Mitral valve repair is a surgical procedure used to reshape the mitral valve and make it completely functional with minimal foreign material implantation. Repair surgery retailors the valve and preserves natural valve tissue. The only foreign material implanted during the repair is an annuloplasty ring, which is necessary for procedure durability. Compared to valve replacement, mitral valve repair is a superior surgical procedure in terms of operative and long-term mortality and morbidity. Anticoagulation therapy is not necessary after the repair if the sinus rhythm is preserved. Therefore, hemorrhagic and thromboembolic complications are rare, as well as possibility of bacterial endocarditis.
Mitral valve repair has an outstanding long-term durability. Depending on etiology, lesions and surgical team experience, twenty-year freedom from repair failure could be up to 95 to 98%. The best results are achieved in degenerative mitral pathology, and if operated in early stages of disease. Ischemic and rheumatic mitral pathology have good long-term results although inferior when compared to degenerative mitral insufficiency.
Therefore, mitral valvuloplasty today, represents the gold standard in mitral disease treatment. When performed on time, in patients with preserved heart function and by experienced surgical team, mitral repair surgery will provide normal life after the procedure. A number of our mitral repair patients are pilots, scuba divers, triathlon participants and etc.
Mitral valve surgery was necessary because of severe mitral regurgitation. In case of valve replacement and anticoagulation therapy he would lose his pilot’s license. Mitral valve repair was performed at Cardiovascular Institute “DEDINJE”, Belgrade, Serbia, five years ago (Dr Stojanovic). One year later, Civil Medical Aviation Board in USA removed all medical restriction for flying. He is still an active pilot and is flying for a national air-company.
Aleksandar Lodjinović, pilot - mitral valve repair
The most common principle in mitral valve repair is to resect and to remove the prolapsed leaflet scallop and to suture remaining leaflet tissue thereafter. Annuloplasty ring use is mandatory in order to reduce and to reshape the mitral annulus. Repair procedure was tested during the surgery by transesophageal echocardiography. Only zero-to-mild residual MR is acceptable and provides excellent long-term durability. If residual MR is greater than mild (>1+), repair has to be revised or valve replaced.
Mitral valve repair could be done in minimally invasive way as well. Partial or “J” sternotomy provides small midline chest scar that is half of the standard sternotomy length, picture on the left side. “Port Access” surgery is directed through a small intercostal incision from the right chest wall. The scar is hidden under the breast and almost invisible, picture on the right side.
“Port-access” mitral valve repair is a minimal invasive cardiac surgery procedure in which we operate mitral valve through a key-whole skin incision. Skin incision is made on the right anterolateral chest wall, at the level of 6th intercostal space. Generally it is located in breast plication and is almost invisible after the surgery.
“Port-access” surgery is less invasive, provides faster post-operative recovery, esthetetic effect is important with all advantages of mitral repair surgery. Patient should take in mind that some mitral repair procedures are so complex and time demanding, and therefore not suitable for “port-access” surgery. Well done and durable mitral repair surgery is essential for patients, and must not be compromised in order to obtain small and hidden scar.
Mitral valve prolapse is by far the most common finding in our everyday praxis. Mitral leaflet become over-mobile due to either chordal rupture or elongation, and therefore prolapses into the left atrium. Such a hypermobility disables leaflet cooptation and results in mitral regurgitation or insufficiency (red arrow).
Mitral annuloplasty ring is an essential part of any mitral repair procedure. Its role is to reduce and to reshape fibrous annulus of diseased mitral valve. This is kidney shape device and generally is made of titanium alloy core and Dacron sewing ring cover. Three months after the surgery endocardial tissue layer covers most rings. During this three-moths postoperative period patients are advised to take anticoagulation drugs.
Port-Access mitral surgery incision is made through a 6-six cm long intercostal incision. The incision is made under the right breast, and scar tissue after the surgery is almost completely hidden. Port-access mitral surgery provides less operative trauma and faster post-op recovery with all other benefits of mitral valve repair surgery.
Professor Alain Carpantier is a founder of modern mitral reconstructive surgery. He introduced most of repair techniques we know today, and invented annuloplasty ring as well. His professional life was dedicated to promotion of the mitral repair. We are grateful to our great teacher for the knowledge that he has transferred to us.