THE SPECIALIST: Dr. Gregory Fischer
The director of adult cardiothoracic anesthesia at Mount Sinai, Dr. Gregory Fischer specializes in taking care of patients who are undergoing heart and lung surgeries, including echocardiography. Eighty percent of his patients have mitral valve problems.
WHO’S AT RISK
The heart’s mitral valve doesn’t get a lot of attention from the public, but doctors estimate that as much as 1%-4% of the population is genetically predisposed for the valve to leak and cause problems.
“The mitral valve lies between the left atrium and left ventricle, and its job is to guarantee one-direction blood flow through the heart and back into the body,” says Fischer. “A leaky valve allows the blood to swish back and forth, which is called regurgitation, a condition that over time will break down heart function and lead to heart failure. Thankfully, we now have very effective surgical options to repair or replace faulty valves.”
The mitral valve has two leaflets that have to align perfectly, or else blood leaks backward as the heart contracts. “It’s like when you have a car where the valves aren’t working right — you’re not going to get 200,000 miles out of the car, because the engine has to work harder to compensate for the leaking,” says Fischer. “The valve won’t close completely if the cords that hold the leaflets get too long or too tight, or if the leaflets themselves are fine but the frame surrounding them — called the annulus — becomes too wide or dilated.”
The most common type of mitral valve problem in this country is called mitral valve prolapse, when the cords become stretched out or tear.
Unlike many heart problems, mitral valve disease is usually independent of lifestyle factors like diet and exercise. “For about 1%-4% of the population, this is a genetic predisposition that is fairly inevitable with time,” says Fischer. “However, not everyone will have severe enough regurgitation to require surgery.” Other root causes of mitral valve disease include atrial fibrillation and rheumatic heart disease.
SIGNS AND SYMPTOMS
One of the problems posed by mitral valve disease is catching it in the first place. “You can go a very long time and be asymptomatic, especially for the patients who have the slowly developing regurgitation,” says Fischer. “I’ve had patients who ran marathons, were very active, and had no idea they had regurgitation — that’s a very challenging subgroup to diagnose.”
The most common pathway to diagnosis is that a doctor hears a heart murmur during a routine examination and orders an echocardiogram, which shows regurgitation. “When patients have symptoms, it’s generalized fatigue, shortness of breath and palpitations, but many people are completely asymptomatic,” says Fischer.
Not all mitral valve problems require treatment. “If you look at the treatment guidelines, the first question is, What is the degree of regurgitation?” says Fischer. “The volume of blood being pushed back can be trace, mild, moderate or severe, and at this point, most people with trace to moderate regurgitation can take the approach of watchful waiting and being followed with serial echocardiograms.”
Eventually, some patients can also benefit from taking ACE inhibitors, which dilate the blood vessels and lower blood pressure.
Once the regurgitation becomes severe, the next question is whether it’s deforming the heart structure. “Surgery is indicated once the ventricle starts dilating to deal with the extra volume, or the ejection fraction — a measure of how well the heart is pumping — falls below 60%,” says Fischer. “Right now, there’s a great push among valve specialists to repair more faulty valves instead of replacing them entirely. In those cases where repair is possible, that’s always the better option.”
American College of Cardiology and American Heart Association guidelines call for all asymptomatic patients who qualify for surgery to be referred to a specialist center where valve repair can be achieved 90% of the time. Valve replacement is not recommended.
There is considerable workup pre-surgery, including extensive imaging. “To see how the valve truly works can only be done by echocardiogram, whose results provide the road map to a successful repair,” says Fischer. “Patients can usually expect to spend one to two days in the critical care unit, and five to six days in the hospital.”
The surgery takes five to six hours total, with two to three hours on the heart-lung machine. “Once the anesthesiologist has prepared the patient with general anesthesia and performed a transesophageal echocardiogram to determine the exact location and extent of the valvular dysfunction, the surgeon opens the patient, either through the middle of the chest or from the right,” says Fischer. “After the patient goes on a heart-lung machine, the heart is stopped while the surgeon examines the atrium and valve. The dysfunctional parts of the valve are corrected using complex surgical techniques that lead to the reconstruction of the valve, almost like a plastic surgery.”
The recovery from mitral valve repair is relatively quick. “It’s a big procedure, so people usually feel pretty awful initially, tired for two to three weeks, and then good and fit in about three to four weeks — though we do advise holding off on lifting heavy weights for three to four months,” says Fischer.
“What’s remarkable is that within a few months, even the patients who had previously declared themselves asymptomatic feel much better. They have more energy, because the heart is working better and the flow is going the right direction. But the main goal is to extend their life.”
Although study after study finds that mitral valve repair has better long-term outcomes than full mitral valve replacement, only 50% of patients in the U.S. are receiving the guideline-recommended approach.
“We still need to improve public awareness, and part of that is helping make people aware of the difference between a reference center that specializes in cutting-edge care and the average cardiology center,” says Fischer. “The future breakthrough might be doing this surgery through catheters, but we’re just not there yet.”
QUESTIONS FOR YOUR DOCTOR
If you’ve been diagnosed with a leaky mitral valve, be sure to ask, “At what point do I become a candidate for surgery?” Once you’ve reached that point, don’t hesitate to ask the surgeon, “How many times have you operated on my type of valve?” and “What are your success rates?”
“Some surgeons only do five repairs of year, and you’re not likely to receive the same quality of care as from a surgeon who does 400,” says Fischer. “With an experienced surgeon, this is a very low-risk surgery that can transform your quality of life and extend your life span.”
WHAT YOU CAN DO
Get informed. “It’s your body, it’s your life — educate yourself,” says Fischer. Trustworthy online sources include the American Heart Association (heart.org) and Mount Sinai (mitralvalverepair.org).
Read the guidelines. The American College of Cardiology and the American Heart Association release joint guidelines for mitral valve surgery. Ask your doctor to provide you with the latest guidelines.
Go to a reference center. Mitral valve surgery is a fine art, and you want to have an experienced and specialized team go to bat for you. “A center that does 400 of these a year is going to offer a different quality than a place doing 10,” says Fischer. “What you do often, you do best.”
Take time to make an informed decision. Some surgeries and procedures have to be done as quickly as possible after diagnosis, but mitral valve problems allow you to spend a few weeks doing the research.