Let’s take a step back and discuss mitral valve disease treatment options in more general terms. It’s mostly about treating mitral valve regurgitation and mitral valve prolapse. Open heart surgery is a classic option for mitral valve treatment. But minimally invasive percutaneous transcatheter treatment techniques are being developed. Now there is a fair amount of experience with transcatheter mitral valve repair. How do you choose the correct method of mitral valve therapy for each patient? How to compare open heart surgery with transcatheter mitral valve repair techniques? Now,
In this new millennium, this is something different from the past. There is the availability of many therapeutic options to correct mitral valve with repair methods. As a matter of fact, we have conventional mitral valve surgery, which is performed through a midline sternotomy. Also, we can have minimally invasive mitral valve surgery, which can be accomplished through a small incision in the right part of the chest. These surgical operations can also be done with the help of robotic technology. And finally, we also have possibilities of correcting the mitral valve by using the catheter in the catheterization laboratory. So these are the main options that we can have for mitral valve repair.
Of course, we have to choose the best treatment option for the individual patient. So we have really to take into account the clinical characteristics of the individual patient. We have to take into account the individual profile of that patient, the age, and so on. We have also to take into account the wishes of the patient. So for the individual patient, taking into account all these things, we can offer the patient the best possible treatment. And of course, this is possible only in so-called Centers of Excellence, where you have the availability of all the therapeutic options.
So that touches on an important point. As they say, sometimes the best surgeon for a patient is the surgeon who is available at the moment when the surgery is required. So the comparison between open heart surgery and transcatheter treatment options depends on the availability of the sophisticated team that can offer those methods.
Exactly. Everything should be available. Because if you have only one technique, obviously, you use that technique which is maybe not appropriate for that individual patient. So the secret nowadays is to be treated – this is very important for the patient – where all these techniques are available. In such a way, the patient can be offered the best solution for his medical problem.
It’s crucial for patients to seek the Centers of Excellence and the surgeons and interventional cardiology specialists who work together to offer the best treatment for that specific patient.
Exactly. One of the new things in the treatment of disease, especially heart disease, is the Heart Team. The Heart Team means that there are many specialists that are cooperating on the side for the patient to make the best decision for the patient and also to deliver the best treatment for him.
One of the reviews caught my eye when researching your extensive medical literature. It is a medical review paper. Is annuloplasty sufficient for early-stage mitral valve repair? You discuss the comparison even when annuloplasty might be suitable for some patients with mitral valve regurgitation, but it really may not be optimal for other patients. Could you please talk a little bit more about those dilemmas?
Exactly. You know the annuloplasty addresses only the annulus of the mitral valve. The mitral valve is a very complex structure. You have the annulus of the mitral valve. You have the leaflets. You have the chordae tendinae. You have the papillary muscle and also the ventricular wall, where the papillary muscles are attached. So the mitral valve is a very complex structure. Annuloplasty can only be effective when the annulus is dilated. In those patients, this is the only change responsible for mitral regurgitation. Very often, the dilatation of the mitral annulus is associated with other changes, including anatomical changes on the valve. For instance, rupture of the chordae tendineae is producing mitral valve prolapse. Of course, in those cases, annuloplasty is not sufficient because a surgeon can reduce the annulus. Still, it is leaving the mitral valve prolapse, which is responsible for mitral regurgitation.
In the case of the chordae tendineae rupture, what is considered to be the optimal technique for the treatment of the mitral valve regurgitation created by the ruptured cordage tendineae?
We have nowadays the use of the artificial chordae tendineae. The GORE-TEX suture chordae are very effective in this situation. Alternatively, you can use the resection of the mitral valve leaflet exactly at the point where the chordae tendineae ruptured. Then it is called quadrangular resection, triangular resection, and other types of these surgical techniques. Also, the edge-to-edge Alfieri technique can be effective in those mitral valve regurgitation situations. There are particular circumstances when the chordae tendineae is ruptured. Then you can simply approximate the free edge of the mitral valve leaflets where the chordae tendineae is ruptured. That will eliminate mitral regurgitation.