Mitral Valve Disease

It would take some extraordinary mechanical engineering to create a more highly synchronized or more efficient organ than the human heart. 

The mitral valve regulates blood flow between the two chambers in the left heart (left atrium and left ventricle). It is replaceable by a man-made prosthetic or animal tissue valve, but that should never be the first choice.

Causes/Symptoms/Risk Factors

What makes the mitral valve such an important component of a healthy heart? A properly functioning mitral valve, situated between the left atrium left ventricle, opens as the left atrium fills with blood. As the heart expands, blood flows into the heart’s main pumping chamber, the left ventricle. The mitral valve then closes as the heart contracts, pushing oxygenated blood into the body’s largest artery, the aorta. 

When the mitral valve doesn’t work as it should, however, your heart might not pump enough of the oxygen-rich blood to your body. 

Types of mitral valve disease

Mitral Valve Regurgitation (MR) is the most common heart-valve disorder. It occurse when mitral valve leaflets become damaged or stretched out where they don’t close properly, which allows blood to flow backward, causing MR. Blood flows backward through the mitral valve and into the left atrium (the heart’s upper chamber) each time the left ventricle contracts. Blood, in effect, is moving in two directions because it’s also flowing from the ventricle through the aortic valve – the heart’s normal function that helps replenish the body with oxygen-rich blood. In this case, however, it’s not enough.

Mitral regurgitation affects an estimated four million people in the United States. If left untreated, MR may lead to chronic heart failure (HF), the leading cause of hospitalization in the United States and Europe.

• Approximately 50% of HF patients will die within five years.
• Approximately 10% of HF patients have symptoms, such as shortness of breath at rest.

Causes

Primary mitral valve regurgitation may be caused by problems like mitral valve prolapse or calcium buildup on the mitral valve. Secondary regurgitation may be caused by coronary artery disease or heart failure. Acute regurgitation is caused by a problem that happens all of a sudden, such as a heart attack.

Symptoms

Sometimes none. But you might experience:

• Rapid breathing.
• Cough.
• Fatigue.
• Light-headedness.
• A feeling that your heart is beating fast than usual.
• Excessive urination at night.
• Awaking shortly after falling asleep because of trouble breathing.

Risk Factors

• Prior heart attacks and coronary heart disease increases the risk of developing of MR.
• Infection of the heart valves.
• Mitral valve prolapse. (See below.)
• Age. (Normal wear-and-tear on the mitral valve.)

Learn more: Mitral Regurgitation

Mitral Valve Prolapse (also known as Barlow’s syndrome or click-murmur syndrome): When the mitral valve’s two flaps bulge back, or prolapse, into the left atrium, it’s usually a harmless malfunction that affects 2 percent to 3 percent of the general population. If the valve does not seal properly, however, some blood can flow back from the ventricle into the atrium (regurgitation).

Causes

Researchers have not found a precise cause of mitral valve prolapse, but most patients who have this condition were born with it. People with connective tissue disorders, such as Marfan syndrome, are more likely to experience mitral valve prolapse.

The prolapse, or bulging, is a byproduct of an abnormal mitral valve: A stretched opening or valve flaps that are too big, too thick or “floppy” (stretched tissue). 

Symptoms

Most people with mitral valve prolapse will never have to deal with symptoms, or a significant valve backflow, related to the condition.

Possible symptoms:

• Shortness of breath.
• Cough.
• Migraine.
• Fatigue.
• Dizziness.
• Anxiety.
• Palpitations.
• Chest discomfort.

Risk Factors

• Connective-tissue disorders (such as Marfan syndrome).
• Skeletal problems (Scoliosis).
• A history of rheumatic fever.
• Muscular dystrophy.
• Graves’ disease (a type of hyperthyroidism).

Mitral Valve Stenosis (MS) (also known as mitral stenosis) is a narrowing of the mitral valve blocking blood flow into the main pumping chamber (left ventricle).

Causes 

MS can be caused by calcium buildup on the valve over time, an unintended consequence of radiation therapy to chest, or as a result of rheumatic fever (untreated strep infection). If left untreated, MS can lead to heart failure symptoms like shortness of breath, fatigue, swelling of the legs, chest discomfort, dizziness or fainting, and heart arrhythmias.

It can cause inflammation of the:

• Myocarditis (heart muscle).
• Endocarditis (heart lining).
• Pericarditis (heart membrane).

In the United States, most cases of mitral valve stenosis are concentrated among older adults who had rheumatic fever before antibiotics were more commonly prescribed. 

Other possible causes, though rare:

• Congenital heart defects.
• Excess calcium.
• Blood clots.
• Tumors.
• Radiation treatment.

