The doctor. Xavier Ruyra is a specialist in cardiovascular surgery, head of service at the Hospital Universitari Germans Trias i Pujol in Badalona and the Cardiac Surgery Unit Vida al Cor in CM Teknon. Within his specialty, he focuses his care activity on cardiac valve repair surgery, Ross operation, bloodless heart surgery and new alternatives for aortic valve pathology in high-risk patients.
How can the heart valves be affected?
There are four heart valves in the heart and their function is to ensure that the flow of blood is done in the right direction and in the right way. Valves can be affected because they are not able to open properly (stenosis) or because they can not close properly (insufficiency). Currently, in Western countries and with the progressive aging of the population, the most frequent pathologies are stenosis of the aortic valve that requires valvular replacement and mitral insufficiency of degenerative origin, which affects 6.4% of people between 65 and 74 years old and to 9.3% of people over 75 years of age.
Why should patients with severe mitral regurgitation be operated on?
When the mitral valve is unable to close properly, a large part of the volume of blood that ejects the heart in each beat is directed backwards, congesting the lungs and exerting a volume overload on the heart itself. That heart, in the attempt to adapt, is going to become large (dilation) and will lose contraction force. The patient will feel more fatigued, with difficulty breathing and may have complications such as arrhythmias or embolisms. It is very important to restore the normal functioning of the valve before the impact on the heart is important.
Is it better to repair the valve than to replace it with an artificial prosthesis?
Until a few years ago, all patients with severe mitral valve insufficiency who underwent surgery had a replacement of the affected valve with an artificial prosthesis.. Today we know that the best option is not replacement but to preserve and repair the patient's own valve. The advantages are very significant:
-We better preserve the architecture and function of the heart.
-In many cases-we avoid having to take anticoagulants like Sintrom® for life.
-We reduce the operative risk and achieve a better and faster recovery.
-We diminish the appearance of complications.
The advantages are so important that, at present, early surgery is recommended (even before having symptoms) of all patients with severe mitral regurgitation, if we can ensure an effective repair in more than 95% of cases and a lower surgical risk from 1%.
Can all valves with insufficiency be repaired?
The mitral valve is a very complex structure, with many anatomical elements that must interact with each other in a coordinated manner to achieve a perfect closure of the valve. We must study the mitral annulus, the two veils (anterior and posterior), the multiple chordae tendineae, the papillary muscles and the wall of the left ventricle itself. In the degenerative disease of the valve, which is the most frequent, we always find an excess in the mobility of the valves during cardiac contraction (prolapse) and a dilatation of the mitral annulus. Tissue involvement may be mild (fibro-elastic deficiency) or affect many parts of the valve (Barlow's disease). Our main objective will be to restore the closing capacity of that mitral valve (coaptation) by normalizing the mobility of the veils and reshaping the mitral ring shape. It is fundamental to fully and individually evaluate each patient with mitral disease to have an exact idea of the reasons why that valve fails.
Currently, echocardiography studies provide us with all the necessary information and are able to predict the reparability of the valve. Then we must refer the patient to surgeons with enough training, experience and skill to repair complex mitral valve alterations and perform this operation in a habitual way (more than 50 mitral repairs per year).
Today, we can safely repair almost 100% of mitral insufficiencies with very good results in the short, medium and long term, and with a very low risk. You need an expert team with good results.
How are mitral valves repaired with insufficiency?
Each patient will be different and we will have to individualize the surgery according to the cause, the anatomical findings and the type of dysfunction that have caused the insufficiency of the valve. There are a lot of surgical techniques that allow us to solve the problem: we can trim the excess tissue, reconstruct the anatomy of the veils, replace the elongated or broken cords with artificial goretex cords, reposition the elements of the mitral apparatus ... In addition, we will always perform an annuloplasty with a prosthetic ring that remodels and stabilizes our repair. Many of these cases can be operated with minimization techniques (6-10 cm) that allow less aggression for the patient and facilitate rapid functional recovery.
What are your results with mitral repair surgery?
Our experience in repair surgery of the mitral valve extends over the last 15 years, with a progressive increase in the number of patients operated and excellent results.. In the last 300 patients referred for this type of surgery, the repair rate was 97.5% and hospital mortality less than 1%. The objective is always the same: to solve the patient's problem with the minimum risk and surgical aggression, to get him to recover quickly and well, to be able to restore his normal life soon, and to enjoy the best quality of life possible.