Mitral valve replacement

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Mitral valve replacement is a cardiac surgery procedure in which a patient’s mitral valve is replaced by a different valve. Mitral valve replacement is typically performed robotically or manually, when the valve becomes too tight (mitral valve stenosis) for blood to flow into the left ventricle, or too loose (mitral valve regurgitation) in which case blood can leak into the left atrium and back up into the lung (The Society 1). Some individuals have a combination of mitral valve stenosis and mitral valve regurgitation or simply one or the other.

A mitral valve replacement/repair is performed to treat severe cases of mitral valve prolapse, heart valve stenosis, or other valvular diseases (BCM Para 1). Since a mitral valve replacement is an open heart surgical procedure, it requires placing the patient on cardiopulmonary bypass to stop blood flow through the heart when it is opened up (The Society 1).

A mitral valve replacement is necessary when the valve doesn’t open or close completely. When the valve narrows or is stenotic the valve doesn’t let blood flow easily into the heart causing the blood to "back up" and pressure to build up in the lungs (The Society 2). This is dangerous because when the leaflets in the valve don’t meet correctly, blood may leak backwards into the lungs each time the heart pumps. If blood leaks backwards, the heart has to pump harder in order to push the same amount of blood forward. This is known as volume overload. The heart may compensate for this overload for many months or even years but eventually the heart begins to fail and patients show symptoms of shortness of breath or fatigue (The Society 2).

Causes

Mitral valve problems are mainly cause from simple wear and tear that causes part of the valve mechanism to fail. Rheumatic fever may also damage the mitral valve causing stenosis or regurgitation, and occasionally the mitral valve is damaged by infection or bacterial endocarditis. Coronary artery disease is also what may cause the mitral valve to leak (The Society 2).

Symptoms

Some symptoms of patients that need mitral valve repair or replacement include: sensations of feeling the heart beat, chest pain, hard to breathe especially after activity, fatigue, coughing, and shortness of breath while lying flat. These symptoms may develop slowly or the patient my not have any symptoms at all (Gandelman 1).

Options

Some surgeons will first recommend repairing the valve instead of replacement, but if the patient is not a good candidate then they must replace the valve (Maryland Para 1).

Many mitral valves can be repaired, especially if the leak is due to wear and tear. When the valve is too damaged to repair, the valve must be replaced with an artificial valve (Sundt 2). There are some advantages to repairing a mitral valve versus replacing it. Some of these advantages are; a lower mortality at the time of operation (1-2% for repair versus 6-8% for replacement), a significantly lower risk of stroke, and a lower rate of infection, improved long-term survival with mitral valve repair. Patients who receive a valve repair stay on the same survival curve as the normal population. A survival curve tends to be a graph of downward steps with the x-axis as time in months and the y-axis as percent still alive (Motulsky Ch 6). After mitral valve repair, blood thinners are not required, in contrast to the life-long requirement for blood thinners after mechanical mitral valve replacement (University 1).

Non-Surgical Options

Most patients can endure surgery without complications; however there are some whose heart functions is too weak to withstand surgery. Some non surgical approaches to treat heart valve disease without surgery are divided into three categories: Clinical Practice treatment (this is used in every day clinical practice), Investigational treatment (current clinical studies that are underway), Early Development treatment (early stages of investigation) (Heart Para 3).

Types of Valves

There are two primary types of artificial mitral valves -- a metal or mechanical valve and a tissue valve or biological valve (Maryland Para 2). The mechanical valves are made entirely from metal and pyrolytic carbon and last a lifetime (Sundt 2). With this valve, patients are required to take blood-thinning medications to prevent clotting. The tissue valve is made from animal tissues (Sundt 2). The tissue valve doesn’t require a patient to take blood thinners, but it only last 10 to 15 years (Maryland Para 2). The choice of which type to use should be made by you and your doctors taking the following into consideration: your age, medical condition, preferences with medication, lifestyle (Sundt 3).

Details of the procedure

A mitral valve replacement procedure is performed under general anesthesia, which will keep you asleep during the whole surgery (BCM Para 1). The preferred method is to first make an incision under the left breast rather than through the breastbone in the front of the chest, to get to the heart. After the heart is exposed, blood must be rerouted to a heart-lung machine (cardiopulmonary bypass) (BCM 1). An incision is made in the left atrium to expose the mitral valve. The valve is then replaced with either a biological valve or mechanical valve. The heart is then closed with sutures (BCM 1). The patient is then taken off the cardiopulmonary bypass and blood is allowed to flow into the coronary arteries. If the heart does not beat on its own, an electric shock is used to start it. Then the chest is closed up (BCM 1).

Below is a video of mitral valve replacement with mechanical valve.

Minimally invasive mitral valve replacement.

Risks

With mitral valve replacement surgery, there are risks such as bleeding, infection, or a complicated reaction to anesthesia (BCM 2). Each risk is determined best with each patients own cardiologist and cardiothoracic surgeon. They will better know each individuals medical history and conditions. Risks depend on a patient’s age, general condition, specific medical conditions, and heart function (Sundt 3).

Postoperative Complications/ Risks

A common postoperative complication with mitral valve surgery in a study involving 99 patients who had surgery for mitral regurgitation from January 1990 to June 1996 is atrial fibrillation. This occurred in 32% of patients. A common pulmonary complication is congestion necessitating prolonged use of oxygen. Other patients required prolonged ventilation of longer than 24 hours for conditions like pulmonary edema, ARDS, and pulmonary thromboemboli (Hurley 1). Nine patients had renal failure with six of them dying within 30 days after their operation. Five patients had permanent strokes, and nine patients were readmitted to the hospital within 30 days of their discharge (Hurley 1).

