Surgical Treatments of Functional Heart Valve Diseases

When we speak of a leaking or narrowed heart valve, what usually comes to mind is a defect in the valve itself; yet in some of our patients the valve leaflets are completely normal in structure and the problem lies in the “frame” around the valve. We can compare this to a door: the door itself is perfectly sound, but if the door frame widens over time the door no longer closes fully and air (in our example, blood) leaks through the gap. This picture is what we call “functional valve disease”. I will address the surgical treatment of valve diseases caused by defects in the valve’s own structure, and other technologies such as transcatheter valve replacement, in separate articles. In this article I focus directly on the surgical and interventional treatment options we use in functional mitral and tricuspid valve regurgitation.

What Is Functional Valve Disease and How Does It Develop?

Functional mitral regurgitation mostly develops as a result of enlargement or weakening of the left ventricle (the heart’s main pumping chamber); as the ventricle dilates, the valve annulus is also stretched, the valve leaflets move away from each other and can no longer close completely. Functional tricuspid regurgitation similarly arises through enlargement of the right heart chambers and of the valve annulus, often due to left-sided heart disease, atrial fibrillation (an irregular heart rhythm) or increased pressure in the lung vessels. In both situations it is not the valve itself but the structure around it that is diseased; and this directly shapes our treatment strategy.

Which Treatment for Whom? Our Decision Criteria

In functional valve regurgitation our first and most important step is to treat the underlying heart failure as well as possible; because as the heart chamber shrinks and recovers, the valve leak may also decrease. In patients who nevertheless continue to have moderate-to-severe or severe regurgitation and are symptomatic, we bring surgical or interventional treatment onto the agenda. In making this decision we use the current 2020 ACC/AHA and 2021 ESC/EACTS Valvular Heart Disease Guidelines as references, together with the large randomised trials that clarified the role of transcatheter treatment in functional mitral regurgitation (COAPT and MITRA-FR). I would like to point out an interesting detail here: these two trials found different results; in the COAPT population, where patients were well selected, the heart chamber was not excessively enlarged and heart failure treatment had already been optimised, transcatheter treatment provided clear benefit, whereas in the MITRA-FR trial, where patient selection was different, this benefit could not be shown. This has taught us that patient selection is far more decisive than the treatment method itself.

Treatment Options

Optimal Treatment of the Underlying Heart Failure: In every patient the first step is to use heart failure medicines at the highest tolerable dose and, in suitable patients, to add treatments such as cardiac resynchronisation therapy (a special pacemaker that coordinates the heart’s pumping). Mitral Valve Repair (Annuloplasty): When surgery is needed, we support and narrow the dilated valve annulus with a ring, allowing the valve leaflets to close fully again; we always regard repairing the valve, rather than replacing it, as our priority. Angiographic Treatments (MitraClip, TriClip): In patients at high surgical risk or unsuitable for surgery, we reduce the leak by bringing the tips of the mitral or tricuspid valve leaflets closer together with a small clip, using a catheter inserted through the groin; we prefer this method particularly in patients whose heart failure treatment has been optimised and whose anatomy is suitable. Tricuspid Valve Repair (tricuspid annuloplasty): If the tricuspid valve annulus is markedly dilated during left-sided valve surgery, we also perform tricuspid annuloplasty in the same session; in symptomatic patients whose only problem is severe tricuspid regurgitation, we consider repair or transcatheter treatment. Valve Replacement: In the rare cases where repair is not technically possible or is not expected to be durable, we replace the valve with a prosthetic one.

The Process After the Procedure

After surgical repair we monitor our patients in intensive care for a short time and usually discharge them within a week. We continue to follow both valve function and the course of the underlying heart failure closely with regular echocardiography, because in functional valve disease success cannot be considered separately from the overall condition of the heart.

Frequently Asked Questions

Are functional valve regurgitation and congenital or structural valve disease the same thing? No. In functional valve disease the valve’s own structure is normal; the problem arises from enlargement of the heart chamber surrounding the valve. If there is a defect in the valve itself we call this organic/primary valve disease, and the treatment approach may differ.

Can a valve leak improve with medical treatment? Yes, in some patients the heart chamber shrinks as heart failure treatment is optimised and the valve leak may decrease; this is why we always complete this step before moving on to interventional treatment.

Can transcatheter edge-to-edge repair be applied to everyone? No. We prefer this method particularly in patients at high surgical risk or unsuitable for surgery whose anatomy is appropriate; in young, low-risk patients surgical repair is usually the preferred option. In all studies, surgical repair has been found superior.

When is the tricuspid valve treated as well? If the tricuspid annulus is markedly dilated during left-sided valve surgery, we prefer to perform repair in the same session in order to prevent future tricuspid regurgitation.

In Summary

In functional heart valve diseases, treatment requires a holistic approach focused on the underlying heart failure rather than on the valve itself. Across this range of options, from optimal medical treatment to surgical repair, and from transcatheter edge-to-edge repair to tricuspid valve treatment, our aim is to improve both the valve and the overall function of the heart together.

If you have shortness of breath, tire easily, or have known heart failure and suspect a valve leak, you can book an appointment for a detailed echocardiographic assessment.

References

1. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease. Circulation. 2021;143(5):e72-e227.
2. Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS Guidelines for the Management of Valvular Heart Disease. Eur Heart J. 2022;43(7):561-632.
3. Stone GW, Lindenfeld J, Abraham WT, et al. Transcatheter Mitral-Valve Repair in Patients with Heart Failure (COAPT). N Engl J Med. 2018;379(24):2307-2318.
4. Obadia JF, Messika-Zeitoun D, Leurent G, et al. Percutaneous Repair or Medical Treatment for Secondary Mitral Regurgitation (MITRA-FR). N Engl J Med. 2018;379(24):2297-2306.