Mitral stenosis surgery procedure


 * Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [mailto:msbeih@perfuse.org]

The Procedure
The Procedure can be done either by the traditional open heart surgery or by the Minimally invasive surgery. Before the surgery, the patient will receive general anesthesia. This will make the patient asleep and pain-free during the entire procedure. Beside Percutaneous mitral balloon valvotomy (PMBV); there are three approaches for Mitral stenosis surgical treatment:

It is the earliest surgical procedure. It is performed on a beating heart. In this procedure; the surgeon makes a left thoracotomy incision and introduce a dilator to the mitral valve via either a transatrial or transventricular approach. Closed commissurotomy is usually indicated for the patients with minimal mitral valve calcifications and in those who lack significant subvalvular involvement. This approach is contraindicated in the following conditions:
 * Closed Commissurotomy
 * Mitral regurgitation (moderate or severe); as regurgitation may be worsened by the procedure.
 * Atrial thrombosis.

The limitation of closed commissurotomy is the difficulty for the surgeon to fully expose and visualize the Mitral valve during the procedure. Some studies showed that Percutaneous mitral balloon valvotomy (PMBV) is associated with better long-term outcomes than closed commissurotomy, recently, closed commissurotomy becomes less performed than before in the developed countries. Also in pregnancy; the PMBV is preferred over closed commissurotomy for mitral valve stenosis treatment.


 * Open Commissurotomy (Valve Repair)

The surgeon performs the procedure via median sternotomy. Via this surgical approach; it is better for the surgeon to fully expose and visualize the mitral valve during the procedure as compared to closed commissurotomy approach. Other advantages for this approach includes:
 * The surgeon can repair the valve by the dipridation of calcium deposits.
 * The surgeon can split fused chordae tendineae or papillary muscles.
 * The surgeon can insert annuloplasty ring to correct the valvular stenosis. This is needed in case of severe mitral regurgitation (grade 3 or 4) as the valve repair alone is in adequate.
 * The surgeon can remove a left atrial thrombus if presents.

Some studies showed that Percutaneous mitral balloon valvotomy (PMBV) is associated with better long-term outcomes than Open commissurotomy, along with shorter hospital stay and less morbidity from thoracotomy (in Open commissurotomy).

This procedure is indicated if the mitral stenosis could not be corrected by other surgical approaches previously mentioned and the patient has one of the following:
 * Mitral Valve Replacement
 * Moderate to severe mitral stenosis (≤1.5 cm2).
 * NYHA class III or IV symptoms.
 * Mild symptoms (NYHA class I or II) that associated with severe mitral stenosis (mitral valve area ≤1.0 cm2) or severe pulmonary hypertension (pulmonary artery systolic pressure >60 to 80 mmHg).
 * Severe mitral stenosis (mitral valve area ≤1.0 cm2) or severe pulmonary hypertension (pulmonary artery systolic pressure >60 to 80 mmHg) even if the patient is asymptomatic.

Mitral valve replacement significantly improves symptoms and has a favorable survival rate at five years. The 2006 ACC/AHA guidelines recommended amputation or ligation the left atrial appendage during mitral valve replacement or open commissurotomy, as this may decrease the risk of potential embolism, but it is not proofed if this may reduce the risk of stroke.

In the Traditional Open Heart Surgery:


 * The surgeon will make a 10-inch-long cut in the middle of the chest (sternum).
 * Next, the surgeon will separate the breastbone (sternum) to be able to see the heart.
 * Most people are connected to a heart-lung bypass machine or bypass pump. The heart is stopped while the patient is connected to this machine. This machine does the work of the heart while the heart is stopped.
 * A small cut is made in the left side of the heart so the surgeon can repair or replace the mitral valve.

In Minimally Invasive Mitral Valve Surgery; there are several different ways to perform the procedure:


 * The heart surgeon may make a 2-inch to 3-inch-long cut in the right part of your chest near the sternum. Muscles in the area will be divided so the surgeon can reach the heart. A small cut is made in the left side of the heart so the surgeon can replace the mitral valve.
 * In Endoscopic surgery, the surgeon makes one to four small holes in the chest, then he or she uses special instruments and a camera to do the surgery.
 * For Robotically-Assisted Valve Surgery, the surgeon makes two to four tiny cuts (about a ½ to a ¾ inch) in the 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.

The patient may or may not need to be on a heart-lung machine for these types of surgery, but if not, the heart rate will be slowed by medicine or a mechanical device.

There are two types of valves:

1. Mechanical which is made of man-made (synthetic) materials, such as a metal like titanium. These valves last the longest, but the patient will need to take blood-thinning medicine, such as warfarin (Coumadin) or aspirin, for the rest of his or her life.

2. Biological which made of human or animal tissue. These valves last 10 to 12 years, but the patient may not need to take blood thinners for life.

Once the new or repaired valve is working, the surgeon will:
 * Close the heart and take you off the heart-lung machine.
 * Place catheters (tubes) around the heart to drain fluids that build up.
 * Close the sternum with stainless steel wires. It will take about 6 weeks for the bone to heal. The wires will stay inside the body.

The patient may have a temporary pacemaker connected to the heart until his or her natural heart rhythm returns.

The surgeon may also perform coronary artery bypass surgery at the same time, if needed.