Effectiveness

In a clinical study done of 99 patients who had mitral valve surgery for regurgitation from January 1990 to June 1996, long-term and short-term outcomes were evaluated. These evaluations included; mortality rate, clinical complications, readmissions, valve deterioration, reoperation, and health perception. Overall mortality was 18%, which included 11 operative deaths and 7 late deaths. Overall 5-year survival rate was 79% (Hurley 1).

Condition after Mitral Valve Replacement

After the surgery the patient is taken to a post-operative intensive care unit for monitoring. A respirator may be required for the first few hours or days after surgery. After a day, the patient should be able to sit up in bed. After two days, the patient may be taken out of the intensive care unit. Patients are usually discharged after about seven to ten days (BCM 1). If the mitral valve replacement is successful, patients can expect to return to their regular condition or even better. Patients who have biological valve are prescribed blood thinners (Anticoagulation) with Coumadin for 6 weeks to 3 months postoperative, while patients with mechanical valves are prescribed blood thinners for the rest of their lives. These blood thinners are taken to prevent blood clots that can move to other parts of your body and cause serious medical problems, such as a heart attack. Blood thinners will not dissolve a blood clot but they prevent other clots from forming or prevent clots from becoming larger. Blood thinners will not dissolve (Heart Disease 1). Once the patient’s wounds are healed they should have few, if any restrictions from daily activities (Sundt 1). Patients are advised to walk or to do other physical activities gradually to regain strength. Patients who have physically demanding jobs will have to wait a little longer than those who don’t. Patients are also restricted from driving a car for six weeks after the surgery (Mitral 2). Once a person has a mitral valve procedure, they are required to have prophylactic antibiotics as a preventative measure against infection whenever they have dental work done (Sundt 4). Depending on the method of surgery, some scarring will occur. If the breastbone is divided, the patient will have a long scar along the breast bone. If the heart is accessed from under the left breast their will be a smaller scar in the spot (Mitral 2).

2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) [1]

Mitral Valve Prosthesis Selection (DO NOT EDIT) [1]

Class I
"1. A bioprosthesis is indicated for MV replacement in a patient who will not take warfarin, is incapable of taking warfarin, or has a clear contraindication to warfarin therapy. (Level of Evidence: C)"
Class IIa
"1. A mechanical prosthesis is reasonable for MV replacement in patients under 65 years of age with long-standing atrial fibrillation. (Level of Evidence: B)"
"2. A bioprosthesis is reasonable for MV replacement in patients 65 years of age or older. (Level of Evidence: C)"
"3. A bioprosthesis is reasonable for MV replacement in patients under 65 years of age in sinus rhythm who elect to receive this valve for lifestyle considerations after detailed discussions of the risks of anticoagulation versus the likelihood that a second MV replacement may be necessary in the future.(Level of Evidence: C)"

Antithrombotic Therapy for Prosthetic Heart Valves (DO NOT EDIT) [1]

Class I
"1. After mitral valve replacement with any mechanical valve, warfarin is indicated to achieve an INR of 2.5 to 3.5. (Level of Evidence: C)"
"2. After aortic valve replacement (AVR) or MV replacement with a bioprosthesis and no risk factors,* aspirin is indicated at 75 to 100 mg per day. (Level of Evidence: C)"
"3. After MV replacement with a bioprosthesis and risk factors,* warfarin is indicated to achieve an INR of 2.0 to 3.0. (Level of Evidence: C)"
"4. For those patients who are unable to take warfarin after MV replacement or AVR, aspirin is indicated in a dose of 75 to 325 mg per day. (Level of Evidence: B)"
"5. The addition of aspirin 75 to 100 mg once daily to therapeutic warfarin is recommended for all patients with mechanical heart valves and those patients with biological valves who have risk factors.* (Level of Evidence: B)"
Class IIa
"1. During the first 3 months after AVR or MV replacement with a bioprosthesis, in patients with no risk factors,* it is reasonable to give warfarin to achieve an INR of 2.0 to 3.0. (Level of Evidence: C)"
Class IIb
"1. In high-risk patients with prosthetic heart valves in whom aspirin cannot be used, it may be reasonable to give clopidogrel (75 mg per day) or warfarin to achieve an INR of 3.5 to 4.5. (Level of Evidence: C)"

* Risk factors include atrial fibrillation, previous thromboembolism, LV dysfunction, and hypercoagulable condition.

Intraoperative Assessment (DO NOT EDIT) [1]

Class I
"1. Intraoperative transesophageal echocardiography is recommended for valve replacement surgery with a stentless xenograft, homograft, or autograft valve. (Level of Evidence: B)"
Class IIa
"1. Intraoperative transesophageal echocardiography is reasonable for all patients undergoing cardiac valve surgery. (Level of Evidence: C)"

Follow-Up Visits in Patients With Complications (DO NOT EDIT) [2]

Class I
"1. Patients with LV systolic dysfunction after valve surgery should receive standard medical therapy for systolic heart failure. This therapy should be continued even if there is improvement of LV dysfunction. (Level of evidence: B)"

Sources

  • 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease [1]

Related chapters

References

  1. 1.0 1.1 1.2 1.3 1.4 Bonow RO, Carabello BA, Chatterjee K; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Unknown parameter |month= ignored (help)
  2. Bonow RO, Carabello BA, Kanu C; et al. (2006). "ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons". Circulation. 114 (5): e84–231. doi:10.1161/CIRCULATIONAHA.106.176857. PMID 16880336. Unknown parameter |month= ignored (help)


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