For more than thirty years the surgeons at Cardiac Vascular and Thoracic Surgery Associates (CVTSA) have been involved in the treatment of mitral valve disease including both mitral valve replacement and the development of reconstructive techniques of the mitral valve. In the last ten years, our mitral valve surgeons have worked on new and innovative minimally invasive mitral valve repair and replacement approaches. When mitral valve patients in the Virginia, Maryland and DC area need mitral valve surgery, they call CVTSA. To make an appointment, please call (703) 280-5858.
What is the Mitral Valve?
The mitral valve is located between the left atrium and the left ventricle. Normally, the valve resembles a parachute; the chute is made-up of leaflets that open and close. When they are open, they allow blood to pass from the atrium into the ventricle. When the leaflets close, they prevent blood from returning to the atrium. Diseases of the mitral valve involve the annulus or the supporting structure to which the leaflets are attached, as well as the leaflets themselves and the structures that hold the valve in place. The goal of mitral valve surgery is to correctly identify the nature of the problem and reconstruct and repairing those abnormalities when possible and, in some instances, replace the valve with either a mechanical or tissue valve.
What are Diseases of the Mitral Valve?
Mitral valve disease has two primary manifestations: mitral stenosis and mitral regurgitation.
In mitral stenosis, the mitral valve does not fully open. In this condition, inflammation of the valve leads to extensive scarring and fusion of the leaflets which leaves a small central opening, rather than a large one. In order for blood to pass from the atrium to the ventricle it must travel through this smaller opening which significantly increases the pressure in the heart.
What Causes Mitral Stenosis?
Mitral stenosis is almost always caused by chronic rheumatic disease (caused from rheumatic fever). While rheumatic disease is unusual in the United States today, we still see a significant number of patients who come to the United States from abroad where there are still areas in which rheumatic fever is common.
In mitral regurgitation, the mitral valve does not fully close, or seal. This means that instead of only pushing blood out to the body the valve pushes blood both out to the body and also back into the atrium. This results in enlargement of the left atrium and increased pressure inside the lungs.
What Causes Mitral Regurgitation?
Mitral regurgitation may also be the result of rheumatic disease in which the leaflets of the valve become distorted and inflamed so they cannot properly close. Generally, people with rheumatic disease have both stenosis and regurgitation. Mitral valve regurgitation is usually caused by degenerative disease, also known as myxomatous disease of the mitral valve. When this occurs, there is abnormality in both the valves leaflets and the valve’s supporting tissue. There is usually prolapse (when the leaflet balloons upward) which means that the valve cannot close properly so blood escapes. This is a common condition that accounts for the majority of the patients with mitral regurgitation in the United States.
Another frequent cause of mitral regurgitation is coronary artery disease. Coronary artery disease causes either ischemia (lack of blood flow to the heart muscle) or infarction (which is damage to the heart muscle that affects the wall of the ventricle and the papillary muscles which support the valve). The mitral valve leaflet becomes pulled down and the supporting annulus is usually dilated or stretched. This results in failure of the leaflets to meet in the middle and causes a leak through the leaflets.
Mitral valve regurgitation can also result from infection of the valve, endocarditis, in which there is damage to the valve leaflets due to bacterial infection.
Finally, in some patients the leaflet and supporting structures may be normal but the patient may have a cardiomyopathy which is a generalized weakness of the ventricle which causes stretching of the valve that in turn pulls apart the leaflets so that they don’t meet in the middle which causes the valve to leak.
Each cause of mitral regurgitation requires proper analysis and a tailored approach to correct the particular problem.
Mitral Valve Surgery
The modern era of mitral valve surgery began in 1960 when Dr. Albert Starr in Portland, Oregon, performed the first mitral valve replacement. The building block, which allowed this first mitral valve replacement to be performed, was the development of effective cardiopulmonary bypass in which patients could be placed on a heart-lung machine allowing surgeons to safely operate within the heart itself. Several of our CVTSA mitral valve surgeons trained with Dr. Starr and worked with him to develop and implement the techniques of mitral valve replacement.
