Mitral Valve Repair

Excerpt

Although the standard of care for degenerative mitral valve disease is surgical repair, patient outcomes depend on several variables, including preoperative status, mitral regurgitation severity, procedural technique, and the surgeon's and center's experience. In appropriately selected patients who undergo timely mitral repair, operative risk is low, and long-term survival approaches that of age- and sex-matched populations. In high-risk individuals, choosing among surgical, percutaneous, and conservative strategies is complex and should be individualized based on comorbid conditions, anatomic suitability, and local expertise. Mitral valve repair generally offers important advantages over valve replacement, but patient-specific clinical and anatomic factors must guide final decision-making. Notably, a substantial proportion—on the order of one-half—of patients with severe mitral valve disease are not candidates for surgery, most commonly because of advanced age, frailty, or significant comorbidities.

Up to 3% of adults in the United States have mitral valve disease (see Image. Insufficient Mitral Valve). Patients with degenerative pathology who develop symptoms of mitral regurgitation have a poor prognosis, with annual mortality rates of up to 34%. Mitral stenosis, primarily caused by rheumatic heart disease, is commonly treated with percutaneous mitral balloon commissurotomy (also called percutaneous mitral balloon valvotomy) or mitral valve replacement. Repair is usually not feasible in patients with rheumatic mitral disease.

Mitral regurgitation is classified as primary or secondary, depending on whether the lesion is located at the valvular apparatus or due to left ventricular changes, respectively. While severe primary mitral regurgitation still receives treatment with surgical intervention, percutaneous techniques for repair and replacement are also gaining traction. Mitral valve replacement may be considered in patients with mitral regurgitation due to papillary muscle rupture, degenerative or ischemic mitral regurgitation, or those with a failed repair undergoing reoperation.