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| '''For the WikiPatient page for this topic, click [[Mitral valve surgery (patient information)|here]]'''
| | #redirect:[[Mitral regurgitation surgery]] |
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| {{CMG}}
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| '''Associate Editor(s)-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]][mailto:msbeih@perfuse.org]; {{CZ}}; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.
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| '''For the WikiPatient page for this topic, click [[Procedure (patient information)|here]]'''
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| ==Overview==
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| Mitral valve surgery is surgery that can either repair or replace the mitral valve in your heart.
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| Blood that flows between different chambers of your heart must flow through a valve. One such valve is called the mitral valve. It opens up enough so blood can flow from one chamber of your heart (left atria) to the next chamber (left ventricle). It then closes, keeping blood from flowing backwards.
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| In open surgery, the surgeon makes a large cut in the sternum to reach the heart.
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| ==Anatomy and pathophysiology==
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| ==Indications for Procedure==
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| ==Treatments for (the disease)==
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| ==Preoperative preparation==
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| ==The procedure==
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| ==Recovery==
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| ==Surgical outcome==
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| ==Possible complications==
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| ==Videos==
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| ==External links==
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| ==References==
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| <references/>
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| ==Indications for Surgery in Chronic Mitral Regurgitation==
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| Indications for surgery for chronic mitral regurgitation include signs of left ventricular dysfunction. These include a [[left ventricular ejection fraction]] ([[LVEF]]) of less than 60% and a left ventricular end systolic dimension (LVESD) of greater than 45 mm.
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| <table border="1" cellpadding="5" cellspacing="0" align="left">
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| <caption>'''Indications for surgery for chronic mitral regurgitation'''<ref name="pmid9809971">{{cite journal |author= |title=ACC/AHA guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association. Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease) |journal=[[Journal of the American College of Cardiology]] |volume=32 |issue=5 |pages=1486–588 |year=1998 |month=November |pmid=9809971 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735109798004549 |accessdate=2011-03-16}}</ref>
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| <tr>
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| <th style="background:#efefef;">Symptoms</th>
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| <th style="background:#efefef;">LV EF</th>
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| <th style="background:#efefef;">LVESD</th>
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| </tr>
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| <tr><td>[[New York Heart Association Functional Classification|NYHA II - IV]]</td><td>> 60 percent</td><td>< 45 mm</td></tr>
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| <tr><td>Asymptomatic or symptomatic</td><td>50 - 60 percent</td><td>≥ 45 mm</td></tr>
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| <tr><td>Asymptomatic or symptomatic</td><td colspan=2>< 50 percent or ≥ 45 mm</td></tr>
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| <tr><td colspan=3>[[Pulmonary artery]] systolic pressure ≥ 50 [[mmHg]]</td></tr>
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| </table>
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| ==Dysfunction with a Dilated Ventricle==
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| The patient with severe LV dysfunction (an LVEF < 30% and/or a left ventricular end-systolic dimension greater than 55 mm poses a higher risk but may undergo surgery if chordal preservation is likely.
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| ==Overview==
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| Mitral valve surgery is indicated when the [[mitral regurgitation]] is severe or when the patient is symptomatic.
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| Valve repair or replacement are the two types of surgeries available to treat these conditions. Decision between valve repair or valve replacement is made based on the type and severity of damage to [[mitral valve]].
