If you're older than 65 then tissue mitral. The cutoff is a bit different. So if you're younger than 70 mechanical and if you're older than 70 tissue. But those are not black and white. Those are just recommendations. Okay. Are we okay, Beatrice? Or should I stop there? I think if we can stop there, Pete, that's all right. But that was really interesting. Thank you. Um, So what we'll do now? Everyone is We're going to split into break out sessions, and we normally split these into what stage? You're out of training. And so on the left hand side of your medal screen, you should see a section that says breakout session. So in a moment, if you can go on to there and go into a breakout room, depending on if you're pre clinical, can you go in the pre clinical room? If you're clinical medical student, but not in your final year. So either year three slash four or four slash five. Can you go in that session and then, if you're a final year students a year, five slash six or an F Y one and above. Can you go into the F Y one in a year? Six student and above session, please. So if you could all go into those rooms now, um, and we'll finish after teaching in there. Which one do you want me to go into? So, if you could go into the final year and above Pete, that'd be great. All right, See you on your sessions are wrong.