Mitral regurgitation surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]

Vasodilator theray with ACE inhibitors and hydralazine is the mainstay of therapy in patient with chronic compensated mitral regurgitation. Acute mitral regurgitation requires urgent mitral valve repair or mitral valve replacement. MV surgery is beneficial for patients with chronic severe MR and NYHA functional class II, III, or IV symptoms in the absence of severe LV dysfunction (severe LV dysfunction is defined as ejection fraction less than 0.30) and/or end-systolic dimension greater than 55 mm. MV surgery is beneficial for asymptomatic patients with chronic severe MR and mild to moderate LV dysfunction, ejection fraction 0.30 to 0.60, and/or end-systolic dimension greater than or equal to 40 mm. MV repair is recommended over MV replacement in the majority of patients with severe chronic MR who require surgery, and patients should be referred to surgical centers experienced in MV repair.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Sara Zand, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S. Synonyms and keywords: MR; Mitral regurgitation; LV; Left ventricle; LVESD; Left ventricular end systolic diameter; LVEF; Left ventricular ejection fraction; CABG; Coronary artery bypass grafting

Chronic secondary MR is associated with impaired prognosis and its management includes electrophysiological, transcatheter, and surgical interventions. Mitral valve surgery is recommended in patients with severe secondary MR undergoing CABG or other cardiac surgery. Decision of surgical approach should be individualized based on the patient characteristics. In selected patients without advanced LV remodelling, mitral valve repair resulted in improvement in symptoms, and reverse LV remodeling. Valve replacement prevents recurrence of mitral regurgitation. Mitral transcatheter edge to edge repair (TEER) with the MitraClip system is a minimal-invasive treatment option for secondary MR. Two RCTs (COAPT and MITRA-FR) demonstrated the safety and efficacy of procedure in patients with symptomatic heart failure and severe secondary MR despite medical therapy, who are not eligible for surgery.

• Primary MR is a mechanical problem of the leaflet coaptation that needs mitral valve mechanical intervention.
• Symptomatic patients with severe MR have worsened prognosis even with normal LV function. Therefore, the onset of symptoms is an indication of mitral valve surgery.^[1]
• The goal of therapy in MR is to correct it before the onset of LV systolic dysfunction.^[2]
• The ideal time for mitral valve surgery is when there is not evidence of LV systolic dysfunction (LVEF ≤60% or LVESD ≥40 mm).^[3]
• Mitral valve repair is recommended in the expertise center. However, mitral valve replacement is preferable to a poor repair.
• Annuloplasty and repair of the posterior leaflet have a lower mortality rate of <1%.^[4]
• The onset of symptoms, LV dysfunction, or pulmonary hypertension worsens the prognosis for MR.
• MR may lead to progressively more severe MR causing LV dilation, stress on the mitral apparatus, further damage to the valve apparatus, more severe MR, and further LV dilation and initiating a cycle of increasing LV volumes and MR.^[5]
• Longstanding volume overload leads to irreversible LV dysfunction and a poorer prognosis.
• Patients with severe MR who develop an LVEF <60% or LVESD ≥40 mm have already developed LV systolic dysfunction.
• LV function and size returned to normal after mitral valve repair in a study.^[6]
• Mitral Transcatheter edge-to-edge repair (TEER) with the anterior and posterior leaflets clipped together at ≥1 location is safe and effective in treating severely symptomatic primary MR who are at high risk for surgery.
• Studies of TEER with a mitral valve clip showed improved symptoms and a reduction in MR by 2 to 3 grades, leading to reverse remodeling of the LV.^[7]
• Rheumatic mitral valve disease is less suitable for mitral repair compared with complex degenerative disease.
• In the presence of thickened or calcified leaflets, an extensive subvalvular disease with chordal fusion and shortening, and progression of rheumatic disease the durability of repair would be limited.
• Repair of rheumatic mitral valve disease should be limited to patients with less advanced disease or in patients that mechanical prosthesis cannot be used because of anticoagulation contraindication.
• Mitral valve repair is recommended as follows:

• Severe primary MR limited to less than one-half of the posterior leaflet
• Inappropriate Mitral valve replacement

• Mortality rate of repair is <1%, long-term survival rate equivalent to that of age-matched general population, approximately 95% freedom from reoperation, and >80% freedom from recurrent moderate or severe (≥3) MR at 15 to 20 years after surgery.^[8]
• Posterior leaflet repair is preferred to mitral valve replacement with a success rate ≥95%.

