Avoiding Open-Heart Surgery for Mitral Valve Regurgitation

What is mitral valve regurgitation?

The heart is a living pump, and the valves help to regulate the flow of blood in one direction through the heart, ensuring adequate flow to the rest of the body. Mitral valve regurgitation occurs when the mitral valve does not close properly; this means that instead of forward flow, some blood flows backwards when the heart pumps. As a result, the heart needs to work harder to distribute blood throughout the body, creating unnecessary strain.

What are the symptoms of mitral valve regurgitation and how does it affect patients?

Experiences vary based on the severity of the condition. Common symptoms are:

• Shortness of breath
• Palpitations
• Swelling of the abdomen, ankles or feet (known as oedema)
• Chest discomfort
• Heart murmur
• Fatigue, especially when active

How is it diagnosed?

Mitral valve regurgitation is diagnosed with a physical exam and the help of some tests. To begin, the doctor will use a stethoscope to listen to the patient’s heart, looking for unusual sounds, or a heart murmur. If further investigation is needed, the doctor may recommend diagnostic tests. These may include an echocardiogram, coronary angiogram (also known as cardiac catheterisation), or electrocardiogram (ECG).

What are the treatment options?

Conventional options include medication, or open-heart surgery to repair or replace the valve. The doctor’s recommendation is based on the severity of the condition, the state of the patient’s health and the presence of other abnormalities in the heart.

The aim of treatment is to reduce the severity of mitral regurgitation, thereby helping to restore optimal blood flow and relieving symptoms. This helps improve a patient’s quality of life.

A newer, less-invasive treatment is known as MitraClip mitral valve repair, and it is an option for patients unsuitable for open-heart surgery.

How does MitraClip work?

The MitraClip mitral repair procedure is performed by an experienced heart team.

Unlike conventional open heart surgery, the chest does not have to be cut open to treat the valve. The MitraClip procedure begins with a small incision in the groin, where a tube will be first inserted and passed up through blood vessels in the leg to the right side of the heart. This tube will pass through the interatrial septum (a structure which separates the left and right heart).

The MitraClip, connected to a delivery system, is then inserted via the tube and positioned over the leaky valve. The delivery system controls the clip, opening, closing or rotating as needed to grasp the mitral valve leaflets. Once this is done, the clips are closed. The valve function is then assessed to determine if there is adequate reduction in mitral regurgitation; the MitraClip is repositioned as needed until the desired effect is achieved.

The MitraClip is then secured into position and detached from the delivery system, leaving the MitraClip attached to the mitral valve leaflets. Some patients may need more than one MitraClip for the regurgitation to be sufficiently reduced.

What are the benefits?

The MitraClip procedure is minimally invasive and poses less risk than open-heart surgery in some patients.

As of March 2019, over 80,000 patients worldwide have been treated, and more than 17,000 of these patients have been followed through multiple studies and registries. Patients monitored for 5 years after undergoing the MitraClip procedure were found to demonstrate continued improvement in heart function and quality of life, including the improved ability to perform day-to-day tasks. Several studies also showed a reduction in hospital visits for heart failure.

What are the risks?

Any type of procedure, even one that is minimally invasive, poses risks.

Among those associated with MitraClip are small risks of infection at the entry site, damage to blood vessels and/or cardiac structures, bleeding and the development of a clot or air bubble, which can lead to stroke. The risks of device migration are uncommon. Occasionally, an inter-atrial communication may persist which requires a separate procedure to close this.

Who is suitable/eligible to undergo the MitraClip procedure?

Approved indications for MitraClip around the world may differ.

In Singapore, patients with moderate to severe mitral valve regurgitation may be considered for MitraClip, especially if they are considered unsuitable for open-heart surgery.

Examples of those most suited for MitraClip are those whose physical condition or pre-existing chronic disease/s would make open surgery too risky.

Unsuitable candidates include those who are at high risk of bleeding and those unable to tolerate the blood thinning medicines required for the procedure; patients with active infection of the mitral valve; patients with severe stenotic rheumatic heart disease; those who have a blood clot within the heart chamber or the blood vessels through which the MitraClip needs to be delivered.

Each individual patient has to be carefully reviewed by cardiologists and/or cardiac surgeons experienced in the MitraClip procedure to determine their suitability. Speak to a cardiologist about your condition to have your concerns addressed before deciding if MitraClip is right for you.