17234 Minimally Invasive Mitral Valve Repair

Overview

Your heart has four valves. They work like one-way doors, opening and closing so blood only moves forward. The mitral valve is the door between the upper left chamber (the left atrium) and the lower left chamber (the left ventricle). When it does not close tightly, blood leaks backwards. Doctors call this mitral regurgitation, or a 'leaky' mitral valve. Mitral valve repair is an operation that fixes your own valve so it shuts properly again. 'Minimally invasive' means the surgeon reaches your heart through one or two small cuts (often about 4 to 8 cm) between the ribs or under the right breast, instead of opening the whole breastbone. People also call it keyhole or port-access heart surgery.

Mitral valve problems are among the most common heart valve conditions in adults. Minimally invasive repair is done in specialist heart centres and is becoming more common, but open surgery is still used when it is the safer choice for that person.

Most people having this operation are adults, often in their 50s to 70s. Some younger adults need it because their valve has stretched out of shape (called mitral valve prolapse) or was damaged by an infection. Children are sometimes born with a mitral valve problem that needs repair, but this is uncommon.

Symptoms

Common symptoms

• Shortness of breath, especially when walking, climbing stairs or lying flat
• Feeling unusually tired or washed out during normal activities
• A racing, fluttering or pounding heartbeat (palpitations)
• Swollen ankles or feet
• A cough, often worse at night or when lying down
• Dizziness or light-headedness
• Chest discomfort or a feeling of pressure
• A heart murmur heard by your doctor through a stethoscope

Symptoms in children

• Feeding slowly or tiring and sweating during feeds
• Poor weight gain or slow growth
• Breathing fast or working hard to breathe
• Getting out of breath quickly when playing
• Frequent chest infections
• Unusual tiredness compared with other children of the same age

Symptoms in older adults

• Breathlessness doing everyday tasks such as housework or shopping
• Tiredness that is easy to blame on getting older
• Swelling in the ankles, legs or tummy
• An irregular or fluttering heartbeat
• Feeling faint or unsteady when standing up
• A night-time cough or needing extra pillows to sleep comfortably
• Being less able to do the things you used to enjoy

Causes

Main causes

• Mitral valve prolapse — the valve flaps stretch and bulge, so they no longer seal (the most common cause in many countries)
• Rheumatic heart disease — lasting damage after rheumatic fever, which can follow an untreated strep throat
• Infection of the valve, called endocarditis
• Wear and tear as the valve ages
• Damage to the heart muscle after a heart attack
• A valve problem you were born with (congenital)

Risk factors

• Getting older
• A family history of mitral valve prolapse or valve disease
• Previous rheumatic fever or repeated strep throat infections
• A previous heart attack
• Connective tissue conditions that affect the body's support tissues
• Past radiotherapy to the chest
• Injecting drugs, which raises the risk of valve infection
• Long-standing high blood pressure

When to see a doctor

See a doctor urgently if:

• Breathlessness that suddenly gets much worse, or comes on at rest
• Chest pain or pressure
• Fainting or near-fainting
• A new, fast or irregular heartbeat
• Fever with no clear cause when you have a known valve problem

Book a routine appointment if:

• You feel more breathless than usual when active
• You are more tired than you would expect
• Your ankles look puffy, or your shoes feel tight by evening
• You notice a fluttering feeling in your chest
• A doctor has told you that you have a heart murmur
• A close relative has had mitral valve surgery, and you would like advice

Diagnosis

Your doctor will start by listening to your heart, asking about your breathing, tiredness and activity levels, and checking your ankles and pulse. If a valve problem is suspected, you will usually be referred for an echocardiogram — a painless ultrasound scan of the heart that shows how the valve moves and how much blood leaks back.

Tests that may be done

• Echocardiogram (ultrasound scan of the heart) — the main test, done on your chest
• Transoesophageal echocardiogram — a small probe passed gently down the throat for clearer pictures, often before surgery
• Electrocardiogram (ECG) — sticky patches on the chest that record your heart rhythm
• Chest X-ray to check the size of your heart and your lungs
• Blood tests to check your general health and look for infection
• An exercise test to see how your heart copes with activity
• Cardiac catheterisation (angiogram) — a thin tube used to check the heart arteries
• CT scan or lung function tests in some cases, to plan the operation

What to expect at your appointment

You will usually see a cardiologist first and then a heart surgeon. They will go through your scan results, explain the benefits and risks for your particular case, and give you time to ask questions — it can help to bring someone with you and write your questions down beforehand. You may be asked to have a dental check and to stop smoking before surgery. Nothing is decided without your agreement.

Treatment

Treatment aims to stop the leak or reduce it, protect your heart muscle and help you feel better. Options range from careful monitoring, to medicines that make the heart's work easier, to surgery. Minimally invasive repair is one type of surgery; the right choice depends on how severe the leak is, your symptoms, your heart's size and strength, your age and your other health conditions.

