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    Mitral valve surgery - minimally invasive

    Mitral valve repair - right mini-thoracotomy; Mitral valve repair - partial upper sternotomy; Robotically-assisted, endoscopic valve repair, Percutaneous mitral valvuloplasty

    Mitral valve surgery is surgery to either repair or replace the mitral valve in your heart.

    Blood flows from the lungs and enters the left atrium of the heart. The blood then flows into the left ventricle. The mitral valve is located between these two chambers. It makes sure that the blood keeps moving forward.

    You may need surgery on your mitral valve if:

    • The mitral valve is hardened (calcified). This prevents blood from moving forward through the valve.
    • The mitral valve is too loose. Blood tends to flows backward when this occurs.

    Minimally invasive mitral valve surgery is done through several small cuts. Another type of operation, open mitral valve surgery requires a larger cut.

    Description

    Before your surgery you will receive general anesthesia.

    You will be asleep and pain-free.

    There are several different ways to perform minimally invasive mitral valve surgery.

    • Your heart surgeon may make a 2-inch to 3-inch-long cut in the right part of your chest near the sternum (breastbone). Muscles in the area will be divided. This lets the surgeon reach the heart. A small cut is made in the left side of your heart so the surgeon can repair or replace the mitral valve.
    • In endoscopic surgery, your surgeon makes 1 - 4 small holes in your chest. Surgery is done through the cuts using a camera and special surgical tools. For robotically-assisted valve surgery, the surgeon makes 2 - 4 tiny cuts in your chest. The cuts are about 1/2 to 3/4 inches each. The surgeon uses a special computer to control robotic arms during the surgery. A 3D view of the heart and mitral valve are displayed on a computer in the operating room. This method is very precise.

    You may need a heart-lung machine for these types of surgery. You will be connected to this device through small cuts in the groin or on the chest. If you do not need a heart-lung machine, your heart rate will be slowed by medicine or a mechanical device.

    If your surgeon can repair your mitral valve, you may have:

    • Ring annuloplasty -- The surgeon repairs the ring-like part around the valve by sewing a ring of metal, cloth, or tissue around the valve.
    • Valve repair -- The surgeon trims, shapes, or rebuilds one or both of the flaps that open and close the valve.

    You will need a new valve if there is too much damage to your mitral valve. This is called replacement surgery. Your surgeon will remove your mitral valve and sew a new one into place. There are two main types of new valves:

    • Mechanical -- made of man-made materials, such as titanium and carbon. These valves last the longest. You will need to take blood-thinning medicine, such as warfarin (Coumadin) or aspirin, for the rest of your life.
    • Biological -- made of human or animal tissue. These valves last 10 - 12 years, but you may not need to take blood thinners for life.

    The surgery may take 2 -4 hours.

    This surgery can sometimes be done through a groin artery, with no cuts on your chest. The doctor sends a catheter (flexible tube) with a balloon attached on the end. The balloon inflates to stretch the opening of the valve. This procedure is called percutaneous valvuloplasty.

    Why the Procedure Is Performed

    You may need surgery if your mitral valve does not work properly because:

    • You have mitral regurgitation -- a mitral valve that does not close all the way and allows blood to leak back into the left atria
    • You have mitral stenosis -- a mitral valve that does not open fully and restricts blood flow
    • Your valve has developed an infection (infectious endocarditis)
    • You have severe mitral valve prolapse that is not controlled with medicine.

    Minimally invasive surgery may be done for these reasons:

    • Changes in your mitral valve are causing major heart symptoms, such as chest pain, shortness of breath, fainting spells, or heart failure.
    • Tests show that the changes in your mitral valve are beginning to harm your heart function.
    • Damage to your heart valve from infection (endocarditis).

    A minimally invasive procedure has many benefits. There is less pain, blood loss, and risk of infection. You will also recover faster than you would from open heart surgery.

    Percutaneous valvoplasty is can only done in people who are too sick to have anesthesia. The results of this procedure are not long-lasting.

