If it’s difficult to visualize how the mitral valve regulates blood flow between the heart’s two pumping chambers, think of the valve as French doors. When the two sides don’t close properly, the valve starts leaking.
The No. 1 disease of the mitral valve is a leaky valve. Anytime you replace a part in the heart, you get something artificial. That artificial piece can wear and tear and create clots that can cause strokes.
If you restore the valve, it's always better because you can restore the valve to its natural form. It does not wear. It does not tear. It resists infection. I've performed more than 2,000 mitral valve repairs since doing the first in New England in 1984. My experience, and multiple research studies, leave little doubt that repair is always a patient’s best option.
The outlook is excellent when patients keep their valve intact and the structure of the heart remains intact. In fact, these patients are like the normal population –- the quality of life and longevity are excellent, far superior to when we replace the valve. I want you to rest assured that our team is by far the most experienced in valve surgery in the state of Connecticut and beyond.
– Introduction by Dr. Sabet Hashim, chairman of cardiac surgery and co-physician-in-chief of the Heart & Vascular Institute.
(Learn more about Dr. Hashim here .)
Three Types Of Mitral Valve Disease
- Mitral Valve Regurgitation: The most common heart-valve disorder, when blood leaks backward through the mitral valve and into the left atrium (the heart’s upper chamber) each time the left ventricle contracts. Blood, in effect, is moving in two directions because it’s also flowing from the ventricle through the aortic valve – the heart’s normal function that helps replenish the body with oxygen-rich blood. In this case, however, it’s not enough.
- Mitral Valve Prolapse (also known as Barlow’s syndrome or click-murmur syndrome): When the mitral valve’s two flaps bulge back, or prolapse, into the left atrium, it’s usually a harmless malfunction that affects 2 percent to 3 percent of the general population. If the valve does not seal properly, however, some blood can flow back from the ventricle into the atrium (regurgitation).
- Mitral Valve Stenosis (also known as mitral stenosis): A narrowing of the mitral valve opening, often scarred or stiffened, that restricts blood flow to the left ventricle from the left atrium. This condition, attributed to rheumatic fever, is rare in the United States
Learn more about symptoms, causes and risk factors of these conditions here.
Here's one mitral-valve patient's story:
Choosing A Surgeon
Because mitral-valve repair is a highly specialize procedure, the quality of the result depends more on the operating surgeon than the disease of the patient.
The American Heart Association and the American College of Cardiology both recommend referral of mitral patients to a surgeon with at least a 90 percent repair (vs. replace) rate. The repair rate for patients with leaking mitral valves at the Heart & Vascular Institute is close to 100 percent. Your surgeon should tell you, before your surgery, whether your valve will be repaired.
What’s New In Mitral Valve Repair?
An innovative adaptation of conventional ring annuloplasty developed by Dr. Hashim has proved a highly effective treatment for patients with severe mitral regurgitation (a leaky valve) resulting from a heart attack.
"Traditionally," he says, "those valves were repaired using a ring around the valve. This has failed. There were a lot of recurrences using this failed method. So the trend now is to replace those valves."
Unfortunately, replacement valves are not as durable, requiring yet another replacement years later and patients' quality of life often suffers.
"Our new technique adds to the ring some new cords made of Gore-Tex that realign the valve's leaflets," says Dr Hashim.
Learn More: Mitral Valve Repair
The conventional procedure uses a ring made of flexible braided polyester or metal sewn around the valve. During the procedure, tissue is typically removed, or resected. “My idea,” says Dr. Hashim, “was to realign the leaflet, using the existing tissue. We apply the same ring while avoiding resection.”
Dr. Hashim and his team presented the results of a 10-year study that followed 60 patients whose mitral valves were repaired using this method at the American Association of Thoracic Surgery’s Mitral Conclave in April 2017.
“During the study,” says Dr. Hashim, “only two patients came back because of a leaky valve.”
