The High Risk or Inoperable Mitral Valve Patient
There are two important questions that need to be asked every time a heart patient is deemed inoperable or is told they have an inoperable mitral valve. These are:
- What makes a stenosis patient or mitral valve regurgitation inoperable?
- How can we improve on our surgical solutions to save the life of a high risk mitral valve disease case?
Well, let me give you first a quick, down-to-earth introduction to the technical aspects involved in the successful surgical management of mitral valve disease. Once you know what the basic technical challenges and options are, you will appreciate the variety of customized solutions we have developed in high risk mitral valve stenosis or insufficiency patients. These new technologies have made the difference for so many heart patients that were otherwise hopeless and inoperable.
There are essentially two malfunctions that can affect a mitral valve:
- Mitral Valve Stenosis. The valve has become heavily calcified and it does not open up wide any more (stenosis). Rheumatic fever is recognized as the cause of the vast majority of stenotic mitral valves. This situation creates a lethal mechanical obstruction that impairs the ability of the heart to function properly. Profound weakness and fatigue, shortness of breath even with very light exercise, palpitations are characteristic symptoms of this condition. If the valve is not promptly replaced, a patient with symptoms will not survive much longer.There is no medical therapy that can help these patients. A surgical or a catheter based procedure are the only two options to treat this problem.
- Mitral Insufficiency or Regurgitation (a leaky valve). The valve cannot close properly and leaks blood backwards into the lung circulation. This malfunction causes a chronically overworked heart that becomes progressively weaker and larger. It is sort of a sneaky disease because most patients start to have symptoms of fatigue and shortness of breath only after the leaky valve has caused significant enlargement and damage to the heart. It is important to realize that many patients with severe leakage of the mitral valve might need surgery before they have symptoms. Waiting until you feel sick is definitely not a good idea. A heart surgeon or a cardiologist should evaluate your heart condition to advise you about the best timing for a mitral valve repair or replacement.
This surgery is performed to repair or replace the defective valve to reestablish regular heart function. The vast majority of isolated mitral valve or double valve pathologies can be routinely treated through a tiny 2″ incision by a competent minimally invasive heart surgeon. This approach allows even the sickest, elderly and frail patients a much faster recovery than traditional bone splitting operations. Here are the most common reasons quoted by physicians and surgeons that deem a mitral valve patient inoperable:
A. “You are too old and frail to survive the surgery”. Nothing is further from the truth!!! If an elderly patient can aspire to an improved quality and duration of life following the surgery, it is simply WRONG not to offer this option. As a matter of fact, a more appropriate reasoning could be that you might be too old and frail to survive your mitral valve disease without an operation. In other words, if you have severe symptomatic mitral valve disease there are no pills or medical therapy that can save your life!! As counterintuitive as it might be medical therapy is much more dangerous than surgery. They might give you some diuretics, such as Lasix or other “water pills” to help you breathe better but that will not fix the unrelenting and lethal mechanical failure of this valve.
B. “You are too frail to have your breast bone split to do the operation” Mitral valve surgery can be performed by an expert minimally invasive heart surgeon through a tiny 2″ chest wall incision between the ribs. This technique does not break any bone and allows most elderly patients to be out of bed walking the day after surgery with very little pain and a fast recovery and return to an independent life. If that option is not available locally, do call a minimally invasive heart center for a second opinion.
C. The patient has any combination of bad lungs, bad kidneys, bad liver and/or a prior open heart operations. Many of the thoughts I expressed in the paragraph D above apply here as well. Know what your chances are with and without surgery. Let’s say you have bad lungs and severe coronary disease. You might be able to breathe better if a good percentage of your breathing problem is caused by a heart condition that could be improved by the surgery. Bad kidneys might not be going to do well if you continue with medical therapy and the heart remains weak and causes congestive heart failure. Bad liver can be a high risk surgical proposition. You need to know how bad it is. There are different stages from mild to severe liver insufficiency and their associated surgical risk can vary a lot from case to case.
D. The heart is too weak. The strength of the heart is commonly measured as Ejection Fraction (EF). A normal EF is 60-65%. The lower the number, the weaker is the heart. The response to this condition can vary significantly among heart specialists. Some surgeons might not be comfortable operating on weak hearts because they feel they might not recover well after surgery. High risk heart surgery specialists might offer a more secure outcome by meticulously managing certain heart conditions before, during and after surgery. The high risk heart patient can be optimized before surgery with adequate preoperative medical intervention, during surgery with advanced minimally invasive techniques and can then recover postoperatively with expert management of congestive heart failure and low ejection fraction.
E. There are other reasons why your doctor might describe your heart condition as inoperable. Please feel free to contact us and discuss your questions and concerns with us.