Mitral Valve Repair Procedure

Before mitral valve repair surgery, a careful history is taken.  The history will focus on other medical problems as well as medications that the patient is taking.  All patients should stop taking aspirin or any other "blood thinners," including coumadin (warfarin) prior to surgery.  Your physician will review your other medications before surgery to determine which medications should be taken on the day of surgery.  A chest x-ray and routine labs are completed prior to mitral valve repair surgery to determine if there are any other potential problems that may arise during the surgery.. 

Upon arrival to the operating room, the anesthesiologist will administer anesthesia to the patient.  The anesthetist places a variety of intravenous lines into the patient's veins and injects an "induction agent" (usually propofol) to render the person unconscious.  An endotracheal tube is then inserted to provide a secure airway, and mechanical ventilation is started.  After anesthesia, a transesophageal echocardiogram is completed to evaluate the blood flow through the mitral valve.  This aids the surgeon in planning for the repair procedure.

The surgeon will then make an incision known as a median sternotomy, and the patient is then placed on cardiopulmonary bypass.  While on bypass, blood that returns to the heart is removed and pumped through the "heart-lung machine," which oxygenates the blood.  The blood is returned to the aorta, thus bypassing the heart and providing oxygenated blood to the body during surgery.  The patient is cooled for the duration of the surgery.

There are a variety of surgical techniques that are used to repair the mitral valve.  The surgeon will carefully review images from echocardiography and visually assess the valve and surrounding structures before deciding on the technique of repair.  There are two main areas that the surgeon focuses on during the repair.  The first is to fix any abnormal motion of the valve leaflets and repair chords.  The second is to reinforce the annulus by implanting a ring.  If the leaflets are enlarged, the surgeon may need to remove excess tissue from the valve leaflets and resuture the edges together.  The surgeon may also need to repair damaged chords with sutures or place new artificial chords to keep the leaflets in place.  

The primary method used to repair a mitral valve is known as "annuloplasty."  During annuloplasty, the surgeon will place an artificial ring around the annulus.  This ring reinforces the annulus and restores the size and shape of the annulus.   The function of the mitral valve leaflets is often restored through this process. 

In some cases the mitral valve is so diseased that repair cannot be attempted and the valve must be replaced.  The surgeon will often need to visually assess the valve before determining if a mitral valve repair is possible.

After the surgery is completed the patient is removed from cardiopulmonary bypass.  The patient is warmed, and the chest incision is closed.  A post-operative transesophageal echocardiogram is then completed to evaluate the effectiveness of the surgery.  If the patient still has significant mitral regurgitation, the patient can be placed back on cardiopulmonary bypass and the mitral valve repair can be revised.  Revision of mitral valve repair is sometimes necessary because it is difficult to determine how the valve will function without the heart pumping blood across the valve.  A single revision often provides significant improvement in the function of the valve. 

After the repair is determined to be successful by post-operative transesophageal echocardiogram, the sternum is wired together and the incisions are sutured closed.  The patient is transferred to the intensive care unit for close monitoring.  Antibiotics are given to prevent infection, and pain is controlled with medications.