Combined Tricuspid & Mitral Valve Procedures

Mitral Valve Procedures

For most patients, the procedure is needed due to mitral insufficiency (or a “leaky” valve). Mitral stenosis is also common. It is often caused by a childhood history of Rheumatic fever.

Mitral Insufficiency

Mitral insufficiency occurs when the mitral valve does not close properly, causing blood to leak from the left ventricle, back through the mitral valve, and up into the left atrium. Mitral insufficiency most often occurs due to age ( as a degenerative condition). Occasionally, the mitral valve is abnormal from birth as a congenital condition. More rarely, the mitral valve may be damaged by infection, known as infective endocarditis. Mitral insufficiency can also occur as a result of coronary artery disease.

Sign and Symptoms

The symptoms of mitral insufficiency vary, depending on the patient’s disease process. They are similar to the symptoms of congestive heart failure and can include:

  • Shortness of breath
  • Fluid accumulation in the lungs (pulmonary edema/pleural effusions)
  • Severe night time shortness of breath and coughing, waking the patient from sleep (known as paroxysmal dyspnea)
  • Decreased exercise tolerance
  • Heart palpitations
  • Cardiovascular collapse with shock
  • A mid diastolilc murmur can be heard with a stethoscope.

Patients with mitral insufficiency may also be asymptomatic. They may have the usual exercise tolerance, with no evidence of heart failure.

Diagnosis

A number of different diagnostic tests may reveal mitral insufficiency, depending on whether the condition is chronic or acute. Tests used to diagnose mitral insufficiency include electrocardiograms (ECGs), echocardiograms, and chest X-rays. The most common diagnostic test is an echocardiogram and more specifically a transesophageal echo.  This gives the closes look possible at the valve.

Treatment

Surgical options to treat mitral insufficiency include mitral valve replacement and mitral valve repair, depending on the condition of the patient. Mitral valve repair is most preferred and often very doable.

Mitral valve replacement involves replacing the diseased mitral valve with a mechanical or bio-prosthetic, tissue, cow (bovine) or pig (porcine)valve.  The traditional approach to repair/replace is via traditional sternotomy, however we offer a mini approach with use of Robot. The robotic approach involves 3-5 3” incisions on the right side of the chest. The surgeon may make the incision either horizontally under the left breast, or vertically through the sternum.

Bio-prosthetic replacement valves have a limited lifespan, usually ten to fifteen years, while synthetic replacement valves require the patients to use blood thinners in the long term, in order to reduce the risk of stroke.

A minimally invasive approach can result in less prominent scarring and frequently allows the patient to return to their normal activities faster, such as with the da Vinci Surgical System. Two weeks recovery time versus two months.

Indications for operation

The need for surgery is typically indicated by severe mitral insufficiency, and the presence of symptoms of congestive heart failure. The diagnosis by echocardiography, without the presence of symptoms, can be enough to justify repair. Enlargement of the left atrium, especially when a recent onset of an irregular heartbeat (often atrial fibrillation) has been observed, is an indication for surgery. Recent data shows much greater benefit and lower risk operations if mitral insufficiency is corrected sooner rather than later.

Outcome

When repair is possible, the probability of long-term success is good, with an 85 to 95% chance of no further procedures being required for approximately ten years. When more complex repair is required, the probability of further surgery goes up. Depending on the cause of the mitral insufficiency, it can be difficult to predict the results of repair.

With successful mitral valve replacement, the patient can expect to return to the same condition or better that they enjoyed prior to the surgery. Blood thinners are often prescribed for six weeks to three months after the operation. Commonly, this prescription is not required in the long term unless other indications are present. There are usually few restrictions on patient activity once surgical wounds have healed.

Mitral Stenosis

Mitral stenosis is a disease of the mitral valve involving the narrowing of the valve. The vast majority of mitral stenosis cases are caused by heart disease secondary to rheumatic fever and rheumatic heart disease. Far less common causes include calcification of the mitral valve leaflets, or congenital heart disease.

