Mitral Valve Repair vs. Replacement: A Guide for Older Adults

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• Mitral Valve Repair in Elderly Patients
• Why Repair is Better Than Replacement
• Advancements in Minimally Invasive Surgery
• How to Choose a Mitral Valve Surgeon
• When Mitral Valve Repair Isn't an Option
• The Mitral Clip for High-Risk Patients
• Future of Mitral Valve Treatments

Mitral Valve Repair in Elderly Patients

Mitral valve repair is a safe and effective surgical option for elderly patients. Dr. Tsuyoshi Kaneko, MD, a leading cardiac surgeon, emphasizes that age alone should not disqualify a patient from this beneficial procedure. He co-authored an extensive review on this topic with Professor Lawrence Cohn, confirming its viability for the older population.

The decision-making process involves a thorough evaluation of the patient's overall health, the specific valve pathology, and the potential for a successful long-term outcome.

Why Repair is Better Than Replacement

Mitral valve repair has been consistently proven superior to mitral valve replacement. Dr. Tsuyoshi Kaneko, MD, states that "superior" means patients live longer with a repaired valve. This survival benefit holds true even for elderly patients, making repair the goal whenever technically feasible.

Repair preserves the patient's native valve apparatus, which is crucial for maintaining optimal heart function. Replacement with a mechanical or biological prosthesis carries risks of blood clots, lifelong anticoagulation therapy, or eventual prosthesis deterioration.

Advancements in Minimally Invasive Surgery

Surgical techniques for mitral valve repair are continuously progressing. Dr. Tsuyoshi Kaneko, MD, highlights the "respect rather than resect" philosophy, which focuses on preserving the valve leaflet tissue instead of removing it. This approach can lead to more durable and physiological repair results.

Furthermore, surgeons are performing more operations using minimally invasive approaches. Dr. Tsuyoshi Kaneko, MD, personally performs mitral valve repair through a small incision on the right side of the chest. This method avoids a large sternotomy, is more cosmetic, and allows for a faster recovery, which is particularly advantageous for older adults.

How to Choose a Mitral Valve Surgeon

The experience of the surgeon and the medical center is a critical factor for a successful mitral valve repair outcome. Dr. Kaneko warns against going to a small center or a surgeon who performs only one or two such operations per year. A direct correlation exists between a surgeon's volume and their patient results.

Dr. Tsuyoshi Kaneko, MD, provides a benchmark: the national median in the US is just 4 mitral valve operations per surgeon annually. He advises seeking a center where surgeons perform more than 10 repairs per year, noting that those doing 20 to 30 are very well-experienced. While surgeons performing over 100 are rare, he estimates about 50 cardiac surgeons in the US perform more than 20 mitral valve repairs annually.

When Mitral Valve Repair Isn't an Option

Despite its advantages, mitral valve repair is not always possible. Dr. Kaneko identifies specific scenarios where replacement becomes the necessary option. These include cases with extensive calcium buildup (calcification) on the valve apparatus or destruction of the valve from infection (endocarditis).

In these situations, the tissue quality is too poor to hold sutures or create a competent repair, making replacement the safer and more reliable surgical strategy to resolve the patient's condition.

The Mitral Clip for High-Risk Patients

For elderly patients who are too frail or high-risk for open-heart surgery, a transcatheter option exists. Dr. Tsuyoshi Kaneko, MD, discusses the MitraClip device, which is approved by the FDA. This procedure is performed through a vein in the groin without a chest incision or a heart-lung machine.

The device clips the mitral valve leaflets together to reduce prolapse and the severity of regurgitation. Dr. Kaneko is clear that the MitraClip is not as effective as a surgical repair but can significantly diminish leakage and improve a patient's symptoms, offering a valuable alternative for inoperable patients.

Future of Mitral Valve Treatments

The field of mitral valve therapy is rapidly evolving. Dr. Tsuyoshi Kaneko, MD, notes that due to the monumental success of TAVR (Transcatheter Aortic Valve Replacement), there is heavy investment in developing new devices for the mitral valve. Several new devices are already entering clinical trials.

Dr. Tsuyoshi Kaneko, MD, predicts that within the next five to ten years, patients and doctors will have many more transcatheter options to treat mitral regurgitation, expanding treatment possibilities for the sickest patients.

Full Transcript

Dr. Anton Titov, MD: Mitral valve repair in elderly patients can be very safe and effective. We discussed with Professor Lawrence Cohn mitral valve repair in elderly patients.

You co-authored an extensive review of mitral valve repair in elderly patients with Professor Lawrence H. Cohn. What is the state of the art in mitral valve repair in the elderly population?

What should patients 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 the 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.

The techniques of mitral valve repair have been slightly progressing. There are some believers of a new mitral valve repair technique. They will not resect the valve leaflet; they will preserve the 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 the chest. This heart surgery method will avoid making a big incision in the middle. It will be much more cosmetic.

Patients recover after the surgical operation earlier. Minimally invasive mitral valve repair techniques have been used in the elderly. The key factor is this.

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 an infection of the mitral valve. In those situations, it is not possible to repair the mitral valve.

But whenever you can, you should undergo mitral valve repair rather than undergo replacement of the 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 heart 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 surgeries, 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, there will probably still be about 50 cardiac surgeons in the US.

Dr. Anton Titov, MD: That's nevertheless an accessible number of experienced cardiac surgeons for mitral heart valve repair.

Dr. Tsuyoshi Kaneko, MD: 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.

There are some new mitral valve treatment options. One device that is approved by the FDA is called a mitral clip. Mitral valve clip clips the valve. You can do that through the groin. You don't need any big chest incision. You don't need to use a 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 a 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 the 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 the 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.

This is very important to know. Mitral valve repair is a very fast-moving field.

Dr. Tsuyoshi Kaneko, MD: It is!