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SurgSpace

03 / Cardiac Surgery · open

Mitral valve repair

Reconstruction of a leaking mitral valve on bypass, resecting or re-suspending the prolapsing segment and reinforcing the annulus with a ring, repair beats replacement when the valve allows it.

Indication: Severe mitral regurgitation from degenerative prolapse, symptomatic or with early ventricular dilatation, ideally repaired before the ventricle pays for the leak.

Part of Cardiac Surgery →4 stages3 complications to knowopen

Read the imaging first

Operative photo
A cardiac surgery operating room with the team, perfusion equipment and monitors in view
Inside the cardiac OR · surgeon, perfusion console and the bypass circuit

On the tray for this operation

Test yourself on the tray

Stage

1 / 4

Bypass and exposure

Sternotomy, cannulation and bypass as for any open-heart case; the heart is arrested and the left atrium opened behind the interatrial groove to display the valve.

🔧 Scalpel🔧 Richardson retractor🔧 DeBakey forcepsExplore anatomy: Coronary circulation

Watch for: Atrial tear during exposure · Circumflex artery injury in the atrioventricular groove

Why are we operating?

Mitral repair fixes the patient's own valve rather than replacing it: for degenerative regurgitation, repair preserves the valve's apparatus and the ventricle's geometry, avoids a prosthesis's compromises, and carries better long-term outcomes in experienced hands. The operation's timing is its art: operate before the regurgitation has remodelled the ventricle, not after symptoms make the case undeniable.

Pulls toward surgery

Severe primary (degenerative) mitral regurgitationSymptoms, or a ventricle beginning to dilate or failHigh repair likelihood on echo (posterior leaflet prolapse classically)New atrial fibrillation or pulmonary hypertension as triggers

Gives the team pause

Secondary (functional) MR, where the ventricle is the diseaseHeavily calcified or rheumatic valves resisting repairA repair promise the local experience cannot keep

Shared foundations

Cardiopulmonary bypass

Most cardiac operations need a still, empty heart. The bypass circuit takes over the circulation so the heart can be stopped: taught once here, referenced by every operation that uses it.

Understand it once, in the specialty hub

Cardioplegia & myocardial protection

A stopped heart must also be a protected heart. Cardioplegia is how the myocardium survives the cross-clamp.

Understand it once, in the specialty hub

What the surgeon is thinking

  • Bypass and exposure

    Why is exposure half this operation?

    The mitral valve lives at the heart's deepest address, behind the interatrial groove: the approach through the left atrium (or trans-septally) must present the valve face-on, because a repair is sewing millimetre geometry, and geometry cannot be sewn at a glimpse.

  • Valve analysis

    What is the segmental analysis actually doing?

    Naming the mechanism before choosing the fix: each leaflet segment and its chords are tested against Carpentier's grammar (normal motion, prolapse, restriction). The repair is then selected by mechanism, resect or re-suspend the prolapsing segment, neochords for ruptured ones, and the analysis on the arrested heart is checked against the preoperative TEE's story.

  • Reconstruction

    Why does nearly every repair end with an annuloplasty ring?

    The annulus dilates as part of the disease and keeps dilating after it: the ring restores the annulus's shape, protects the leaflet repair from future stretch, and is the single most consistent element of durable repairs. It is the frame that keeps the restored painting flat.

  • Testing and weaning

    How is a repair examined before the chest closes?

    Twice: saline filling the ventricle on the arrested heart gives a first look at the coaptation line, then the weaning TEE examines the repair under real pressure. It grades residual MR, measures the new orifice for stenosis, and looks for systolic anterior motion, the specific failure where the anterior leaflet obstructs outflow, because each of those findings has a different in-theatre fix.

Decision points

  • The valve resists a confident repair after two attempts. Persist, or replace?

    • Further repair attempt

      Justified while a mechanism-based plan remains: each run back on bypass has a cost, so 'try again' needs a new idea, not just hope.

    • Replace, preserving the subvalvular apparatus

      An honest replacement that keeps the chordal skeleton beats a leaking repair: ventricular function is protected by what is preserved beneath.

    Repair is preferred, not sacred: the exit to replacement is part of the plan and part of the consent. What separates centres is knowing before the operation which valves are repairable, so the mid-operation surrender is rare.

  • The weaning TEE shows systolic anterior motion with a gradient. What is the sequence?

    • Physiology first: fill, slow, wean inotropes

      SAM loves an empty, fast, squeezed ventricle: correcting those abolishes many cases without a stitch.

    • Back on bypass and revise

      For SAM that survives optimisation: the repair's geometry (excess leaflet, small ring) is revisited, because leaving fixed obstruction is not an option.

    SAM has a hierarchy of fixes and the cheap ones are physiologic: the discipline is trying them properly before recutting a repair, and the confidence to revise when they fail. The TEE arbitrates each step.

Leaving the OR

The handoff

Procedure
Mitral repair: P2 triangular resection, 32 mm annuloplasty ring
Bypass / clamp
102 min / 74 min
Echo
Trivial residual MR, no SAM, mean gradient 3 mmHg
Rhythm
Sinus; atrial wires in; amiodarone plan documented
Watch for
AF window, drains, tamponade physiology; echo before discharge

A fictional educational patient, handed over the way real ones are.

The postoperative course

  1. ICU arrivalStandard post-bypass care with one addition: the repaired valve's behaviour is assumed good only because the TEE said so, and any haemodynamic wobble asks the question again.
  2. POD 0-1Extubation and weaning; atrial arrhythmias are both common and better tolerated than they feel.
  3. POD 2-4Drains and wires out; the AF window managed with the long-term rhythm strategy in mind, not just tonight's rate.
  4. DischargeA pre-discharge echo as the baseline for a lifetime of surveillance; anticoagulation short-term per rhythm and repair, not forever by default.
Continue this patient as a case

Watch it done

Find Mitral valve repair videos on YouTube

What can go wrong

Postoperative bleedingAtelectasis & pulmonary complicationsVenous thromboembolism
OR Prep this operationReview the instruments