Deciding whether you need surgery to fix your mitral valve
Three different procedures are used to treat mitral valve stenosis:
- Valve replacement surgery
- Balloon valvotomy (percutaneous balloon valvotomy)
- Open or closed mitral commissurotomy
Valve replacement and open commissurotomy are major, open-heart procedures that place considerable stress on your body. But they may be needed to prevent potentially debilitating complications associated with mitral valve stenosis. Balloon valvotomy is a catheter-based procedure and an alternative to open-heart surgery. While very successful for most people, this procedure may have to be repeated.
Deciding whether you need surgery and if so, when, are the major treatment decisions for mitral valve stenosis. Three factors should be assessed when making this decision: the severity of your mitral valve stenosis, the possibility that it will get worse, and the risks of surgery.
Assessing severity and its effect on your heart
The guiding factors when deciding to have valve surgery are the severity of your mitral valve stenosis and the effect it is having on your heart. Valve surgery is usually performed only if the stenosis is serious and in danger of doing irreparable damage to your heart. In this case, the danger to your heart outweighs the risks associated with surgery. Fortunately, mitral valve stenosis typically progresses very slowly (though it tends to accelerate as you age). You may have as many as 10 years from the time you develop symptoms until your mitral valve stenosis becomes severe.
Your symptoms and the area of your mitral valve determine how severe your mitral stenosis is: the smaller the area, the lower the volume of blood that is able to pass through it, and hence the more severe your stenosis. The pressure difference between your left atrium and left ventricle, as well as the blood pressure in your lungs, is also used to assess severity. In general, surgery is recommended to repair or replace the mitral valve when your valve area drops below 1.5 cm2 and you have symptoms that are significantly interfering with your lifestyle.
Repair or replacement of any kind is recommended if you do not have symptoms but your mitral valve stenosis is severe. But other risk factors including age, speed of deterioration, and overall health are also considered. And these may determine that you need surgery despite not having any symptoms.
Will your mitral valve stenosis get worse?
Another important factor is the likelihood that your condition will get worse rapidly without surgery. If your mitral valve stenosis has been progressing slowly or if your symptoms are mild, then surgery may not be immediately needed. But the presence of other compounding factors, such as pulmonary hypertension (high blood pressure in your lungs), abnormal heartbeat (arrhythmia), and coronary artery disease (CAD), will likely accelerate the progression of your mitral valve stenosis. In this case, surgery may be needed in the near future.
Risks of surgery
The severity of your mitral valve stenosis and the likelihood that it will get worse need to be balanced against the risks of having valve surgery. Specifically, mitral valve replacement has an operative mortality rate of less than 5%. But this rate can be as high as 10% to 20% for people who also have pulmonary hypertension.1 Although most people have successful outcomes, the risk of death and serious problems during surgery is real. It should be strongly weighed in the decision to replace your valve, particularly if you have other serious health issues.
Both commissurotomy and valve replacement are surgical procedures. A commissurotomy can be either open-heart, where your chest is opened and heart bypass is done through a heart-lung machine, or closed, where an incision is made in the chest but a heart bypass is not done. The heart-lung machines can increase risk.
Balloon valvotomy is a catheter-based procedure (a catheter is threaded through a vein in your leg to your heart) and so is not considered a surgical procedure. But it, too, carries some risk. Much of this risk depends on the skill of the doctor doing the procedure. So you should consider the number of procedures performed by the individual doing your valvotomy when deciding to have the procedure. The overall mortality rate for valvotomy is 1% to 3%, though in high-volume centers, it can be under 1%.1
- Bonow RO, et al. (2006) ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease). Circulation, 114(5): e84–e231.
Last Updated: February 10, 2010
Author: Robin Parks, MS