Mitral regurgitation is one of the most commonly diagnosed heart defects. Most of the elderly are affected, but it can also affect children and younger adults.
A "mitral valve insufficiency" is when the heart valve between the left atrium and the left ventricle does not close properly. Normally, the oxygen-enriched blood is pumped from the lungs via the left atrium into the left ventricle. The heart valve between the atrium and the heart chamber, the mitral valve, then closes again to pump the blood from the ventricle through the aorta into the body. If the mitral valve does not close properly, blood flows back into the atrium, resulting in a permanently increased amount of blood that increases the heart load.
Mitral valve insufficiency is rare. One of the main causes of istrheumatic fever is streptococcal upper respiratory tract infection. In most cases, mitral regurgitation occurs only at an advanced age due to wear and / or calcification of the mitral valve.
Rarer causes include Marfan syndrome, a genetic connective tissue disease, or Ehlers-Danlos syndrome, a connective tissue disorder in which collagen synthesis is disturbed, resulting in the skin being easily overstretched or injured and thereby organs and vessels can tear.
Cause can also be a heart attack in a basic coronary disease or heart valve inflammation (endocarditis). If the causes are not treated or not treated in time, prolonged overload can cause damage to the heart muscle.
Classification of mitral valve insufficiency into 4 different degrees of severity
Mitral regurgitation, like aortic valve insufficiency, can be judged by its regurgitation fraction and divided into four grades:
- Grade I: regurgitation fraction <20%, only a small amount of contrast medium enters the left atrium, it is completely excreted during systole.
- Grade II: regurgitation fraction 20 - 39%, the left atrium fills completely, but weakly after several cardiac actions with contrast agent.
- Grade III: Regurgitation fraction 40 - 60%, the left atrium fills completely with contrast medium, the contrast medium density in the left atrium corresponds to the density in the left ventricle.
- Grade IV: regurgitation fraction> 60%, the left atrium fills completely with contrast agent in the first or second heart action, the contrast medium density is higher in the left atrium than in the left ventricle, there is a reflux of the contrast agent in the pulmonary veins.
Mitral regurgitation can go on for a long time without discomfort. It can make itself felt for the first time by strong palpitations in left lateral position. In the advanced stage it comes to stronger complaints, first to a shortness of breath during physical exertion, later also at rest and at night, nocturnal coughing attacks can occur because the heart is overwhelmed with the increased blood volume.
This builds up in the lungs and is pressed against the air-filled area of the lungs, causing coughing fits. In case of persistent overload, cardiac arrhythmias may occur with atrial fibrillation in the left atrium. As a result, the heart is weakened and there is a risk of blood clots if the blood accumulates too long in the atrium. If these dissolve and get into the bloodstream, they can clog small blood vessels and z. B. trigger a stroke in a brain vessel. Symptoms of progressive mitral regurgitation may be general weakness and fluid retention in the lungs.
The doctor can usually hear the characteristic sounds of mitral regurgitation with the stethoscope. As a rule, however, an ECG is additionally performed. In the next step, an echocardiography, ultrasound examination of the heart (usually with Doppler ultrasound) performed, in order to better assess the non-closing heart valve and the returning blood volume. With this method, even existing blood clots can be detected.
An x-ray of the upper body can also provide information on whether the left atrium and the left ventricle are enlarged. Through this recording can also be seen whether it has already come to changes in the pulmonary vessels by the backwater of the blood.
Mitral valve insufficiency causes severe heart complaints in the patient. In the worst case, these can also lead to death of the patient if treatment for this disease is not initiated. As a rule, those affected suffer from heart stuttering or palpitations.
Likewise, disturbances of the heart rhythm can occur, so that it comes to unusual noises at heart. Those affected also suffer from tiredness or low resilience. Furthermore, breathing difficulties can also occur, leading to a loss of consciousness or damage to the internal organs.
Without treatment of mitral regurgitation, the patient's life expectancy is significantly reduced. Not infrequently, the affected people also suffer from depression or often a fear of death, if it comes to an oppressive sensation or a pricking in the chest. The quality of life is significantly limited by mitral valve insufficiency for this reason.
The treatment of this disease depends on the symptoms and the causes. As a rule, however, an operation is necessary, which does not lead to special complications. Furthermore, the use of medication is usually necessary to prevent inflammation and infection.
When should you go to the doctor?
Changes and abnormalities of the heart rhythm should be presented to a doctor as soon as possible. If it comes to interruptions of the heart rhythm, rapid heartbeat or a strong palpitations, a doctor must be consulted. Audible and unfamiliar noises are cause for concern. A doctor's visit is necessary to determine the cause of the symptoms. A decrease in normal performance, a lower emotional and physical resilience and increased fatigue are to be examined and treated. People who suffer from sleep disorders, feel an inner turmoil or experience a lack of concentration should have a medical check-up carried out.