The next major development in surgery of the mitral valve involved techniques to repair the mitral valve, rather than replace it. Through the years the mitral valve surgeons at CVTSA have participated in the development of these techniques and today, over 75% of all patients with mitral disease undergo mitral valve repair, and over 90% of patients with degenerative or myxomatous disease of the mitral valve undergo mitral valve repair. This compares very favorably with the national average across the United States of mitral valve repair of 40-50%.
Mitral Valve Repair
Repair of the mitral valve is an option for some patients and involves sewing a ring around the valve to improve its size or shape and or removing tissue to allow the valve’s leaflets to better open and close. In many instances, stretched or torn chords are replaced with artificial gortex chords.
Mitral Valve Replacement
Mitral valve replacement includes using both biologic and mechanical valves. The choice of valve depends upon the particular circumstances of each individual patient, including the underlying condition, age of the patient and their medical history.
Biological valves (tissue valves) can be made from pig tissue (porcine) or pericardial cow tissue (bovine). These valves are easy to insert, generally last fifteen to twenty years and allow patients to avoid lifetime use of anticoagulants (blood thinning medication) such as Coumadin.
These are made completely of mechanical parts, are easy to insert and are durable (generally lasting greater than twenty years), but all patients need to take anticoagulant medication such as Coumadin for the rest of their lives. The disadvantage of a mechanical valve is the risk of developing clots or bleeding problems because of anticoagulation medication.
For more information about the kinds of replacement valves used in surgery, click here.
What are the Symptoms of Mitral Valve Disease?
- Waking up short of breath or coughing
- Becoming short of breath when you exert yourself, lie down or are emotionally stressed
- Excessive tiredness, with activity or as the day goes on
- Dizziness or lightheadedness
- Swollen ankles or feet
- A fast, pounding or irregular heartbeat
- A fluttering feeling in your chest
How is Mitral Valve Disease Diagnosed?
- Physical examination.
- Electrocardiogram (EKG or ECG). In this test, electrodes are attached to your chest and the rhythms of your heart are recorded.
- Chest x-ray. This x-ray provides your doctor with information about your heart and lungs. It lets the doctor know if you heart is enlarged or if there is fluid in your lungs.
- Echocardiogram. The most commonly used diagnostic tool, an echocardiogram is an ultrasound of your heart that helps define the severity (mild, moderate, or severe) of the problem with your heart valve.
- Cardiac catheterization. An examination of your heart conducted by threading a catheter through a blood vessel in your groin and advancing it to your heart. A cardiac catheterization can be used to assess the condition of your heart and coronary arteries.
Will I Have a Large Incision or a Minimally Invasive Incision?
Mitral valve replacement is performed while the patient is on cardiopulmonary bypass and may be performed through either standard open chest incision (median sternotomy) or through a keyhole incision (a small incision between the ribs). The benefits of a small incision include a smaller scar, and may include a reduced risk of infection, less pain and trauma, decreased length of hospital stay and decreased recovery time.
For more than a decade, CVTSA surgeons have been involved in developing robotic and non-robotic minimally invasive mitral valve techniques.
Your doctor will talk to you about the best option for your medical condition.
What Are the Risks of Mitral Valve Surgery?
While most valve surgeries have excellent outcomes, any major surgery does carry some risk of complications. For valve surgery, these include:
- The need for a blood transfusion due to bleeding
- Blood clots
- Damage to the heart
- Failure of the new valve
- Problems with your heart rhythm
- Stroke, heart attack or death
- Problems with the lungs or kidneys
Located just off the Beltway and Rt. 50 in Falls Church, VA, CVTSA proudly serves patients needing mitral valve surgery options in Virginia, Maryland and DC. To make an appointment, please call (703) 280-5858.