    Risks

    Risks for any surgery are:

    • 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

    Minimally invasive surgery techniques have far fewer risks than open surgery. Possible risks from minimally invasive valve surgery are:

    • Damage to other organs, nerves, or bones
    • Heart attack, stroke, or death
    • Infection of the new valve
    • Irregular heartbeat that must be treated with medicines or a pacemaker
    • Kidney failure
    • Poor healing of the wounds

    Before the Procedure

    Always tell your doctor or nurse:

    • If you are or could be pregnant
    • What medicines you are taking, even drugs, supplements, or herbs you bought without a prescription

    You may be able to store blood in the blood bank for transfusions during and after your surgery. Ask your surgeon about how you and your family members can donate blood.

    If you smoke, you must stop. Ask your doctor for help.

    During the days before your surgery:

    • For the 2-week period before surgery, you may be asked to stop taking medicines that make it harder for your blood to clot. These might cause increased bleeding during the surgery. Some of these medicines include aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn).
    • If you are taking warfarin (Coumadin) or clopidogrel (Plavix), talk with your surgeon before stopping or changing how you take these drugs.
    • Ask your doctor which drugs you should still take on the day of your surgery.
    • Prepare your house for when you get home from the hospital.
    • Shower and wash your hair the day before surgery. You may need to wash your body below your neck with a special soap. Scrub your chest 2 or 3 times with this soap. You also may be asked to take an antibiotic to prevent infection.

    On the day of the surgery:

    • You may be asked not to drink or eat anything after midnight the night before your surgery. This includes using chewing gum and mints. Rinse your mouth with water if it feels dry. Be careful not to swallow.
    • Take the medicines your doctor told you to take with a small sip of water.
    • Your doctor or nurse will tell you when to arrive at the hospital.

    After the Procedure

    Expect to spend 3 - 5 days in the hospital after surgery. You will wake up in the intensive care unit (ICU) and recover there for 1 or 2 days. Nurses will closely watch monitors that display your vital signs (pulse, temperature, and breathing).

    Two to three tubes will be in your chest to drain fluid from around your heart. They are usually removed 1 - 3 days after surgery. You may have a catheter (flexible tube) in your bladder to drain urine. You may also have intravenous (IV) lines to get fluids.

    You will go from the ICU to a regular hospital room. Your nurses and doctors will monitor your heart and vital signs until you are ready to go home. You will receive pain medicine for pain in your chest.

    Your nurse will help start activity slowly. You may begin a program to make your heart and body stronger.

    A pacemaker may be placed in your heart if your heart rate becomes too slow after surgery. This may be temporary or permanent.

    Outlook (Prognosis)

    Mechanical heart valves do not fail often. However, blood clots can develop on them. If a blood clot forms, you may have a stroke. Bleeding can occur, but this is rare.

    Biological valves have a lower risk of blood clots but tend to fail over time.

    The results of mitral valve repair are excellent. For best results, choose to have surgery at a center that does many of these procedures. Minimally invasive heart valve surgery has improved greatly in recent years. These techniques are safe for most patients, and can reduce recovery time and pain.

    References

    Fullerton DA, Harken AH. Acquired heart disease: valvular. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, Pa: Saunders Elsevier; 2012:chap 61.

    Webb JG. Percutaneous therapies for structural heart disease in adults. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 59.

    Bonow RO, Mann DL, Zipes DP et al. Valvular heart disease.In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 66.

    Verma S, Mesana TG. Mitral-valve repair for mitral-valve prolapse. N Engl J Med. 2009; 361: 2261-2269.

    Brinkman WT, Mack MJ. Transcatheter cardiac valve interventions. Surg Clin North Am. 2009;89:951-966.

    Chandrashekhar Y, Westaby S, Narula J. Mitral stenosis. Lancet. 2009;374:1271-1283. Epub 2009 Sep 9.

    Enriquez-Sarano M, Akins CW, Vahanian A. Mitral regurgitation. Lancet. 2009;373:1382-1394.

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                  Review Date: 2/6/2013

                  Reviewed By: Matthew M. Cooper, MD, FACS, Medical Director, Cardiovascular Surgery, HealthEast Care System, St. Paul, MN. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Bethanne Black, and the A.D.A.M. Editorial team.

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