Signs and symptoms

Symptoms of mitral stenosis include:

  • Symptoms of heart failure:  breathlessness during exercise or exertion, shortness of breath while lying flat, and severe nighttime shortness of breath and coughing,often waking the patient from sleep
  • Palpitations
  • Chest pain
  • Coughing up blood or bloody phlegm
  • Blood clots
  • Accumulation of fluid in the lungs, abdomen, or swelling in the legs

Symptoms that increase with exercise and pregnancy can include fatigue and weakness.

Treatment

Treatment for mitral stenosis may not be necessary in patients who do not experience symptoms. Options include medical management, mitral valve replacement, and balloon dilatation.

The Tricuspid Valve

The tricuspid valve is positioned on the right side of the heart between the right ventricle and the right atrium. Most tricuspid disease develops secondarily to left-sided heart disease or failure.

Primary tricuspid disease – without prior left sided heart disease is less common. Therefore, most surgical treatment of the tricuspid valve occurs concomitantly with mitral valve, aortic valve, or coronary artery bypass operation.

Tricuspid Insufficiency

Tricuspid insufficiency is a valvular heart disease (sometimes referred to as “tricuspid regurgitation”). It is the failure of the heart’s tricuspid valve to close properly during heartbeats. When tricuspid insufficieny occurs, each heartbeat passes some blood from the right ventricle to the right atrium, this is the opposite of the normal direction of blood flow. Tricuspid insufficiency is rare and occurs in approximately less than 1% of people. Most people with the condition do not experience any symptoms.

Signs and symptoms

  • Although most patients with tricuspid insufficiency are asymptomatic, some may experience symptoms similar to those of right-sided heart failure, which include:
  • Accumulation of fluid in the abdomen, or swelling of the legs
  • Enlargement of the liver
  • Jugular venous distension
  • Vague upper abdominal discomfort from a congested liver
  • Fatigue due to diminished cardiac output

Causes

Most cases of tricuspid insufficiency are caused by dilation of the right ventricle. There are number of diseases which can have a direct effect on the tricuspid valve. Most common is rheumatic fever. Another condition that harms the tricuspid valve is endocarditis. Endocarditis is often infectious in nature and commonly associated with IV drug abuse.

Less frequent causes of tricuspid insufficiency include:

  • Carcinoid tumors
  • Connective tissue diseases such as Marfan syndrome
  • Systemic lupus erythematosus
  • Myxomatous degeneration
  • Injury
  • Rheumatoid arthritis
  • Radiation therapy
  • Use of diet medications including phentermine and fenfluramine or dexfenfluramine
  • Congenital defects

Treatment

Primary treatment of tricuspid insufficiency involves treating the underlying cause or causes. With many cases, surgery is not needed because the underlying problem is a dilated or damaged right ventricle. The standard medical therapy involves the use of diuretics, although this can lead to decreased cardiac output. Other medications are also available

When surgery is indicated, the options include tricuspid valvular repair, valvuloplasty (the widening of the valve using a balloon catheter) or valve replacement. The traditional approach to repair/replace is via traditional sternotomy, however we offer a mini approach with use of robot. The robotic approach involves 3-5 3” incisions on the right side of the chest. It results in less prominent scarring and frequently allows the patient to return to their normal activities faster. 2 weeks recovery time versus 2 months.

Tricuspid Stenosis

Tricuspid Stenosis is a disease resulting in the narrowing of the orifice of the tricuspid valve. It is a generally uncommon condition that decreases blood flow through the valve. Tricuspid stenosis is almost always caused by rheumatic fever and is frequently accompanied by mitral stenosis.

Other causes are rare but include endocarditis, carcinoid syndrome, lupus erythematosus, endomyocardial fibrosis, right atrial myxoma, and congenital tricuspid atresia.

Signs and Symptoms

A mid diastolic murmur can be heard with a stethoscope. It is caused by the blood flow through the stenotic valve. Diagnosis and the severity can be determined with echocardiography.

Treatment

Tricuspid valve stenosis by itself doesn’t commonly require treatment. But if there is also damage to other heart valves, then it may be necessary to consider surgical repair or replacement.

If you are in need of a tricuspid or mitral valve procedure or to find out if you are a candidate for minimally invasive robotic surgery, please contact us.