Mitral valve repair

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Mitral valve repair is a cardiac surgery procedure performed by cardiac surgeons to treat stenosis (narrowing) or regurgitation (leakage) of the mitral valve. The mitral valve is the "inflow valve" for the left side of the heart. Blood flows from the lungs, where it picks up oxygen, through the pulmonary veins, to the left atrium of the heart. After the left atrium fills with blood, the mitral valve allows blood to flow from the left atrium into the heart's main pumping chamber called the left ventricle. It then closes to keep blood from leaking back into the left atrium or lungs when the ventricle contracts (squeezes) to push blood out to the body. It has two flaps, or leaflets.

The techniques of mitral valve repair include inserting a cloth-covered ring around the valve to bring the leaflets into contact with each other (annuloplasty), removal of redundant/loose segments of the leaflets (quadrangular resection), re-suspension of the leaflets with artificial (Gore-Tex) cords. More recently the Alfieri stitch (or "bow-tie") has been adapted to allow percutaneous repair in select patients.

Procedures on the mitral valve usually require a median sternotomy, but advances in non-invasive methods (such as keyhole surgery) allow surgery without a sternotomy (and resulting pain and scar). Minimally invasive mitral valve surgery is much more technically demanding and may involve higher risk.

Occasionally, the mitral valve is abnormal from birth (congenital). More often the mitral valve becomes abnormal with age (degenerative) or as a result of rheumatic fever. In rare instances the mitral valve can be destroyed by infection or a bacterial endocarditis. Mitral regurgitation may also occur as a result of ischemic heart disease (coronary artery disease).

History of Mitral Valve Repair

In 1923 Dr. Elliot Cutler of the Peter Bent Brigham Hospital performed the world’s first successful heart valve surgery - a mitral valve repair. The patient was a 12-year-old girl with rheumatic mitral stenosis.

The development of the heart-lung machine in the 1950s paved the way for replacement of the mitral valve with an artificial valve in the 1960s. For decades after mitral valve replacement was the only surgical option for patients with a severely diseased mitral valve. However there are some significant downsides to an prosthetic mitral valve. Infection of the valve can occur, which are dangerous and difficult to treat. Patients with mechanical heart valves are required to take blood thinners for the rest of their lives which presents a risk of bleeding complications. The artificial mitral valve has an elevated risk of stroke. Finally artificial tissue valves will wear out - on average lasting between 10 and 15 years, requiring further surgery at an advanced age.

In the last two decades, some surgeons have embraced surgical techniques to repair the damaged native valve, rather than replace it. These techniques were pioneered by a French heart surgeon, Dr. Alain F. Carpentier. A repair still involves major cardiac surgery but for many patients presents the major advantage of avoiding blood thinners and may provide a more durable result. Not all damaged valves are suitable for repair - in some the state of valve disease is too advanced and replacement is necessary. Often a surgeon can only make a decision of repair versus replace during the actual operation.

In the 2000s there have been several trials of a newer strategy of mitral valve repair that does not require major cardiac surgery. Through a catheter inserted in the groin the valve leaflets are clipped together. This technique - percutaneous mitral valve repair - remains under trial, is very specialized and is only available at a select number of hospitals worldwide.

Below is a video of mitral valve repair in commissural prolapse {{#ev:youtube|7NdPjob4ZFE}}

Animation of minimally invasive robotic mitral valve repair {{#ev:youtube|VrIxRfWDOm8}}

2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT)

Myxomatous Mitral Valve (DO NOT EDIT)

Class I

"1. MV repair is recommended when anatomically possible for patients with severe degenerative MR who fulfill clinical indications, and patients should be referred to surgeons who are expert in repair. (Level of Evidence: B)"

"2. Patients who have undergone successful MV repair should continue to receive antibiotics as indicated for endocarditis prophylaxis. (Level of Evidence: C)"

"3. Patients who have undergone successful MV repair and have chronic or atrial fibrillation should continue to receive long-term anticoagulation with warfarin. (Level of Evidence: B)"

"4. Patients who have undergone successful MV repair should undergo 2D and Doppler echocardiography before discharge or at the first postoperative outpatient visit. (Level of Evidence: C)"

"5. Tricuspid valve repair is beneficial for severe TR in patients with MV disease that requires MV surgery. (Level of Evidence: B)"

Class IIa

"1. Oral anticoagulation is reasonable for the first 3 months after MV repair. (Level of Evidence: C)"

"2. Long-term treatment with low-dose aspirin (75 to 100 mg per day) is reasonable in patients who have undergone successful MV repair and remain in sinus rhythm. (Level of Evidence: C)"

"3. Tricuspid annuloplasty is reasonable for mild TR in patients undergoing MV repair when there is pulmonary hypertension or tricuspid annular dilatation. (Level of Evidence: C)"

Class IIb

"1. In patients with MR and a history of atrial fibrillation, a Maze procedure may be considered at the time of MV repair. (Level of Evidence: B)"

Intraoperative Assessment (DO NOT EDIT)

Class I

"1. Intraoperative transesophageal echocardiography is recommended for valve repair surgery. (Level of Evidence: B)"

Class IIa

"1. Intraoperative transesophageal echocardiography is reasonable for all patients undergoing cardiac valve surgery. (Level of Evidence: C)"

Sources

• 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease

Related chapters

• Aortic valve repair
• Cardiac surgery