Mitral valve repair
Encyclopedia
Mitral valve repair is a cardiac surgery
procedure performed by cardiac surgeon
s 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 vein
s, 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).
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 a prosthetic mitral valve
. Infection of the valve can occur, which is 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 past 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 significant 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 must decide during the operation itself whether a repair or replacement is the best course of action.
There has been great debate about timing of surgery in patients with asymptomatic mitral valve regurgitation. There are minimally invasive (port access) options available pioneered by Hugo Vanerman in Belgium. These methods may be safer, and allow the patient to return to their normal activity much sooner than the standard approach. Robotic mitral valve repair operations are also being tested at some medical centers.
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.
Cardiac surgery
Cardiovascular surgery is surgery on the heart or great vessels performed by cardiac surgeons. Frequently, it is done to treat complications of ischemic heart disease , correct congenital heart disease, or treat valvular heart disease from various causes including endocarditis, rheumatic heart...
procedure performed by cardiac surgeon
Cardiac surgeon
A cardiac surgeon is a surgeon who performs cardiac surgery—operative procedures on the heart and great vessels.-Training:A cardiac surgery residency typically comprises anywhere from six to nine years of training to become a fully qualified surgeon...
s to treat stenosis
Stenosis
A stenosis is an abnormal narrowing in a blood vessel or other tubular organ or structure.It is also sometimes called a stricture ....
(narrowing) or regurgitation
Regurgitation (circulation)
Regurgitation is blood flow in the opposite direction from normal, as the backward flowing of blood into the heart or between heart chambers. Can be categorized by:...
(leakage) of the mitral valve
Mitral valve
The mitral valve is a dual-flap valve in the heart that lies between the left atrium and the left ventricle...
. The mitral valve is the "inflow valve" for the left side of the heart
Heart
The heart is a myogenic muscular organ found in all animals with a circulatory system , that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions...
. Blood
Blood
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....
flows from the lungs, where it picks up oxygen, through the pulmonary vein
Pulmonary vein
The pulmonary veins are large blood vessels that carry blood from the lungs to the left atrium of the heart. In humans there are four pulmonary veins, two from each lung...
s, to the left atrium
Left atrium
The left atrium is one of the four chambers in the human heart. It receives oxygenated blood from the pulmonary veins, and pumps it into the left ventricle, via the mitral valve.-Foramen ovale:...
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
Ventricle (heart)
In the heart, a ventricle is one of two large chambers that collect and expel blood received from an atrium towards the peripheral beds within the body and lungs. The Atria primes the Pump...
. 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
Mitral valve annuloplasty
Mitral valve annuloplasty is a surgical technique for the repair of leaking mitral valves. Due to various factors, the two leaflets normally involved in sealing the mitral valve to retrograde flow may not coapt properly...
), removal of redundant/loose segments of the leaflets (quadrangular resection), re-suspension of the leaflets with artificial (Gore-Tex
Gore-Tex
Gore-Tex is a waterproof/breathable fabric, and a registered trademark of W. L. Gore and Associates. It was co-invented by Wilbert L. Gore, Rowena Taylor, and Gore's son, Robert W. Gore. Robert Gore was granted on April 27, 1976, for a porous form of polytetrafluoroethylene with a...
) cords. More recently the Alfieri stitch (or "bow-tie") has been adapted to allow percutaneous
Percutaneous
In surgery, percutaneous pertains to any medical procedure where access to inner organs or other tissue is done via needle-puncture of the skin, rather than by using an "open" approach where inner organs or tissue are exposed .The percutaneous approach is commonly used in vascular procedures...
repair in select patients.
Procedures on the mitral valve usually require a median sternotomy
Median sternotomy
Median sternotomy is a type of surgical procedure in which a vertical inline incision is made along the sternum, after which the sternum itself is divided, or "cracked"...
, 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
Rheumatic fever
Rheumatic fever is an inflammatory disease that occurs following a Streptococcus pyogenes infection, such as strep throat or scarlet fever. Believed to be caused by antibody cross-reactivity that can involve the heart, joints, skin, and brain, the illness typically develops two to three weeks after...
