December 20, 2019
Mitral valve insufficiency affects 4.5 million-6 million U.S. patients. While about 90% of these patients are candidates for surgical treatment to reduce symptoms, delay heart failure and decrease mortality, only a small fraction receives surgical care.
Mitral valve repair – conventional, robotic or catheter-based – has become the standard of care for mitral valve insufficiency. The University of Kansas Health System has significant experience with these procedures and, in partnership with the University of Kansas Medical Center, participates in clinical trials for advanced options that may provide hope to patients thought to be without options beyond medical management.
Mitral valve repair: today's care standard
About 90% of patients with mitral valve leakage or insufficiency should be eligible for valve repair. Repair carries a much lower mortality risk and requires less maintenance than replacement. Of those who are eligible for repair based on preoperative studies, a high percentage are good candidates for robotic mitral valve repair using the Da Vinci® surgical system. Our experienced cardiothoracic surgeons have been using the system since 2009. It has become the standard of care.
A robotic surgical approach to mitral valve repair may be suitable for patients who have not had previous cardiac surgery and have a BMI of less than 30; the body shape must allow for adequate visualization.
The robotic valve repair technique is no different from the technique used in the traditional open approach, but it is accomplished in a minimally invasive manner through 5 small incisions. This results in less pain and a much faster recovery. With the traditional approach, patients are typically hospitalized for a week and take 2-3 months to recover at home. In contrast, with the robotic approach, they're hospitalized only 3-4 days, and they're back to their normal routine and feeling well in just 3-4 weeks.
While many hospitals offer robotic valve repair, community physicians would be wise to consider the experience and volume of the surgeons to whom they're referring patients. We have data to show significant differences in success rates for surgeons doing 20 or more valve repairs each year. I perform 30-40 robotic valve repairs annually, and our observed-to-expected mortality is 0 for the last 18 months, compared to an expected rate of .6-.7.
Many patients with severe mitral valve regurgitation, insufficiency or leakage are asymptomatic. Even these patients should be treated to lower their risk of developing heart failure or becoming riskier surgical candidates later.
Catheter-based procedures also available
Patients with moderate to severe symptomatic mitral valve regurgitation who are not good surgical candidates may be appropriate for MitraClip transcatheter mitral valve repair (TMVR). These patients may have a reasonable life expectancy but are high surgical risks because of advanced age, left ventricle dysfunction or other comorbidities.
My colleague, interventional cardiologist Mark Wiley, MD, and I participated in the recently completed COAPT trial that proved using the MitraClip procedure reduced mortality by 50% over medical management and also decreased the rate of repeat hospitalizations by 50% – much better than expected. These outcomes suggest that all patients with moderate to severe mitral valve regurgitation should be evaluated for potential life-extending treatment.
For patients who can't risk surgery and are not candidates for valve repair, a catheter-based mitral valve replacement device called the Intrepid™ may be an option. The Intrepid is currently being studied in the Apollo trial. The University of Kansas Hospital, in partnership with the University of Kansas Medical Center, is 1 of 25 hospitals around the country currently participating in a trial seeking to understand how replacement with the Intrepid compares with medical therapy alone. We are seeking referring physicians' assistance in identifying candidates.
To participate in this trial, subjects must meet all of the following inclusion criteria.
- Subject has moderate to severe or severe symptomatic mitral valve regurgitation as defined by the American Society of Echocardiography 2017 Guidelines and Standards – Recommended for Non-invasive Evaluation of Native Valvular Regurgitation.
- Heart team agrees that patient is candidate for bioprosthetic mitral valve replacement.
- Subject and treating physician agree that the subject will return for all required post-procedure follow-up visits.
- Subject meets the legal minimum age to provide informed consent.
Coordinating care together
Our team of cardiothoracic surgeons and interventional cardiologists is interested in helping the thousands of patients who suffer from untreated mitral valve insufficiency. Together, we offer several options that can prevent mortality and improve symptoms. If you have a patient who is not being treated, please consider consulting with us. We will be happy to work with you to explore options as part of a collaborative care team.
Dr. Daon is a cardiothoracic surgeon at The University of Kansas Health System and program director of the cardiothoracic surgery fellowship. His specialties include cardiothoracic surgery, atrial fibrillation management, atrial fibrillation surgery, bypass surgery and cardiac surgery.
Advantages of robotic surgery
- Less postoperative pain
- Faster recovery time
- Reduced hospital stay
- Earlier return to normal routine
- Lower risk of infection/complications
- Small incisions and less scarring