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Advancements in Minimal Invasive Mitral Valve Repair

Surgical repair is the only therapy proven to prevent the negative prognostic consequences of heart failure associated with chronic, untreated mitral valve regurgitation.


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Mitral valve regurgitation caused by a leaflet prolapse is one of the most frequent, degenerative heart conditions in the Western world. Many patients will remain with little or no symptoms for years, until the deleterious effects of associated left ventricular dysfunction develop.

Conventional Cardiac SurgerySurgical repair is the only therapy proven to prevent the negative prognostic consequences of heart failure associated with chronic, untreated mitral valve regurgitation.

Preoperative atrial fibrillation has been found to be an independent predictor of mortality. As a consequence, operative risk is increased if surgery to correct mitral valve regurgitation is delayed, until the onset of atrial fibrillation.

Delaying mitral valve repair in asymptomatic patients with severe mitral regurgitation

This can be done while allowing either:

  • the left ventricular ejection fraction to fall below 0.60
  • an increment of the left ventricular end-systolic diameter beyond 40 mm
  • or, the onset of symptoms

However, this delay can unduly expose patients to excess early and late death; after eventual surgical correction.

Asymptomatic patients who undergo early mitral valve repair

In contrast, these cases benefit from:

  • normalisation of late survival
  • improved regression of heart dimensions and overall geometrical remodelling
  • a better recovery of normal left ventricular ejection fraction, with time

Surgical intervention
The unwillingness of asymptomatic patients to submit to an invasive procedure brings great importance in the debate regarding the ideal timing of surgical intervention. This is because asymptomatic patients are generally reluctant to submit to an invasive procedure, due to the perceived drawback in subsequent, temporary functional limitation, during their post-surgical recovery.

Median sternotomy is the most frequent surgical approach used to perform mitral valve operations worldwide, and is associated with excellent clinical outcomes. More than one in three patients, in both the US and Europe, are presently treated with minimal invasive or robotic strategies which do not require opening the full chest in a traditional way. However, this method must necessitate specific surgical team skills and the use of advanced instrumentation. The percentage of the patients operated in specific specialised surgical centres has increased 90 per cent.

The availability of high-definition thoracoscopic imaging, new surgical instrumentation and even robotic technology, has allowed surgeons at The Wellington Hospital to routinely perform mitral surgery through small, right thoracic, soft tissue incisions. This obviates the need for traditionally large chest openings or breast bone fractures.

Minimal Access SurgicalBenefits of minimally invasive surgical techniques include: diminished post-operative functional limitation, decreased use of pain killers, less bleeding and use of blood transfusion postsurgery, lower infection rates and shorter hospital stays. There is also a shorter time period in which patients can return to normal daily activities,compared to post-traditional cardiac surgery.

A meta-analysis and systematic review published in 2014, (analysing more than 20,000 patients from 45 studies) found that stroke rate and all cause mortality were similar in patients treated via minimal invasive or conventional median sternotomy. The length of stay in the intensive care unit, the time spent on the ventilator postsurgery and the hospital stay were all significantly shorter in the minimal invasive group, where blood losses and blood transfusions were also decreased. In contrast, operation times were longer in the minimal invasive group with the occurrence of new atrial fibrillation after surgery appearing less*.

For those patients who have been diagnosed with mitral valve disease, they can be reviewed and assessed for suitability for minimal invasive surgery at the Platinum Medical Centre.


Keywords

Mr Roberto Casula, Cardiothoracic, Minimal Invasive Mitral Valve Repair, Cardiac, degenerative heart conditions, heart, surgical correction



Issue
Number:
18
Title:
Orthopaedics: Non-surgical and operative solutions
Published:
November 2014
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Mr Roberto Casula

Consultant Cardiothoracic Surgeon

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