Mitral stenosis surgery

	Mitral stenosis surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]

Indications for Mitral Stenosis Surgery

The Procedure can be done either by the traditional open heart surgery or by the Minimally invasive surgery. Before the surgery, the patient will receive general anesthesia. This will make the patient asleep and pain-free during the entire procedure. Beside Percutaneous mitral balloon valvotomy (PMBV); there are three approaches for Mitral stenosis surgical treatment:

Closed commissurotomy

It is the earliest surgical procedure. It is performed on a beating heart. In this procedure; the surgeon makes a left thoracotomy incision and introduce a dilator to the mitral valve via either a transatrial or transventricular approach. Closed commissurotomy is usually indicated for the patients with minimal mitral valve calcifications and in those who lack significant subvalvular involvement. This approach is contraindicated in the following conditions:

Mitral regurgitation (moderate or severe); as regurgitation may be worsened by the procedure.
Atrial thrombosis.

The limitation of closed commissurotomy is the difficulty for the surgeon to fully expose and visualize the Mitral valve during the procedure. Some studies showed that Percutaneous mitral balloon valvotomy (PMBV) is associated with better long-term outcomes than closed commissurotomy ^[1], recently, closed commissurotomy becomes less performed than before in the developed countries. Also in pregnancy; the PMBV is preferred over closed commissurotomy for mitral valve stenosis treatment ^[2].

Open commissurotomy (valve repair)

The surgeon performs the procedure via median sternotomy. Via this surgical approach; it is better for the surgeon to fully expose and visualize the mitral valve during the procedure as compared to closed commissurotomy approach. Other advantages for this approach includes:

The surgeon can repair the valve by the dipridation of calcium deposits.
The surgeon can split fused chordae tendineae or papillary muscles.
The surgeon can insert annuloplasty ring to correct the valvular stenosis. This is needed in case of severe mitral regurgitation (grade 3 or 4) as the valve repair alone is in adequate.
The surgeon can remove a left atrial thrombus if presents.

Some studies showed that Percutaneous mitral balloon valvotomy (PMBV) is associated with better long-term outcomes than Open commissurotomy ^[3], along with shorter hospital stay and less morbidity from thoracotomy (in Open commissurotomy) ^[1]^[4].

Mitral valve replacement

This procedure is indicated if the mitral stenosis could not be corrected by other surgical approaches previously mentioned and the patient has one of the following:

Moderate to severe mitral stenosis (≤1.5 cm2).
NYHA class III or IV symptoms.
Mild symptoms (NYHA class I or II) that associated with severe mitral stenosis (mitral valve area ≤1.0 cm2) or severe pulmonary hypertension (pulmonary artery systolic pressure >60 to 80 mmHg).
Severe mitral stenosis (mitral valve area ≤1.0 cm2) or severe pulmonary hypertension (pulmonary artery systolic pressure >60 to 80 mmHg) even if the patient is asymptomatic.

Mitral valve replacement significantly improves symptoms and has a favorable survival rate at five years ^[5]^[6]. The 2006 ACC/AHA guidelines recommended amputation or ligation the left atrial appendage during mitral valve replacement or open commissurotomy, as this may decrease the risk of potential embolism ^[5], but it is not proofed if this may reduce the risk of stroke ^[7].

In the traditional open heart surgery:

The surgeon will make a 10-inch-long cut in the middle of the chest (sternum).
Next, the surgeon will separate the breastbone (sternum) to be able to see the heart.
Most people are connected to a heart-lung bypass machine or bypass pump. The heart is stopped while the patient is connected to this machine. This machine does the work of the heart while the heart is stopped.
A small cut is made in the left side of the heart so the surgeon can repair or replace the mitral valve.

In minimally invasive mitral valve surgery; there are several different ways to perform the procedure:

The heart surgeon may make a 2-inch to 3-inch-long cut in the right part of your chest near the sternum. Muscles in the area will be divided so the surgeon can reach the heart. A small cut is made in the left side of the heart so the surgeon can replace the mitral valve.
In Endoscopic surgery, the surgeon makes one to four small holes in the chest, then he or she uses special instruments and a camera to do the surgery.
For Robotically-assisted valve surgery, the surgeon makes two to four tiny cuts (about a ½ to a ¾ inch) in the chest. The surgeon uses a special computer to control robotic arms during the surgery. The surgeon sees a three-dimensional view of the heart and mitral valve on the computer. This method is very precise.

The patient may or may not need to be on a heart-lung machine for these types of surgery, but if not, the heart rate will be slowed by medicine or a mechanical device.