Abbreviations: AF: Atrial fibrillation; LA: Left atrial; LV: Left ventricle; LVESD:Left ventricular end systolic diameter ; SPAP:Systolic pulmonary arterial pressure; LVEF: Left ventricular ejection fraction; TEER: Transcatheter edge to edge repair;

Abbreviations: AF: Atrial fibrillation; LA: Left atrial; LV: Left ventricle; LVESD:Left ventricular end systolic diameter ; SPAP:Systolic pulmonary arterial pressure; LVEF: Left ventricular ejection fraction; TEER: Transcatheter edge to edge repair;

• The COAPT trial of transcatheter treatment of secondary MR showed improvement in survival, hospitalization, symptoms, and quality of life in patients undergone TEER compared to only medical therapy.^[11]
• A greater reduction in MR severity with TEER is associated with greater LV and LA reverse remodeling.^[12][13]
• MR may develop in patients with preserved LV systolic function who have progressive LA dilation, leading to enlargement of the mitral annulus and malcoaptation of the leafle.
• This may arise in setting such as HF with preserved LVEF, restrictive cardiomyopathy, and nonobstructive hypertrophic cardiomyopathy.
• Presence of AF in these patients contributes to the progression of LA and annular dilation, thus increasing the severity of MR.^[14]
• Successful ablation of AF may reduce or eliminate MR.
• Mitral valve surgery was not associated with improved survival in symptomatic patients with secondary MR.However, surgery may improve symptoms and quality of life in symptomatic patients despite medical therapy.
• Small RCTs demonstrate that mitral valve surgery reduces chamber size and improves peak oxygen consumption in chronic severe secondary MR.
• Ischemic or dilated cardiomyopathy are different challenges for mitral repair.
• Regurgitation is caused by annular dilation, as well as by apical and lateral displacement of the papillary muscles.
• Progression of ventricular dilation has a negative effect on the long-term durability of the repair.
• In an RCT of mitral valve repair versus mitral valve replacement in patients with severe ischemic MR, there was no difference between repair and mitral valve replacement in survival rate or LV remodeling at 2 years. However, the rate of recurrence of moderate or severe MR over 2 years was higher in the repair group than in the replacement group, leading to a higher incidence of HF and repeat hospitalization.^[15]

Abbreviations: CABG: Coronary artery bypass grafting; CRT: Cardiac resynchronization therapy; LV: Left ventricle; MV:Mitral valve ; PCI:Percutaneous coronary intervention; LVAD: Left ventricular assist devices; TEER: Transcatheter edge to edge repair; TAVI: Transcatheter aortic valve implantation; CAD: Coronary artery disease

Abbreviations: CABG: Coronary artery bypass grafting; CRT: Cardiac resynchronization therapy; LV: Left ventricle; ERO:Effective regurgitation orifice area ; PCI:Percutaneous coronary intervention; LVEF: Left ventricular ejection fraction; TEER: Transcatheter edge to edge repair; TAVI: Transcatheter aortic valve implantation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]

Some of the tests that can be done before the procedure include cardiac catheterization, chest x-ray, echocardiogram (Doppler echocardiogram) and ECG. Usually, coronary disease treated at the same operation if CABG (Coronary artery bypass grafting) is indicated

The patient may need to have some tests before the procedure. The Cardiologist usually conducts a physical examination and diagnose the condition within few days, he or she will assess the general health of the patient and will recommend the most appropriate treatment for the patient and if he or she needs surgery. Some of the tests that can be done before the procedure include:

• Cardiac catheterization
• Chest x-ray
• Computed tomography scan
• Echocardiogram (Doppler echocardiogram)
• Electrocardiogram (ECG)
• Electrophysiology tests
• Exercise tests
• Holter monitor
• Magnetic resonance imaging (MRI)

Many patients with chronic MR requiring surgery also have coronary artery disease^[1]. Usually coronary disease treated at the same operation if CABG (Coronary artery bypass grafting) is indicated. Studies showed that concurrent bypass surgery adds little morbidity to the valvular procedure and does not increase the mortality ^[2]. The 2006 ACC/AHA guidelines on the treatment of valvular heart disease included recommendations for coronary angiography prior to valve surgery in those who are suspected to have coronary artery disease and in those at risk for coronary disease ^[2]. A noninvasive angiography using computed tomography (CT) or magnetic resonance imaging may be an alternative.

