- About 24 million people around the world are affected by a type of heart valve disease called mitral regurgitation.
- Doctors normally turn to surgery or a less invasive procedure for treating mitral regurgitation.
- Researchers from West Virginia University report that the rate of successful repair in the United States was more than 90% and mortality risk after surgery was less than 1% for most people.
- Scientists plan to use these findings to create a new online risk calculator to help doctors predict 30-day outcomes based on the patient’s health conditions.
About 24 million people globally are affected each year by mitral regurgitation — a type of heart valve disease.
Traditionally, people with the condition will undergo surgery to repair the mitral valve of the heart. Additionally, doctors can use a less invasive procedure called transcatheter edge-to-edge repair for people who are too high risk for surgery.
Doctors use risk estimation to decide which type of treatment will have the best outcome.
Now, researchers from West Virginia University report that the rate of successful repair for people who underwent surgical mitral valve repair is more than 90% in the United States. They add that the mortality risk after surgery was less than 1% for the majority of people.
Researchers say their research can help develop a new risk model for predicting 30-day outcomes based on a person’s health conditions. This could be used to develop a new online risk calculator for doctors to use.
The study was recently published jointly in the journals The Annals of Thoracic Surgery and the Journal of the American College of Cardiology.
What does the mitral valve do?
The mitral valve is one of the heart‘s four valves.
It is located on the left side of the heart between the upper left heart chamber and lower left heart chamber, also known as the left atrium and left ventricle.
This heart valve is responsible for ensuring blood flows in a forward direction between the left atrium into the left ventricle. It also makes sure blood does not flow backward.
Sometimes the mitral valve may become damaged due to age or certain diseases, such as high blood pressure and coronary heart disease.
If the mitral valve does not close properly, blood can flow backward from the left ventricle into the left atrium. Backward blood flow lowers the amount of blood flowing through the body, causing the heart to have to pump harder.
This can lead to health issues, including arrhythmia, congestive heart failure, and infective endocarditis, where the inner lining of the heart’s chambers and valves becomes infected.
What is mitral regurgitation?
There are three main types of mitral valve diseases:
- mitral valve prolapse
- mitral valve stenosis
- mitral regurgitation
Mitral regurgitation occurs if the mitral valve does not close properly, allowing blood to leak back through the valve and into the left ventricle.
Symptoms of mitral regurgitation include:
- heart palpitations
- shortness of breath
- tiredness
- swelling in the hands and feet
Doctors use a variety of tests to determine if a person has mitral valve disease, including x-rays, echocardiograms, and electrocardiograms.
Treatment for mitral regurgitation includes certain medications, such as blood thinners and beta blockers, and potentially a physical repair of the mitral valve.
Mitral valve surgery vs TEER
If a person with mitral regurgitation needs to have their mitral valve physically repaired, this may be done through surgery or through a less invasive procedure called transcatheter edge-to-edge repair (TEER), depending on a person’s risk factors.
“Surgical mitral repair is performed either via a sternotomy or, with increasing frequency, performed robotically via a small 3 cm incision in the right chest,” explained Dr. Vinay Badhwar, a professor of cardiovascular and thoracic surgery at West Virginia University and lead author of this study.
“The direct surgical repair of mitral regurgitation involves precise treatment of the leaflet pathology and placement of a ring or band to support the valve repair and prevent future dilatation of the valve, known as an annuloplasty,” Badhwar told Medical News Today.
Transcatheter edge-to-edge repair (TEER), Badhwar said, is another therapy that does not involve open surgery but utilizes a puncture in the femoral vein to access the mitral valve and deliver a clip-like device to stabilize the leak by fusing the two leaflets at the point of the focal leak.
“This creates a bridge of tissue that helps to reduce mitral regurgitation, but it does not include an annuloplasty,” he said. “TEER is a very valuable option for patients of elevated risk of surgery. The availability of these devices — currently two that are FDA-approved — enhances the offering to patients who may be elderly or at otherwise prohibitive risk for surgery in order for us to offer a therapy that may reduce MR and potentially improve quality of life.”
Badhwar added that the TEER approach is currently approved for people who are at prohibitive risk for surgical repair.
“However, there are two clinical trials currently evaluating TEER vs. surgical repair in lower-risk patients, age 65 or older, so as to ascertain which one has superior results long term,” he added.
Examining surgical mitral valve repair
For this study, Badhwar and his team evaluated data from more than 53,000 people listed in The Society of Thoracic Surgeons Adult Cardiac Surgery Database who underwent planned surgical mitral valve repair for primary mitral regurgitation between 2014 and 2020.
The researchers reported there was an increase in the number of surgeries done in a minimally invasive way, including through the use of robots.
The scientists also found that of the people who underwent surgical mitral valve repair, the rate of successful repair had reached more than 90% in the United States.
Additionally, the mortality risk for people who had surgical mitral valve repair was less than 1%.
“There has been a significant effort within the surgical community over the last decade to educate and train surgeons on the techniques and outcomes of mitral valve repair of primary [mitral regurgitation],” Badhwar said. “The precision of this paper, (which) focuses for the first time only on primary [mitral regurgitation], documents these excellent results. As this data represents all surgeons at all institutions and not just high-volume programs, it is both a testament to this national effort, but also to the actual very low risk of this operation.”
Building a risk calculator
Badhwar and his team plan to use the study’s results to build a risk model for predicting 30-day outcomes based on a person with MR’s health conditions.
This would be the basis for a new online risk calculator doctors could use to figure out which type of physical mitral valve repair would be right for each person.
“The parallel effort of this risk model was to produce a risk calculator that is available to any physician or provider as well as to the public via the following link,” he continued. “As this is now the formal calculator for this specific disease, all medical practitioners can apply the information from the risk model at their fingertips while evaluating a patient, even at the bedside, to help inform patient-centered clinical decision-making.”
“Following the implementation of this risk model and availability of the risk calculator, we plan to track ongoing outcomes of surgical treatment of primary [mitral regurgitation] and report this in the future,” Badhwar said. “The impact of this information will hopefully be felt at the level of clinical decision-making between TEER and surgical therapy, particularly outside of clinical trials.”
Providing good insight
Medical News Today asked Dr. Nish Patel, an interventional cardiologist and structural heart cardiologist at the Baptist Health Miami Cardiac and Vascular Institute in Florida, to review this study and provide his thoughts.
“This risk model for predicting 30-day outcomes can provide incredibly good insight to an individual program and heart team about quoting patients about their risk of mortality after surgery based on the number of surgical mitral valve repair the program performs annually and what are the chances that the patient may convert to mitral valve replacement,” he said.
Patel added he would also like to see a similar risk prediction model for the currently available non-surgical option.
“This study only looks at low-risk surgical patients — <75 years of age — with normal left ventricular function,” he explained. “The risk prediction model for non-surgical options or MitraClip would give useful information for the patients who are at high-risk — usually >75 years of age — for surgical mitral valve repair.”
Medical News Today also spoke with Dr. Devin Kehl, a cardiologist at Providence Saint John’s Health Center in California, about this study.
“I think the take home is that for the vast majority of patients, the risk of operative mortality is very low – lower than previously felt,” he said. “I think it will shift a lot of patients and physicians in the direction of proceeding with a surgical approach.”
“There still are definitely going to be patients who are at high risk, prohibitive risk even, of receiving surgery,” Kehl continued. “And for those patients, a transcatheter approach – a non-surgical approach – is still appropriate and is still an effective treatment. But this publication basically says that many patients in whom we might have been more concerned about the risk of mortality, especially a younger patient population, is very low.”
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