Surgical Mitral Commissurotomy

Overview

Commissurotomy is a surgical procedure used to open up and help enhance blood flow through one of the heart valves, usually the mitral valve. The left atrium, or upper left chamber of the heart, and the left ventricle, or lower left chamber, are separated by the mitral valve. The bicuspid valve is another name for the mitral valve. This is as a result of its two cusps, or flaps, which open and close to control blood flow.

This valve can become dysfunctional due to a variety of mitral valve diseases. A type of mitral valve stenosis limits the valve’s ability to open to its optimal width. A reduced blood flow to the left ventricle can result in a backup of blood within their heart. This may eventually put stress on their heart and lungs and result in problems like heart failure.

Mitral commissurotomy, a treatment for early-stage mitral stenosis, has become less common today. Healthcare professionals typically reserve this procedure for cases where minimally invasive options are not feasible. Open-heart surgery is the usual method for performing mitral commissurotomy, but it does come with associated risks.

Balloon valvuloplasty is a first-line treatment that involves stretching open the valve with a pressurized balloon. Due to their heart’s structure or for other reasons, some persons are not candidates for balloon valvuloplasty. A commissurotomy would be a good choice if that’s the case.

Reasons for undergoing the procedure

When a patient has mitral valve stenosis and is deemed unsuitable for balloon valvuloplasty or if other treatment options have proven ineffective, a commissurotomy may become necessary. In cases where additional cardiac interventions are warranted, healthcare providers may recommend a commissurotomy as an adjunct procedure, and these treatments can often be performed simultaneously by the surgeon.

Recognizing that not all patients with mitral valve stenosis are candidates for a commissurotomy is important. It is reliant upon the cause of their mitral stenosis.

Mitral stenosis has two primary causes:

• Rheumatic mitral stenosis, or damage resulting from rheumatic heart disease.
• Progressive valve breakdown over time, also known as degenerative mitral stenosis.

Commissurotomy proves especially advantageous for individuals afflicted with rheumatic mitral stenosis. In such instances, the heart valve damage results from an autoimmune condition known as rheumatic fever, which may remain latent for several years before manifesting as valve damage.

In rheumatic mitral stenosis, the commissures of the mitral valve tend to thicken and sometimes even fuse together. Ideally, these commissures should be easily distinguishable. The mitral valve’s two leaflets or flaps are normally connected at these commissures. This fused effect occurs in mitral stenosis, leading to a reduction in the flow of blood through the valve.

Risk

Mitral valve regurgitation, or a leaky valve, is the most frequent complication following an open commissurotomy. Some additional potential concerns include:

• Arrhythmia or abnormal heart rhythm.
• Heart block
• Bleeding
• Cardiac tamponade
• Confusion
• Heart attack
• Infection
• Stroke
• Allergic reaction to anesthesia.

Patients who receive care at a major hospital with surgeons skilled in valve surgery are less likely to suffer these complications.

Certain medical condition could increase the risk of complications such as chronic obstructive pulmonary disease (COPD), diabetes, kidney disease, obesity, or peripheral artery disease.

It is important to discuss with the healthcare provider regarding the risk and complications of the procedure and how could they lessen the risk.

Procedure

When the commissures become fused, a commissurotomy procedure is employed, involving small surgical incisions to separate them. This can enhance blood flow through the heart for individuals with rheumatic mitral stenosis. However, in degenerative mitral stenosis, the commissures are usually unaffected, and the valve’s other components need attention. Therefore, commissurotomy is generally not a suitable option for degenerative mitral stenosis patients, who may require alternative methods such as mitral valve replacement or repair.

Before the procedure

The weeks or months leading up to the surgery day are spent in preparation. A comprehensive medical evaluation is conducted by the healthcare team, consisting of a primary care physician, cardiologist, and cardiothoracic surgeon. Your healthcare team will request tests to assess the condition of your mitral valve and to detect any obstructions in your coronary arteries.

• Reviewing your symptoms and medical history.
• A thorough physical examination.
• Blood test.
• Echocardiogram.
• Coronary angiogram.
• Computed tomography (CT) scans.

Patients should speak with their healthcare providers if they have any questions or concerns. Obtain the information required for them to feel more at ease regarding their impending surgery.

They will be given information by their healthcare provider on how to get ready for surgery. These will advise them on when to start fasting (stopping food and liquids intake) and what adjustments to make to their medication intake.

To reduce the risk of complications, it’s important that the patient stop using tobacco products or smoking before the procedure. Request quitting resources from the healthcare provider.

During the procedure

The following steps will be taken by the surgical care team:

• Patient will be given anesthesia to put the patient into deep sleep.
• Make an incision in the sternum, or breastbone, midway down their chest. A median sternotomy is the name given to this operation.
• Connect them to a heart-lung machine for cardiopulmonary bypass. A surgeon may perform surgery on a heart that is not beating thanks to this machine. It maintains blood flow to their organs and tissues by taking over for the heart and lungs during the procedure.
• Open the left atrium and examine the mitral valve.
• To release the mitral valve’s fused commissures, make tiny incisions in them.
• The procedure involves disconnecting you from the cardiopulmonary bypass machine and then restarting both your heart and lungs.
• Do a transesophageal echocardiography to examine your valve and ensure that everything proceeded as expected.

During the same treatment, surgeons may repair other valves, such as the tricuspid or aortic valve. They may also perform additional cardiac operations. If this is the case, the healthcare provider will let them know and go over what to anticipate.

After the procedure

They will stay in the hospital for roughly a week after the procedure to recover. They will spend the first few days in the intensive care unit (ICU). Healthcare provider will keep a careful eye on them and look out for any indications of serious issues.

Prior to their discharge from the hospital, the healthcare provider will advise them about:

• People recovering from heart surgery may find cardiac rehab to be a beneficial choice. It may help them in regaining the strength to carry out their daily activities.
• How to take care of the incision. To reduce the chance of infection and promote wound healing, it’s necessary to provide incision care.
• The duration the patient should wait before resuming driving and engaging in regular activities.

Make sure to arrange transportation for your journey back home from the hospital.

Outcome

The risk of problems from mitral stenosis and its accompanying symptoms can be reduced with surgery. It becomes a valuable choice when the stenosis doesn’t reach the severity necessitating a mitral valve replacement or when percutaneous balloon valvuloplasty is not feasible.

Open mitral commissurotomy often yields excellent success rates, effectively treating stenosis and improving blood flow. However, it is not a definitive treatment plan. For many patients who undergo a commissurotomy, a mitral valve replacement becomes necessary in the long run.

When seeking information about their specific prognosis, individuals should rely on their healthcare provider as the primary source. This is because every person’s recovery is distinct and influenced by various factors, including the extent of previous mitral valve damage, their age, and overall health.

If they show any signs of infection while they recover, get them checked out. These consist of:

• Fever
• Pressure, pain, or discomfort in the chest.
• Redness or drainage in the area around the incision.

Call emergency number if you encounter:

• Any signs of heart attack.
• Slurred speech or other signs of stroke.