. In rare instances the mitral valve can be destroyed by infection or a bacterial endocarditis
Endocarditis
Endocarditis is an inflammation of the inner layer of the heart, the endocardium. It usually involves the heart valves . Other structures that may be involved include the interventricular septum, the chordae tendineae, the mural endocardium, or even on intracardiac devices...
. Mitral regurgitation may also occur as a result of ischemic heart disease (coronary artery disease).
History
In 1923 Dr. Elliott CutlerElliott Cutler
Brigadier General Elliot Carr Cutler CB, OBE, FRCS, MD, FACS was an American surgeon and medical educator. He was Moseley Professor of Surgery at Harvard Medical School, Surgeon-in-Chief at Peter Bent Brigham Hospital from 1932 to 1947., and a Brigadier General in the U.S...
of the Peter Bent Brigham Hospital
Brigham and Women's Hospital
Brigham and Women's Hospital is the largest hospital of the Longwood Medical and Academic Area in Boston, Massachusetts. It is directly adjacent to Harvard Medical School of which it is the second largest teaching affiliate with 793 beds...
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
Artificial heart valve
An artificial heart valve is a device implanted in the heart of a patient with heart valvular disease. When one of the four heart valves malfunctions, the medical choice may be to replace the natural valve with an artificial valve. This requires open-heart surgery.Valves are integral to the normal...
in the 1960s. For decades after, mitral valve replacement
Mitral valve replacement
Mitral valve replacement is a cardiac surgery procedure in which a patient’s mitral valve is replaced by a different valve. Mitral valve replacement is typically performed robotically or manually, when the valve becomes too tight for blood to flow into the left ventricle, or too loose in which...
was the only surgical option for patients with a severely diseased mitral valve. However, there are some significant downsides to a prosthetic mitral valve
Artificial heart valve
An artificial heart valve is a device implanted in the heart of a patient with heart valvular disease. When one of the four heart valves malfunctions, the medical choice may be to replace the natural valve with an artificial valve. This requires open-heart surgery.Valves are integral to the normal...
. Infection of the valve can occur, which is 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 past 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
Alain F. Carpentier
Alain Frédéric Carpentier M.D. Ph.D. is a French surgeon whom the President of the American Association for Thoracic Surgery calls the father of modern mitral valve repair. He is the recipient of the 2007 Lasker Prize.-Biography:A professor emeritus at Pierre and Marie Curie University, in the...
. A repair still involves major cardiac surgery but for many patients presents the significant 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 must decide during the operation itself whether a repair or replacement is the best course of action.
There has been great debate about timing of surgery in patients with asymptomatic mitral valve regurgitation. There are minimally invasive (port access) options available pioneered by Hugo Vanerman in Belgium. These methods may be safer, and allow the patient to return to their normal activity much sooner than the standard approach. Robotic mitral valve repair operations are also being tested at some medical centers.
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
Percutaneous
In surgery, percutaneous pertains to any medical procedure where access to inner organs or other tissue is done via needle-puncture of the skin, rather than by using an "open" approach where inner organs or tissue are exposed .The percutaneous approach is commonly used in vascular procedures...
mitral valve repair - remains under trial, is very specialized and is only available at a select number of hospitals worldwide.
Further reading
- Visit the educational website www.themitralvalve.org. This is the first and the most comprehensive web portal tracing the history of valvular heart disease over a five-century period. The Historic Review component of the website has an extensive section on the history of mitral valve surgery.
External links
- Mitral Valve Repair at The Mount Sinai Hospital
- Brigham and Women's Hospital Valve Centre
- Co-ordinating centre for trial of percutaneous mitral valve repair in the United States
- Mitral Valve Repair at the University of Maryland Medical Center
- Mitral Valve Repair at NYU Langone Medical Center's Cardiac and Vascular Institute
- http://www.themitralvalve.org/mitralvalve/index.html Filsoufi F, Carpentier A. www.themitralvalve.org-the most comprehensive educational website on mitral valve disease