The surgical reconstruction, or mitral valve replacement, is the second most common surgery on the heart valves. In European countries with developed medicine, the interventions on the mitral valve are increasingly performed endoscopically, using minimally invasive technique. For example, 61 out of 80 specialized cardiac surgery clinics in Germany actively apply this technique, performing 45% of all isolated mitral valve operations using it.
The risks associated with the surgery using the MitraClip system are much lower than the surgical risks in the conventional, open reconstruction or valve replacement. It is successfully used in elderly patients and patients with severe comorbidities. However, the technique has a number of limitations, therefore it can be recommended for a limited number of patients. Another important condition for the successful treatment is a decent technical equipment of the hospital and surgeon's experience in carrying out such interventions.
Who is the mitral valve reconstruction indicated for?
Mitral regurgitation, or mitral insufficiency, is a congenital or acquired heart disease. In patients with mitral insufficiency the valve leaflets cannot close completely. In each contraction of the left ventricle, some blood flows back into the left atrium, and not into the aorta, as it should normally be. The excess blood in the left atrium gradually hampers blood flow from the lungs, leading to respiratory failure and pulmonary edema in severe cases.
Most often, the mitral valve is affected in such cases:
- Congenital heart defect (for example, splitting of the mitral valve leaflet). In a small defect size, such diseases are detected already in adulthood.
- Rheumatic heart disease, group A streptococcal infection.
- Infective endocarditis (bacterial or viral one).
- Connective tissue diseases (systemic lupus erythematosus, systemic scleroderma).
- Ischemic heart disease (papillary muscle dysfunction or postinfarction left ventricular aneurysm).
- Dilated or hypertrophic cardiomyopathy, myocarditis.
- Genetic syndromes (e.g., Marfan syndrome).
The need for a surgical treatment is determined by patient’s clinical condition and degree of the defect impact on hemodynamics. For example, if a patient has no complaints on shortness of breath and tolerates physical activity well, then a cardiologist recommends dynamic observation and supportive therapy.
If the shortness of breath in minimal physical activity, lower limb swelling, rapid heart rate, cough in the prone position and weakness are present, mitral insufficiency is considered clinically significant. If the conservative drug therapy does not provide a lasting improvement, a cardiologist recommends surgical correction of the defect.
Minimally invasive surgical technique
The essence of the minimally invasive operation using MitraClip system consists in the firm connection of weakened or deformed mitral valve leaflets using a special clip made of an alloy of chromium and cobalt. Unlike the classical intervention, during which the mitral valve leaflets were stapled manually with the help of a suture, the MitraClip system is placed endoscopically on the affected valves without thoracotomy.
- At the first stage of the operation, anesthesia is performed, and a probe is installed in order to carry out a transesophageal echocardiography (EchoCG) in real time. The echocardiographic monitoring allows a surgeon to track the movement of the catheter with the MitraClip device through the blood vessels and placement of the system on the mitral valve leaflets.
- After that, a guiding catheter is inserted through a small incision into the femoral vein of the patient. At its end the MitraClip device is located.
- Moving along the blood vessels under ultrasound control (EchoCG), the catheter reaches the left atrium. Here the flaps of the MitraClip are opened and the device is placed on the affected side of the mitral valve.
- After fixation of the MitraClip, the control echocardiography is performed. A surgeon assesses the blood flow through the reconstructed mitral valve. The EchoNavigator software, which combines the information obtained during echocardiography and radiography, can also be used for control. According to the results of the control examination, a surgeon can place an additional MitraClip on the valve leaflets.
- The guiding catheter is removed from the femoral vein. A purse-string is sutured on the incision. It is removed in 8 hours after the procedure completion. The total duration of the operation is 1-1.5 hours.
Due to the good tolerability of the procedure, the patient can go home in 1-3 days after the intervention. Further recommendations include the outpatient follow-up by a cardiologist and administration of antiplatelet drugs – Plavix for 1 month and Aspirin for 6 months.
Benefits and limitations of the minimally invasive mitral valve surgery
Minimally invasive mitral valve repair using the MitraClip combines the following advantages of the effective surgical treatment and endoscopic surgical access:
- Low operational risks: there is no need to perform a sternotomy, the thorax remains intact; low risk of haemorrhage and no need for blood transfusion; no need to connect the patient to the heart-lung machine.
- Low injury rate and minimal pain. The operation is performed through a small incision in the groin.
- Excellent cosmetic result. Sutures are removed on the next day after the intervention.
- Short period of hospitalization. The patient is discharged in 1-3 days after the intervention. Symptoms of mitral insufficiency completely disappear or alleviate significantly within the aforementioned period.
- Low risk of recurrence. In 90% of operated patients, the mitral valve retains its function for 10 years or more. Safety and effectiveness of the technique are confirmed by the results of the EVEREST II trial (Endovascular Valve Edge-to-Edge Repair Study).
However, use of the MitraClip has some limitations, such as:
- The technique is applied only if the initial area of the mitral valve is >4 sq.cm. Otherwise, there is a risk of postoperative mitral stenosis.
- The technique demonstrates lower efficiency in comparison with the classical operation. The comparison of effectiveness was carried out according to the degree of mitral regurgitation reduction (pathological blood flow through a damaged mitral valve).
- Objective data on the efficacy and safety of the MitraClip system is limited to the results of the EVEREST II trial. Such information is not sufficient for a comprehensive assessment of the long-term effectiveness and risks of the technique.
Thus, use of the MitraClip system is mainly indicated for elderly patients with high surgical risks. The technique is better tolerated, compared to the classic open surgery, but at the same time it does not replace the total mitral valve repair surgery.
Leading hospitals specializing in minimally invasive interventions
In order to perform minimally invasive cardiac interventions, the hospital must have appropriate endoscopic equipment and equipment for high-quality imaging during surgery (echocardiograph, high resolution CT and MRI). Another prerequisite is surgeon’s specialization in operations of this kind and sufficient number of operations per year (at least 250).
Such medical institutions are the following hospitals:
- University Hospital Oldenburg, Oldenburg, Germany
- Medipol Mega University Hospital Istanbul, Istanbul, Turkey
- University Hospital Ulm, Ulm, Germany
- University Hospital Tuebingen, Tuebingen, Germany
- University Hospital Erlangen, Erlangen, Germany
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Author: Dr. Nadezhda Ivanisova