Endoscopic mitral valve repair or replacement

Mitral valve surgery is a type of heart surgery which is carried out to fix problems with the your mitral valve, which is located between the left atrium and the left ventricle of your heart. The most common problems people experience with their mitral valve are that it allows blood to leak backwards (mitral valve regurgitation, commonly caused by mitral valve prolapse) or that it becomes thick or stiff, reducing blood flow (mitral valve stenosis).

Symptoms of mitral valve disease can include dizziness, shortness of breath, fatigue, an irregular heartbeat (arrhythmia) or heart palpitations (where you can feel your heart beating). None of these symptoms are a definite indication of mitral valve problems, however they are a cause for concern, so if you are experiencing any of them, do speak to a doctor.

Problems with your mitral valve do not necessarily mean you need repair or replacement surgery, but in the case that your problems are severe and can't be treated with other methods, your consultant might recommend this type of surgery. When successful, it can improve your heart function and avoid heart failure in the future.

This new approach is a minimally invasive procedure, otherwise known as endoscopic mitral valve surgery. It can be used to perform either mitral valve replacement or mitral valve repair.

While open heart surgery necessitates a large incision (cut) down the front of your chest, endoscopic surgery is performed using a 'keyhole' approach. This particular procedure will generally require a one-inch incision into your groin and a two-inch incision into the right side of your chest, along with around four smaller (one centimetre or less) incisions around the right breast area.

During a preoperative CT scan, which gives us intricate details of the inside of your body, we will be able to see whether this endoscopic approach will be safe for you. It won't be the right choice for everyone, and we'll explain our recommendations to you in full before you decide on surgery.

When it is appropriate, the minimally invasive endoscopic procedure has been shown to get patients back to a normal quality of life quicker than with open surgery, as well as offering better cosmetic results (less scarring).

The procedure can also be used to repair the tricuspid valve, which controls blood flow between the right atrium and right ventricle, and to treat people with atrial fibrillation. It is also effective for repairing holes in the heart and removing tumours in the atrium.

It might be that you need more than one of the procedures and, if so, we can do these during the same endoscopic operation.

Is endoscopic heart surgery right for me?

"Most patients who need mitral or tricuspid valve surgery will be suited to this approach," says Consultant Cardiothoracic Surgeon Mr Joseph Zacharias. "However if you have narrowed arteries in your groin or heart then it might not be suitable for you. A CT scan helps us decide that."

He continues: "This approach is very attractive to young patients who may be more concerned about the cosmetic results. It is also good for elderly patients who recover quicker from this smaller incision and can go back to independent living faster. The reduction in chest wound pain and infection is a big advantage to all age groups."

Endoscopic mitral valve surgery is performed under a general anaesthetic and usually takes between three and four hours.

Your surgeon will make three or four small incisions into your chest, through which they'll insert specially designed surgical tools, including an endoscope. A high-definition 3D camera is attached to the endoscope and is used to guide the procedure inside the heart, transmitting to a screen so that your surgeon can see exactly what's going on, allowing them to repair or replace your damaged mitral valve. The repair or replacement happens in the exact same way as if you were having open heart surgery.

An incision in the groin is made to use the artery and vein in the groin to put the patient onto the bypass machine. Once inside the heart, the repair or replacement technique is carried out in exactly the same way as the sternotomy operation but using endoscopic instruments.

If you are having mitral valve repair surgery, your surgeon will partially sew the flaps of the valve together, stopping blood from flowing through the wrong way.

If you are having a mitral valve replacement, your consultant surgeon will replace your mitral valve either with a mechanical replacement or with one made from animal tissue (called a bioprosthetic valve).

You will need to be supported by a cardiopulmonary bypass machine during your surgery, which is sometimes known as a heart-lung machine. This is a device that takes over for your heart and lungs while you have your operation. A small incision is made into your groin and the machine is connected to your artery and vein via your groin.

The proven benefits of having your mitral valve repair or replacement via endoscopic surgery include:

• A much quicker recovery period. Usually after about three weeks you will feel better and be able to undertake most of your normal activities
• There will be less post-operative discomfort and pain after a few days
• Your hospital stay will be shorter, at around three to four days
• Less risk of wound infection and blood transfusion
• You can drive after four weeks if you’re feeling well enough to do so
• Restrictions relating to lifting and pushing up from a bed or chair do not apply with patients who have not had a sternotomy wound
• The cosmetic result is generally excellent, particularly for women as the scarring is hidden under the right breast

The consultant will explain the procedure step by step, answering every question you might have.

These two types of surgery offer a high success rate, however with any type of surgery there is always a certain risk of complications arising.

Mitral valve replacement surgery has a higher risk of life-threatening problems than mitral valve repair surgery.

Risks associated with any surgical procedure:

• Pain
• Bleeding
• Blood clots
• Blood loss
• Breathing problems
• Infection
• Allergic reactions to the medicines

Specific risks of endoscopic mitral valve surgery:

• Conversion in 2% of patients to a sternotomy
• Stroke (less than 1%)
• Infection in the groin wound (less than 2%)
• Heart attack (less than 2%)

After the operation you will be transferred to the cardiac intensive care unit or the high dependency unit, usually for 24 hours, and then after that you'll be moved to the ward.

You should be able to go home after three to four days.

