Summary

Mitral Valve is an important valve in the human heart and like any other part of the body, it can also develop a host of conditions. One such condition is Regurgitation where-in, the blood flows back in the opposite direction because the valve cannot close properly. While earlier, open-heart surgery was the only option to treat this condition, in the past couple of decades, minimally invasive procedures such as the Mitra-clip are becoming more popular. In this article, we will learn more about this procedure.

Introduction: What is the Mitral Valve?

The human heart is made of 4 chambers: the upper chambers being left atrium and right atrium, and lower chambers being left ventricle and right ventricle. Purified blood that comes from the lungs arrive at the left atrium. The left atrium contracts and the blood here is pushed into the left ventricle below. A valve called the Mitral Valve regulates this flow. The leaflets of this valve open to allow the blood-flow and then close on each other, to prevent back-flow of blood. From the right ventricle, the purified blood is pushed to the aorta, and hence rest of the body.

Mitral Valve abnormalities

In some people, and over time, the Mitral Valve can develop one or more of the below abnormalities:

• Mitral Valve Regurgitation (MVR): In some people, the leaflets of the valve don’t close properly on each other. So in-between heart-beats, some of the blood in the left ventricle regurgitate or push back into the left atrium. The mitral valve is then said to be leaking, or become a leaky valve. The condition is also called Mitral Insufficiency or Mitral Incompetence.
• Mitral Valve Stenosis (MVS): In some people, the leaflets become thick and, in some cases, they even fuse. This makes the opening of the valve narrow thereby constricting the blood-flow (called stenosis). Due to this, less of purified blood reaches the left ventricle from the left atrium. As a result, less of purified blood is sent to rest of the body.
• Mitral Valve Prolapse (MVP): In some people, the mitral valve is floppy or loose, so it does not close properly. When the left atrium contracts, the leaflets flop upwards into the left atrium, creating a parachute-like structure.

For the purpose of this article, we will stay focused on MVR alone.

Causes and Risk-factors for MVR

• Mitral valve prolapse
• Rheumatic fever
• An earlier heart attack
• Congenital heart defects that affect the structure of the heart and valves
• Thickening of the heart muscle (called cardiomyopathy)
• Damaged tissue cords of the mitral valve
• Endocarditis, an inflammation of the inner lining of the heart’s chambers and valves
• Radiation therapy for cancer
• Advancing age

Symptoms of MVR

• Fatigue is the most common symptom of MVR, however, please note, fatigue is a symptom with almost any and every heart condition
• Irregular heartbeat, also called as arrhythmias
• Dyspnoea or shortness of breath, especially when lying down which is unusual
• Palpitations which manifest as rapid, fluttering or pounding heartbeat
• Swollen feet or ankles: this is due to water accumulation in the body
• Dry hacking cough
• Excessive urination
• Inability to exercise
• Fainting (syncope)

Complications from untreated MVR

• Atrial fibrillation, an irregular and rapid heartbeat
• High blood-pressure in the lungs (pulmonary hypertension)
• Congestive heart-failure

Treating MVR: Repair or Replacement?

The very first consideration for the doctors is whether the patient needs a valve repair or the entire valve has to be replaced? Heart valve replacement is done in case damage to the valve is significant and repair is not possible. The defective valve may be replaced with a new, mechanical valve, or a biological one (created using tissue taken from the body of a cow or pig). Most often, a repair will be good enough and replacements are rare. The doctors will arrive at the decision after undertaking a chest X-ray to look at the heart’s structure, an electrocardiogram to check the heart rhythm, an echocardiogram to look at the heart’s anatomy and blood-flow, and finally a doppler ultrasound to assess how the blood flows through his/her heart. For the purpose of this article, we will stay focused on valve repair, not replacement.

Repairing a leaky mitral valve

There are different treatment options for repairing the leaky Mitral Valve depending on the person’s age, overall health, comorbidities and severity of the leakage or regurgitation. The heart specialists will choose the most suited option for the patient, based on the same diagnostic tests mentioned earlier. Treatment options are:

Open-heart procedure

As the name implies, the surgeons will make a long incision on the chest to access the heart. The patient will be under general anaesthesia. These are of 2 types again:

• Manual: Here, all the interventions and surgical tasks are undertaken by a team of surgeons, doctors and nursing staff.
• Robot-assisted: Here, the chief surgeon sits at a computer console from which he/she is able to control and manipulate a robot. The robot has human-like arms whose tips are fitted with various surgical instruments. One arm has a camera fitted at the end, so the chief surgeon has an enhanced and magnified view of the inside of the heart at the computer console. This helps him/her to guide the robot precisely.

Minimally Invasive procedures

• Catheter-based procedure: here, the surgeons will make tiny incisions on the chest of the patient and a thin, flexible tube called catheter is inserted into the heart. The catheter has a camera-lens fitted at its end, as well as surgical instruments. The camera-lens relays images to a computer-screen kept in the OR which helps guide the surgeons. The surgical instruments are capable of performing the required interventions, as and how they are guided by the surgeons’ movements.

