Mitral Valve Repair at Cleveland Clinic
At Cleveland Clinic we have the world's greatest experience with mitral valve repair, the best option for most patients with a leaking mitral valve (mitral regurgitation).
Our surgeons have special expertise in mitral valve repair. As a consequence, at Cleveland Clinic, nearly all leaking mitral valves are repaired rather than replaced. A repair rate of nearly 100% for patients with leaking mitral valves provides patients with ideal outcomes. And for those with isolated mitral valve problems, the majority of operations are performed robotically or minimally invasively, ensuring rapid recovery.
In 2019, patients traveled to Cleveland Clinic from all 50 states and 103 countries for their cardiovascular care.
What are the symptoms of a leaking mitral valve?
Many patients with mitral valve disease are asymptomatic (have no symptoms), even with a leak that is severe. When symptoms develop, they include shortness of breath, fatigue, loss of energy, swelling of the ankles and palpitations (extra or skipped heart beats).
How is a leaky mitral valve diagnosed?
The first step involves listening with a stethoscope. Using a stethoscope, the doctor hears a murmur, which represents turbulent blood flow across an abnormal valve. The diagnosis is confirmed by an echocardiogram. Ultrasound is used in an echocardiogram to allow the doctor to visualize the heart valves and determine the severity and cause of the leak. In most patients, a standard transthoracic echocardiogram (a probe placed on the skin of the chest) is adequate to visualize the valve. Sometimes a transesophageal echocardiogram (a probe passed through the mouth into the esophagus) is necessary to more closely visualize the valve; this is an outpatient procedure.
What is mitral valve prolapse?
Mitral valve prolapse is a common condition in which the mitral valve leaflets are floppy or loose. Mitral valve prolapse is diagnosed by echocardiography. Most patients with mitral valve prolapse do not have a leaky valve and do not require surgery. When a valve with prolapse has a severe leak, surgery should be considered.
Mitral Valve Prolapse
What are the indications for surgical repair of a leaking mitral valve?
Surgery should be considered when the leak is severe. In most facilities, the regurgitation (leak) is graded on a scale from 0 to 4, with 0 being no leak and 4 being a severe leak.
Surgery should be considered in virtually all patients with a leak that is graded as a 4 (severe) and in some patients with a leak that is graded as a 3 (moderately severe). When a patient with mitral regurgitation develops symptoms, a decrease in heart function, or an increase in heart size, surgery is nearly always recommended. Surgery should also be considered when a patient develops atrial fibrillation, which is an irregular heartbeat. Surgery is also recommended in most asymptomatic patients who have a severe leak. In asymptomatic patients with severe mitral regurgitation, surgery improves long-term survival. In contrast, waiting for the development of symptoms or changes in heart function can leave patients with permanent heart damage.
What is the chance that a leaky mitral valve can be repaired?
Nearly 100%. The most common cause of mitral regurgitation is a condition called degenerative mitral valve disease—this is also called mitral valve prolapse, myxomatous mitral valve disease, and a floppy mitral valve. Such valves can be repaired (rather than replaced) in more than 95% of patients. Cleveland Clinic heart surgeons have the world's largest experience with mitral valve repair.
What is the chance that a leaky mitral valve can be repaired minimally invasively?
Approximately 60-80%. When a patient requires isolated mitral valve surgery for a degenerative valve, at Cleveland Clinic we can perform the operation through a 2 to 4 inch skin incision in in the majority of cases. Preoperative testing enables us to choose the safest approach for each patient. We offer several different minimally invasive approaches, including a small incision on the right chest, a small incision in the mid-line, and robotically assisted procedures. Expertise with several approaches enables us to determine the best procedure for each patient, optimizing results.
Minimally Invasive Mitral Valve Repair
Cleveland Clinic surgeons are pioneers in the development of minimally invasive techniques for mitral valve repair. Today, the majority of isolated mitral valve repairs can be performed through a 2-3 inch incision on the right side of the chest. In many cases, we can employ the surgical robot and limit incision size to 1 inch.
Several minimally invasive approaches are available to patients. Minimally invasive approaches may also be used for patients who require aortic valve or tricuspid valve surgery, alone or in combination with mitral valve surgery. In addition, Cleveland Clinic is a leader in percutaneous (through the skin) approaches to mitral valve repair, which may lead to additional treatment options in the future.