There are two types of valves:

1. Mechanical which is made of man-made (synthetic) materials, such as a metal like titanium. These valves last the longest, but the patient will need to take blood-thinning medicine, such as warfarin (Coumadin) or aspirin, for the rest of his or her life.

2. Biological which made of human or animal tissue. These valves last 10 to 12 years, but the patient may not need to take blood thinners for life.

Once the new or repaired valve is working, the surgeon will:

Close the heart and take you off the heart-lung machine.
Place catheters (tubes) around the heart to drain fluids that build up.
Close the sternum with stainless steel wires. It will take about 6 weeks for the bone to heal. The wires will stay inside the body.

The patient may have a temporary pacemaker connected to the heart until his or her natural heart rhythm returns.

The surgeon may also perform coronary artery bypass surgery at the same time, if needed.

Recovery

Recovery at hospital

The patient may spend 4 to 7 days in the hospital after surgery (much less in Minimally invasive mitral valve surgery-3 to 5 days). Then patient will wake up in the intensive care unit (ICU) and recover there for 1 or 2 days. Two to three tubes will be in the patient's chest to drain fluid from around the heart. They are usually removed 1 to 3 days after surgery.

The patient may have a catheter in the bladder to drain urine, and may also have intravenous lines to get fluids. Nurses will closely watch monitors that show information about the vital signs (pulse, temperature, and breathing).

The patient will be moved to a regular hospital room from the ICU. The nurses and doctors will continue to monitor the heart and vital signs until the patient is stable enough to go home. The patient will receive pain medicine to control pain around your surgical cut.

A nurse should help the patient to slowly resume some activity, and the patient should begin a physical therapy program to make the heart and body stronger. A temporary pacemaker may be placed in the patient's heart if the heart rate becomes too slow after surgery.

Recovery at home

The patient should be informed about the following:

Taking care for his or her healing incisions.
Recognizing signs of infection or other complications.
Coping with after-effects of surgery.
Followup appointments, medicines, and situations when he or she should call the doctor right away.
When he or she can go back to daily routine, such as working, driving, and physical activity.

After-effects of heart surgery are normal. They may include muscle pain, chest pain, or swelling. Other after-effects may include loss of appetite, problems sleeping, constipation, and mood swings and depression. After-effects usually go away over time.

Less recovery time is needed for off-pump heart surgery and minimally invasive heart surgery.

Ongoing care

Ongoing care after valve surgery may include periodic checkups with the doctor. During these visits, the patient may have blood tests, an EKG (electrocardiogram), echocardiography, or a stress test. These tests will show how the patient's heart is working after the surgery.

Routine tests should be done to make sure the patient is getting the right amount of the blood-thinning medicine in case of mechanical valve placement.

The patient may be advised to change his or her lifestyle, this includes: quitting smoking, making changes to diet, being physically active, and reducing and managing stress.

Surgical Outcome

The results of mitral valve stenosis surgery are excellent in centers that regularly perform this surgery.

Techniques for minimally invasive heart valve surgery have improved greatly over the past 10 years. These techniques are safe for most patients, and they reduce recovery time and pain.

Results of the commissurotomy should be assessed with hemodynamics and echocardiography.
If second inflation is needed mitral regurgitation should be assessed.
In general increasing valve area to greater than 1 cm2/m2 is an acceptable result.
Usually the valve area doubles and the pulmonary pressures degrease immediately.
5 year survival is in the 90% range.

Mechanical versus biological valves

Mechanical heart valves do not fail often. They last from 12 to 20 years. However, blood clots develop on them. If a blood clot forms, the patient may have a stroke. Bleeding can occur, but this is rare. Biological valves tend to fail over time ^[8]^[9], but they have a lower risk of blood clots.

Possible Complications

Risks of any surgery

Blood clots in the legs that may travel to the lungs.
Blood loss.
Breathing problems.
Infection, including in the lungs, kidneys, bladder, chest, or heart valves.
Reactions to medicines.

Possible risks from having open-heart surgery

Heart attack or stroke.
Heart rhythm problems.
Infection in the cut, which is more likely to happen in people who are obese, have diabetes, or have already had this surgery.
Memory loss and loss of mental clarity, or "fuzzy thinking."
Post-pericardiotomy syndrome, which is a low-grade fever and chest pain. This could last for up to 6 months.

Prosthetic heart valves are associated with a variety of complications

Structural deterioration, particularly with bioprosthetic valves.
Valve obstruction due to thrombosis or pannus formation.
Systemic embolization.
Bleeding.
Endocarditis and other infections.
Left ventricular systolic dysfunction, which may be preexisting.
Hemolytic anemia.

Videos

Mitral valve replacement surgery animation

Robotic mitral valve repair surgery animation