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Surgical Repair of the Mitral Valve
LEARNING OBJECTIVES
- 1.
Review the advantages that mitral valve repair confers over mitral valve replacement in degenerative disease.
- 2.
Discuss the preoperative and intraoperative assessment of the mitral valve used in determining candidacy for valve repair.
- 3.
Describe how disease etiology and mechanism of mitral regurgitation inform the decision to repair or replace the mitral valve.
- 4.
Highlight key mitral valve repair techniques commonly employed in the treatment of mitral regurgitation.
- 5.
Describe our general philosophy concerning the approach to mitral valve repair.
INTRODUCTION
When surgical intervention is indicated, mitral valve repair is the procedure of choice across most causes of mitral regurgitation (MR). This is owed to significant advantages over mitral valve replacement concerning long-term survival, freedom from reoperation, preservation of ventricular function, and avoidance of complications related to anticoagulation, particularly in those with degenerative mitral valve disease. Over the last 50 years the techniques for mitral valve repair have been refined, with over 95% of patients with degenerative disease being candidates for valve repair. ,
Beginning with Dr. Carpentier’s famous description of the French Correction, , the utility and applicability of mitral valve repair has continued to evolve, with surgeons now employing a number of different repair techniques to achieve successful repair. Along with the emergence of the “respect versus resect” philosophy concerning the treatment of leaflet tissue at the time of repair, techniques such as artificial chord repair, pericardial patch reconstruction, and other nonresectional strategies have emerged and broadened the applicability of mitral valve repair in the modern era.
In this chapter we will explore the surgical considerations that go into determining the feasibility of mitral valve repair, as well as various techniques that surgeons have at their disposal to perform successful valve repair. We will conclude by describing our philosophy in the approach to mitral valve repair in modern surgical practice.
CANDIDACY FOR VALVE REPAIR
Preoperative Evaluation (Demographics and Echocardiography)
Routine preoperative assessment considering a patient’s medical history, baseline cardiac function, and echocardiographic findings is fundamental in ascertaining the likelihood of successful valve repair. Depending on the course of surgery, this evaluation may influence whether valve repair or replacement should be undertaken. For example, sicker patients may benefit from a shorter operative duration, in which case a simple and quick mitral valve replacement might be preferable to a complex and time-consuming mitral valve repair.
The routine review of preoperative transthoracic echocardiography (TTE) coupled with intraoperative transesophageal echocardiography (TEE) is essential for surgical planning and avoiding unanticipated findings at the time of surgery. Morphological assessment of the mitral valve should include evaluation of both leaflets, the mitral annulus, as well as the subvalvular apparatus. TTE can identify leaflet abnormalities, detect annular calcification and provide information on ventricular size and function, while the superior diagnostic accuracy of TEE is useful for real-time intraoperative management. Newer imaging modalities such as 3D echocardiography, cardiac magnetic resonance imaging (MRI), and intracardiac ultrasound are being evaluated to see if they offer advantages in the setting of mitral valve disease.
Surgical Approach
For many cardiac surgeons, sternotomy is the default approach to mitral valve repair, owing to optimal exposure and greater control over operative conduct. This is particularly beneficial in cases where unanticipated findings are encountered and/or when concomitant procedures are required. Minimally invasive chest wall approaches, such as partial sternotomy or right thoracotomy, have been developed and can be employed at the discretion of the surgeon in select patients. Innovations in robotic surgery have facilitated the emergence of robotic-assisted mitral valve repair, where this minimally-invasive alternative to the conventional approach maintains the advantages that valve repair has over valve replacement. In our practice, we employ a screening algorithm to identify patients who would benefit from robotic-assisted repair. Illustration of the various chest wall approaches utilized in mitral valve surgery can be found in Fig. 19.1 .
Technical Implications of Mitral Regurgitation Etiology
The majority of cases requiring surgery for MR are due to degenerative disease. Additional common causes of MR include endocarditis, rheumatic heart disease (RHD), ischemic cardiomyopathy (ICM), and others (i.e., congenital, hypertrophic obstructive cardiomyopathy [HOCM], drug-induced, etc.). Here we’ll discuss the surgical and technical implications of some of the more common causes of MR encountered by cardiac surgeons.
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