It takes an average of three to four weeks to recover from this type of operation. Most people are normally able to drive within four weeks.

Your surgeon, physiotherapist and occupational therapist will discuss your individual case with you and offer personal advice as to when you can return to your usual activities. Regular exercise should help you to get back to normal as soon as possible. However, before you start exercising, you should ask a member of the healthcare team or your GP for advice.

Most people make a good recovery, with no more breathlessness or chest pain. You may also find you have more energy after you recover.

What is mitral valve disease?

In your body, the mitral valve sits on the left-hand side of your heart between your left atrium and ventricle. It regulates blood flow from your lungs into your left ventricle. Mitral valve disease is an umbrella term used to describe two types of damage to this valve: stenosis and regurgitation.

Mitral valve stenosis occurs when the mitral valve in your heart is narrowed and does not open as widely as it should, restricting blood flow to the heart.

Meanwhile, mitral regurgitation is caused by mitral prolapse (when the valve becomes floppy and does not close tightly), which leads to blood flowing the wrong way in the heart.

What are the symptoms of mitral valve disease?

The first symptom of mitral valve disease is a murmur on the left-hand side of your chest. Your GP can identify this through a simple stethoscope check. Your doctor will then perform an echocardiogram test. This will confirm the severity of damage to your mitral valve.

Other symptoms might include:

• Palpitations
• Breathlessness
• Dizziness
• Swollen legs

However, any swelling mostly occurs at a later stage of mitral valve damage. It is also worth nothing that not all people experience symptoms with mitral valve disease.

What causes mitral valve disease?

This question is asked so frequently it deserves a Nobel Prize!

At the moment, we haven't discovered why some people get mitral valve disease and others don't.

Some patients struggle with it after they experience an infection of their heart valves. This leaves the valves inflamed and therefore more likely to become infected.

Does mitral valve disease always require surgery?

Thankfully, for many people who struggle with mitral valve disease the condition can be treated with medication.

This includes blood thinners and high blood pressure medications - but while medication treats mitral valve disease, it does not cure it.

If you suffer from stenosis or regurgitation, mitral valve surgery (sternotomy or endoscopic) is required to repair or replace the mitral valve in your heart. This can then cure mitral valve disease.

What is the difference between keyhole surgery and sternotomy?

Surgery to repair or replace your mitral valve can be performed by sternotomy or endoscopic (keyhole) surgery.

Sternotomy

Sternotomy is a traditional approach to treating mitral valve damage.

To carry out the procedure, a surgeon will make an incision along your chest and partially clip or sew the flaps to reduce any blood leaking.

This method gives the surgeon wide access into the chest to perform the operation.

It has been performed for over 50 years and is considered a very safe approach, but it will leave a 9-12-inch scar on the front of your chest.

Some people are saddened by the prospect of a 9-12-inch scarring after surgery, while others are not as emotionally affected by this outcome – it’s entirely dependent on the individual.

Keyhole surgery

In keyhole (endoscopic) surgery, the aim is to perform the same operation without disturbing the bones of your chest.

During keyhole surgery, we use an endoscope to provide light and magnification to guide the procedure precisely.

We also use special instruments to help perform the procedure safely.

What are the risks of keyhole surgery?

The risks from keyhole surgery are similar to those associated with traditional open-heart surgery.

These risks include bleeding, stroke and infection. Risks associated with surgery are often related to your personal fitness levels.

Trainers with weights and healthy food

They are also impacted by the extent of damage to your heart valve.

What are the benefits of keyhole surgery?

Infection is less likely

You are less likely to develop an infection following keyhole surgery.

You will not lose much blood

You will lose less blood during and after keyhole surgery than an open-heart procedure.

Your recovery time will be faster

You do not have to wait for your breastbone to heal after keyhole surgery. As a result, the recovery period is much shorter.

Generally you will spend less time in intensive care and hospital after keyhole surgery, which can heighten its appeal for many people.

After three to four weeks, you would then be able to carry out most of your normal daily activities as by this point, scars are likely to have healed and pain won’t be an issue.

Of course, recovery time depends on your health and fitness levels prior to having surgery.

At the moment we are undergoing a research trial funded by NIHR (The National Institute of Health Research) to look into this topic and reach a definitive answer.

How can I take care of my heart?

There are many ways to take good care of your heart and decrease the likelihood of developing mitral valve damage.

This mostly includes implementing diet and lifestyle changes. 

If you are struggling with mitral valve disease, remember that keyhole surgery is a trusted treatment method and Circle Health Group consultants including myself are here and ready to help.

Read more: 5 tips for a healthy heart.

This interview was given by Consultant Cardiothoracic Surgeon, Joseph Zacharias.

When you choose to go private with Circle Health Group, you'll benefit from:

• Flexible appointment times to fit your schedule
• The freedom to choose your hospital and your consultant
• Bespoke, consultant-led treatment plans tailored to your individual needs
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• Tasty and nutritious meals cooked to your dietary requirements
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If you're ready to start your treatment journey with one of our heart specialists, book your appointment online today or call a member of our team directly on 0141 300 5009.

Content reviewed by Mr Joseph Zacharias in December 2022. Next review due December 2025.

1. Mitral valve problems, NHS
2. Mitral valve repair and mitral valve replacement, Mayo Clinic
3. Valve heart surgery, British Heart Foundation