Self-care at home

• If you smoke, stopping is the single biggest thing you can do for your heart — ask your doctor for support
• Stay as active as your body allows, and build up gently rather than in bursts
• Weigh yourself at the same time each day and note any sudden gain
• Check your ankles and legs for new swelling
• Tell your dentist that you have a heart valve problem, and keep up regular dental care
• Take any prescribed medicines as agreed, and ask your pharmacist before starting new ones
• Keep your blood pressure and cholesterol in a healthy range
• Get help to cut back on alcohol if it is more than the recommended limits

Medical treatments

No medicine can repair a leaky valve. Medicines are used to ease symptoms and protect the heart — for example to remove extra fluid from the body, lower blood pressure, slow a fast heartbeat, or reduce the risk of clots if your heart rhythm is irregular. Your doctor will choose what suits you and review it regularly. If the valve itself needs fixing, surgery is currently the only way to do that. Your care team will discuss all options with you clearly before anything goes ahead.

When is surgery considered?

Surgery is usually recommended when the leak is severe and you either have symptoms or tests show your heart is starting to enlarge or weaken — this can be true even if you feel well. Repair is often preferred to replacement when the valve can be fixed, particularly in younger people. Occasionally the valve fails suddenly, and surgery is then needed urgently.

Living with this condition

You will usually spend a day or two in intensive care or a high-dependency unit, then move to a normal ward. Most people are up and walking within a day or two and go home around 4 to 7 days after surgery. For the first few weeks you will feel more tired than usual, and your chest and shoulder may ache. You will be asked not to lift anything heavy or drive for a period set by your team — often around 4 to 6 weeks. Most people return to office-type work in 4 to 8 weeks and to heavier physical work later than that. Follow the plan your own team gives you, as it is tailored to you.

Lifestyle tips

• Build activity up slowly — short walks little and often work better than one long push
• Keep the wound area clean and dry, and follow your team's washing instructions
• Avoid crowded places and people with coughs and colds for the first few weeks
• Take daytime rests and protect your sleep while you recover
• Keep up dental hygiene and regular dental check-ups
• Ask your team before flying, long car journeys or travel abroad
• Keep a simple record of your weight, breathlessness and energy so you notice changes early

Diet and exercise

Eat a balanced, heart-friendly diet: plenty of vegetables, fruit, wholegrains, beans and fish, and less salt, processed meat and sugary food and drink. Cutting back on salt helps keep fluid from building up. Alcohol is best kept low. Most heart centres offer a cardiac rehabilitation programme — a supervised mix of exercise, education and support that helps you get fit safely. Ask your team to refer you; it is one of the most helpful things you can do after valve surgery.

Mental health and emotional wellbeing

It is very common to feel anxious before heart surgery and low or tearful afterwards. Many people find their sleep is disturbed, their memory feels fuzzy for a few weeks, and they worry about every twinge. This usually settles, but you do not have to put up with it silently — tell your doctor or nurse, as talking therapy and support groups genuinely help. If you ever feel hopeless or have thoughts of harming yourself, contact your local emergency number or a crisis line in your country straight away.

Prevention

Not every valve problem can be prevented, and some are simply down to ageing or genetics. But some causes can be reduced. Treating strep throat properly with the antibiotics your doctor prescribes helps prevent rheumatic heart disease. Good dental care and healthy gums lower the risk of valve infection. Keeping blood pressure, cholesterol and weight in a healthy range protects the heart. Not smoking and avoiding injecting drugs also reduce risk.

Vaccines

Ask your doctor about flu and pneumonia vaccinations. Infections put extra strain on a heart with a valve problem, and vaccination is a simple way to lower that risk.

Screening programmes

There is no routine national screening programme for mitral valve disease. If you have a family history of mitral valve prolapse or a connective tissue condition, or if a doctor has heard a murmur, ask whether an echocardiogram would be worthwhile for you.

Complications

If left untreated

• Heart failure — the heart struggles to pump enough blood, causing breathlessness and swelling
• An irregular heart rhythm such as atrial fibrillation, which can cause palpitations and raise the risk of stroke
• High blood pressure in the lungs (pulmonary hypertension)
• Extra strain and enlargement of the left side of the heart
• Infection of the valve (endocarditis), which is serious but treatable

Long-term outlook

The outlook after mitral valve repair is generally good, especially when the leak is fixed before the heart muscle has been strained for a long time. Most people notice easier breathing and more energy within a few months. Some people need to be followed up with regular scans, and a small number may need further treatment years later. Your team will keep a close eye on you, and there is plenty of support to help you get back to the things you enjoy.

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