Surgical reconstruction of the mitral valve

Reconstruction or replacement of the mitral valve

Surgical mitral valve replacement is mainly performed in cases of narrowed (stenosed) or combined disease (valvular vitiation) of the mitral valve.

Through the preceding diagnostics with cardiac catheterization and echocardiography, it can already be well estimated preoperatively whether a reconstruction or a replacement is necessary. However, the final decision can only be made intraoperatively.

During the operation, the patient requires a general anaesthetic and is connected to the heart-lung machine via the inguinal vessels. At the Heart Valve Center, the operation is usually performed using minimally invasive surgical procedures via a small access in the intercostal space.

Surgical mitral valve replacement

Surgical mitral valve reconstruction

Criteria for surgical reconstruction of the mitral valve

A reparative reconstruction of the mitral valve is possible if the annulus, the valve leaflets, the chordae and the papillary muscles do not show severe tissue changes, e.g. due to calcification or severe thickening or infection. Typically, only pathological enlargements of the valve apparatus leading to an inability to close (insufficiency) can be reconstructed.

Surgical reconstruction of the mitral valve is recommended in patients who experience performance limitations even at low to moderate levels of stress. Patients are usually under 75 years of age and have a low risk.

In rare cases, severe concomitant diseases (e.g. pulmonary hypertension, severely impaired liver and/or kidney function) may be a reason against conventional valve surgery. In these cases, interventional mitral valve treatment is an alternative.

Surgical mitral valve replacement

Surgical mitral valve reconstruction

Diagnosis before surgical reconstruction of the mitral valve

The backflow of blood from the left ventricle through the diseased mitral valve into the left atrium of the heart is easily audible through the stethoscope and often represents the initial diagnosis.

The electrocardiogram (ECG) examination records the electrical activity of the heart and allows the detection of an abnormal heartbeat due to the enlarged atrium.

The enlargement of the left atrium and water accumulation in the lungs (edema) can be clearly seen on the chest X-ray.

Cardiac catheterization can also determine the amount of blood that flows back from the left ventricle through the diseased mitral valve into the left atrium with each heartbeat.

However, the gold standard examination to determine mitral valve disease is by echocardiography (ultrasound) of the heart. This can accurately quantify the extent of valve leakage and the underlying anatomical cause to assess when surgery is necessary.

Surgical reconstruction methods of the mitral valve

Only the optimal interaction of the four valve components - two leaflets, suspension of the leaflets in the valve ring, tendon filaments and papillary muscles - guarantees the healthy closure mechanism of the mitral valve. Any single pathological change of these components already leads to a disturbance of the valve closure. Often several components of the mitral valve are affected.

The goal of mitral valve reconstruction is to restore near-natural valve function without having to implant an artificial valve.

Ring stabilization: Is done by taking industrially produced rings to restore the natural shape.

Sail reconstruction: Is done by reduction, rarely by gathering or enlargement.

Tendon suture replacement: Is performed by means of replacement, only rarely by means of gathering, repositioning or lengthening.

Papillary muscle shortening: Is rarely performed nowadays, as the above mentioned techniques have proven to be the most effective.

Surgical mitral valve replacement

Surgical mitral valve reconstruction

Procedure of mitral valve surgery

Surgical procedures on the mitral valve are open-heart operations and are performed under general anesthesia. In total, a heart valve operation lasts around 3 hours. In almost all patients, mitral valve surgery can be performed minimally invasively. In this case, an intercostal space is opened, the skin incision is only 5-6 cm.

During the procedure, the patient is connected to the heart-lung machine (HLM) and the heart is stopped with the help of a solution (cardioplegia). The heart-lung machine temporarily takes over the pumping function of the heart and enriches the blood with oxygen.

With the help of echocardiography before surgery, it can be well estimated whether reconstruction is possible. Nevertheless, the decision can ultimately only be made in the operating room, i.e. when the operating heart surgeon performs the functional tests of the individual valve components. Here it is decided whether the heart valve can be sufficiently restored via repair or whether valve replacement is necessary after all.

After the reconstruction is completed, the heart and lungs resume their function and the heart-lung machine is stopped. Still in the operating room, the surgical result is confirmed with the help of transesophageal echocardiography (ultrasound of the heart through the esophagus).

Surgical mitral valve replacement

Surgical mitral valve reconstruction

Minimally invasive mitral valve surgery is standard procedure at the Heart Valve Center

At the Heart Valve Center, minimally invasive procedures in which the mitral valve is operated on via a right-sided minithoracotomy under video assistance have become established as the standard. The results are comparable to the conventional procedure.

However, all procedures require the use of the heart-lung machine installed via the inguinal vessels. This is the only way to repair or replace the malformed heart valve on the resting heart. Access is then gained through a small chest opening on the right side. The procedure is only considered for isolated mitral valve defects, as not all regions of the heart can be reached through the small incision.

Advantages of the method include a reduction in ventilation time and ICU stay, as well as a lower incidence of respiratory failure. Patients also benefit from less pain and bleeding, faster recovery and a better cosmetic result due to the small incision and few wound infections.

Unfortunately, this procedure cannot be used after operations of the lungs or after irradiation of the right side due to adhesions in the thoracic region.

Surgical mitral valve replacement

Surgical mitral valve reconstruction

Catheter-based reconstruction of the mitral valve (MitraClip)

The catheter-based MitraClip valve reconstruction allows the two leaflets of the mitral valve to be attached and positioned via a catheter system inserted through the veins to the heart, thereby reconstructing the function of the mitral valve.

Catheter-based reconstruction of the mitral valve (MitraClip)

Surgical replacement of the mitral valve

Surgical mitral valve replacement is performed in cases of severe stenosis or unreconstructable insufficiency. The operation is usually performed in a minimally invasive surgical procedure without opening the entire sternum and with the use of the heart-lung machine. The altered valve is carefully removed through the opened atrium and replaced by a biological or mechanical valve prosthesis.

Surgical mitral valve replacement

Surgical mitral valve reconstruction