Anterior Leaflet Prolapse

Today I am going to give a talk to try and introduce patients to anterior leaflet prolapse.

My name is Dr. David Adams and I am the professor and chairman of the Department of Cardiothoracic Surgery at the Mount Sinai Medical Center in New York and I am also the President of the Mitral Foundation in New York City. By way of disclosure I am an inventor of several different products that can be used to repair both mitral and tricuspid valves and I will show some of those products today in short video clips. The idea to create this talk actually came from Adam Pick. Adam is really a remarkable person. He had heart valve surgery and he then dedicated a significant amount of time to help educate future patients about heart valve surgery and for those of you that may face heart valve surgery I highly recommend his book, “The Patient’s Guide To Heart Valve Surgery”, which is really a must read. His website heart-valve-surgery.com is also a remarkable source for patients and he has a blog on that site and that really was the motivation behind this talk and I will share that with you.

Adam received this slide earlier in December to his website and I am just going to read it. It is from a patient named Ruth. It says, hello again Adam. I would like to be in touch with any patients who have had a prolapse anterior leaflet of the mitral valve. I have been told by my local cardiologist that repair may not be possible but I have also read the doctors at the Cleveland Clinic are doing anterior leaflet repairs. I was terrified and anxious before my TEE but now knowing my problem with the anterior leaflet is less common and more difficult to repair I am beyond terrified. Do you have any information on the risk involved with this type of repair and the length of the surgery or time on bypass? Well I am fortunate that I know Adam, we have actually hosted him in our hospital and I really admire the work he is doing in patient education which is something very important to our mitral foundation and I was really glad that Adam shared this e-mail with me. He wrote me, “Hi Dr. Adams, I hope all is well with you and your practice. I recently received an interesting e-mail from Ruth, a patient evaluating mitral valve repair. Given your specialty, I felt you are the best positioned to provide a response. Ultimately, I would like to take your response and feature it at my blog to further educate patients and caregivers. Best regards, Adam.”

I really appreciate Adam sharing that with me and as I said that was really the motivation behind this short talk I am going to give and I am going to try and give it in a language that I hope patients will find useful and understandable.

So the mitral valve actually is a fascinating structure inside the heart. It separates the collecting chamber from our lungs from the pumping chamber called the left ventricle and as you can see on this drawing we have two leaflets to our mitral valve; an anterior leaflet and a posterior leaflet. And here is how the valve opens to allow blood to come from the lungs into the ventricle and then when the valve squeezes you see these chordae lineup a coaptation zone that seals the valve and now all the blood leaves the heart through the aortic valve. So the mitral valve is a very important valve to protect our lungs against the pressure required to push blood out of the ventricle toward the body and it closes each time our heart beats. Here you can see the normal mitral valve in action as it opens and shuts as the ventricle squeezes. So the key structure to line up the valve are called chordae. What you can see these little strings where the chordae attach the leaflet. Think of the strings on a parachute or how an umbrella is supported against the wind and you can see how they provide the structure to the valve to not prolapse back towards the lungs and seal the chamber. So these little strings are very important and when they break or elongate that is the most common cause of a prolapse of the anterior leaflet. So here is a typical prolapse of the posterior leaflet and what you can see is the broken chord and that will cause a prolapse of the middle section of the posterior leaflet, now this is a very common lesion and a very simple one to repair. In most centers today in the United States that are experiencing valve surgery, they are going to be able to perform a repair of a posterior leaflet prolapse. This is a more complicated valve. This valve has, first of all, bileaflet prolapse, but what I want to highlight is the ruptured chordae to the anterior leaflet. So here is the anterior leaflet and this large segment of the anterior leaflet margin now is not supported because of these broken strings or chords. So this valve is a much more complicated valve to repair unless you have specific experience performing anterior leaflet reconstruction. The other defect in chords I would like to show you is chordal elongation. Sometimes all of the strings diffusely elongate as opposed to a single string breaking and this actually leads to a very complex form of prolapse of the anterior leaflet and sometimes the area between the anterior leaflet and the posterior leaflet called the commissure. And so when you have diffuse chordal elongation that also requires a special expertise to perform valve reconstruction.

