Mitral Valve Repair

Mitral valve repair is commonly used for patients with mitral regurgitation (MR) due to mitral valve prolapse (degenerative disease), annular dilatation and leaking associated with enlarged hearts (coronary disease or dilated hearts). It is the standard of care for treating patients with degenerative mitral disease with prolapse in major cardiac surgery centers. The advantage of a repair compared to a replacement is the avoidance of having a prosthetic valve with limited durability (10-15 years) and/or avoiding life-long blood thinner use. Furthermore, a repair also results in having a life expectancy comparable to the same age-sex population. Unfortunately, 40-50% of patients with severe mitral disease are not candidates for surgery due to advance age, frailty or associated medical issues. Many patients have valves anatomically no repairable or disease in which repair is not advisable (endocarditis, failed repairs, ischemic MR and others)

Mitral repair patient outcomes depend on many factors such as preoperative functional status, etiology of the leak, complexity of the prolapse, surgeon and center experience and volume and technique of repair.

The younger the patient, the longer the life expectancy and the lowest the symptom level, the higher should be the repairability rate and lowest the surgical mortality. Centers of high volume of mitral valve surgery and expertise, like ours, offer a repairability rate > 95% and mortality rate of < 1 % for patients with isolated mitral valve prolapse and also high success rates with repair for the other forms of mitral regurgitation.

In high surgical risk patients, prior surgery or advanced age, the choice of surgery, percutaneous clipping (TEER) or medical management should be carefully decided.

Standard mitral valve repair is performed commonly through a sternal incision using full cardiopulmonary bypass and stopping and protecting the heart (cardioplegic arrest). Other surgical approaches with limited incisions include partial sternotomy, mini-thoracotomy and robotically assisted. The main goals of a mitral repair are to preserve the patient’s own valve and create durable competency by normalizing coaptation of the leaflets and decreasing the size of the annulus by using a thin prosthetic ring or band. Different techniques are used to reduce the size of the leaflets (partial resection) or using artificial sutures (chorda) to bring the prolapsed leaflet segment down to the plane of coaptation.

The most common approach to expose the valve is through a median sternotomy. It is the gold standard of all heart operations. In our service, it is used through a limited skin incision of 10-12 cm for cosmesis. It provides excellent exposure and shorter cross clamp and operative time. It is necessary also for patients requiring associated procedures such as coronary bypass (CABG), aortic aneurysm repair and other valves like the aortic or tricuspid.

Less invasive approaches such as the mini-thoracotomy incision is used selectively in patients. It is performed through a small lateral incision (6-8 cm) and through the rib cage. Requires an additional groin incision to use the femoral vessels for canulation and bypass. Although the operation entails longer bypass and cardiac arrest time, results in a better cosmetic result.

The transcatheter mitral valve repair (TEER procedure) or Mitra-clip is a new technique used to clip the mitral valve leaflets to reduce leakage. It is performed through a catheter placed through the groin vein and then advanced through the heart chambers. It is reserved for patients with very high or prohibitive surgical risk for open repair. In our Program, Mitra-clip (TEER) is performed routinely by our structural heart disease colleagues and we make decisions about these different therapies available as a multi-disciplinary team.