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| ==Indications==
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| '''[[Mitral valve repair]]''' is recommended in following:
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| *Limited damage to certain areas of the mitral valve leaflets or [[chordae tendineae]]<ref name="pmid12830055">{{cite journal| author=Gillinov AM, Faber C, Houghtaling PL, Blackstone EH, Lam BK, Diaz R et al.| title=Repair versus replacement for degenerative mitral valve disease with coexisting ischemic heart disease. | journal=J Thorac Cardiovasc Surg | year= 2003 | volume= 125 | issue= 6 | pages= 1350-62 | pmid=12830055 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12830055 }} </ref>
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| *Limited calcification of the leaflets or annulus
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| *[[Mitral valve prolapse|Prolapse]] of less than one-third of either leaflet
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| *Pure annular dilatation
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| *Valvular perforations
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| *Incomplete [[papillary muscle rupture]]
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| '''[[Mitral valve replacement]]''' is recommended in following:
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| *Extensive calcification or degeneration of a leaflet or annulus
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| *[[Mitral valve prolapse|Prolapse]] of more than one-third of the leaflet tissue
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| *Extensive chordal fusion, calcification, or [[papillary muscle rupture]]
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| *Extensive damage of mitral valve secondary to [[endocarditis]]
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| ==Clinical trial data==
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| *Multiple studies have shown that there are better outcomes in terms of left ventricular function and survival with mitral valve repair compared to valve replacement.<ref name="pmid3769948">{{cite journal| author=Krayenbuehl HP| title=Surgery for mitral regurgitation. Repair versus valve replacement. | journal=Eur Heart J | year= 1986 | volume= 7 | issue= 8 | pages= 638-43 | pmid=3769948 | doi= | pmc= | url= }} </ref><ref name="pmid7850937">{{cite journal| author=Enriquez-Sarano M, Schaff HV, Orszulak TA, Tajik AJ, Bailey KR, Frye RL| title=Valve repair improves the outcome of surgery for mitral regurgitation. A multivariate analysis. | journal=Circulation | year= 1995 | volume= 91 | issue= 4 | pages= 1022-8 | pmid=7850937 | doi= | pmc= | url= }} </ref><ref name="pmid10612761">{{cite journal| author=Yau TM, El-Ghoneimi YA, Armstrong S, Ivanov J, David TE| title=Mitral valve repair and replacement for rheumatic disease. | journal=J Thorac Cardiovasc Surg | year= 2000 | volume= 119 | issue= 1 | pages= 53-60 | pmid=10612761 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10612761 }} </ref><ref name="pmid9918527">{{cite journal| author=Tribouilloy CM, Enriquez-Sarano M, Schaff HV, Orszulak TA, Bailey KR, Tajik AJ et al.| title=Impact of preoperative symptoms on survival after surgical correction of organic mitral regurgitation: rationale for optimizing surgical indications. | journal=Circulation | year= 1999 | volume= 99 | issue= 3 | pages= 400-5 | pmid=9918527 | doi= | pmc= | url= }} </ref>
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| *In a 6 year follow-up study<ref name="pmid16293530">{{cite journal| author=Kouris N, Ikonomidis I, Kontogianni D, Smith P, Nihoyannopoulos P| title=Mitral valve repair versus replacement for isolated non-ischemic mitral regurgitation in patients with preoperative left ventricular dysfunction. A long-term follow-up echocardiography study. | journal=Eur J Echocardiogr | year= 2005 | volume= 6 | issue= 6 | pages= 435-42 | pmid=16293530 | doi=10.1016/j.euje.2005.01.003 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16293530 }} </ref> of 45 patients with isolated non-ischemic [[mitral regurgitation]] and [[EF]] ≤50%, who underwent either valve repair(27 patients) or replacement(18 patients) following results were observed:
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| ::*5 patients and 6 patients died in repair group and replacement group respectively.
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| ::*2 patients underwent valve replacement due to failure of valve repair while 1 patient in valve replacement group underwent re-operation due to [[prosthetic valve endocarditis]].
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| ::*Incidence of [[atrial fibrillation]] was similar between both groups.
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| ::*Left ventricular end diastolic dimension(LVEDD), [[velocity time integral]] and [[ejection fraction]](EF) improved with valve repair while LVEDD and EF worsened in valve replacement patients.
