Mitral Valve Repair
An illustrated surgical sequence for instruction and reference

Type

Illustrated sequence

Tools

Adobe Photoshop, Hunt 102 nib, Speedball Super Black ink, Vellum paper

Client

Prof. Michael Corrin (MSC2001Y)

Subject Expert

Dr. K. An, Dr. D. Rushani

Target Audience

Surgeons-in-training, medical students, cardiologists

Date completed

April 14, 2022

Goals

To create an anatomically-accurate surgical sequence in grayscale

Process

We were fortunate to be able to visit the Mount Sinai Hospital Surgical Skills Centre (SSC) where we observed surgeons during their training sessions. Unfortunately, due to certain constraints we weren’t able to observe a real human heart surgery procedure in situ. Instead, the training surgeons practiced on a bovine heart that had a slightly different morphology. This meant that a lot of reconstruction had to be done on our part in order to tell the story properly. 

Copy draft

To start, extensive background research through journal articles, textbooks, and instructional videos was done on the mitral valve repair procedure. Combined with the notes taken during the observation day, I drafted the steps of the surgical sequence as how it was performed during observation in point-form. These steps were then edited to be numerically arranged into a sequential step-by-step instruction. As the illustrations received weekly revisions in the span of nine weeks, the textual descriptions underwent a similar refinement procedure. 

Thumbnails

Using the textual descriptions along with the rough sketches drawn during observation, I developed thumbnail sketches to get a sense of perspective as well as a rough idea of how many steps I’ll need for the sequence.

Comprehensive sketches

During the span of nine weeks, the sequential illustrations received weekly updates in response to the feedback given by the class instructor. Here, I’ll present 3 working versions and share the major changes that were updated in each version.

Week 1

In the first iteration, I utilized an oblique perspective as I thought it would provide a more interesting viewpoint. Each step was brief and provided the bare-bones information to understand the sequence. The first page attempts to explain the set-up before the surgery (a cardiopulmonary bypass) but the details are fairly glossed over as we thought to focus on the mitral valve instead. 

Week 4

At this stage, the cardiopulmonary bypass and setup has been fleshed out further (no pun intended) into 2 different steps comprised of opening the chest cavity (1A and 1B) and entry into the mitral valve area (2A and 2B). Another major change was also the insertion of steps about the actual repair of the prolapsed leaflet (4A and 4B). In addition, the view of the mitral valve was changed to be closer to what a surgeon would see in an actual procedure. This straight-on view also provided the reader with a greater sense of the symmetry needed during the suturing steps (5 to 8).

Week 8

By the eighth week a lot of refinement was being done in line quality and weighting. Feathering and shading of different structures were done carefully to ensure proper depiction of volume and surface form. Compared to previous versions, there’s also an omission of soft shading as the main constraint of the project is to utilize pen and ink as the medium. The prolapse repair step was also changed slightly to a more simple procedure of interrupted sutures instead of uninterrupted. 

Final Layout

For the final, I focused on cleaning the lines and creating a more dynamic layout that lead the readers down the page. The assets in page 3 of the final layout were redone using a Hunt 102 nib and Speedball ink on vellum paper. 

References

  1. Carpentier, Alain, David Adams, and Farzan Filsoufi. 2000. Carpentier’s Reconstructive Valve Surgery. 1st ed. Vol. 1. Missouri: Saunders Elsevier.
  2. Cohn, Lawrence H. 1998. “Mitral Valve Repair.” Operative Techniques 3 (2): 109–25. doi:https://doi.org/10.1016/S1522-2942(07)70080-6.
    CTSNetVideo. 2018. “Cardiopulmonary Bypass: An Introduction.” Youtube. Dec 4. https://www.youtube.com/watch?v=IDWtAt2VdYA
  3. Forno, Benedetto del, Alessandro Castiglioni, Alessandra Sala, Alberto Geretto, Andrea Giacomini, Paolo Denti, Michele de Bonis, and Ottavio Alfieri. 2017. “Tutorial: Mitral Valve Annuloplasty.” Multimedia Manual of Cardio-Thoracic Surgery. October 6. https://mmcts.org/tutorial/821.
  4. Gillinov, A Marc, and Delos M Cosgrove. 1998. “Mitral Valve Repair.” Operative Techniques 3 (2): 95–108. doi:https://doi.org/10.1016/S1522-2942(07)70079-X.
  5. Larbalestier, Robert I., Richard B. Chard, and Lawrence H. Cohn. 1992. “Optimal Approach to the Mitral Valve: Dissection of the Interatrial Groove.” The Annals of Thoracic Surgery 54 (6): 1186–88. doi:10.1016/0003-4975(92)90094-K.
  6. Malik, Mahim, and Ahmet Kilic. 2015. “Biatrial Transseptal Approach for Combined Mitral Valve and Tricuspid Valve Operations.” Operative Techniques in Thoracic and Cardiovascular Surgery 20 (1). W.B. Saunders: 2–16. doi:10.1053/j.optechstcvs.2015.02.004.
  7. Mohebali, Jahan, and Frederick Y Chen. 2015. “Mitral Valve Repair for Ischemic Mitral Regurgitation Art of Operative Techniques.” Cardiothorac Surg 4 (3): 284–90. doi:10.3978/j.issn.2225-319X.2015.05.05.
  8. Pezzella, A Thomas, Joe R Utley, and Thomas J vander Salm. 1998. “Operative Approaches to the Left Atrium and Mitral Valve: An Update,” 74–94.
  9. Rausch, Manuel K., Wolfgang Bothe, John Peder Escobar Kvitting, Julia C. Swanson, D. Craig Miller, and Ellen Kuhl. 2012. “Mitral Valve Annuloplasty: A Quantitative Clinical and Mechanical Comparison of Different Annuloplasty Devices.” Annals of Biomedical Engineering 40 (3): 750–61. doi:10.1007/s10439-011-0442-y.
  10. Reser, Diana, Etem Caliskan, Herman Tolboom, Andrea Guidotti, and Francesco Maisano. 2015. “Tutorial: Median Sternotomy.” Multimedia Manual of Cardio-Thoracic Surgery. August 23. https://mmcts.org/tutorial/80.