In adulthood, it is also advisable to take part in the medical check-ups offered for the purpose of the early detection of diseases. If you experience a shortness of breath or fears of reduced oxygen supply, a doctor is needed. In case of thrombosis or the development of edema, a doctor visit is necessary. Irritability, mood swings and behavioral abnormalities indicate irregularities that should be discussed with a physician. Can the everyday or sporting activities are no longer carried out, it comes to a reduced well-being and a withdrawal from the participation in social life, a visit to a doctor is recommended. A clarification of the cause is recommended so that no life-threatening condition occurs.
The treatment of heart failure can be done in the initial stages and missing complications with medication. Effectively is a reduction in the afterload, e.g. by ACE inhibitors. Basic diseases that promote progression (CHD, arterial hypertension, endocarditis) should be consistently treated with medication.
Surgical therapy should be considered in primary mitral regurgitation. Although primary mitral regurgitation is still asymptomatic and complication-free, intervention should be preventative. High grade heart failure, worsening of left ventricular function and dilation strengthen the indication for surgery.
Common surgical procedures are:
- Mitral valve repair
- Mitral valve replacement by valve prosthesis
Mitral valve reconstruction, which preserves the valve framework, shows better long-term results.
Mitral Valve Repair
Interventions on the mitral valve have increased significantly in the last 12 years. The proportion of valve reconstructions, ie restoration of the valve function with retention of the valve has increased disproportionately since then and outweighed for three years compared to the replacement. Increasingly, isolated mitral valve defects are being treated minimally invasively.
The primary goal of mitral valve operation in the event of a leak is to preserve the valve. This is done by a so-called mitral valve reconstruction, in which various surgical techniques can be used to repair diseased parts of the valve (sails, ring, tendons). We achieve a repair rate of 90% in our clinic. Parts of the valve leaflet can be removed, tendon threads shortened and newly implanted. A plastic ring, which is sewn to the flap approach, prevents a new extension of the valve ring. Compared to mitral valve replacement, repair offers better preservation of cardiac function, lower complication rates, better long-term outcomes, and often no blood-thinning medications (eg, Marcumar®). The chances for a valve reconstruction can already be estimated preoperatively with the help of echocardiography, only in individual cases the flap has to be replaced.
Ring stabilization with annuloplasty ring
A wealth of different rings is offered by the manufacturers. Rigid, semi-flexible and flexible rings, closed, half-closed or open rings. The materials are different too. But all of them have in common that they consist of non-dissolving material, so they have to wax. That but also that, although the natural valve remains functional, since the patient's own sails are preserved, but still permanently artificial material remains in the body. However, this does not pose a problem if the patient takes care to take antibiotics (so-called Endokarditisprophylaxe) in inflammation, where there is a risk that bacteria can get into the bloodstream.
Tendon and papillary muscle correction
A very typical treatment is correction of the posterior posterior quadrangular sail and stabilization of the valve ring with an artificial ring.
MIC mitral valve surgery
Interventions on the mitral valve can also be made minimally invasive. However, here too the use of the heart-lung machine is necessary, which is installed via the inguinal vessels. Access to the Zeren then takes place via a small thoracic opening on the right side. The procedure is only suitable for isolated mitral valve defects, as other areas of the heart can not be reached. Reconstructions or replacement are just as possible as in the open procedure. In case of adhesions in the thorax after operations or even radiation, these procedures can not be used. However, an increasing number of patients with isolated mitral valve defects are now receiving minimal invasive care in Germany.
Minimally invasive mitral valve surgery sets itself apart from conventional mitral valve surgery by altering the access route to the heart. While in conventional mitral valve surgery the sternum is completely opened, the surgeon selects a small 5-7 cm incision on the right lateral chest wall during the minimally invasive approach. In addition, a small incision must be made in the area of the right groin in order to introduce the heart-lung machine via cannulae to the artery and femoral vein. An advantage of the minimally invasive technique is the preserved integrity of the bony breast skeleton. The wound pain decreases significantly after the third postoperative day. The patient can be allowed full weight on the body just two weeks after surgery. The recovery is thus accelerated. Cosmetically, a small incision on the lateral chest wall is significantly cheaper than the middle opening of the sternum with a scar running longitudinally across the middle of the entire thorax.
The disadvantages are: The surgical technique is much more demanding and should only be performed by experienced and experienced surgeons. The operating times are usually longer.
Mitral Valve Replacement
If the flap can not be repaired, the flap must be removed and a valve prosthesis inserted. You can choose from biological and artificial prostheses. Mechanical and biologic valve prostheses differ in some respects in selecting the most appropriate valve for the patient. Mechanical heart valves have a much longer lifespan than biological valve prostheses and are mostly selected in younger patients with a long life expectancy and without contraindications for effective anticoagulation. A major disadvantage of the mechanical flaps is the coagulation-activating surface. This leads to an increased risk of thrombosis and makes a lifelong intake of blood-thinning medications necessary. The biological prostheses have a limited shelf life (about 15 years) and are used in older age (over 65 years) or in women with children.