Before the surgery:

• The surgeon needs to know if the patient is taking any drugs, supplements, or herbs before the procedure.
• The patient may be able to store blood in the blood bank for transfusions during and after the surgery. The family members can also donate blood (autologous donation).
• For the 2-week period before surgery, the patient should be asked to stop taking drugs that make it harder for the blood to clot. These might cause increased bleeding during the surgery. Some of these drugs are aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn).
• The day before the surgery, the patient should shower and shampoo well and wash the whole body below the neck with a special soap.
• The patient may also be asked to take an antibiotic to guard against infection.
• The patient should be informed which drugs he or she should still take on the day of the surgery.
• The patient should stop smoking.

On the day of the surgery:

• An intravenous (IV) line will be placed into a blood vessel in the patient’s arm or chest to give fluids and medicines.
• The patient should be asked not to drink or eat anything after midnight the night before surgery. This includes chewing gum and using breath mints. The patient can rinse mouth with water if it feels dry without swallowing.
• Make sure that the patient is taking the drugs that he or she needs to take with a small sip of water.
• Hair near the incision site may be shaved immediately before the surgery.
• The patient should be informed when to arrive to hospital on the day of the surgery.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]

The Procedure can be done either by the traditional open heart surgery or by the minimally invasive surgery. The patient may or may not need to be on a heart-lung machine for these types of surgery, but if not, the heart rate will be slowed by medicine or a mechanical device.

• The Procedure can be done either by the traditional open heart surgery or by the minimally invasive surgery. Before the surgery, the patient will receive general anesthesia. This will make the patient asleep and pain-free during the entire procedure.^[1][2]

• Traditional open heart surgery:
  • The surgeon will make a 10-inch-long cut in the middle of the chest (sternum).
  • Next, the surgeon will separate the breastbone (sternum) to be able to see the heart.
  • Most people are connected to a heart-lung bypass machine or bypass pump. The heart is stopped while the patient is connected to this machine. This machine does the work of the heart while the heart is stopped.
  • A small cut is made on the left side of the heart so the surgeon can repair or replace the mitral valve.
• Minimally invasive mitral valve surgery; there are several different ways to perform the procedure:
  • The heart surgeon may make a 2-inch to 3-inch-long cut in the right part of your chest near the sternum (breastbone). Muscles in the area will be divided so the surgeon can reach the heart. A small cut is made in the left side of the heart so the surgeon can repair or replace the mitral valve.
  • In endoscopic surgery, the surgeon makes one to four small holes in the chest, then he or she uses special instruments and a camera to do the surgery.
  • For Robotically-assisted valve surgery, the surgeon makes two to four tiny cuts (about a ½ to a ¾ inch) in the chest. The surgeon uses a special computer to control robotic arms during the surgery. The surgeon sees a three-dimensional view of the heart and mitral valve on the computer. This method is very precise.

The patient may or may not need to be on a heart-lung machine for these types of surgery, but if not, the heart rate will be slowed by medicine or a mechanical device.

• If the surgeon can repair the mitral valve, the patient may have:
  • Ring annuloplasty: The surgeon repairs the ring-like part around the valve by sewing a ring of metal, cloth, or tissue around the valve.
  • Valve repair: The surgeon trims, shapes, or rebuilds one or more of the three leaflets of the valve. The leaflets are flaps that open and close the valve.
• If the mitral valve is too damaged, the patient will need a new valve. This is called Replacement surgery. The surgeon will remove the mitral valve and sew a new one into place. There are two types of valves:
  • 1. Mechanical which is made of man-made (synthetic) materials, such as a metal like titanium. These valves last the longest, but the patient will need to take blood-thinning medicine, such as warfarin (Coumadin) or aspirin, for the rest of his or her life.
  • 2. Biological which made of human or animal tissue. These valves last 10 to 12 years, but the patient may not need to take blood thinners for life.
• Once the new or repaired valve is working, the surgeon will:
  • Close the heart and take you off the heart-lung machine.
  • Place catheters (tubes) around the heart to drain fluids that build up.
  • Close the sternum with stainless steel wires. It will take about 6 weeks for the bone to heal. The wires will stay inside the body.
• The patient may have a temporary pacemaker connected to the heart until his or her natural heart rhythm returns.
• The surgeon may also perform coronary artery bypass surgery at the same time if needed.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]

The patient may spend 4 to 7 days in the hospital after surgery (much less in minimally invasive mitral valve surgery-3 to 5 days). Then patient will wake up in the intensive care unit (ICU) and recover there for 1 or 2 days. Two to three tubes will be in the patient’s chest to drain fluid from around the heart. They are usually removed 1 to 3 days after surgery.