Advantages of minimally invasive approaches include faster recovery, less pain, reduced need for blood transfusion and better cosmetic result. We evaluate each patient for robotic and minimally invasive surgery and work with the patient to choose the best and safest approach in each case.
Learn about minimally invasive mitral valve repair: types of incisions, surgical options, photos and videos.
Mitral Valve Repair Surgery — Surgical Techniques
Cleveland Clinic surgeons have been instrumental in the development and application of modern mitral valve repair techniques. Problems with the posterior leaflet are generally corrected by a small series of chords or a small resection of the abnormal portion of the valve. Anterior leaflet dysfunction is managed by creation of new chords or chordal transfer. Anterior leaflet repair techniques are technically challenging, requiring a skilled and experienced surgical team to achieve the best result. All repairs include an annuloplasty, which is a complete or partial ring placed around the circumference (rim) of the valve.
Mitral Valve Posterior Leaflet Prolapse — Valve Repair Surgery
During mitral valve repair heart surgery, triangular resection is the technique used most frequently for posterior leaflet prolapse.
Triangular Resection Mitral Valve Repair
Ruptured chords at free edge of posterior leaflet. Region to be resected is indicated.
Abnormal segment has been removed. Leaflet edges are sewn together.
Annuloplasty completes the repair.
Mitral Valve Anterior Leaflet Prolapse — Valve Repair Surgery
When there is mitral valve prolapse of the anterior leaflet, repair is more complex and requires greater surgical expertise. To correct anterior leaflet prolapse caused by a ruptured or elongated chord, we usually create new chords out of Gore-Tex. These Gore-Tex chords generally last forever. A second technique used for correction of anterior leaflet prolapse is chordal transfer, which involves transfer of chords from another part of the valve to the area with abnormal chords. Both techniques provide excellent long-term results for patients.
Gore-Tex® Chord for Correction of Anterior Leaflet Prolapse
After Chordal Repair
Chordae may be constructed from Gore-Tex® sutures. A Gore-Tex® suture is affixed to the head of the papillary muscle and then passed through the free edge of the unsupported anterior leaflet, providing support.
Long-term durability is excellent. The new chordae do not rupture or elongate.
Chordal Transfer to Treat Anterior Leaflet Prolapse
Chordal transfer to correct anterior leaflet prolapse.
Posterior leaflet chordae are transferred to the unsupported free edge of the anterior leaflet. The posterior leaflet is then repaired. A cloth annuloplasty band completes the repair.
Mitral Valve Repair — Special Situations
Mitral Valve Repair and Atrial Fibrillation
Many patients with mitral valve disease have atrial fibrillation, (an abnormal heart rhythm.) For these patients, at the time of mitral valve repair, Cleveland Clinic surgeons perform an ablation (Maze procedure) with the intent of curing the atrial fibrillation. In some patients with atrial fibrillation, a sternotomy (standard) approach may provide the best results.
Previous Mitral Valve Repair with Recurrent Mitral Regurgitation
In rare instances, a mitral valve repair may fail over time. While most surgeons replace such valves, Cleveland Clinic surgeons can frequently re-repair these valves, offering excellent long-term durability and the important advantages that go with mitral valve repair.
Previous Heart Surgery with Recurrent Mitral Regurgitation
Occasionally, a patient who has had previous bypass surgery, aortic valve surgery or other heart surgery develops a new problem with the mitral valve. In these re-operative settings, Cleveland Clinic surgeons can safely and effectively repair nearly all leaking mitral valves.
Mitral Valve Repair for Endocarditis
When infection damages a mitral valve (endocarditis), repair is particularly challenging. Because of their extensive experience with such patients, Cleveland Clinic surgeons successfully repair the mitral valve in the majority of patients who have had endocarditis.
Occasionally, a patient with mitral regurgitation has extensive calcium deposits on the valve leaflets or annulus. The calcium makes repair difficult and requires application of advanced surgical techniques and sound judgment. Cleveland Clinic surgeons have the expertise to ensure excellent outcomes in patients with calcified mitral valves.
Mitral Valve Repair in Women with Breast Implants
We can usually perform a minimally invasive approach in women with breast implants. Working with a plastic surgeon, we remove the right breast implant through a small, cosmetic incision We then repair the mitral valve through the same incision. The plastic surgeon then replaces the breast implant, often upgrading to a newer implant.