This is an algorithm published by the American College of Cardiology and the American Heart Association. It really serves as the guideline or foundation with how to treat patients that have chronic severe mitral valve regurgitation, including those that have anterior leaflet prolapse. What you can see in the center of the guidelines is mitral valve repair. I always make this point when I give talk to doctors about mitral valve disease that there is no question that every patient should have a mitral valve repair. You should only have a mitral valve replacement if it is not possible to perform a mitral valve repair. Why is that? Because patients that have mitral valve repair will have a better event-free survival. Many studies have documented not only will you live longer but you will have a better quality of life and a lower stroke rate if your own mitral valve is preserved as opposed to replaced. So, it is extremely important that any patient that has a chance to keep their valve keeps their valve and as I showed you the guidelines make this point crystal clear for physicians. In fact, what you can see as we move into an era of operating before the heart is damaged or before patients become symptomatic, the guidelines ask this question clearly; is mitral valve repair likely? So you can have a patient that is completely asymptomatic, very healthy, very active, if they have severe regurgitation and it is clear they are going to have a mitral valve repair, many of them now are referred for mitral valve reconstructive surgery. It is extremely important that a patient knows before they go to sleep what the likelihood of valve repair is and it is incredibly important to understand there is a difference in anterior and posterior leaflet prolapse. Just as Ruth pointed out in her e-mail I shared with you a few minutes ago. The reason that is important is shown here; this is a study from a good friend, Jim Gammie, at the University of Maryland that was published in the Annals of Thoracic Surgery in 2009. And what Dr. Gammie did was he looked at data from the Society of Thoracic Surgeons and asked the question; are we repairing more valves and how much further do we need to go to get to this bar of 90% repair?, which is emphasized in the guidelines. What you can see is that the rate of mitral valve repair has gradually increased in the United States. Nonetheless, that number seems to be frozen around 70%. I think that most people would agree that 70%-75% of valves that are repaired are repaired today keeping in mind that leaves a practice gap somewhere between 10% and 20% meaning as many as one in four patients or one in five patients that perhaps had a reconstructible valve did not undergo a valve repair, that is very important.

Whenever I speak to physicians, I often show the slide as a wakeup call. What it shows is a mechanical valve versus a ring, a mitral valve ring that we use to do a valve repair and it has not been predictable and it should not be the flip of a coin for a patient and I often emphasize just as Ruth in her e-mail pointed out. One of the reasons is complexity of disease in anterior leaflet repair, at least in the literature, is seen as more complex. Now the guidelines give clear instruction how to optimize the chance the patient will have a valve repair. You can see they emphasize surgical expertise and skill and experience of surgeons in performing valve repair. They go on to encourage cardiologists to refer patients that could have a mitral valve repair to surgical centers that are experienced in performing valve repair. And when you remember Ruth’s e-mail, the cardiologist suggested that to her. He recognized this was a more complex repair and that she would likely have to go somewhere that specializes in anterior leaflet repair to have a valve repair, so this is an important point for patients to keep in mind as well as for all of us as physicians and care providers. Now when we look between the lines, not the overall repair rate, but we look at just to document that posterior leaflet repairs, I explained before, is easier and more likely to happen in high volume centers of mitral valve repair. I will show you a few papers and there are many more like this that document that. You can see in this series a patient that had posterior leaflet repair had a 70% chance of valve repair whereas patients that had bileaflet prolapse that would require a repair of both the anterior or the posterior leaflet or just an anterior leaflet prolapse had a lower rate of valve repair. In this series, only 16% of patients with anterior leaflet prolapse had a successful anterior leaflet valve repair.

Here is another series that was recently published with that same message. You can see in this institution the overall repair rate was 66%, 96% of patients that had a posterior leaflet prolapse underwent a successful valve repair. You can see patients that had anterior leaflet prolapsed, whether it was the anterior leaflet and particularly bileaflet prolapse where both leaflets were involved, the repair rates were much lower, only 21% in patients with bileaflet prolapse. This recent paper from one of the largest mitral valve repair centers in Europe shows that even in very experienced centers bileaflet or anterior leaflet valve repair is less common than posterior leaflet valve repair. The message from all of these papers I have shared with you is that when the anterior leaflet prolapses, you really must be in a center of excellence to have the best chance at valve repair.

There are many techniques to repair the anterior leaflet. Sometimes we use chords from the same leaflet and move it to the margins. Sometimes we will take a piece of one leaflet and detach it and then reattach it to a prolapsing segment. We can use artificial chords to replace the damaged chords. Sometimes, we will perform a resection of the leaflet and occasionally we will attach corners of the leaflet together or use a piece of the patient’s tissue around the heart to rebuild a section of the anterior leaflet. There are numerous techniques we can use to reconstruct an anterior leaflet and it is very important again if you have a prolapse of the anterior leaflet to go to a center that is experienced in all of these different techniques.

