Mitral valve surgery - minimally invasive

Description

Before your surgery you will receive general anesthesia. This will make you unconscious and unable to feel pain.

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 so your surgeon can 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 one to four small holes in your chest. Then your surgeon uses special instruments and a camera to do the surgery.
• For robotically-assisted valve surgery, the surgeon makes two to four tiny cuts (about ½ to ¾ inch) in your 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.

You may or may not need to be on a heart-lung machine for these types of surgery, but if not, 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 leaflets of the valve. The leaflets are flaps that open and close the valve.

If your mitral valve is too damaged, you will need a new 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, or ceramic. These valves last the longest, but 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 also 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 stretches 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 medications

Minimally invasive surgery may be done for these reasons:

• Changes in your mitral valve are causing major heart symptoms, such as chest pain (angina), shortness of breath, fainting spells (syncope), or heart failure.
• Tests show that the changes in your mitral valve are beginning to seriously affect your heart function.
• Your heart valve has been damaged by 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 a procedure that is 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 drugs 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.

For the 2-week period before surgery, you may be asked to stop taking drugs that make it harder for your blood to clot. These might cause increased bleeding during the surgery.

• Some of them are 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.

Prepare your house for when you get home from the hospital.

The day before your surgery. Shower and shampoo well. You may be asked to wash your whole body below your neck with a special soap. Scrub your chest two or three times with this soap. You also may be asked to take an antibiotic to guard against infection.

During the days before your surgery:

• Ask your doctor which drugs you should still take on the day of your surgery.
• If you smoke, you must stop. Ask your doctor for help.
• Always let your doctor know if you have a cold, flu, fever, herpes breakout, or any other illness in the time leading up to your surgery.

On the day of the surgery:

• You will usually be asked not to drink or eat anything after midnight the night before your surgery. This includes chewing gum and using breath mints. Rinse your mouth with water if it feels dry, but be careful not to swallow.
• Take the drugs 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 show information about 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, in a vein) lines to get fluids.

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

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

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

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 tend to fail over time, but they have a lower risk of blood clots.

The results of mitral valve repair are excellent. To get the best treatment, go to a center that regularly performs this type of 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.

Alternative Names

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

References

Fullerton DA, Harken AH. Acquired heart disease: valvular. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2008:chap 62.

Popma JJ, Baim DS, Resnic FS. Percutaneous coronary and valvular intervention. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 55.

Otto CM, Bonow RO. Valvular heart disease. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 62.

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.

Update Date: 1/26/2011

Updated by: Shabir Bhimji, MD, PhD, specializing in General Surgery, Cardiothoracic and Vascular Surgery, Midland, TX. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.