In the open-heart procedures as well as the catheter-based procedure, the purpose is as below:

• To patch up holes in the valve
• To reconnect the leaflets of the valve
• To remove excess tissue from the valve so that the flaps are lighter, more agile now and can close tightly
• Repair the structure or anatomy of the mitral valve by replacing cords that hold it together
• To separate the valve leaflets if they are fused together

Other Minimally Invasive procedures

• Annuloplasty: In this, the structure of the valve is rectified. The ring or the cords that hold it, are augmented (given additional support) by a man-made ring that is inserted now.
• Valvuloplasty: Also called Balloon Valvulotomy: In this, a catheter with a deflated balloon at its tip is inserted into an artery in the arm or groin of the patient. The catheter is then threaded gently till it reaches the heart and the mitral valve in it. The deflated balloon is positioned at the centre of the valve opening and inflated. This helps open up the valve. The balloon is then deflated and the catheter pulled out of the body.
• Mitral Valve clip: In this, a tiny metal clip, which is round and thin like a dime, and enclosed in a polyester jacket, is inserted in to the mitral valve to fix the leakage. More details are given below.

How is Mitra-clip Procedure done

Before

In the week before the procedure, the patient must:

• Take all the prescribed medications for MVR symptoms
• Inform the doctor about medications for other conditions that he/she is taking
• Inform the doctor about any allergies he/she has
• Follow all instructions given by the doctor or nurse for the previous day
• Arrive at the hospital on the appointed day, along with a friend or relative

During

The patient is given local anaesthesia in the chest region to minimize pain, and a mild sedative to minimize discomfort.

• He/she is brought to the procedure room where he/she lies on the bed.
• The heart doctor will make a small incision in his/her groin to access the femoral vein
• A catheter is inserted through the incision
• The surgeon gently pushes or threads the catheter all the way to the heart, while being guided by imagery from X-ray and echocardiography
• A small tool at the tip of the catheter will make a tiny hole in the wall that divides the chambers of the heart
• The catheter is now positioned near the mitral valve
• The metal clip along with the polyester fabric is inserted through the catheter and placed at the edges of the mitral valve to prevent leakage henceforth
• Once the clip is firmly in place, the catheter is pulled out of the body and incisions stitched up.

After

• The patient will spend two days in the hospital during which time, his/her vitals are monitored constantly
• Once all vitals are stabilized, the patient will be discharged
• The doctors will give clear instructions and medication for continued recovery at home. This will include aspirin to be taken to prevent a heart-attack or stroke
• The patient must visit the hospital after a month for checkups that ensure everything is fine with the clip
• The doctors will recommend a complete cardiac rehabilitation that will cover diet, exercise and medication

Long-term care after a Mitra-clip procedure 

• The patient must visit the hospital once a year for checkups that ensure everything is fine with the clip
• Any and every-time he/she is advised an MRI scan, he/she must inform the doctors or lab-technicians upfront. They will exercise more caution then.

Benefits/advantages of doing a Mitra-clip procedure 

• Life-saving: There has been a 33% reduction in relative risk of mortality due to MVR, after the procedure
• Fewer Hospitalizations: There is a 51% reduction in relative risk of heart-failure hospitalization
• Improved quality of life: Patients who had the procedure were studied for 5 years thereafter. They were found to have 2.5 times improvement in their heart function, quality of life, and ability to perform day-to-day tasks.
• Safe and well tolerated: Patients were found to have 96.6% freedom from device-related complications over 12 months after the procedure
• Minimally Invasive: Being minimally invasive, the procedure does not require opening the chest, or stopping the heart temporarily. This speeds up the healing and recovery time. There is less pain, reduced scarring, lower risk of infection, lower blood-loss and reduced dependency on opioids. The procedure is quick and typically lasts 1 to 3 hours. Hospital stay thereafter is short.

At Kauvery Hospital, we strive to provide state-of-the-art care to patients suffering from heart conditions like mitral valve regurgitation. Our team of experienced doctors and surgeons offers the most advanced treatment options, including the minimally invasive Mitra-clip procedure. With branches in Chennai, Hosur, Salem, Tirunelveli, and Trichy, high-quality cardiac care is easily accessible to you. Trust us with your heart health, for a healthier and happier future.

Frequently Asked Questions

What is Mitral Valve Regurgitation (MVR)? 

Mitral Valve Regurgitation (MVR) is a condition where the mitral valve in the heart does not close properly, causing blood to flow backward into the left atrium. 

What are the symptoms of Mitral Valve Regurgitation? 

Symptoms of MVR include fatigue, irregular heartbeat, shortness of breath, palpitations, swollen feet or ankles, dry cough, excessive urination, and fainting. 

How is the Mitra-Clip procedure done? 

The Mitra-Clip procedure involves inserting a small metal clip through a catheter to the mitral valve to prevent leakage. It is a minimally invasive procedure performed under local anesthesia. 

What are the benefits of the Mitra-Clip procedure? 

Benefits include reduced mortality risk, fewer hospitalizations, improved quality of life, safety, and faster recovery due to its minimally invasive nature. 

What should I do before a Mitra-Clip procedure? 

Before the procedure, take prescribed medications, inform your doctor about any allergies or other medications, and follow pre-procedure instructions from your healthcare provider. 

What is the long-term care after a Mitra-Clip procedure? 

Long-term care involves annual checkups, taking prescribed medications, and informing doctors about the Mitra-Clip before any MRI scans.

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