Many surgical techniques in Turkey are available for mitral valve replacement surgery, the only option for patients whose damaged valve cannot be repaired.
Overview of the mitral valve
The mitral valve is one of the four heart valves that allow blood to flow in only one direction. It is located between two of the heart’s left chambers – the left atrium and the left ventricle – and consists of two leaflets, anterior and posterior.
The mitral heart valve allows blood to pass from the left atrium to the left ventricle, which pumps oxygen-rich blood throughout the body and prevents it from returning in the opposite direction, and any damage to the valve’s function will result in insufficient blood reaching the body.
There are two types of mitral valve issues:
- Mitral valve stenosis: The valve is stiff and calcified, and the two flaps of the valve may partially fuse together and not open fully, resulting in insufficient blood flow from the left atrium to the left ventricle.
- Mitral valve insufficiency (mitral regurgitation): occurs when the two valve flaps do not close tightly when closing, causing blood to leak from the left ventricle into the left atrium instead of going to the body’s arteries, and may occur as a result of mitral valve prolapse.
These mitral valve issues may present with symptoms such as fatigue, respiratory distress, dizziness, chest pain, and, if left untreated, may progress to atrial fibrillation, pulmonary hypertension, or heart failure.
When the mitral valve injury is mild, the doctor may suggest some general tips to improve lifestyle and visit the clinic frequently for monitoring, and may also prescribe some medications that increase blood flow and improve the patient’s symptoms.
Sometimes the doctor has to perform surgery to treat the mitral valve, and surgical options include mitral valve repair and mitral valve replacement surgery.
What are the indications for mitral valve replacement surgery?
Mitral valve repair is preferable to replacement, and current guidelines recommend against replacing the mitral valve except in cases where it is irreparable, as the results of replacement are short-lived and the patient will likely require re-replacement within 10-20 years.
However, the presence of significant calcification of the valve annulus, degeneration of the valve tissue, inflammatory or septic changes in the valve, subvalvular thickening or fusion, or cardiomyopathy may allow for mitral valve replacement in order to avoid the adverse outcomes associated with some failed attempts at mitral valve repair in such cases.
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Types of replacement mitral valves
There are two main types of mitral valve replacements, each of which has special features and applications depending on the patient’s age, health condition, and lifestyle: artificial (mechanical) valves and bioprostheses used in mitral valve replacement surgery.
Although artificial valves force the patient to take blood thinners and increase the risk of bleeding, studies show that both types of valves used in mitral valve replacement surgery have the same long-term outcome.
Artificial valves
These valves are made of metal, carbon, or plastic and last for about 20-30 years, but the patient will need to take blood-thinning medications for the rest of his life due to the risk of blood clots forming when using this type of valve.
Biological valves
Valves made from human or animal tissue last about 10-15 years or less when used in children and young adults. They have a shorter lifespan than artificial valves but do not require the use of blood thinners, which increase the risk of bleeding.
Risks of mitral valve replacement surgery
Most mitral valve replacement surgeries are successful; however, any surgical procedure carries risks and complications. The risk of surgery generally depends on the patient’s overall health, age, and other factors.
Some of the potential risks of mitral valve replacement surgery:
- Bleeding and sepsis
- Irregular heartbeat
- Form blood clots that can lead to a heart attack or stroke
- Complications from anesthesia
- Death
Death during mitral valve replacement is uncommon, and studies have shown a mortality rate of about 6% in all patients who undergo mitral valve replacement, regardless of risk factors.
Some factors increase the risk of the surgical procedure:
- Chronic diseases
- Other heart conditions
- Pulmonary Problems
- Aging
- Obesity
- Smoking
- Infections
How to perform mitral valve replacement surgery in Turkey
When a patient decides to undergo mitral valve replacement surgery, they must stop smoking for several weeks before the procedure, inform their doctor about any medications they are taking, and stop eating starting at midnight the night before the operation.
Upon arrival at the hospital, some routine tests and examinations will be performed to ensure the patient’s health before the operation, including a simple chest X-ray, EKG, ECG, and blood tests.
At the beginning of mitral valve replacement surgery, the patient will be placed under general anesthesia to sleep deeply and not feel pain during the procedure. It should be noted that there are two ways to reach the heart to replace the mitral valve: open-heart surgery and minimally invasive heart surgery, where the doctor chooses the safest and most suitable option for the patient.
Open surgery mitral valve replacement
The surgeon makes a wide incision in the sternum longitudinally to access the heart, then attaches a cardiopulmonary bypass device directly to the patient’s heart.
