Ask the Heart Doctor: Mitral Valve Surgery

Our heart valve disease experts answer real questions from real people about the mitral valve. Learn about diagnosis and treatment options for heart valve disease, including nonsurgical valve procedures and surgical options for repairs and replacements.

Schedule an appointment at Cleveland Clinic by calling 844.868.4339.

Meet our panel:
Amar Krishnaswamy, MD, Cardiologist, Section Head, Invasive & Interventional Cardiology https://my.clevelandclinic.org/staff/16286-amar-krishnaswamy
Serge Harb, MD, Cardiologist  https://my.clevelandclinic.org/staff/17645-serge-harb
Xiaoying Lou, MD, Cardiac Surgeon https://my.clevelandclinic.org/staff/30230-xiaoying-lou
Tarek Malas, MD, CM, MPH, FRCSC, Cardiac Surgeon https://my.clevelandclinic.org/staff/22424-tarek-malas

Learn more about the Valve Center. https://my.clevelandclinic.org/departments/heart/depts/valve-center

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Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. This podcast will explore disease prevention, testing, medical and surgical treatments, new innovations and more. Enjoy.

Amar Krishnaswamy, MD:

Thank you, everyone, for joining us. This is the edition of Ask The Heart Doctor where we're going to focus on valvular heart disease, from diagnosis to treatment. My name is Amar Krishnaswamy. I'm the Section Head of Interventional Cardiology, and I specialize in the transcatheter treatment of valvular heart disease. I'm joined today by a fantastic panel of colleagues and friends. We have Dr. Xiaoying Lou, who is a cardiac surgeon and an expert in aortic valve surgery. We have Dr. Tarek Malas, who's also a cardiac surgeon and an expert in mitral valve surgery, and Dr. Serge Harb, who is one of our cardiac imagers and a specialist in the diagnosis and guidance of transcatheter heart procedures with cardiac imaging.

We appreciate your engagement in this program. We've received almost 250 different questions. We're going to try to do our best to answer as many of them as we can in a comprehensive fashion. But please, if there are questions we don't answer, feel free to reach out. There will be contact information at the end of this program. 

Turning to you again, Dr. Tarek Malas. He's one of our cardiac surgeons and a specialist in surgery on the mitral valve. We have a number of questions on mitral valve surgery here. Dr. Harb has mentioned to us when we make the decision for someone to need a mitral valve surgery, so now they've come to you. How do you parse out if someone requires a surgical mitral valve repair or a valve replacement?

Tarek Malas, MD:

We get a range of patients that have different pathologies. I rely on experts like Dr. Harb to give us information about the valve and try to understand the valve better. Generally speaking, a valve can either leak or it can be stenotic, meaning it's calcified and it's not moving very well. When the valve is calcified and it's stenotic, we usually lean on a mitral valve replacement. We prefer to replace those valves, because repairs don't generally last very long in that type of group. Versus, a valve that's leaking, in the majority of cases here at Cleveland Clinic, we're able to repair those valves. That really depends on the type of pathology. That's where we require certain imaging to understand the valve, and an expert on our heart team to make that decision. The best judgment to repair the valve is also made intraoperatively, when we take a look at the valve with our eyes and we make the decision whether we can repair or need to replace that valve.

Amar Krishnaswamy, MD:

I always find it striking that there appears to be very clear data that for patients who have degenerative mitral valve regurgitation, so mitral valve prolapse or flail, that unquestionably the outcomes are better for someone who's had a valve repaired than someone who has had a valve replaced. This is both functional outcomes and survival outcomes. Yet, nationally, many surgeons don't end up repairing the valve. The last statistics I saw were that for somebody with a degenerative mitral valve, less than half of the patients are actually having a valve repair, as opposed to a valve replacement. At Cleveland Clinic, for you and the mitral valve group, what percentage of patients with a degenerative mitral valve are having a repair?

Tarek Malas, MD:

Unfortunately, we do see that variation in data. There are studies that show that centers that have a higher volume of mitral valve repair tend to do much more repair and do a better job at that. This is why centers of excellence are the best place to have that type of repair. At the Cleveland Clinic, we repair a majority. If we look at, for example, our robotic background, Dr. Marc Gillinov and myself do robotic mitral valve repairs, we have a 99% repair rate. The mortality rate is extremely low, less than 0.05%. That speaks to the experience and the expertise in that field, versus looking at other centers that do not repair these valves and replace these valves. Unfortunately, in the long-term replacements, while they are fantastic surgeries, they do have a smaller survival compared to repairs. This is a tenet that we hold very dearly here at Cleveland Clinic. We try to repair valves if we think they're repairable.

