High-Tech Heart Procedures Expand Options for Mitral Valve Repair

If you have been diagnosed with a heart condition called a defective mitral valve, there’s encouraging news. Not long ago, repairing this condition almost always required open-heart surgery—an invasive procedure with a prolonged recovery time. Today, interventions are evolving rapidly, and many people are eligible for less invasive options that offer quicker healing, smaller incisions, and excellent results.

The mitral valve is one of four small but powerful valves that help the heart pump blood in the right direction. It’s also one of the valves that is most likely to wear out with age, though it can also cause problems for younger people who are otherwise healthy.

“The ability to fix somebody’s mitral valve without open-heart surgery—and to do it through a small incision between the ribs or through a catheter inserted into the groin—is really incredible,” says Marc Pelletier, MD, MSc, chief of cardiac surgery for Yale Medicine and Yale New Haven Hospital, and physician-in-chief of cardiac surgery for the Heart and Vascular Center of Yale New Haven Health system.

Robotic surgery has taken minimally invasive mitral valve repair even further, making procedures more precise and easier for surgeons to perform, while enhancing safety for patients. “They go home within a few days, they’re driving in a week or two, and they’re back to normal activities within a few weeks,” Dr. Pelletier says.

The mitral valve controls blood flow between the heart’s left atrium and left ventricle. Think of it as a small but essential gate that keeps blood flowing from one chamber to another, and then out to the rest of the body. Like all heart valves, the mitral valve has two leaflets, or “flaps,” that open and close tightly with each heartbeat to pump oxygen-rich blood to the body.

As people age, the mitral valve is one that often can develop problems. The most common problem is mitral valve regurgitation, which affects 2% to 3% of the population. Regurgitation occurs when the valve’s two flaps become “floppy” and don’t seal tightly. It’s most often diagnosed in people in their 50s, 60s, and 70s, but it can appear earlier—either at birth or later in life—and even in people in their 80s.

Many people with mitral valve regurgitation never experience symptoms, and medication, which can lower blood pressure and make the valve less leaky, may be enough to manage the condition. Lifestyle changes may help by improving strength and fitness. But for others, mitral valve regurgitation can cause shortness of breath, dizziness, fatigue, panic attacks, palpitations, and chest pain.

Fortunately, most cases of mitral valve regurgitation can be repaired—and repaired valves generally last longer and function better than valve replacements.

Robotic surgery is considered one of the least invasive and most precise approaches to mitral valve repair. Studies show it results in less bleeding, less trauma, lower infection risk, and reduced need for transfusions.

Doctors at Yale New Haven Hospital began performing robotic mitral valve surgeries in late 2018 and have since completed more than 200 mitral valve repairs—all with excellent outcomes, no major complications, and zero mortality, Dr. Pelletier says.

These procedures typically take three to four hours, depending on the complexity of the repair. They are performed using the da Vinci Surgical System, a sophisticated robotic platform that looks like a computer console connected to several mechanical arms. Each arm holds tiny surgical instruments or a high-definition camera. Patients receive general anesthesia for the procedure and are connected to a heart–lung bypass machine, which temporarily takes over the heart’s function. But unlike traditional open-heart surgery, the breastbone is not split, which eliminates the need for a large chest incision and dramatically shortens recovery time.

Surgeons make small chest incisions and guide the robotic instruments through the ribs to reach the heart. The surgeon controls the robot arms while standing at the console, while monitoring the movements on a high-definition monitor.

Robotic surgery benefits patients and surgeons alike, Dr. Pelletier explains. The robotic arms allow a greater range of motion than the human hand and eliminate any natural tremor. “The magnification is three-dimensional and high definition, so we can see structures in greater detail,” he says. “That’s especially important for the mitral valve, which can be difficult to visualize properly during an open operation.”

For people who have severe mitral valve regurgitation and for whom open-heart surgery is not recommended, a catheter-based device called the MitraClip™ may be an option.

Using a small puncture in the groin, the physician threads a catheter through a vein to the heart. Positioned on the mitral valve, the MitraClip then clips the leaflets together so they close more effectively, reducing backward blood flow.

The MitraClip was approved by the U.S. Food and Drug Administration (FDA) in 2013 for people for whom surgery is considered higher risk. Since then, next-generation MitraClip devices have been introduced, and in 2022, the FDA approved a similar device—the PASCAL Precision Transcatheter Valve Repair System—offering another nonsurgical option.

“The procedure is ideal for some patients where surgery is higher risk, especially those who have weaker hearts or advanced age,” explains John K. Forrest, MD, director of interventional cardiology and structural heart programs for the Yale New Haven Heart and Vascular Center and Yale New Haven Health System. “For patients who are lower risk for surgery and have severe mitral regurgitation and a valve that can be repaired, the best option is still surgery.”

There is currently no FDA-approved transcatheter mitral valve replacement (TMVR) technology. Yale New Haven Hospital was the first hospital in Connecticut to offer TMVR as part of the APOLLO multicenter randomized clinical trial, which is testing the Medtronic Intrepid™ replacement system for patients who have severe symptomatic mitral regurgitation.

Using a small incision in the groin, surgeons insert a catheter and guide it to the heart, using ultrasound and X-ray imaging. The Intrepid valve is positioned inside the diseased valve—while the heart is still beating. Patients typically stay in the hospital briefly and return for scheduled follow-up visits each year.

BATMAN stands for balloon-assisted translocation of the mitral anterior leaflet. It’s used as part of a mitral valve replacement strategy for patients with complex anatomy or health conditions that mean they are not candidates for open surgery, standard transcatheter approaches, or MitraClip repair.

The BATMAN procedure can be performed using a transcatheter approach. Physicians insert a catheter with a deflated balloon into the blood vessels of a patient’s leg and thread it to the mitral valve. Once in place, the balloon is gently inflated to temporarily reshape the valve’s anterior leaflet, making room for a new valve to be implanted.

Standard open-heart surgery for mitral valve repair can still be the best choice for certain people, such as those with complex anatomy or previous chest surgeries, says Dr. Forrest. Most patients who undergo this type of cardiac surgery are fully recovered after two to three months.

Minimally invasive and robotic mitral valve surgery, when possible, is linked with lower complication rates, shorter hospital stays, and excellent long-term outcomes. “Performing a less invasive procedure allows patients to recover more quickly,” Dr. Forrest says. “Most patients experience a significant improvement in symptoms and can expect nearly normal life expectancy afterward.”

If you qualify for a less invasive procedure, it’s essential to choose a surgeon with specialized training and extensive experience performing minimally invasive and robotic heart procedures. “It’s important to ask surgeons about their experience,” says Dr. Pelletier, noting that clinical studies show that performing at least 50 mitral valve operations a year is a strong benchmark for surgical expertise.

Yale Medicine’s Robotic Mitral Valve Repair Program offers one of New England’s highest-volume programs, with a multidisciplinary team that includes cardiac surgeons, interventional cardiologists, cardiac physician assistants, nurses, anesthesiologists, perfusionists, and cardiac imaging specialists.

Dr. Pelletier expects the availability of minimally invasive mitral valve approaches to expand. “We are seeing more procedures become less invasive,” he says. “I think that trend will continue to include even more heart valve repairs, including the tricuspid and aortic valves.”