Re: Surgery

Posted By CCF CARDIO MD - DLB on May 09, 1998 at 17:29:41:

In Reply to: Surgery posted by Barry Townsend on May 09, 1998 at 00:29:28:






Thank you for providing this forum.
In 1994 a family physician noticed a heart murmur during a routine physical and referred me to a cardiologist who subsequently diagnosed me with mitral regurgitation due to mitral valve prolapse. He recommended annual echocardiograms. On April 1, 1998 I got another echocardiogram and, this time, was recommended for valve surgery within the next year.
This last echo revealed severe mitral regurgitation, myxomatous leaflet abnormalities, severe mitral valve prolapse, left ventricle and left atrium enlargement (mild), and trace tricuspid regurgitation. This news has been somewhat of a shock because I did not expect to have this surgery so soon after the initial diagnosis in 1994. I also have had no history of heart problems (I am 35).
I am confused because the cardiologist and surgeon seem to have differing opinions on the optimal timing for this type of surgery. I am also confused because, if I opted for the surgery, it seems the surgeon would do a valve replacement using traditional open heart surgery. Evidently, there is only one cardiac surgeon in the area and he has done only 15 valve surgeries (but has performed over 200 other open heart surgeries) in the past year. This concerns me.
My question(s) are: What is the optimal timing for mitral valve replacement in the case of severe regurgitation? Is repair an option for myxomatous valve degeneration? Does a repair last long or will it begin to degenerate again? Does it make sense to undergo an open heart operation if places like the Cleveland Clinic do minimally invasive procedures? Are my choices really limited by my HMO or can I pay less and volunteer as a research patient in a place like the Cleveland Clinic?
Thanks so much.
Barry Townsend
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Dear Barry:
Myxomatous degeneration of the mitral valve is a common cause of mitral regurgitation.  The most common indication for mitral valve repair in this country is mitral valve prolapse.  The optimal timing of surgery for mitral regurgitation has been an area of controversy for many years, but now experts believe that the time to operate is when the echo shows signs of left ventricular dysfunction or dilation.  This is true even if the patient has no symptoms.  The problem with heart disease caused by mitral regurgitation is that by the time symptoms develop, the heart has already been damaged irreversibly.  The key lies in early diagnosis by echocardiography.  
There is no question that mitral valve repair is tricky surgery.  The more experienced the surgeon, the better the results.  While replacing a valve is relatively easy surgery, repairing a valve properly is difficult.  Frankly, I think it would be a big mistake to go to a surgeon who does just a few mitral valve repairs.  And for mitral valve prolapse, mitral valve repair is better than mitral valve replacement, if the valve anatomy allows it. There are a lot of data to support my view; in addition, common sense would suggest that the more you do of something, the better you are at doing it.
The long-term results of mitral valve repair are excellent, if done correctly.  Research done at the Cleveland Clinic has shown that placement of a ring around the mitral valve at the time of repair dramatically improves long term results.  Nonetheless, it is very possible that you will need repeat surgery several years from now to once again repair, or at that older age, replace the valve.
As far as minimally invasive mitral valve repair, the Cleveland Clinic is a world leader in this area also.  Minimally invasive heart surgery involves a different incision on the chest.  It is generally a smaller incision that patients may prefer cosmetically.  However your question implies that minimally invasive heart surgery is not an open heart procedure - this is incorrect.  Minimally invasive surgery is still a serious undertaking.  Again, a surgeon that does more is better.
As far as your question regarding being an experimental subject, that would not apply for this type of surgery which is no longer experimental.  I honestly believe that you should be evaluated for mitral valve repair at a medical center that does a large number of them.  I highly recommend the Cleveland Clinic.  Most unbiased cardiologists and cardiac surgeons would agree that Cleveland Clinic cardiologists and cardiac surgeons  pioneered this surgery.  If your HMO does not allow you to come here, I urge you to seek referral to a large medical center that performs a high volume of mitral valve repair.  You should speak to your cardiologist, who will hopefully do the right thing, and refer you to a medical center that does an adequate number of these procedures.  If your HMO does not allow that, you may need to talk to the HMO administrator.
I hope this response has been useful to you.  I wish you the best of luck.

Information provided here is of a general nature.  Specific diagnoses and treatments can only be made by your doctor.  If you would like to be seen at the Cleveland Clinic, please call 1-800-CCF-CARE for an appointment with a cardiologist who specializes in echocardiography at Desk F15.