Amar Krishnaswamy, MD:

That's very helpful. Tarek, you mentioned there briefly something about robotic mitral valve surgery. It sounds futuristic and very exciting. Can you help us understand a little bit? What is robotic mitral valve surgery and how do you decide? Can all patients have a robotic mitral valve surgery?

Tarek Malas, MD:

Robotic surgery is an excellent alternative to open-heart surgery. It's not for everybody, but we have certain criteria that we look at. First of all, we look at patient factors, we look at anatomical factors. Finally, we look at the valve. We make sure that the valve is a good valve to repair or replace. Currently, we can do both replacements and repairs with a robot. We do have to have preoperative testing. We rely on experts like Dr. Harb as well to look at the valve, to understand the pathology. Also, we look at important anatomical factors like how calcified is this valve, is this valve repairable? Then that gives us a decision as to see if somebody is a robot candidate or not.

We usually perform the robotic surgery without having to cut any bones. Rather than go through the sternotomy, which is the incision that we cut the breastbone, we actually go through the side, between the ribs. That involves a small incision of about four to five centimeters. We insert three robot arms between the rib spaces. It's truly, almost like a video game console, you sit in a console and you control the robot arms, do the repair. Our results have been excellent in that.

The beauty of robotic repair is you're able to see the valve at about a 10-time magnification. That allows us to assess the valve better, and to perform a durable and strong repair. Again, we usually go through the heart-lung machine, through the legs. We use anatomical criteria to make that decision. If you're to come here for robotic surgery, you'd want to have a CT scan to look at the anatomy and make a decision as to whether you're a robotic candidate or not.

Amar Krishnaswamy, MD:

That's really exciting. Parenthetically, Tarek and I were just talking the other day. He told me that even if he has an extra strong cup of coffee and his hands get a little shaky, the robot can actually steady the hands. 

We have a lot of questions here about less invasive or transcatheter treatments for mitral valve disease. These questions came through as asking about the MitraClip. What I would mention is that the MitraClip was the historic and predicate device, the first device approved. We now call the procedure Transcatheter Edge-to-Edge Repair or TEER. All of my answers are going to specifically use that term for those of you who know it as MitraClip. There is another device that's approved called the PASCAL device, which is a somewhat similar, somewhat different device, but affects a similar transcatheter-based treatment of the mitral valve.

What we do for the TEER procedure, again, this is for patients with mitral valve regurgitation, whether it's primary or degenerative mitral valve regurgitation or secondary mitral regurgitation that we used to call functional. We place a catheter at the top of usually the right leg, in the right femoral vein. We pass that catheter up to the mitral valve. On the end of that catheter is this TEER device that looks like a little clothespin. If the valve isn't coming together properly, we can actually hold the valve together. As opposed to TAVR, this is a procedure that is routinely done under general anesthesia with a breathing tube, not under conscious sedation.

For the most part, the procedure can take anywhere from 25 minutes to two hours. It really depends on the complexity of the mitral valve disease, whether we have to place one device or more than one device, and various different analyses that we do during the procedure to make sure that we're affecting the best solution, the best treatment option for that patient. 

There's a question here. How effective is the MitraClip for mitral valve regurgitation? For the most part, both the technology of TEER, as well as the imaging and the guidance provided by Dr. Harb and his colleagues, have improved substantially over the last 15 years that we've been using the TEER devices. As a result, and for the most part, we find that more than 90% of patients will be left with less than a moderate degree of mitral valve regurgitation. That's what we consider as the standard for a good result. Generally speaking, over 91% of patients in recent series will have one plus or less mitral valve regurgitation at the end of the procedure. 

I will make the caveat that we do treat a number of patients with a TEER device who are not, in fact, anatomically good candidates for a TEER procedure. But either due to age or different comorbid conditions, they're simply not candidates either for a transcatheter-based mitral valve replacement or a surgical mitral valve repair or replacement. We know that for those patients, when we analyze them in a case-by-case basis, that even if we cannot affect an A+ strategy for a TEER procedure, even reducing their mitral valve regurgitation to some degree can be beneficial with regard to functional outcomes and how they feel in their day-to-day. So, I think this is an important consideration. It's not always just about how low is the final mitral regurgitation grade, but are we doing it for a patient that doesn't have another option and we can still help them to feel better. 