The bypass machine performs the functions of the heart and lungs in pumping and oxygenating blood while the heart is temporarily stopped, allowing the surgeon to replace the diseased valve.
An incision is made in the left atrium of the heart to access the mitral valve, and the diseased valve leaflets are removed before the new mitral valve is implanted.
After the valve is in place, the left atrium is closed and the heart is resuscitated to start pumping blood, and after confirming that the new valve is working, the chest is closed with sutures and wires.
Minimally Invasive Mitral Valve Replacement
This procedure replaces a poorly functioning mitral valve with a replacement valve without the need for open-heart surgery. It is called minimally invasive because it requires small incisions and is performed using specialized instruments instead of the large incision used in traditional surgery.
The surgeon performs minimally invasive surgery whenever possible, because minimally invasive surgery has several benefits and advantages over open surgery, including
- Smaller incisions and better cosmetic results
- Lower risk of bleeding and sepsis
- Less pain after the procedure
- Shorter hospital stays
- Recovering from surgery and returning to work faster
Studies show that open-heart surgery and minimally invasive surgery have similar therapeutic outcomes for the mitral valve.
There are several methods for performing a minimally invasive mitral valve replacement. The surgeon can either perform the procedure through a single small incision between the ribs or multiple incisions, or they can perform it without any incision in the chest.
These are some of the techniques used to perform minimally invasive mitral valve replacement:
Right Mini-Thoracotomy
In mitral valve replacement surgery using this technique, the surgeon makes a small incision of 2–3 inches (5–7 cm) between the ribs in the right chest (specifically in the right fifth rib), called the keyhole, and the operation is performed through it. In addition, several other small incisions are made on the right anterior and posterior axillary lines to insert the scope and forceps, which is why it is also referred to as a laparoscopic mitral valve replacement.
The cardiopulmonary bypass device is inserted through a small incision in the glottis, allowing the surgeon to stop the heart and replace the valve.
A soft tissue retractor is used to separate and stabilize the ribs so that the surgeon can insert the instruments for the procedure. The operation is performed with the help and guidance of a laparoscope, which provides a precise and direct view of the mitral valve.
By using this technique in mitral valve replacement surgery, the patient preserves the rib cage bones without damage, which stabilizes the chest, speeds up post-operative recovery, and results in nearly invisible surgical scars.
Robotic-Assisted
It is considered the least invasive technique in the chest, where mitral valve replacement surgery is performed through 2–4 small surgical incisions, each 1–2 cm long, to insert robotic arms controlled by the surgeon via a special computer in the operating room.
A 3D image of the heart and mitral valve is projected onto this computer, allowing the surgeon to perform the procedure by looking at the screen and controlling the robotic arms remotely.
As in the previous technique, the cardiopulmonary bypass device is inserted through a small incision in the glottis to stop the heart during mitral valve replacement surgery.
Transcatheter TMVR
In this technique, a catheter with a balloon at the end is inserted and carries the replacement valve through a large vessel (often the pericardium) to the heart.
When the catheter reaches the location of the mitral valve, the balloon is inflated to remove the old valve and place the new valve in its place, and then the new valve is fixed in place.
Compared to other minimally invasive techniques, transcatheter mitral valve replacement is a non-surgical technique that is performed without the need to stop the heart.
Minimally invasive techniques, especially transcatheter mitral valve implantation (TMVI), are promising technologies in the medical field that will revolutionize the field of mitral valve replacement, as studies have shown.
Recovery after mitral valve replacement surgery
Immediately after mitral valve replacement surgery, the patient is transferred to the intensive care unit to be monitored for complications and remains there for one or two days, then is moved to a regular hospital room for about a week until they are able to get out of bed.
The patient may experience fatigue and pain in the first few weeks after mitral valve replacement surgery, and these symptoms often improve within 4–6 weeks. However, most patients will notice an immediate improvement in the symptoms they had before the procedure.
The patient will be able to perform many daily activities 4–6 weeks after the operation, but before this period, they should avoid lifting heavy objects and refrain from any activity that strains the chest or upper limb muscles.
A patient whose mitral valve has been replaced with an artificial valve will need to take blood-thinning medications (such as warfarin) for the rest of their life to prevent blood clots from forming.
It is also important for the patient to follow a healthy and balanced diet, exercise regularly, and stop smoking if they are a smoker.
It should be noted that recovery time after mitral valve replacement surgery varies from patient to patient, depending on their health condition before the operation, their adherence to the doctor’s instructions, and the type of operation performed.
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