Reference mitral repair surgeons usually perform a large number of mitral procedures annually, with the highest volume surgeons performing over 50 per year.
It is ischaemic, degenerative, rheumatic, infection, heart muscle dysfunction or something else. If it is the degenerative type, it is Barlow’s Disease? The type of the disease that you have determines the expertise required to fix it. For Barlow’s Disease, Infections and Rhematic Disease, you will generally need a very experienced repair team to maximize your likelihood of repair.
You should expect that your surgeon does at least 25 repairs a year for the mitral disease you may have.
It is not enough to ask you surgeon for his or her overall repair rate. You will need to know his or her success rate for the specific problem that you have. A surgeon may be successful in repairing 90% of all valves, but on the other hand, may be successful in repairing only 50% of Barlow valves. You should go ahead with a repair only if the surgeon feels he or she can guarantee a repair with a high probability, especially if you are asymptomatic.
If the number of replacements a surgeon does is similar to the number of repairs, then chances are that he or she is not a reference mitral repair surgeon. Reference mitral repair surgeons would generally repair well over 90% of valves they encounter. You can also ask your surgeon how many mechanical valves he or she does in a year – these operations are often done for degenerative disease which should have a high repair rate, so a surgeon who does a lot of mechanical valves is unlikely to be a mitral repair expert.
There is no role for quick surgery in a valve repair. Sometimes it will take several hours to achieve a good repair. You need to be certain that your surgeon will invest as long as it takes to achieve a repair if necessary rather than opt for the quicker valve replacement operation. Most surgeons can do a valve replacement in under 2 hours but a complex valve repair can take up to 2 hours longer.
Residual mitral regurgitation refers to patients who continue to have a significant leakage after a repair. A good repair should eliminate all leakage (or leave a minimal inconsequential leakage). Expert mitral regurgitation surgeons know their residual mitral regurgitation rate, which is usually well below 10%.
To answer the question, the surgeon must study the video images your echocardiogram. In this way, he evaluates the degree of work needed to correct the leakage. Ask your surgeon about his or her experience and repair rate for Barlow valves. Reference mitral repair surgeons can repair up to 95% of Barlow’s valves.
The midline incision is the standard approach and all reparable valves can be repaired through this incision. Many valves can be repaired through incisions at the side or under the breast, but this limits the options available for repair. Be certain that your surgeon can deliver a quality repair for your valve through a side incision before opting for this approach. The more complex your valve disease, the less the likelihood that a quality repair may be achieved through a side approach, unless the surgeon is very experienced in that approach. Minimally invasive approaches can be undertaken from either the side or in the midline and result in cosmetically appealing small incisions. Not all side incisions fall in the minimally invasive category, so before opting for a minimally invasive approach, ask your surgeon how long the incision will be and if there will be other incisions. A true minimally invasive incision should be less than 10cm, often much smaller. Ask if this approach will increase your risk or reduce the chances of repair. Ask the surgeon if you have a choice in the incision he or she uses.
Increasing evidence is that a sizeable proportion of patients with mitral regurgitation also have an abnormal tricuspid valve which should be fixed at the time of surgery. Ask your surgeon how many of his or her patients having mitral repairs have tricuspid repair at the same time. Many mitral experts now repair the tricuspid valve concurrently in over half of patients undergoing mitral valve repair.
Adapted from the Sinat Mitral Valve Repair Centre