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Aug 21 2013
Robotic-Assisted Mitral Valve Surgery (Part 1)
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I’m somewhat new to blogging, so bear with me! The topic of today’s blog is robotic-assisted mitral valve surgery. Before we get into some of the details of surgical procedures, it’s important to briefly provide some background information. I want to stress that the purpose of this blog is educational in nature. My goal is to provide background information on mitral valve disease and the surgical treatment options available at St. Joseph’s Hospital in Syracuse. It is not to provide individual treatment recommendations that can only be done for a each patient after thoughtful consultation with a cardiologist and cardiac surgeon.

 

The mitral valve is a parachute like structure composed of two thin leaflets that separates the heart from the lungs. The early anatomists thought the valve resembled a bishop’s mitre…hence the name mitral. When the heart contracts the mitral leaflets seal forcing blood out the aortic valve.

 

The most common mitral disease today is mitral valve prolapse. In the past the most common disease was rheumatic mitral valve disease from rheumatic fever. With modern antibiotic treatment this is much less common today. When diseased the mitral valve can either become stenotic (tight) or regurgitant (leak). A leaky mitral valve is much more common than a tight mitral valve and is most commonly caused by mitral valve prolapse. A leaky mitral valve can also be caused by a weak heart muscle (cardiomyopathy). Most of this blog will focus on the leaky mitral valve due to mitral valve prolapse because it is the most common mitral valve problem we see today. 

In the past the diagnosis of mitral valve disease was made by a doctor placing a stethoscope on the patient’s chest and listening for a heart murmur. Today the diagnosis is often made that way but is confirmed by an echocardiogram, a sophisticated ultrasound test that can measure the degree of stenosis or regurgitation. This test is performed by a cardiologist.

 

With mitral valve prolapse the chords (string like structures that connect the leaflets to the heart muscle) stretch out over time. There is probably a genetic cause to this defect, but the details are still being worked out. As the chords stretch they weaken and may eventually snap, causing the valve to leak. When the mitral valve leaks some of the blood that normally passes out the aortic valve is forced back to the lungs. When mild or moderate the leak is normally well tolerated and can often be treated by observation or medication. When the leak becomes severe close follow-up with a cardiologist becomes essential. A severe leak causes a cascade of detrimental effects on the heart and lungs over time. The volume of additional blood passing back into the lungs with every heartbeat causes the left atrium and mitral valve itself to stretch and become larger over time.

One of my old Pathology professors, Dr. Robert Rohner, a man with legendary status in the Syracuse medical community due to his exceptional teaching ability, used to say “ Like an old shoe, collagen (the backbone of heart tissue) under sustained pressure stretches!”

This stretching is not good for the heart muscle, valves or blood vessels leading to and from the lungs. The end result if completely untreated over time is heart failure and a dramatically shortened life expectancy.

With a severe leak the patient may experience no symptoms (asymptomatic) or experience symptoms of shortness of breath with exertion. The onset of these symptoms is often gradual so patients may not notice them or attribute them to old age. Often patients will experience fatigue or not be able to exercise at the same level over time. If a patient has a severe leak and has symptoms then surgery is generally indicated. The key caveat in this recommendation is that the valve should be repairable. This caveat is based on extensive data showing that patients who undergo mitral surgery will do much better in the short and long term if the valve can be repaired and not replaced.

By "better" I mean improved heart function and improved survival. As I tell patients, the number one goal of mitral valve surgery is to stop the leak. The best way to do this is by repairing the valve. If a patient has a severe leak, a likely (>90% chance) repairable valve, and no symptoms but the heart is showing signs of strain from the leak, then surgery is generally recommended as well.

The guidelines stress that the surgical center be experienced in mitral valve repair techniques and have an excellent mitral valve repair rate. Patients in Central New York are fortunate that the cardiac surgeons at St. Joseph’s Hospital all have extensive experience in mitral valve repair techniques and make every effort to repair valves that are repairable.

The topic of the next blog will be the details of surgical repair techniques and approaches. Thanks for reading!

 


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