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| *In another study, lower operative mortality (2.6% vs 10.3%), greater increase in left ventricular [[EF]] and higher 10 years survival rate (68% vs 52%) were observed among patients who underwent valve repair compared to valve replacement.<ref name="pmid9323067">{{cite journal| author=Ling LH, Enriquez-Sarano M, Seward JB, Orszulak TA, Schaff HV, Bailey KR et al.| title=Early surgery in patients with mitral regurgitation due to flail leaflets: a long-term outcome study. | journal=Circulation | year= 1997 | volume= 96 | issue= 6 | pages= 1819-25 | pmid=9323067 | doi= | pmc= | url= }} </ref>
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| *A survival benefit with valve repair may not be seen in high risk patients with [[ischemic MR]].<ref name="pmid11726887">{{cite journal| author=Gillinov AM, Wierup PN, Blackstone EH, Bishay ES, Cosgrove DM, White J et al.| title=Is repair preferable to replacement for ischemic mitral regurgitation? | journal=J Thorac Cardiovasc Surg | year= 2001 | volume= 122 | issue= 6 | pages= 1125-41 | pmid=11726887 | doi=10.1067/mtc.2001.116557 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11726887 }} </ref><ref name="pmid11726886">{{cite journal| author=Grossi EA, Goldberg JD, LaPietra A, Ye X, Zakow P, Sussman M et al.| title=Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications. | journal=J Thorac Cardiovasc Surg | year= 2001 | volume= 122 | issue= 6 | pages= 1107-24 | pmid=11726886 | doi=10.1067/mtc.2001.116945 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11726886 }} </ref>
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| *Long term rates of re-operation appear to be similar in both valve repair and replacement.<ref name="pmid16928491">{{cite journal| author=Suri RM, Schaff HV, Dearani JA, Sundt TM, Daly RC, Mullany CJ et al.| title=Survival advantage and improved durability of mitral repair for leaflet prolapse subsets in the current era. | journal=Ann Thorac Surg | year= 2006 | volume= 82 | issue= 3 | pages= 819-26 | pmid=16928491 | doi=10.1016/j.athoracsur.2006.03.091 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16928491 }} </ref> However, among patients who underwent mitral valve surgeries between 1984 and 1997, 10 year rates of re-operation was shown to be lower with valve repair.<ref name="pmid12835220">{{cite journal| author=Thourani VH, Weintraub WS, Guyton RA, Jones EL, Williams WH, Elkabbani S et al.| title=Outcomes and long-term survival for patients undergoing mitral valve repair versus replacement: effect of age and concomitant coronary artery bypass grafting. | journal=Circulation | year= 2003 | volume= 108 | issue= 3 | pages= 298-304 | pmid=12835220 | doi=10.1161/01.CIR.0000079169.15862.13 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12835220 }} </ref>
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| ==Summary==
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| '''Advantages of [[Mitral valve repair]]:'''
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| #Improves left ventricular [[EF]] and function.
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| #Preserves native heart valve.
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| #Avoids long term use of [[anticoagulants]].
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| #Lower risk for [[endocarditis]].
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| #Has good overall outcome with good survival rates.
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| Based on above, '''ACC/AHA 2008 guidelines'''<ref name="pmid18848134">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 13 | pages= e1-142 | pmid=18848134 | doi=10.1016/j.jacc.2008.05.007 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18848134 }} </ref> recommend [[mitral valve repair]] rather than [[mitral valve replacement]] if the anatomy is appropriate, including patients with [[rheumatic]] mitral valve disease<ref name="pmid10612761">{{cite journal| author=Yau TM, El-Ghoneimi YA, Armstrong S, Ivanov J, David TE| title=Mitral valve repair and replacement for rheumatic disease. | journal=J Thorac Cardiovasc Surg | year= 2000 | volume= 119 | issue= 1 | pages= 53-60 | pmid=10612761 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10612761 }} </ref> and mitral valve prolapse<ref name="pmid11568020">{{cite journal| author=Mohty D, Orszulak TA, Schaff HV, Avierinos JF, Tajik JA, Enriquez-Sarano M| title=Very long-term survival and durability of mitral valve repair for mitral valve prolapse. | journal=Circulation | year= 2001 | volume= 104 | issue= 12 Suppl 1 | pages= I1-I7 | pmid=11568020 | doi= | pmc= | url= }} </ref> (Grade 1C). The procedure should be performed at experienced surgical centers.
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| ==References==
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| {{Reflist|2}}
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| [[Category:Cardiology]]
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| [[Category:Surgery]]
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| [[Category:Cardiac surgery]]
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| [[Category:Surgical procedures]]
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| [[Category:Overview complete]]
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| [[Category:Template complete]]
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| [[Category:For review]]
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| {{WH}}
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| {{WS}}
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