mitral valve repair for severe regurgitation

[Jjtigg]

My husband (now 47) was diagnosed with mitral valve prolapse about 10 years ago.  He has progressed over the past few years from moderate to severe regurgitation.  He is said to have mild to moderate prolapse of the posterior leaflet with a thickened valve and some enlargement of the left ventricle and dilation of the left atrium.  His left ventricular systolic function is hyperdynamic with EJ of 82%.  As far as we can tell he is asymptomatic.  (LVIDd 6.4cm, LVIDs 3.1cm, LVOT diam 2.4cm, pulmonary artery pressure 14mmHG). Is a minimally invasive mitral valve repair appropriate at this point to avoid any dysfunction BEFORE it occurs. Thank you.

[CCF-M.D.-MJM]

Great question.  If you ask 10 cardiologist this question and may get several different answers.

The answer from the ACC cardiolgy guidelines for mitral valve repair/replacement is:

If the ejection fraction is great than 60%, the end diastolic dimension is normal (3.1 cm is normal) and he is truly asymptomatic, atrial fibrillation or pulmonary hypertension should be present before proceeding with surgery.  Some institutions will do mitral valve repair on patients without symptoms. If your husband is in nornmal sinus rhythm, he does not need surgery now.

In the hands of an experienced operator, this is a very low risk surgery, but there it is important to remember there are always risks.  If I were you I would obtain a second opintion and if the opinion is to wait, I would feel comfortable waiting at this stage.

I hope this helps answer your question. Good luck.

[Emmaj]

Hi Jjtigg, Below is the website to find these aac guidelines and read a little more. Also, you and your husband would probably find the valvereplacement.com website interesting. It seems to me that minimally invasive surgery is not an option for mitral valve repair/replacement... this because the valve is inside the heart. I could be wrong, but I think that applies to coronary bypass, mainly. Your husband should "listen to his body," particularly for irregular (not just rapid) heart rhythm, namely afib. He should see a doc if he has any arrhythmia, but the reason I mention afib is that if he has surgery before afib establishes itself, he may be lucky and be "afib-free" after surgery. I was not so lucky in that regard (but overall, very lucky!). Another reason for your husband to "listen" is that the symptoms can come on rather slowly, and a person may not really be aware of just how bad he/she is feeling -- that is, not till the valve is fixed! Best of luck to you!

http://www.acc.org/clinical/guidelines/valvular/dirindex.htm

[DottyCece]

This is a very difficult question.  I had an enlarged left atrium and pulmonary hypertension and rapid uncontrolled atrial fibrillation when it was discovered that is severe mitral regurgitation and wouldn't get better unless I had surgery.  In retrospect, I wish my situation was discovered at your point.  I would definitely had surgery to repair or replace that valve.  Because in my situation, I ended up with sick sinus syndrome after the surgery (they did a maze procedure for the Atrial fib) and then a permanent pacemaker.  After surgery I had persistent re-occurring atrial flutter and fibrillation which required cardioversions aver ten times.  After a few months I had increased pulmonary hypertension, SOB, right heart failure etc.  I then had to have a re-do valve surgery because something was wrong with how the valve was implanted...though it was never clear what really happened.  After that, I did well for a while then went back into rapid uncontrolled atrial fib and eventually had an AV nodal ablation.  A couple months later I went into heart failure with an EF under 30%.  So, then I had a bi-ventricular pacer and ICD implanted and happy to say I am better...my EF went up 10% which was fantastic.  I am on a boat load of medications though which are no fun.  

Anyway to make a long story short, I would have had surgery before any symptoms occurred.  Once they occurred they tended to persist and were very difficult to treat.  It definitely changed the quality of my life.  I had two heart surgeries in 11 months and yes there are complications but I did well surgically speaking.  I guess I do not understand why they would wait until atrial fib would develop because so oftenit will re-occur even it if it cardioverted or whatever.  Pesonally, I would do everything different if I could.  I wasn't followed by cardiology over the years and for that I blame my primary care physician who was the gate keeper...you know HMOs.  That is all water under the dam and now it is time to move on and be glad for what I do have left and still can do.

[Emmaj]

Whoa, Dotty, that is a terrible story!! I didn't really understand what had precipitated your problems. My experience, though not desirable, was not as bad. However, I also have a nagging 20-20 hindsight.... more than once I ignored symptoms that should have sent me to my doc -- which might have prevented my current situation. Jj, as I understand it, your husband could get away with afib episodes for as long as a couple of months presurgery though, and still be afib-free afterword. I just want to say that if he does have afib, he should not panic. An afib episode is not life threatening. If he is not tuned into his heart rhythm (or lack of rhythm) he should note any episodes of dizziness or lightheadedness - for they may be symptoms of afib. Take care all~

[DottyCece]

No atrial fib is not life threatening in and of itself.  But, it can cause clots to form and stokes to occur.  I have seen some profound cases of that.  In my mind and after all the things that have happened to me, I'd rather not be in atrial fib.  For one thing, coumadin woulld be required.

[Emmaj]

Dotty, yes, afib increases the risk of strokes and for that reason it is advised some people take Coumadin (not necessarily all -- see below sentence from ccf mjm from an archives question re warfarin vs aspirin -- which infers that for people under 60 with isolated episodes of afib, warfarin, aka coumadin, might not be necessary)... but anyway, what I was saying was that if this man experiences afib as a symptom of mv disease, he should contact his doc, yes (!), but at the same time, he shouldn't panic and think he's doomed to a postsurgical experience such as you or I have had... he has a window of a couple of months to have surgery... and still be afib-free afterwords. Hopefully he does take aspirin daily, antibiotics for dental work, avoid heavy lifting... and follow his doc's advice...  


"There is an algorhythm used to determine risk / benefits of coumadin vs. aspirin. If your age is great than 60 and you have atrial fibrillation, you should be on coumadin unless there are other contraindicatins."