Risks / Benefits
Advantages of Mitral Valve Repair: Why Repair Is Better Than Replacement
Mitral valve repair is the best option for nearly all patients with a leaking (regurgitant) mitral valve and for many with a narrowed (stenotic) mitral valve.
Compared to valve replacement, mitral valve repair provides better long-term survival, better preservation of heart function, lower risk of complications, and usually eliminates the need for long-term use of blood thinners (anticoagulants). For these reasons, Cleveland Clinic surgeons are committed to mitral valve repair, when possible.
Advantages of Mitral Valve Repair:
- Better early and late survival (Longer life!)
- Improved lifestyle
- Better preservation of heart function
- Lower risk of stroke and infection (endocarditis)
- No need for blood thinners (anticoagulation)
Your Mitral Valve
Mitral Valve Chordae and Papillary Muscles
What is the risk of mitral valve surgery?
For asymptomatic patients having mitral valve repair, the operative risk is approximately 1 in 1000. Risk in symptomatic patients remains well under 1%. The presence of coronary artery disease or other conditions that require surgical treatment will affect your individual risk. Ask your doctor about your surgical risk.
What is the durability of a mitral valve repair?
After mitral valve repair, 95% of patients are free of reoperation at 10 years, and this figure is approximately 90% at 20 years. Thus, reoperation is uncommon after a successful mitral valve repair. An echocardiogram is recommended annually to assess valve function. In addition, patients who had valve surgery must take steps to prevent infection and reduce the risk of endocarditis (an infection of the valve).
Why is it important to have my surgery at a center with a large experience in mitral valve repair?
Mitral valve repair is the best option for nearly all patients with a leaking (regurgitant) mitral valve and for many with a narrowed (stenotic) mitral valve.Compared to valve replacement, mitral valve repair provides better long-term survival, better preservation of heart function, lower risk of complications, and usually avoids the need for long-term use of blood thinners (anticoagulation). For these reasons, Cleveland Clinic surgeons are committed to mitral valve repair.
Advantages of Mitral Valve Repair
- Better early and late survival
- Improved lifestyle
- Better preservation of heart function
- Lower risk of stroke and infection (endocarditis)
- No need for blood thinners (anticoagulation)
Mitral valve repair is more challenging than mitral valve replacement, and experienced surgeons are more likely to be able to repair the valve and ensure an excellent outcome.
Doctors who treat
Cleveland Clinic has the nation's largest valve treatment program.
Doctors vary in quality due to differences in training and experience; hospitals differ in the number of services available. The more complex your medical problem, the greater these differences in quality become and the more they matter.
Clearly, the doctor and hospital that you choose for complex, specialized medical care will have a direct impact on how well you do. To help you make this choice, please review our Miller Family Heart, Vascular & Thoracic Institute Outcomes.
Cleveland Clinic Heart, Vascular & Thoracic Institute Cardiologists and Surgeons
The following Mitral Valve Center surgeons specialize in mitral valve surgery:
- Marc Gillinov, MD* Department Chairman, Thoracic and Cardiovascular Surgery
- Daniel Burns, MD*
- Kenneth McCurry, MD
- Per Wierup, MD, PHD*
*Performs robotically assisted mitral valve surgery
The Mitral Valve Center surgeons offers expertise and experience to provide the best outcomes possible.
Departments and Sections:
Choosing a doctor to treat your heart valve disease depends on where you are in your diagnosis and treatment. The following Heart, Vascular & Thoracic Institute Sections and Departments treat patients with Heart Valve Disease:
Department of Thoracic and Cardiovascular Surgery: Surgeons in the Department of Thoracic and Cardiovascular Surgery are experts in the treatment of valve disease, including valve repair or replacement, minimally invasive heart valve surgery, and re-do operations depending on the individual needs of the patient. For surgical review or more information, call toll-free 877.843.2781 (877-8Heart1) 6 a.m. – 9 p.m. EST, Monday - Friday or request an appointment online.
Department of Cardiovascular Medicine: Heart valve specialists in the following sections provide evaluation, medical management and life-long care of patients with heart valve disease:
Call Cardiology Appointments at toll-free 800.223.2273, extension 4-6697 or request an appointment online.
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