Heart health: MHH offers innovative procedure for mitral valve replacement

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With the help of a rod-shaped introducer, the experts bring the mitral valve proWith the help of a rod-shaped introducer, the experts bring the mitral valve prosthesis into the heart Copyright: Anna Junge / MHH
Interdisciplinary team of heart surgeons and cardiologists has good experience with a prosthesis implanted via the apex of the heart

The mitral valve is one of our four heart valves. If it does not close properly, experts call it mitral valve insufficiency. It is the second most common heart valve disease in adults. Depending on the cause and severity, there are different treatment methods - from medication to repair or replacement of the valve. An innovative procedure is the implantation of a mitral valve prosthesis through the apex of the heart. It is particularly suitable for patients of advanced age or with pre-existing conditions. Hannover Medical School (MHH) is the only hospital in the Hannover region to use this new treatment method. The procedure is implemented by an interdisciplinary team from the Clinic for Cardiac, Thoracic, Transplantation and Vascular Surgery, the Clinic for Cardiology and Angiology and the Clinic for Anaesthesiology and Intensive Care Medicine.

Backflow of blood into the lungs

Heart valves work like valves: they make sure that the heart muscle pumps the blood in the right direction. This is how oxygen-poor blood enters the lungs and oxygen-rich blood leaves the lungs and enters the body. The mitral valve, which consists of two valve leaflets, is located between the left atrium and the left main chamber of the heart. If it leaks, blood can back up into the lungs and, in the long run, cause serious damage to the heart and other organs. To restore valve function, so-called heart valve reconstruction, or repair, is a treatment option. "For patients for whom major surgery is too high a risk, for example because they are very old or have a history of disease, catheter-based repair has proven its worth in recent years," explains Professor Dr Tibor Kempf from the Department of Cardiology and Angiology. One example is the MitraClip system. "With this system, a clip is inserted via the inguinal vein with the help of a catheter, which connects the anterior to the posterior mitral leaflet and thus reduces the leakage," Professor Kempf explains.

Valve replacement instead of repair

But there are always patients for whom the MitraClip system is not optimal. "In addition, there is a risk that the insufficiency will return in the long term," reports private lecturer Dr Fabio Ius from the Clinic for Cardiac, Thoracic, Transplantation and Vascular Surgery. This is where the innovative procedure comes in - the implantation of a mitral valve prosthesis through the transapical approach. "Transapical" means "via the tip of the heart". The interdisciplinary MHH team works with the artificial Tendyne valve from Abbott, which simulates and plans each intervention in advance with the help of patient-related image data. The experts access the heart via a six to eight centimetre long incision between the ribs under the left breast. Through the opening, they use a so-called introducer, a special catheter system, to bring the prosthesis through the tip of the heart to its destination between the left atrium and the left main chamber of the heart. "We place the prosthesis in the old mitral valve and open it there. When the optimal position is reached and the new valve is working well, we can remove the introducer again," Dr Ius explains. The prosthesis is held in place with a tendon that passes through the left ventricle and ends on the outside in a pad that is fixed to the apex of the heart. The entire process is monitored and controlled with the help of imaging: for this, a cardiologist takes a swallow echo. "In the process, we obtain high-resolution ultrasound images of the heart structures via the oesophagus. At the same time, we also use X-ray images to have an exact insight into the processes," explains Dr Dominik Berliner from the Clinic for Cardiology and Angiology.

Many disciplines and professions involved

The operation has to be very well prepared by the team, but it only takes about two hours for the patient in the operating theatre. One day in the intensive care unit is usually followed by a week in the normal ward. This is followed by a stay in a rehabilitation clinic. Dr Fabio Ius sees the new procedure as a good alternative to the MitraClip system for certain patients. "Experience shows that in certain patients a permanent and complete replacement of the mitral valve can be achieved," he says. The mitral valve prosthesis can be implanted without the use of a heart-lung machine and is therefore particularly suitable for older or pre-diseased people.

Cardiologist Professor Kempf and cardiac surgeon Dr Ius are pleased to be able to offer the new treatment method at the MHH. "Innovations like this can only be implemented if different disciplines and professions work well together," emphasises Dr Ius. Implantation of a mitral valve prosthesis via the apex of the heart involves specialists from cardiac surgery, cardiology and anaesthesia, cardiac catheterisation laboratory and operating theatre nurses as well as a cardio technician.