There's a question here – for someone over age 75, is a TEER procedure a better option? So, as with everything, including with aortic valve disease, mitral valve disease, our decision-making here is not based simply on age, but looking at the valve pathology. How effective can we be with a TEER procedure versus with cardiac surgery? What are the other conditions that the patient is facing? We tend to focus a little bit less on age than we do these other factors. It's true that for the most part, for somebody over the age of 80, their surgical risk is likely going to be higher. At the current time, we focus on TEER device treatments for patients who are considered at a high risk for cardiac surgery. This is based on the FDA approvals. 

Having said that, those approvals are over a decade old. We know, again, as I mentioned earlier, that the technology of the TEER devices and the imaging that we use to direct these procedures is far better than it ever was. So, our head of cardiac surgery, Dr. Marc Gillinov, along with a cardiac surgeon named Jo Chikwe at Cedars-Sinai, are leading an NIH-sponsored trial called PRIMARY, where we take patients who are above the age of 60 at any level of surgical risk, who have suitable anatomy for a TEER procedure or a mitral valve surgical repair, and they're randomized between one or the other. Again, this is not a decision made in isolation. We all analyze these patients as interventional cardiologists, cardiac imagers, cardiac surgeons, to say that we all feel that these can be an equivalent strategy, surgery or catheter treatment for these patients, and that's how the patients get randomized. If there's a younger patient who is at a low or even an intermediate medium surgical risk, who's not interested in the randomized trial, then the only option at the current time is for a surgical valve repair, as Dr. Malas has elucidated for us. 

Question here – if you've had a mitral valve repair in the past, can it be repaired again or does it need to be replaced? Perhaps I'll address that from a transcatheter perspective. Dr. Malas, if you can answer from a surgical perspective. Whether someone has had a transcatheter TEER procedure in the past or a surgical mitral valve repair, there are opportunities for us to repair that valve again with a TEER device in either of those situations. The key decision there is based on the anatomy. That anatomy is information we get from imagers like Dr. Harb, to show us exactly what's wrong with the valve now, why is it leaking again, and can we fix it with a TEER device.

If you've had a mitral valve replacement in the past, universally those patients tend to be a bit more elderly, often at a higher surgical risk. It is very rare that we cannot do a transcatheter valve replacement for someone who has a failing surgical mitral valve bioprosthetic. 

Dr. Malas, let me turn it to you. What do you do for a patient who has a recurrent mitral valve regurgitation or a stenosis after a prior surgical valve repair or even a TEER?

Tarek Malas, MD:

This speaks highly of the way we function here at the Cleveland Clinic, where we have experts like Dr. Krishnaswamy and Dr. Harb. We sit down together as a group and we look at each patient based on the patient's values. We look at the patient's imaging, and we also look at factors like age and comorbidities. That helps us get a global idea of what the best treatment strategy is. This is something we discuss together before offering either a surgical intervention or a transcatheter repair. In my practice, we have been able to re-repair valves in a good majority of patients that come back with mitral valve regurgitation after a previous failed mitral valve repair. That decision is difficult to make. We look at the imaging, of course, initially, but the best time to make that decision obviously is in the operating room when we evaluate the leaflet quality, what type of pathology is causing the issue.

If it's a stenotic valve, then we usually replace that valve. Sometimes you can repair that valve as well, but in the majority of cases we replace. If it's a valve that has leaked again after a previous repair, then we can either repair or replace that valve. I would say in about 50% of cases, given approximation, if we can't repair the valve, then we replace that valve. That sets us up perfectly for the future for a transcatheter approach as well. If we have a failed MitraClip, then we can replace that valve in the majority of cases. That really depends on the procedure that was done, the age, the comorbidities. That's something that we study together as a group.

Amar Krishnaswamy, MD:

Thanks again to Dr. Harb from cardiac imaging, Dr. Malas from cardiac surgery, Dr. Lou from cardiac surgery. And to those of you watching, we appreciate your time. Take care.

Announcer:

Thank you for listening to Love Your Heart. We hope you enjoyed the podcast. For more information or to schedule an appointment at Cleveland Clinic, please call 844-868-4339. That's 844-868-4339. We welcome your comments and feedback. Please contact us at heart@ccf.org. Like what you heard? Subscribe wherever you get your podcasts or listen at clevelandclinic.org/loveyourheartpodcast.