Symptoms 

• Shortness of breath, especially during or after exercising.
• Difficulty breathing when sleeping or lying down.
• Fatigue.
• Respiratory infections (bronchitis).
• Palpitations.
• Dizziness, fainting.
• Chest discomfort.
• Cough.
• Severe headache or stroke-like symptoms.

Risk Factors

• Rheumatic fever.
• Renal falilure (dialysis).
• Atherosclerosis.
• Radiation therapy. 

Note: Rheumatic fever, though rare in the United States, is still prevalent in developing nations. 

Learn more: Mitral Stenosis

Diagnosis

Your doctor, using a stethoscope, might detect a problem with a heart valve during a routine physical examination.

Several tests can help a cardiologist diagnose coronary heart disease: 

Electrocardiogram: A device that measures the heart’s electrical activity, its rate and regularity. 

Echocardiogram: An ultrasound test that uses a transducer to send out high-frequency sound waves toward the heart. The device in a traditional echocardiogram, when moved over the chest and abdomen, turns the echoes of sound waves redirected from various parts of the heart into detailed images of organs, blood flow and tissues. A transesophageal echocardiogram, using a device inserted into your esophagus, gives a more detailed picture of your heart.

Stress Test: A measure of your heart rate as you walk on a treadmill that tells doctors if your heart works properly when required to pump more blood. 

Chest X-ray: A picture of the chest area, including the heart and lungs, captured by X-rays.

Cardiac Catheterization: Diagnostic tests and imaging using a flexible tube (catheter) your doctor threads to your heart from a blood vessel in your arm, upper thigh or neck.

Holter Monitor: A portable device worn for two days that records the heart’s electrical activity, including heartbeats. A patient who feels symptoms while wearing the device can press a button that records heart rhythms at that time.

Learn More: Mitral Valve

The repair rate for patients at the Heart & Vascular Institute with leaking mitral valves is close to 100 percent. Our experience is an important part of that success. More than 40 years of research has determined that, for most complex procedures, the hospitals and surgeons who perform them most often have the best patient outcomes. Specifically, a study of mitral valve replacement published in May 2017 in the Journal of the American College of Cardiology found much higher survival rates – and a greater likelihood of valve repair than replacement – when the surgeon had performed the procedure at least 25 times each year. 

Since performing New England’s first mitral valve repair in 1984, more than 2,000 of these procedures were performed. We continue to seek new ways to reduce physical intrusion – with incisions now as small as 3 inches -- while minimizing the patient’s recovery period. Not all mitral valves are repairable, but always consult a surgeon experienced in mitral valve repair before agreeing to replacement surgery.

If You Have The Procedure: The Incision

Anterior Thoracotomy Incision

The anterior thoracotomy approach avoids cutting the sternal bone and instead utilizes a 2-inch horizontal incision lateral to the nipple. The chest is entered between the ribs in the fourth intercostal space. The use of long-shafted instruments and a magnifying camera allow for precise work on the mitral valve. Dr. Hashim favors this new approach over robotic surgery, as it uses the same incisions and access but provides for tactile feedback from the instruments as they navigate the tissues of the valve. 

The Mini Lower Sternotomy Incision

The mini lower sternotomy incision is a 3-inch vertical incision over the lower part of the sternum. This incision avoids the upper sternum and provides the patient in recovery with greater flexibility in movement of the upper chest, enabling for an early return to driving.

Submammary Incision

The submammary approach provides the same inside access as the mini lower sternotomy, but uses a 2-inch curvilinear skin incision located within the bra line. Dr. Hashim developed this technique to provide his female patients who require a lower sternotomy incision with optimal aesthetic results.

Alternative Options to Open Heart Surgery for Mitral Valve Disease

There have been significant advances in minimally invasive ways to treat mitral valve disease. It is one of the fastest growing areas in cardiac intervention. Hartford Hospital is honored to be able to offer these new cutting edge technologies and procedures to patients who have symptomatic mitral valve disease. We use a team based approach to help you decide which option is safest and most effective for you. Our team is composed of cardiac interventionalists, cardiologists, cardiac surgeons, echocardiography physicians, imaging specialists, and heart failure physicians who specialize in valvular heart disease management and treatment.

Less invasive options to treat symptomatic mitral valve disease for patients who are not a candidate for traditional surgical mitral valve replacement or repair

• Mitral Clip procedure (Transcatheter Edge to Edge Repair of Mitral Valve)
• TMVR procedure (Transcatheter Mitral Valve Replacement)
• APOLLO Trial (Transcatheter Mitral Valve Replacement)
• RESTORE Trial (Harpoon Transcatheter Mitral Valve Repair)

Mitral Clip (Transcatheter Edge to Edge Repair of Mitral Valve)

Mitral Clip is a procedure done to reduce the amount of mitral regurgitation in patients who are symptomatic, have been on optimal medical therapy, and are not a candidate for surgical repair. The COAPT trial showed that symptomatic patients with severe mitral regurgitation who received mitral clip had superior results when compared to similar patients who only received medical therapy. Mitral clip patients had less symptoms, better quality of life and less heart failure hospitalizations at 24 months compared to those that received medical therapy only.

