Not all patients with mitral valve abnormalities require treatment. Some patients just need to have their doctor monitor their condition periodically. For instance, patients with mitral valve prolapse but no regurgitation (leaking) may not need treatment. Treatment options for those that do require more than this are numerous. Patients should educate themselves on what is wrong with their mitral valve and learn about all the options for treatment. Important components of knowing what should be done include symptoms, physical examination findings, test results, and the severity of the problem. There are guidelines published by the American College of Cardiology and American Heart Association to guide physicians and patients in this decision-making based on currently available information.
You and your medical team may decide medical management is most appropriate for you. Such patients might have a less than severe mitral regurgitation or stenosis (or none at all, just prolapse), be deemed too high risk for surgery relative to the benefits, or have a valve that is not likely repairable in the setting of no symptoms and a normal heart. Medical management of both mitral stenosis or regurgitation generally includes diuretics ("water pills") to reduce the amount of fluid buildup in the body and control of high blood pressure. Once mitral disease becomes severe, medicine is generally not as effective as surgery provided the patient is a candidate for surgery. A recent paper concluded that early surgical repair of mitral valve regurgitation was associated with greater long-term survival and freedom from heart failure than medical management.
Indications for Surgery
The first question to ask is whether you have "severe" mitral regurgitation or not. Echocardiography is the generally accepted method of determining this. If you have been found to have "severe" or "moderate to severe" mitral regurgitation based on echocardiographic criteria, you may be a candidate for a procedure to correct it. the next question to ask is whether you have symptoms, most typically shortness of breath, fatigue, irregular heart beat, etc. (see symptoms section of this webpage). If you have symptoms attributable to your mitral valve and are felt by your doctors to be able to undergo surgery with a reasonable risk (heart function not too bad, other medical conditions don't increase risk excessively, etc.), surgery is usually recommended. If you don't have symptoms but have an enlarged heart with decreased function (as measured by EF or Ejection Fraction and size), atrial fibrillation, pulmonary hypertension and are otherwise a candidate based on risk assessment by your doctors, surgery will generally be recommended. If you are completely asymptomatic with a normal heart, surgery can be a good option if the valve is repairable and the procedure is performed at a center with significant experience in valve repair. Another issue that often comes up is whether the regurgitation is truly "severe" or "moderately severe". I am not an expert in echocardiography, but there does appear to me to be some subjectivity to these measurements. When there is doubt, I often get additional opinions from several experts and discuss the issue in detail with the patient and their family. Studies have shown that even moderate mitral regurgitation is associated with a decreased life expectancy if uncorrected.
Mitral stenosis is most frequently associated with rheumatic heart disease, a condition caused by exposure to strep throat years prior to developing the valve problem. As with mitral regurgitation, the first question is whether the stenosis is "severe" or not. Both echocardiography and cardiac catheterization are used to confirm the diagnosis and severity of the narrowing, usually by measuring or estimating the "mean pressure gradient" and the "valve area". Symptoms are also important as interventions are usually done only on symptomatic patients (see symptom section of this website). If a patient with significant symptoms has "severe" or "moderate to severe" mitral stenosis, he/she should be considered for intervention. In patients with a valve that is not too immobile and calcified or leaky/regurgitant (favorable morphology), percutaneous balloon valvuloplasty may be the best option. Patients deemed by their physicians to be too high risk for surgery but unfavorable morphology may also be considered for this less invasive procedure based on a risk/benefit assessment by the patient and their doctors. Patients with reasonable surgical risk and symptomatic "severe" or "moderate to severe" mitral stenosis for whom percutaneous intervention is not ideal should be considered for surgery which can consist of valve repair or replacement.
Although for mitral regurgitation due to "myxomatous" disease should almost universally be repaired, many patients with stenosis secondary to rheumatic disease should have their valves replaced. Centers that brag about 100% repairability are generally not referring to heavily calcified, stenotic, diseased valves for which replacement is clearly the right thing to do for the patient. However, some valves can be repaired. In our practice this often involves leaflet augmentation techniques. We are more aggressive in younger patients in whom prosthetic valves are not optimal.
I like to say there are many different ways to repair/replace the mitral valve and for each way of doing it, I can tell you of a surgeon I would trust my family with. The priorities, in my opinion, when deciding what type of operation to undergo are (in this order): 1. Survive the procedure, 2. Fix the problem, 3. Minimize complications as much as possible, 4. Minimize the invasiveness as much as possible without compromising priorities #1-3, and 5. Optimize the patient and family experience. No matter how you and your medical team decide to have the valve surgery performed, there are risks and benefits to each approach. Generally speaking, you want your surgery performed by a surgeon and team with a significant volume of experience in repair and replacement. If the valve is leaky, you should want it performed at a center with a high rate for repair for this condition. In my personal opinion, mitral valve surgery, particularly repair, is becoming almost a subspecialty.
My preferred procedure for most patients requiring isolated mitral valve surgery (with or without tricuspid valve procedures or MAZE procedure for atrial fibrillation) is totally endoscopic robotic mitral valve repair or replacement with an emphasis on repair when appropriate. What this means to me is that the incisions are so small that none of the procedure can be performed by looking through any of the incisions. For a mitral repair, our biggest incision in the chest is 15mm and for replacement 30-35mm (in order to get the new valve into the chest). What makes this possible is the extremely small size of the robotic instruments (much smaller than surgeons' hands)
Other options typically done for mitral valve surgery include : full sternotomy (breastplate divided), partial sternotomy (breastplate partially divided), right chest thoracotomy or "mini" thoracotomy (cut under the right breast), also called "port access" sometimes. We prefer the robotic totally endoscopic approach because it allows us to make the smallest incisions possible which may reduce postoperative pain, blood loss, and improve early return to activity.
For additional details on robotic mitral valve surgery, see my other website: www.roboticheartsurgeon.com.
Percutaneous balloon valvuloplasty for mitral stenosis is a well-established technique to treat mitral stenosis. In fact, it really is preferred in patients who have appropriate anatomy based on published criteria or who are not surgical candidates (after a thorough risk/benefit assessment and discussion with the medical team and patient). The MitralClip is currently approved for inoperable patients with mitral regurgitation due to prolapse. The MitraClip trial is also being studied in the COAPT trial for functional mitral regurgitation. Details of the trial can be found at: Link to Clinical Trials.Gov (COAPT Trial Details) There are a number of other percutaneous devices in various phases of development for mitral regurgitation in high risk patients.