Surgical Mitral Commissurotomy

What is a commissurotomy?

A commissurotomy is surgery that helps improve blood flow through one of your heart valves, typically your mitral valve. Your mitral valve is the door between your left atrium (top left heart chamber) and left ventricle (bottom left chamber). Your mitral valve is also called your bicuspid valve. That’s because it has two cusps (flaps) that open and close to manage blood flow.

Several different forms of mitral valve disease can prevent this valve from working normally. One form, mitral valve stenosis, prevents your valve from opening as wide as it should. As a result, less blood can flow to your left ventricle, causing blood to back up in your heart. Over time, this can strain your heart and lungs and lead to complications like heart failure.

A mitral commissurotomy is one treatment option for people with mitral stenosis in its early stages. However, it’s relatively uncommon today. Healthcare providers usually perform it as an open-heart surgery, which carries some risks. When possible, providers first treat mitral stenosis with minimally invasive procedures. A current first-line treatment is a balloon valvuloplasty, in which a pressurized balloon stretches open your valve. Some people can’t have a balloon valvuloplasty due to their heart anatomy or other reasons. If that’s the case, a commissurotomy may be a suitable option.

Who needs a commissurotomy?

You may need a commissurotomy if you have mitral valve stenosis and:

• Other treatment options haven’t helped you.

Or:

• You’re not a candidate for balloon valvuloplasty.

Your provider may also recommend a commissurotomy if you need other procedures done on your heart. Your surgeon can perform them at the same time.

It’s important to know that not everyone with mitral valve stenosis can have a commissurotomy. It depends on what’s causing your mitral stenosis.

There are two main causes of mitral stenosis:

• Damage from rheumatic heart disease (rheumatic mitral stenosis).
• Breakdown of your valve over time (degenerative mitral stenosis).

A commissurotomy specifically helps people with rheumatic mitral stenosis. In this condition, an autoimmune disease (rheumatic fever) causes damage to your heart valve that doesn’t show up until many years later.

In rheumatic mitral stenosis, your mitral valve’s commissures become thickened or even fused. Normally, they should separate easily. The commissures are the areas where the two leaflets (flaps) of your mitral valve join together.

To picture what this looks like, look into a mirror and smile without parting your lips. The pointed corners where your lips meet look a bit like the commissures of your mitral valve. Your lips are like the two flaps of your mitral valve. Keep smiling, and put a finger firmly on each corner of your lips so they can’t separate. In that position, it’s difficult to open your mouth wide enough to speak or eat. That fused effect happens in mitral stenosis — but the result is reduced blood flow through your valve.

A commissurotomy uses small surgical cuts to release those commissures when they’ve become fused. This can help someone with rheumatic mitral stenosis have better blood flow through their heart. But in degenerative mitral stenosis, the commissures usually aren’t damaged. Instead, other parts of the valve need repair. So, people who have degenerative mitral stenosis usually can’t have a commissurotomy. They need other types of mitral valve repair or a mitral valve replacement.

What happens before an open commissurotomy?

Preparation begins weeks or months before your surgery day. Your care team (usually a primary care physician, cardiologist and cardiothoracic surgeon) performs a medical evaluation, which includes:

• A thorough physical exam.
• Blood tests.
• Discussion of your symptoms and medical history.

Your care team will order tests to check your mitral valve and look for blockages in your coronary arteries. These tests may include:

• Echocardiography.
• Computed tomography (CT) scans.
• Coronary angiography.

If you have questions or concerns, talk to your provider. Get the information you need to feel more comfortable with your approaching surgery.

Your provider will give you instructions on how to prepare for your surgery. These will tell you when you should begin fasting (avoiding foods and drinks) and what changes you must make to your medication schedule.

If you smoke or use tobacco products, it’s important to quit before your surgery to lower your risk of complications. Ask your provider for resources to help you quit.

How is a commissurotomy done?

