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Isolated cleft mitral valve

Posted by Michael on May 05, 1999 at 13:36:56
I am a 38 year old male with an isolated cleft mitral valve.  I have been evaluated on a yearly basis from birth. When I was 16 I had a catherization which concluded that my heart was functioning normally but with a mild to moderate mitral insufficiency.  When I was around 28, an echocardiogram revealed the cleft.  The cardiologist told me that this kind of defect was rare.  I was advised to get yearly echo tests from then on.  I am very healthy and active and feel fine.
All of my echo tests where "status quo" until the most recent one.  This echo showed that my left atrium has dilated from 4.3cm to 5.0cm.  All other measurements were ok and the mitral regurgitation was still described as moderate.  My cardiologist told me that the year prior the left atrium went from 4.0cm to 4.3cm.  I am now rescheduled for an echo in 6 months.  My cardiologist told me that we need to see if this is going to progress or "plateau".  I was also informed of the possibility of A-fib due to the left atrium size.
My question is one of timing to repair or replace the valve.  From what I read it seems to me that time is now.  My cardiologist wants to wait for the next echo in 6 months and see how I am doing then.  He thinks that I may not need corrective surgery for 2 to 3 years or possibly 20 years but would rather not speculate at this point.  This new situation has just started to make me concerned about getting A-fib and sustaining any damage to my heart.  Would valve surgery correct this problem?  After surgery would the left atrium normalize in size?  At this point would waiting 2-3 years for surgery make a big difference in outcome?  What I fear is development of symptoms at which point the surgery will less effective.  I am under the care of a very good cardiologist at Columbia Presbyterian Medical Center (New York) and feel confident in his handling of my case.  He tells me don't worry.  I worry anyway.
I am going to discuss the Cleveland Clinic with my cardiologist.  From what I read I believe that I would have the absolute best chance for getting my valve repaired and increase my probability of a good outcome.  I would also be interested in the minimally invasive approach.  Thanks so much for your help!
Posted by CCF CARDIO MD-APS on May 07, 1999 at 10:25:21
Dear Michael,
It is good that you will be discussing this with your cardiologist since part of the answer to when is it time is dependent on you, the patient.
In general, the larger the atrium, the more likely the atrial fibrillation, and the more likely it will not shrink down near normal size with valve repair/replacement ( fixing the valve removes the mitral regurgitation or MR and this removes the back force on the left atrium that is causing it to dilate.)
It is somewhat controversial when to fix a mitral valve in a patient who is asymptomatic.  Knowing that waiting for symptoms is sometimes equivalent to  "too late", many cardiologists are working to better understand when to go to the OR all the while taking in to account the risk to life and health (mortality and morbidity respecitively) for the patient by the surgery itself.
Easy patients to send to the OR for repair/replacement are those with 4+MR(severe), those with symptoms, those whose left ventricle is dilating, those with a left ventricle that does not respond during exercise the way it should (i.e. with an increased ejection fraction) that is assessed with a stress echocardiogram, and for those who go in to atrial fibrillation.
Of course not everyone is  a candidate for repair, at the Cleveland Clinic, Dr.Cosgrove (one of the pioneers of valve repair and our Chairman of Cardiothoracic Surgery) considers all patients for repair and only replaces if neccessary.  Cleft mitral valve is rare and is not the typical abnormality that is repaired.  
Chest deformities and such are things that make patients NOT candidates for minimally invasive surgery.
Discuss all these points with your cardiologist as well as your appropriate concern regarding waiting until it is too late to go to the OR for valve surgery.  It is hard to believe that your MR is only moderate and that your LA continues to dilate (altough this is not impossible); I think that a TEE to get a better look at the valve and the MR, as well as a stress echo to assess the LV compensation should be considered for you if they have not already been done (i.e. prior to saying "when" would be the best time to get the valve taken care of.)
I hope you find this information useful. Information provided in the heart forum is for general
purposes only. Only your physician can provide specific diagnoses and therapies. Please feel free to
write back with additional questions. Good luck.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call
1-800-CCF-CARE or inquire online by using the Heart Center website at
www.ccf.org/heartcenter. The Heart Center website contains a directory of the cardiology staff that
can be used to select the physician best suited to address your cardiac problem.

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