Why should patients with severe mitral insufficiency undergo surgery?

Dr. Xavier Ruyra is a specialist in cardiovascular surgery, head of service at the Germans Trias i Pujol University Hospital in Badalona and the Vida al Cor Cardiac Surgery Unit at CM Teknon. Within his specialty, he focuses his care activity on the Reconstructive Surgery of Heart Valves, the Ross operation, bloodless heart surgery and new alternatives for the pathology of the aortic valve in high-risk patients.

How can heart valves be affected?

There are four heart valves in the heart and their function is to ensure that blood flows in the right direction and in the right way. The valves can be affected because they are not able to open properly (stenosis) or because they cannot close properly (insufficiency). Nowadays, in Western countries and with the progressive aging of the population, the most frequent pathologies are aortic valve stenosis requiring valve replacement and mitral insufficiency of degenerative origin, which affects 6.4% of people between 65 and 74 years of age and 9.3% of people over 75 years of age.

Why should patients with severe mitral regurgitation undergo surgery?

When the mitral valve is unable to close properly, a large part of the volume of blood expelled by the heart at each beat is directed backwards, congesting the lungs and placing a volume overload on the heart itself. This heart, in the attempt to adapt, will become larger (dilatation) and will lose contractile force. The patient will feel more fatigued, with breathing difficulties and may have complications such as arrhythmias or embolisms. It is very important to restore the normal functioning of the valve before the repercussions on the heart become significant.

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Is it better to repair the valve than to replace it with an artificial prosthesis?

Until a few years ago, all patients with severe mitral valve insufficiency who underwent surgery had the affected valve replaced with an artificial prosthesis. Today we know that the best option is not replacement but preservation and repair of the patient’s own valve. The advantages are very significant:

  • We better preserve the architecture and function of the heart.
  • In many cases we avoid having to take anticoagulants such as acenocoumarol for life.
  • We reduce the operative risk and achieve a better and faster recovery.
  • We reduce the occurrence of complications.

The advantages are so important that early surgery (even before symptoms) is now recommended for all patients with severe mitral regurgitation, if we can ensure an effective repair in more than 95% of cases and a surgical risk of less than 1%.

Can all valves with insufficiency be repaired?

The mitral valve is a very complex structure, with many anatomical elements that must interact with each other in a coordinated manner to achieve perfect valve closure. We must study the mitral annulus, the two leaflets (anterior and posterior), the multiple chordae tendineae, the papillary muscles and the wall of the left ventricle itself. In degenerative valve disease, which is the most common, we always find excessive mobility of the leaflets during cardiac contraction (prolapse) and dilatation of the mitral annulus. Tissue involvement may be mild (fibroelastic deficiency) or involve many parts of the valve (Barlow’s disease). Our fundamental objective will be to restore the closing capacity of that mitral valve (coaptation) by normalizing leaflet mobility and remodeling the shape of the mitral annulus. A complete and individual evaluation of each patient with mitral disease is essential to have an accurate idea of the reasons for mitral valve failure.

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Nowadays, echocardiographic studies provide us with all the necessary information and are able to predict the reparability of the valve. We should then refer the patient to surgeons with sufficient training, experience and skill to repair complex mitral valve alterations and who perform this operation on a regular basis (more than 50 mitral repairs per year).

Today, we can repair with guarantees almost 100% of mitral insufficiencies with very good results in the short, medium and long term, and with a very low risk. It is necessary to have an expert team with good results.

How are mitral valve insufficiencies repaired?

Each patient will be different and we will have to individualize the surgery according to the cause, the anatomical findings and the type of dysfunction that has caused the valve insufficiency. There are a large number of surgical techniques that allow us to solve the problem: we can trim the excess tissue, reconstruct the anatomy of the leaflets, replace the elongated or broken chordae with artificial goretex chordae, reposition the elements of the mitral apparatus…. In addition, we will always perform an annuloplasty with a prosthetic ring that reshapes and stabilizes our repair. Many of these cases can be operated on with minimally invasive techniques (6-10 cm) that allow less aggression for the patient and facilitate rapid functional recovery.

What are your results with mitral valve repair surgery?

Our experience in mitral valve repair surgery extends over the last 15 years, with a progressive increase in the number of patients operated on and excellent results. In the last 300 patients referred for this type of surgery, the repair rate was 97.5% and hospital mortality less than 1%. The objective is always the same: to solve the patient’s problem with the minimum risk and surgical aggression, to get him to recover quickly and well, to restore his normal life soon, and to enjoy the best possible quality of life.