Mitral valve repair is a

cardiac surgery Cardiac surgery, or cardiovascular surgery, is surgery on the heart or great vessels performed by cardiac surgeons. It is often used to treat complications of ischemic heart disease (for example, with coronary artery bypass grafting); to corr ...

procedure performed by

cardiac surgeon Cardiac surgery, or cardiovascular surgery, is surgery on the heart or great vessels performed by cardiac surgeons. It is often used to treat complications of ischemic heart disease (for example, with coronary artery bypass grafting); to cor ...

s to treat

stenosis A stenosis (from Ancient Greek στενός, "narrow") is an abnormal narrowing in a blood vessel or other tubular organ or structure such as foramina and canals. It is also sometimes called a stricture (as in urethral stricture). ''Stricture'' ...

(narrowing) or regurgitation (leakage) of the

mitral valve The mitral valve (), also known as the bicuspid valve or left atrioventricular valve, is one of the four heart valves. It has two cusps or flaps and lies between the left atrium and the left ventricle of the heart. The heart valves are all one-w ...

. The mitral valve is the "inflow valve" for the left side of the

heart The heart is a muscular organ in most animals. This organ pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste such as carbon dioxide t ...

Blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the c ...

flows from the

lungs The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of th ...

, where it picks up oxygen, through the

pulmonary vein The pulmonary veins are the veins that transfer oxygenated blood from the lungs to the heart. The largest pulmonary veins are the four ''main pulmonary veins'', two from each lung that drain into the left atrium of the heart. The pulmonary vein ...

s, to the

left atrium The atrium ( la, ātrium, , entry hall) is one of two upper chambers in the heart that receives blood from the circulatory system. The blood in the atria is pumped into the heart ventricles through the atrioventricular valves. There are two atr ...

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, known as cusps. 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), and re-suspension of the leaflets with artificial (

Gore-Tex Gore-Tex is a waterproof, breathable fabric membrane and registered trademark of W. L. Gore & Associates. Invented in 1969, Gore-Tex can repel liquid water while allowing water vapor to pass through and is designed to be a lightweight, waterpr ...

) cords. Procedures on the mitral valve usually require a

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 using a sternal saw. This procedure provides access to the heart and lungs for surgical pro ...

, but advances in non-invasive methods (such as

keyhole surgery Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medl ...

) 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 A birth defect, also known as a congenital disorder, is an abnormal condition that is present at birth regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. The disabilities can ...

). More often the mitral valve becomes abnormal with age ( degenerative) or as a result of

rheumatic fever Rheumatic fever (RF) is an inflammatory disease that can involve the heart, joints, skin, and brain. The disease typically develops two to four weeks after a streptococcal throat infection. Signs and symptoms include fever, multiple painful jo ...

. In rare instances the mitral valve can be destroyed by infection or a bacterial

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 the ...

. Mitral regurgitation may also occur as a result of

ischemic heart disease Coronary artery disease (CAD), also called coronary heart disease (CHD), ischemic heart disease (IHD), myocardial ischemia, or simply heart disease, involves the reduction of blood flow to the heart muscle due to build-up of atherosclerotic pla ...

(coronary artery disease) or non-ischemic heart disease (dilated cardiomyopathy).

History

In 1923 Dr.

Elliott Cutler Elliot Carr Cutler (July 30, 1888 – August 16, 1947) was an American surgeon, military physician, and medical educator. He was Moseley Professor of Surgery at Harvard Medical School, surgeon-in-chief at Peter Bent Brigham Hospital from 1932 t ...

of the

Peter Bent Brigham Hospital Brigham and Women's Hospital (BWH) is the second largest teaching hospital of Harvard Medical School and the largest hospital in the Longwood Medical Area in Boston, Massachusetts. Along with Massachusetts General Hospital, it is one of the two fo ...

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 Mitral valve replacement is a procedure whereby the diseased mitral valve of a patient's heart is replaced by either a mechanical or tissue (bioprosthetic) valve. The mitral valve may need to be replaced because: * The valve is leaky ( mitral va ...

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 Anticoagulants, commonly known as blood thinners, are chemical substances that prevent or reduce coagulation of blood, prolonging the clotting time. Some of them occur naturally in blood-eating animals such as leeches and mosquitoes, where the ...

for the rest of their lives, which presents a risk of bleeding complications. The artificial mitral valve has an elevated risk of stroke. Patients with mechanical heart valves who use warfarin for anticoagulation have to be on long-term anticoagulation therapy. This means they must go to the clinic and have a lab blood draw done, typically once a month but more frequently if the level needs to be closely monitored until it is in the therapeutic range. The therapeutic range for most adults with a mechanical valve is an INR of 2.5–3.5. 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

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 a ''replacement'' is the best course of action. For patients with the most common type of mitral valve disease, termed "degenerative" or "myxomatous" mitral valve disease, repair rates are very high and long term durability is excellent. There has been great debate about timing of surgery in patients with asymptomatic mitral valve regurgitation. The traditional surgical approach to a mitral valve repair is a full or partial sternotomy, in which the surgeon cuts through the breastbone at the center of the chest to access the heart. There are

minimally invasive Minimally invasive procedures (also known as minimally invasive surgeries) encompass surgical techniques that limit the size of incisions needed, thereby reducing wound healing time, associated pain, and risk of infection. Surgery by definition ...

(port access) options available pioneered by Hugo Vanerman in Belgium. The minimally invasive approach does not involve cutting the breastbone, but instead uses multiple incisions in the side of the chest and the leg. Cardiac surgeons are not unanimous about the relative merits of sternotomy versus the minimally invasive approach. The minimally invasive approach can produce a less prominent scar, is beneficial for very obese patients, and may allow the patient to return to their normal activity sooner than a sternotomy. But some cardiac surgeons argue that unless performed by the most experienced cardiac centers, minimally invasive surgery can involve a longer time on a bypass machine, a lower repair rate, and higher (although still low) risk of stroke. One cardiac surgery professor said, "I think the only benefit is for

cosmesis Cosmesis is the preservation, restoration, or bestowing of bodily beauty.''Dorland's Medical Dictionary''. 25th ed. Philadelphia: W.B. Saunders Co.; 1995 In the medical context, it usually refers to the surgical correction of a disfiguring defect, o ...

for the patient and the benefit is for marketing and growing our practices for ourselves because it’s a good way to grow one's practice." Robotic mitral valve repair operations are also being utilized throughout the United States. 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 {{More citations needed, date=January 2021 In surgery, a percutaneous procedurei.e. Granger et al., 2012 is any medical procedure or method where access to inner organs or other tissue is done via needle-puncture of the skin, rather than by using ...

mitral valve repair – is available in Europe but still in clinical trial in the United States. It is a highly specialized technique only available at select hospitals. Early trial results suggest that it may be a beneficial approach for patients who are at high risk from conventional surgery. As early as January 2000 a team of doctors at the Instituto de Cardiología y Cirugía Cardiovascular in

La Habana Havana (; Spanish: ''La Habana'' ) is the capital and largest city of Cuba. The heart of the La Habana Province, Havana is the country's main port and commercial center.

Cuba Cuba ( , ), officially the Republic of Cuba ( es, República de Cuba, links=no ), is an island country comprising the island of Cuba, as well as Isla de la Juventud and several minor archipelagos. Cuba is located where the northern Caribbea ...

have performed beating heart mitral valve repair or replacement. The beating heart mitral valve replacement technique is as safe as the arrested heart technique, and is the recommended alternative to arrested heart technique.

History

See also

References

Further reading