What are the preoperative preparations and surgical techniques for mitral valve repair?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: October 1, 2025 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Preoperative Preparation and Surgical Techniques for Mitral Valve Repair

Thorough preoperative evaluation with transesophageal echocardiography (TEE) is essential for successful mitral valve repair, with patient selection focusing on valve morphology, ventricular function, and anatomical considerations to determine repair feasibility and approach. 1

Patient Selection and Preoperative Evaluation

Echocardiographic Assessment

  • Transthoracic echocardiography (TTE) is the preferred initial imaging technique for diagnosis and severity assessment of mitral valve disease 1
  • Transesophageal echocardiography (TEE) is crucial for:
    • Evaluating presence and severity of concurrent mitral regurgitation
    • Clarifying severity and mechanism of valve lesions
    • Determining appropriateness for valve repair over replacement
    • Obtaining detailed information on mitral anatomy before intervention 1
  • 3D TEE provides greater accuracy of measurement of mitral valve area 1

Ideal Candidates for Initial Mitral Valve Repair

  • Patients requiring simple annuloplasty
  • Focal posterior leaflet prolapse
  • Mitral valve replacement candidates without complex pathology 1

Relative Contraindications for Minimally Invasive Approach

  • Significant mitral annular calcification requiring extensive debridement
  • Extremely complex repairs (e.g., rheumatic disease)
  • Left ventricular ejection fraction <25%
  • Severe right ventricular dysfunction
  • Pulmonary artery pressure >70 mm Hg
  • Significant aortic regurgitation (more than mild)
  • Kyphoscoliosis and pectus excavatum 1

Additional Preoperative Testing

  • Computed tomography angiography (CTA) to evaluate:
    • Ascending aortic disease
    • Vascular access for cannulation
    • Anatomical considerations 1
  • Coronary angiography for:
    • Men >40 years
    • Post-menopausal women
    • Patients with cardiovascular risk factors or history of coronary artery disease 1

Surgical Techniques for Mitral Valve Repair

Fundamental Principles

  1. Total removal of infected/damaged tissues
  2. Reconstruction of cardiac morphology
  3. Valve repair whenever possible, particularly for mitral valve 1

Specific Repair Techniques

  • Simple lesions:

    • Perforations in valve cusps/leaflets: repair with untreated or glutaraldehyde-treated autologous or bovine pericardial patch
    • Isolated/multiple ruptured chordae: replacement with polytetrafluoroethylene neo-chordae 1

  • Complex lesions:

    • Extensive destruction of single leaflet or abscess presence may still be repairable
    • Intraoperative assessment after debridement is crucial to evaluate tissue quality
    • Pericardial patches, tricuspid autografts, or flipped-over mitral patches may be used 1

Repair vs. Replacement Decision-Making

  • Mitral valve repair is strongly preferred over replacement when:

    • Pathology is limited to posterior leaflet (highest success rates)
    • A successful and durable repair can be accomplished for anterior or bileaflet involvement 2
    • The patient has favorable valve morphology 1, 2

  • Consider replacement in patients with:

    • Unfavorable morphological characteristics
    • Significant mitral annular calcification
    • Rheumatic valve disease requiring complex repair 1

Surgical Approach Options

  • Traditional sternotomy
  • Minimally invasive approaches:
    • Right mini-thoracotomy
    • Port-access techniques
    • Robotic-assisted surgery 1

Perioperative Considerations

Anesthesia and Monitoring

  • Intraoperative TEE is essential to:
    • Determine exact location and extent of pathology
    • Guide surgery
    • Assess repair results
    • Help in early postoperative follow-up 1

Myocardial Protection

  • For minimally invasive approaches:
    • Consider lower systemic perfusate temperatures
    • More frequent redosing of cardioplegia
    • Optimal venous drainage is crucial, especially in patients with RV dysfunction 1

Postoperative Management

  • Careful anticoagulation management for patients with mechanical valves
  • Consider intravenous heparin or subcutaneous low-molecular-weight heparin to cover periods of subtherapeutic anticoagulation in high-risk patients 1

Importance of Surgical Expertise

  • Outcomes of mitral valve repair are highly dependent on surgeon experience and center volume 1, 2
  • High-volume centers can achieve repair rates approaching 100% for degenerative mitral valve disease 3
  • Referral to a Heart Valve Center of Excellence is recommended when complex repair is anticipated 2

Common Pitfalls and Caveats

  • Underestimating the complexity of repair in cases with significant annular calcification
  • Inadequate preoperative imaging leading to unexpected findings during surgery
  • Failure to recognize unfavorable valve morphology preoperatively
  • Attempting complex repairs without adequate surgical expertise
  • Not considering the patient's comorbidities and operative risk in decision-making 1

By following these guidelines and principles, successful mitral valve repair can be achieved in the majority of patients, leading to better long-term outcomes compared to valve replacement.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Mitral Valve Repair and Replacement Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Related Questions

What is the recommended management for a 77-year-old female with normal left ventricular (LV) systolic function, mild mitral valve regurgitation, and grade I diastolic dysfunction?
Where on the chest wall is the mitral valve best heard?
Can mitral valve disease be reversed?
What is the clinical management for severe mitral regurgitation?
What is the best next step in managing a 22-year-old male with recent atrial fibrillation and severe mitral regurgitation due to a Barlow valve?
What is the recommended dosage of terlipressin for hepatorenal syndrome?
What is the recommended duration to hold Plavix (clopidogrel) before a Transurethral Resection of the Prostate (TURP) procedure?
What are the treatment options for erectile dysfunction (ED) with medications?
Can valley fever cause residual lung damage after treatment?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question