Dr. Hashim, who performed the first heart transplant in Connecticut in 1984, says this technique has changed the outlook for patients with severe mitral regurgitation.
“We’ve shown that this type of repair is durable and patients live longer and they do live better,” he says. “I firmly believe there is a repair for these types of patients and I think this technique is the answer.”
Dr. Hashim describes his technique in this video:
MitraClip: A Less-Invasive Procedure
Some of Dr. Hashim’s colleagues at the Heart & Vascular Institute are using a technique called MitraClip for mitral-regurgitation patients too ill to withstand open-heart surgery and a temporary stoppage of the heart. In this less-invasive approach, doctors reach the heart through a thin tube called a catheter inserted into a vein in your leg.
The MitraClip, as the name suggests, is a mesh clip no taller than a dime that attaches to your mitral valve, allowing the valve to close more securely and prevent the backflow of blood into the atrium from the ventricle. In most cases, patients are released from the hospital within three days.
Watch this simulation of a mitraclip procedure:
If You Have A Mitral Valve Repair Procedure
Through Dr. Hashim’s work, incisions are now as small as three inches in a mitral valve procedure. Here are three options:
Anterior Thoracotomy Incision: The anterior thoracotomy approach avoids cutting the sternal bone and instead utilizes a 2-inch horizontal incision lateral to the nipple. The chest is entered between the ribs in the fourth intercostal space. The use of long-shafted instruments and a magnifying camera allow for precise work on the mitral valve. Dr. Hashim favors this new approach over robotic surgery, as it uses the same incisions and access but provides for tactile feedback from the instruments as they navigate the tissues of the valve.
The Mini Lower Sternotomy Incision: The mini lower sternotomy incision is a 3-inch vertical incision over the lower part of the sternum. This incision avoids the upper sternum and provides the patient in recovery with greater flexibility in movement of the upper chest, enabling for an early return to driving.
Submammary Incision: The submammary approach provides the same inside access as the mini lower sternotomy, but uses a 2-inch curvilinear skin incision located within the bra line. Dr. Hashim developed this technique to provide his female patients who require a lower sternotomy incision with optimal aesthetic results.
What's New In Mitral Valve Replacement?
The expanded use of a heart-valve replacement technology for patients too ill for open-heart surgery, approved in June 2017 by the Food and Drug Administration, was adopted quickly by doctors at the Heart & Vascular Institute.
Transcatheter Mitral Valve Replacement, or TMVR, allows doctors to replace a malfunctioning mitral valve -- either the patient's own or bioprosthetic valve from a previous surgery -- using a small tube called a catheter inserted into a large vein in the groin instead of conventional open-heart surgery. The FDA's approval applies specifically to the Sapien 3 Transcatheter Heart Valve from Edwards Lifesciences..
"Approval is limited to patients who are deemed a high risk for repeat open-heart surgery," says Dr. Raymond McKay, one of the doctors who performed the first TMVR procedure at the Heart & Vascular Institute in August, "and only for patients who have already undergone previous surgical mitral valve replacement."
The mitral valve, two flaps between the left atrium and left ventricle, controls blood flow between the two chambers. It's a one-way valve, allowing blood from the left atrium into the left ventricle while preventing the reverse flow into the left ventricle. Mitral valve regurgitation, when the valve doesn't close properly and allows backward blood flow, can cause shortness of breath, fatigue, swollen ankles or feet and heart palpitations.
TMVR uses the same technology as as the Transcatheter Aortic Valve Replacement, or TAVR, approved by the FDA in November 2011 for use in inoperable patients and in October 2012 for use in high-risk patients. The procedure, which places a new aortic valve within the existing valve, is also being used now in moderate-risk cases.
Some hospitals use what's known as off-label TAVR, not approved by FDA -- about 10 percent of all TAVR procedures in the United States. These procedures were associated with higher in-hospital 30-day and one-year mortality rates, though the one-year mortality rate was similar to the FDA-approved TAVR, according to the Transcatheter Valve Therapy Registry.