Mitral valve stenosis and mitral valve prolapse in elderly patients. Replace or repair mitral valve? 5
Mitral valve repair in elderly patients can be very safe and effective. Dr. Anton Titov, MD. We discussed with Professor Lawrence Cohn mitral valve repair in elderly patients. You co-authored an extensive review of the mitral valve repair in elderly patients with Professor Lawrence H. Cohn. What is the state of the art in mitral valve repair in elderly population? Dr. Anton Titov, MD. What patients should know about mitral valve treatment options, including surgery? Dr. Tsuyoshi Kaneko, MD. Mitral valve repair or mitral valve replacement is an important surgical operation. Replacement of Mitral heart valve is the other option to treat mitral valve disease. Mitral valve repair has been repeatedly shown to be superior compared to mitral valve replacement. “Superior” meaning that you live longer. Even in the elderly you get better results with repairing the mitral valve. Dr. Tsuyoshi Kaneko, MD. The techniques of the mitral valve repair have been slightly progressing. There are some believers of new mitral valve repair technique. They will not resect the valve leaflet, they will preserve mitral valve leaflet. They call it “respect rather than resect”. We also have been doing more and more minimally invasive procedures through a smaller incision. I personally do mitral valve repair through a small incision in the right side of chest. This heart surgery method will avoid making a big incision in the middle. It will be much more cosmetic. Dr. Anton Titov, MD. Patients recover after surgical operation earlier. Minimally invasive mitral valve repair techniques have been used in the elderly. The key factor is this. Dr. Tsuyoshi Kaneko, MD. Mitral valve disease requires highly specialized treatment skills. You may have a significant prolapse of the mitral valve. Then you should go to a medical center that can repair the mitral valve rather than replace the mitral valve, if possible. There are a lot of cases where we can’t repair the mitral valve. You may have too much calcium in the mitral valve. You may have infection of the mitral valve. In those situation it is not possible to repair mitral valve. But whenever you can, you should undergo mitral valve repair rather than undergo replacement of mitral valve. Dr. Anton Titov, MD. There was a medical publication. It said that the surgeon’s volume of mitral valve repair directly correlates to the results. Dr. Tsuyoshi Kaneko, MD. When you must have mitral valve surgery, you should not go to a small medical center. You should not go to surgeons who do only one or two mitral valve repair operations per year. You should go to a heat valve treatment center where there are very very experienced heart surgeons. How would you define a “very experienced surgeon” for mitral valve repair surgical operation? The United States national average, or median number of mitral valve surgery is 4 operations per year per surgeon. You may go to the medical center that is doing more than 10 mitral valve repair operations per year per surgeon. That’s probably an experienced surgeon. You may go to the center where surgeons do 20 or 30 mitral valve operations per year. That is a very well experienced heart surgeon. There are surgeons that do 100s to 200s mitral valve repair surgeries every year. But those are very rare. If you go to a medical center that does more than 10 operations per year, I think you’re in good hands. Dr. Anton Titov, MD. In the United States, how many surgeons do more than 20 or 50 mitral valve repair operations per year? Is it a single-digit number of heart surgeons? Dr. Tsuyoshi Kaneko, MD. No, I think for over 20 mitral valve repair surgeries per year, I think there will probably still be about 50 cardiac surgeons in the US. Dr. Anton Titov, MD. That’s nevertheless an accessible number of experience cardiac surgeons for mitral heart valve repair. Yes, I think so. There are other options to treat mitral valve prolapse. Some elderly patients are very very sick, some older patients are very frail. Dr. Tsuyoshi Kaneko, MD. There are some new mitral valve treatment options. One device that is approved by FDA is called a mitral clip. Mitral valve clip clips the valve. You can do that through a groin. You don’t need any big chest incision. You don’t need to use heart-lung machine. Mitral clip clips your valve to prevent valve prolapsing. Instead of prolapsing the mitral valve, you clip the valve to prevent that prolapse. That has shown that it does cause decrease in the amount of mitral regurgitation. Mitral clip is not nearly as good as surgical mitral valve repair. Mitral clip will not completely fix the mitral valve. But at the same time it may diminish the amount of leakage through mitral valve. The patients may feel better afterwards. Mitral clip is a treatment option for patients who are too frail to get open-heart surgery. Dr. Anton Titov, MD. There are several devices that are in the pipeline. We have at least two or three devices that are entering clinical trials. Dr. Tsuyoshi Kaneko, MD. Mitral valve repair and replacement is a very heavily invested field. A lot of the companies are trying to bring in new devices. Because TAVR device had so much success. People are looking at the mitral valve as a new platform. There has been a lot of investments that are being done. Dr. Anton Titov, MD. I think in the next five to ten years we will see a lot more devices to treat mitral regurgitation. These treatment options can be used for very sick patients to repair these mitral valves. Well, this is very important to know. Mitral valve repair is a very fast-moving field. It is!
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