This first case I am going to show you is a young patient. She is 16 years old. She has a diffuse anterior leaflet prolapse from chordal elongation. You can see an eccentric jet of mitral valve regurgitation back into the left atrium. She was very symptomatic and in fact had stopped being able to participate in her physical education classes and there was a lot of question about whether she could have a successful valve repair and she actually traveled a great distance to come here so that she could have a valve reconstruction as opposed to a replacement. Here you can see we are using water to demonstrate the override of the anterior leaflet and all of the chords in the anterior leaflet are diseased. We are placing in the tip of the papillary muscle these artificial strings or neochordae. They are made out of a Gore-Tex or PTFE material. So we place those in the muscle and then we tie one of these mitral valve repair rings around the valve; that restores the normal shape of the valve, and then you can see we are passing the loops of our new suture or neochordae through the margin of the leaflet. And then we can adjust the height by shortening or tightening our knot and then as we fill the ventricle with saline, we can continue to confirm that we have now adjusted the height of the anterior leaflet with these neochordae to the correct position. Now you can see how the anterior leaflet comes together and the echo shows no residual leak backwards into the atrium.

Now, the next case I would like to show you also involves an anterior leaflet prolapse and in this case the prolapse is happening near the corner of the valve, and that is called the commissure. So here we need to correct both an anterior and posterior leaflet prolapse. This part of the valve has actually a small amount of tissue. You see the elongated chord. We cannot perform a resection here. So we are going to re-suspend the corner and I will show you how we do that. We are marking where the prolapse is and now we are going to perform a commissuroplasty and you can see how we are imbricating the two leaflet edges, just like the corner of your lip, to bring the edges together and evert them. Next, we will use a neochordae or a Gore-Tex suture to reconstruct the support to the margin of the commissure. All mitral valve repairs involve a repair ring to restore the normal kidney-bean shape of the mitral valve and you can see we are using an additional chord here to correct a midsection anterior leaflet prolapse. Then we can adjust the height of the knot while we fill the ventricle with saline, and that allows us to wind up the valve perfectly and make it watertight. And again the echo now shows no residual leak back into the atrial chamber.

The last case I will show you is a more complex form of bileaflet valve prolapse. This is the typical disease that young patients that have Barlow’s disease present. In this case, you can see why they have called it floppy valve disease in the literature. All of the segments of the valve diffusely prolapse and this will require a more complex repair of both the anterior and the posterior leaflet. Whenever we have a diffuse case of bileaflet prolapse, we always start with a reconstruction of the posterior leaflet. We are performing a valve analysis confirming all of the segments of the valve will require surgery, and as a first step, we will resect a redundant and prolapsing portion of the posterior leaflet. You can see we detached the remainder of the posterior leaflet from the annulus so that we can shorten the height of the leaflet segment. This patient also has calcification of the papillary muscle apparatus, so we are going to decalcify her papillary muscles and then we are going to use several running sutures to reconstruct the posterior leaflet. Now, we are marking the prolapse of the anterior leaflet and we will place Gore-Tex sutures in the tip of the papillary muscle and these will become new chordae for the patient. Here we are doing a chordal transfer. We are taking a small piece of tissue and transferring it with the chord to the anterior leaflet and now we are using the same technique I have shown you before where we tighten the knots while we fill the ventricle with saline and that allows us to adjust the height perfectly of the anterior leaflet. You can see again there is no residual leak now back toward the left atrium and when we mark the valve with ink we can show how much of the valve coapts when we fill the ventricle with saline.

So all of these videos were to demonstrate to you that anterior leaflet repair is feasible in essentially all cases by an expert mitral valve surgeon. We wrote this article earlier this year in the European Heart Journal and we called it “Degenerative Mitral Valve Regurgitation: Best Practice Revolution”. And one of the many points we made in this paper was that we have to do a better job of matching patients to the skill of surgeon so that every patient that could have a mitral valve repair will get one. I wanted to share this one table with you about targeted surgeon referral for degenerative mitral valve disease and you can see the point we made, if you have Barlow’s disease that complex disease I showed you in the last video. If you are a younger patient. If you are having early surgery, you are asymptomatic, but your heart is starting to dilate or if you have anterior leaflet or both leaflets including the anterior leaflet prolapsing, any of those conditions should lead you to seek out a reference mitral surgeon in your geographic location. If it is necessary to travel to go to one and you fulfill one of those criteria, we strongly recommend that you do that. That is the best way to achieve or to make sure a patient will have an anterior leaflet repaired and not replaced.

While I would like to end again by thanking Adam for bringing this patient’s e-mail to my attention. I thought it was a great opportunity to provide some knowledge for patients. Adam and I really share a commitment to patient education and again I recommend that you visit his web site and certainly if you are contemplating having heart surgery, I highly recommend that you look at his book “The Patient’s Guide to Heart Valve Surgery.”

Thank you very much for allowing me to explain anterior leaflet prolapse to you.