This is a catheter based procedure done through the vein in your groin. We use a special echocardiogram (transesophageal echocardiogram) to guide the placement of the mitral clip device. The device is a clip with two arms that close to bring the mitral valve leaflets together and lock them in place. Patients usually stay one to two nights in the hospital for monitoring. There is minimal downtime post procedure.

Prior to the procedure you will need to be evaluated by an interventional cardiologist and cardiac surgeon to determine candidacy. You will also need a transesophageal echocardiogram at Hartford Hospital to assess your mitral valve anatomy.

Learn more: MitraClipLearn more (video)

TMVR (Transcatheter Mitral Valve Replacement)

TMVR is a procedure done to replace the mitral valve in patients who have already undergone a surgical mitral valve replacement or repair in the past and are not a candidate for repeat surgery. This procedure is recommended for patients with either severe mitral regurgitation or mitral stenosis of their bioprosthetic valve.

The technology and procedure is similar to the transcatheter aortic valve replacement. It is a catheter based approach through the vein in the groin. The new valve is placed on top of the old valve pushing the leaflets out of the way. Unlike surgery, the old valve or ring is not removed. Patients usually stay one to two nights in the hospital for monitoring. The procedure requires minimal downtime.

Prior to the procedure you will need to be evaluated by a cardiac surgeon and interventional cardiologist to determine candidacy. You will need a transesophageal echocardiogram, cardiac angiogram, and CT scan to assess your cardiac anatomy and determine if TMVR is right for you.

Learn more: TMVRLearn more (video)

APOLLO Trial (Transcatheter Mitral Valve Replacement)

Our first patient to successfully be enrolled in the APOLLO trial and undergo the TMVR procedure at his thirty day follow-up.

APOLLO trial is a study that Hartford Hospital has been chosen to be a part of. We are ONE of ONLY FIFTY-FIVE sites in the United States and 100 sites world-wide able to enroll in this study. This procedure provides another option for patients with symptomatic moderate to severe mitral regurgitation or a combination of mitral regurgitation and mitral stenosis in those who have not had a prior surgical mitral valve replacement. Patients are required to meet a list of inclusion and exclusion criteria in order to enroll in the study. Requirements include a visit with a cardiac surgeon, cardiac interventionalist, and heart failure specialist, along with a transesophageal echocardiogram, cardiac angiogram, and CT scan. Testing may need to be repeated if done at another institution or outside a certain time frame in order to enroll. Enrollment is done in phases. First, we have patients undergo the CT scan to determine anatomical candidacy. About 50% of patients are accepted based on their anatomy. Then patients are reviewed by the national study committee and they determine which patients are ultimately enrolled.

The procedure is done through the groin or through a small incision in the left side of the chest where a catheter is inserted at the apex of heart and the valve is deployed using transesophageal echocardiogram guidance. This procedure is done on a beating heart and cardiopulmonary bypass is not needed like traditional open heart surgery. Patients can expect to stay in the hospital for four to five days after the procedure for monitoring.

Following the procedure, there is required follow-up at various time periods to be done at Hartford Hospital which requires physical exams, echocardiograms, and CT scans.

Learn more: APOLLO Clinical Trial

RESTORE Trial (Harpoon Transcatheter Mitral Valve Repair):

RESTORE trial is another study that Hartford Hospital has been chosen to be part of. We are ONE of ONLY FORTY sites in the United States, Canada and Europe. This procedure is yet another option for patients with symptomatic severe mitral regurgitation caused by posterior leaflet prolapse. Enrollment is dependent on certain inclusion and exclusion criteria set forth by the study. Patients would need to meet with a cardiac surgeon and cardiac interventionalist and undergo a transesophageal echocardiogram to assess anatomy. Patients are submitted to the study committee for review. Final enrollment is decided by the committee.

The procedure is done through a small incision on the left side of the chest. A catheter based device is inserted near the apex of the heart. The device is guided by transesophageal echocardiogram to place sutures that mimic chords to the mitral valve leaflet that reduce prolapse of the leaflet. This procedure is done on a beating heart and eliminates the need for cardiopulmonary bypass. The recovery requires minimal downtime.

There are certain follow-up requirements to be met after the procedure which involve physical exams and echocardiograms.

Learn more: RESTORE TrialLearn more (video)