Your surgical care team will perform the following steps:

1. Give you anesthesia to put you into a deep sleep.
2. Make an incision down the middle of your chest in your sternum (breastbone). This procedure is called a median sternotomy.
3. Connect you to a cardiopulmonary bypass (heart-lung) machine. This machine allows your surgeon to operate on a still (non-beating) heart. It takes over for your heart and lungs during the surgery and keeps blood flowing to your organs and tissues.
4. Open your left atrium.
5. Examine your mitral valve.
6. Make small cuts in the commissures of your mitral valve, so they’re no longer fused.
7. Disconnect you from cardiopulmonary bypass and restart your heart and lungs.
8. Perform a transesophageal echocardiogram to check your valve and confirm everything went as it should.

Sometimes, surgeons repair other valves (like your aortic valve or tricuspid valve) during the same procedure. Or, they do other heart procedures. Your care team will tell you if this is the case and explain what you can expect.

What happens after this procedure?

After your surgery, you’ll spend about a week recovering in the hospital. For the first couple of days, you’ll be in the intensive care unit (ICU). Healthcare providers will closely monitor you and watch for any signs of complications.

Before you leave the hospital, your provider will give you information about:

• Cardiac rehab. This is a helpful option for people recovering from heart surgery. It can help you regain your strength to do your normal tasks.
• How to care for your incision. Incision care is important to lower your risk of infection and help the wound heal.
• How long you should wait before driving and returning to some of your other usual activities.

Be sure to arrange for someone to drive you home from the hospital.

What are the advantages of a mitral commissurotomy?

This surgery can help relieve mitral stenosis and associated symptoms, and lower your risk of complications. It’s a beneficial option when the stenosis isn’t severe enough to require a mitral valve replacement and other treatment options aren’t helping you, or you can’t have percutaneous balloon valvuloplasty.

What are the risks or complications of this procedure?

The most common complication of an open commissurotomy is mitral valve regurgitation (leaky valve). Other possible complications include:

• Adverse reaction to anesthesia.
• Arrhythmia or heart block.
• Bleeding.
• Cardiac tamponade.
• Confusion or trouble thinking.
• Heart attack.
• Infection in your incision.
• Stroke.

You have a lower risk of these complications if you seek care at a major medical center with surgeons experienced in valve surgery.

Some medical conditions may also raise your risk of complications. These include:

• Chronic obstructive pulmonary disease (COPD).
• Diabetes.
• Kidney disease.
• Obesity.
• Peripheral artery disease.

Talk with your healthcare provider about your risk for complications and what you can do to lower them.

What is the outlook following a commissurotomy?

The success rate of open mitral commissurotomy is excellent. The surgery usually treats the stenosis and helps your blood flow better. However, it’s not a final treatment strategy. Most people who undergo a commissurotomy ultimately need a mitral valve replacement in the future.

Your healthcare provider is the best person to ask about your specific prognosis. That’s because each person’s recovery is different, and many factors impact your recovery. These include your age, your overall health and the extent of prior damage to your mitral valve.

When should I see my healthcare provider?

As you recover, call your provider if you have signs of infection. These include:

• Chest pain, pressure or discomfort.
• Fever.
• Redness or drainage near your incision.

Call 911 or your local emergency number if you experience:

• Signs of a heart attack.
• Slurred speech or other signs of a stroke.

What is aortic commissurotomy?

Aortic commissurotomy is similar to mitral commissurotomy. Both procedures help one of your heart valves function better. Also, they both refer to a surgery that makes small cuts in a heart valve to improve blood flow through the valve. But healthcare providers usually perform aortic commissurotomy on babies with congenital heart defects that affect their aortic valve. Providers perform mitral commissurotomy on adults with rheumatic mitral stenosis.

A note from Cleveland Clinic

A commissurotomy is a treatment option that can help you manage mitral valve stenosis. If your healthcare provider recommends a commissurotomy, other treatment options either haven’t helped you or aren’t likely to help you, but your valve isn’t diseased enough to require replacement.

You might feel nervous or overwhelmed at the thought of heart surgery. But your medical care team is there to answer your questions, calm your nerves and give you the treatment you need to live a healthier life.