Recovery at hospital

• The patient may spend 4 to 7 days in the hospital after surgery (much less in minimally invasive mitral valve surgery-3 to 5 days). Then patient will wake up in the intensive care unit (ICU) and recover there for 1 or 2 days. Two to three tubes will be in the patient’s chest to drain fluid from around the heart. They are usually removed 1 to 3 days after surgery.^[1]
• The patient may have a catheter in the bladder to drain urine, and may also have intravenous lines to get fluids. Nurses will closely watch monitors that show information about the vital signs (pulse, temperature, and breathing).
• The patient will be moved to a regular hospital room from the ICU. The nurses and doctors will continue to monitor the heart and vital signs until the patient is stable enough to go home. The patient will receive pain medicine to control pain around your surgical cut.^[2]
• A nurse should help the patient to slowly resume some activity, and the patient should begin a physical therapy program to make the heart and body stronger.
• A temporary pacemaker may be placed in the patient’s heart if the heart rate becomes too slow after surgery.

Recovery at home

• The patient should be informed about the following:

• Taking care for his or her healing incisions.
• Recognizing signs of infection or other complications.
• Coping with after-effects of surgery.
• Followup appointments, medicines, and situations when he or she should call the doctor right away.
• When he or she can go back to daily routine, such as working, driving, and physical activity.

• After-effects of heart surgery are normal. They may include muscle pain, chest pain, or swelling.
• Other after-effects may include loss of appetite, problems sleeping, constipation, and mood swings and depression. After-effects usually go away over time.
• Less recovery time is needed for off-pump heart surgery and minimally invasive heart surgery.

Ongoing care

• Ongoing care after valve surgery may include periodic checkups with the doctor. During these visits, the patient may have blood tests, an EKG (electrocardiogram), echocardiography, or a stress test. These tests will show how the patient’s heart is working after the surgery.
• Routine tests should be done to make sure the patient is getting the right amount of the blood-thinning medicine in case of mechanical valve placement.
• The patient may be advised to change his or her lifestyle, this includes quitting smoking, making changes to diet, being physically active, and reducing and managing stress.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]

The results of mitral valve repair are excellent in the centers that regularly perform this surgery. Techniques for minimally invasive heart valve surgery have improved greatly over the past 10 years. These techniques are safe for most patients, and they reduce recovery time and pain.

• The results of mitral valve repair are excellent in the centers that regularly perform this surgery.
• Techniques for minimally invasive heart valve surgery have improved greatly over the past 10 years. These techniques are safe for most patients, and they reduce recovery time and pain.

Valve repair versus valve replacement

• Advantages of mitral valve repair include:^{[1][2][3][4][5][6]}
  • Lower operative mortality rate
  • Improves left ventricular ejection fraction EF and function
  • Preserves native heart valve and avoids the use of a prosthetic heart valve with its complications.
  • Has good overall outcome with good survival rates
  • Lower risk for endocarditis
  • Avoids long term use of anticoagulants

Mechanical versus Biological valves

• Mechanical heart valves do not fail often. They last from 12 to 20 years. However, blood clots develop on them. If a blood clot forms, the patient may have a stroke. Bleeding can occur, but this is rare.
• Biological valves tend to fail over time, but they have a lower risk of blood clots.^[7][8]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]

Common complications of mitral regurgitation surgery blood loss, systemic embolization, structural deterioration, left ventricular systolic dysfunction, endocarditis and other infections.

• Common complications of mitral regurgitation surgery including:^[1][2][3]

Risks for any surgery

• Blood clots in the legs that may travel to the lungs
• Blood loss
• Breathing problems
• Infection, including in the lungs, kidneys, bladder, chest, or heart valves
• Reactions to medicines

Possible risks from having open-heart surgery

• Heart attack or stroke
• Heart rhythm problems
• Infection in the cut, which is more likely to happen in people who are obese, have diabetes, or have already had this surgery.
• Memory loss and loss of mental clarity, or “fuzzy thinking.”
• Post-pericardiotomy syndrome, which is a low-grade fever and chest pain. This could last for up to 6 months.

Prosthetic heart valves are associated with a variety of complications

• Structural deterioration, particularly with bioprosthetic valves
• Valve obstruction due to thrombosis or pannus formation
• Systemic embolization
• Bleeding
• Endocarditis and other infections
• Left ventricular systolic dysfunction, which may be preexisting.
• Hemolytic anemia

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Mohammed A. Sbeih, M.D. [2]

• Minimally invasive mitral valve surgery (right thoracotomy approach)

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• Robotic mitral valve repair surgery animation- part 1

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• Robotic mitral valve repair surgery animation- part 2

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