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A change of heart for appropriate patients
A new surgical procedure may focus more attention on the role of the mitral valve in treating patients with heart failure.
The technique uses a ring to reinforce the valve so it can keep more blood from flowing backward into the left atrium. With a more efficient blood flow through the heart, patients may be able to regain cardiac performance over time. For now, the procedure may help some patients in advanced heart failure live longer, even if they are not candidates for a transplant. Researchers hope that as they learn more about who is right for the procedure, they can use it to help their patients avoid the downward spiral of heart failure.
"We think this is a viable alternative," says Steven Bolling, MD, a cardiothoracic surgeon at the University of Michigan Medical Center in Ann Arbor. He says when the heart enlarges during failure, its inner walls pull at the mitral valve. The pressure causes a problem, not in the organic makeup of the valve, but in the way it functions. Because it can’t stay closed when it should, half of the blood that should be exiting the heart goes back into the atrium. This reverse flow becomes an obstacle to circulation the heart has to overcome.
Going in to replace the valve has meant robbing the heart of some pumping power. Because the patients were already compromised by heart failure, the loss was too much. Bolling says these patients just "have nothing more to give."
Surgeons learned to leave the valve alone when the ejection fraction (EF) was low. Bolling says this procedure is different than traditional attempts to replace the mitral valve. Instead of replacing it, his procedure involves "scrunching it down" and keeping it in place so the heart won’t pull it open when it should stay closed. Better flow is restored without the loss in power.
"We are taking no function away from the heart," he says, which could make the procedure available to a broader spectrum of CHF patients.
"We have to change our thinking about these patients," he says.
He recently operated on a patient with an EF of 5. The patient came into the surgical program after living with CHF for years. Bolling says he wishes he could have performed the operation on her 10 years ago, before her quality of life declined to a point where she had to spend most of her day sitting in a chair.
It will take about two years to be more certain of the long-term benefits, Bolling says. Right after surgery, her EF probably was the same as before. But without the regurgitation, her heart has a better chance of regaining some lost ground.
Changing the way doctors think about these patients, he says, begins with understanding the relationship of valve and ventricle. Both elements are working together and should not be seen as separate parts. "We are not treating a ventricular problem with a valve solution," he says. "We are treating a ventricular problem with a ventricular solution."
In the first phase of his study, Bolling says he operated on nearly 100 patients, and 70% to 80% were alive two years after surgery (compared to about 10% if the patient didn’t have the surgery). He reported his findings at the American Heart Association conference in November.
"He is getting some marvelous results," says Mehmet C. Oz, MD, a cardiothoracic surgeon at Columbia-Presbyterian Medical Center in New York City. Oz says his hospital has performed a dozen mitral valve procedures with similar outcomes.