If the patient additionally has atrial fibrillation, this can be treated during mitral valve surgery using the ultrasound ablation method.
Expiration of a conventional heart valve operation
Conventional heart valve surgery typically involves the following steps:
- After initiating general anesthesia, the doctors sever the breastbone and open the thorax.
- A heart-lung machine is connected: The device aspirates blood from the vena cava, saturates it with oxygen and pumps it back into the main artery. Thus, the machine takes over the circulation function.
- The heart itself can now be shut down with special infusions - the surgeon works on the resting heart muscle.
- The defective valve is either replaced by a prosthesis or, if possible and useful, restored by special surgical techniques.
- The blood is again passed through the heart and warms it; The organ often begins to beat spontaneously or with the help of electrical impulses.
- After ultrasound control of heart valve function, the surgical team decouples the heart-lung machine.
- The breastbone is wired, the thorax is closed.
Artificial or biological heart valve prosthesis?
When choosing the heart valve replacement, there are two options:
- The replacement with a so-called artificial flap. Such valves last for a very long time, even more than a lifetime. However, the patient must take life-long blood-thinning medications (Falithrom ™, Marcumar ™).
- The replacement by a so-called biological valve. With these valves, blood-thinning drugs need only be given for a short period of about 3 months until the valve is healed. Thereafter, the medication can be discontinued completely. A disadvantage, however, is that these valves only last a limited period of time in the body. After about 10 years, they are usually worn out and need to be replaced in another operation.
In both types of valves, there are various modern models that are adapted to the individual situation inside the body. There are z. As heart valves for patients with particularly small arteries, or heart valves that do without scaffolding and z. B. for very young patients in question. The choice of one of these two options and the special models is not easy. The treating surgeon will advise you and choose the most suitable flap for you.
Risks of surgery
There are no absolute exclusion criteria for surgery on the mitral valve. As always, it is useful to review the risks of surgery, which are very different and dependent on various comorbidities.
Minimally invasive surgery is not available for the following diseases: aortic valve leaks, previous thoracic surgery, calcifications of the ascending aorta (ascending aorta), degenerative changes of the aorta, pelvic arteries and leg arteries.
For all operations on the heart and thus the mitral valve, the surgical risks of a major surgical procedure apply, also with regard to anesthesia. Possible risk factors are recorded by the anesthesiologists prior to the operation in an informational discussion with the patient. In addition to modern and safe anesthetics, comprehensive surveillance measures for safe surgery are available during the procedure.
Cardiac surgery (1%), stroke (1-2%), main artery injury (<1%), severe infection (2%), allergic reaction and drug intolerance are at risk for the following serious complications:
In the minimally invasive surgical technique, a special risk is known for aortic injury or aortic dissection (1-1.5%), for the appearance of a lymph fistula in the area of the right groin (2-4%) and for impairments of the right phrenic nerve to injury (<1%).
After the Operation
After the mitral valves OP, the patient first comes to the intensive care unit and from there, when the desired stability is achieved, to a so-called intermediate care station. Here then all drainages are removed. If the patient does not need any oxygen support, a transfer to the standard bed ward can be made. For the next eight days blood tests, control of the heart rhythm, a review of the surgical result with ultrasound of the heart and an early mobilization of the patient are carried out. As mentioned, follow-up treatment is followed for 18 days. Here the patient is mobilized further. The result of the operation is finally checked, the drugs are reduced or extended, depending on the medical indication.
Follow-up examinations take place after 6 months and then once a year.
If the patient returns to his home environment after the follow-up treatment, physical protection in the narrower sense is no longer required. Nevertheless, the full capacity is not yet restored so that the patient should continue the physical training. The patient should not drive for legal reasons during the first eight weeks. In the minimally invasive surgery, a special protection of the upper body after completing follow-up treatment is not necessary. Normally, the patient is not dependent on outside help after the follow-up treatment.
Pain in the surgical wound is normal for the first five days after the mitral valve OP. But then they usually turn off. Pain can also occur in the area of the right groin. These should also decrease after a few days.
The rehabilitation is carried out in a certified cardiology center. As an alternative, a home-based outpatient rehabilitation can be sought. Here, a consultation with the health insurance companies is necessary because not all health insurance companies reimburse this form of rehabilitation. The outpatient rehabilitation center must also be certified for follow-up treatment after cardiac surgery.
After completion of the follow-up treatment, the job is easily possible in light physical activity. Occupations with very high physical demands can be taken up after eight weeks. Competitive sports should be avoided in the first three months after the mitral valve OP.