Degenerative mitral valve (MV) disease is the result of progressive leaflet damage that leads to blood flowing backwards from the left ventricle into the left atrium. Although patients with severe mitral regurgitation (MR) can remain asymptomatic for years, they will eventually develop heart failure, atrial fibrillation, and pulmonary hypertension.
Therapeutic options for MR include surgical repair or replacement and transcatheter edge-to-edge repair (TEER). Patients with a higher risk of surgical complications or death are typically offered TEER. Surgery can take the form of valve repair or — if the MV is too damaged — replacement. Repair restores the patient’s valve from leaky to competent and is more likely to result in a normal life expectancy than replacement. It also carries a lower risk of mortality, stroke, recurrent endocarditis, and reoperation. Importantly, centers that perform higher volumes of TEER also have lower postsurgical mortality rates.
Robotic repair for degenerative MV disease
Most MV repairs in the United States are performed by dividing the breastbone via sternotomy. Alternatively, the MV can be repaired via a small thoracotomy incision between the ribs, and the size of the incision can be further reduced with robot assistance. Duke Health focuses on minimally invasive MV repair to restore quality of life with faster recovery.
“With robotic surgery, the patient has a smaller incision and faster recovery than with a sternotomy,” says Duke Health heart surgeon Brittany Anne Zwischenberger, MD. “It’s especially well-suited for younger patients who want to get back to work faster: For sternotomy, we have lifting restrictions for six weeks afterward. In minimally invasive surgeries, patients can return to normal lifting after just two weeks.”
Robotic surgery can also reduce blood loss, insensible loss, and subsequent downstream problems. The technology offers advantages for the surgeon as well. “The camera improves visualization with much higher resolution,” says Zwischenberger. “As surgeons become more familiar and facile with the robot, robotic-assisted MV operations have increased.”
When to refer for MV disease
In its early stages, MV disease may be treated with lifestyle changes and medication. However, the MV may continue to degenerate and ultimately require surgery. Although MV deterioration is correlated with aging, younger patients may also experience deterioration.
Patients with severe MR may or may not present with symptoms. “If patients are symptomatic with reduction in maximum exercise capacity, day-to-day functional activities, or quality of life, we want to see them immediately to proceed with repair,” says Zwischenberger.
For asymptomatic patients, Zwischenberger offers two options. “If the heart does not show signs of heart failure on echocardiograms,” she says, “then patients have the option of repeating echo in six months or proceeding with surgery immediately to prevent the development of heart failure signs and symptoms.”