Mitral Valve Repair: What to Expect

From the authors of The Cardiac Surgery Playbook: Daniel T. Engelman, MD, Cheryl Crisafi, MSN, RN, and Armando Paez, MD

If you have been told your mitral valve leaks and needs surgery, the first question to ask is whether it can be repaired rather than replaced. For most leaking mitral valves, an experienced surgeon will say yes. This page explains what a repair involves, how to choose a surgeon, and what to expect afterward. Your own team's advice comes first.

What the mitral valve does

The mitral valve separates the heart's two left-sided chambers: the upper one that collects blood from the lungs and the lower one that pumps it out to the body. Two leaflets swing open to let the pumping chamber fill, then meet in the middle to seal. Thin cords, often likened to parachute strings, tether the leaflets so they do not blow backward when the heart contracts.

How the valve fails

The usual problem is a leak, called mitral regurgitation. The leaflets no longer meet, often because cords have stretched or snapped or the leaflets have become floppy, and some blood washes backward with each beat. The heart ends up pumping the same blood twice. Over time it enlarges and weakens, and the lungs grow congested.

Less often the valve becomes stiff and narrow, called mitral stenosis. Either way, the typical symptoms are breathlessness, tiredness, and palpitations. Some people feel nothing yet are advised to have surgery on the strength of their tests, because waiting too long can weaken the heart muscle in ways an operation cannot undo.

Why repair is preferred

For the mitral valve, repair is the goal whenever it can be achieved. A repaired valve is your own tissue, tends to outlast a replacement, and usually spares you lifelong blood thinners. In experienced hands, most leaking mitral valves can be repaired, especially those caused by wear and tear.

If the valve is too scarred or calcified to fix, the surgeon replaces it with a tissue or a mechanical valve. A mechanical valve lasts longest but needs warfarin for life, and in the mitral position the blood thinner target is higher than for an aortic valve. A tissue valve avoids that but wears out over time. Our page on heart valve surgery explains those trade-offs.

What the surgeon actually does

Each repair is tailored to what is wrong. The surgeon may trim a floppy segment of leaflet, replace stretched or broken cords with artificial ones, or close a small gap. Most repairs also add a ring, called an annuloplasty ring, stitched around the valve opening to restore its shape and support the repair for the long term.

The heart is stopped and the heart-lung machine supports you during the repair. Before the operation ends, the team checks the valve with an ultrasound probe in the esophagus. If it still leaks, the surgeon corrects it then and there. You should wake up with a valve that works.

Choosing a surgeon: ask about repair rates

Mitral repair is a specialized skill, and results depend heavily on the surgeon's experience with it. Ask plainly what share of leaking mitral valves the surgeon repairs rather than replaces, and how durable those repairs have been. You are looking for someone who repairs most of them. Our page on questions to ask your heart surgeon has the full list.

Minimally invasive and robotic repair

Mitral repair is among the heart operations most commonly done without dividing the breastbone, either through a short incision between the ribs on the right side or robotically through several pencil-width ports. The repair inside the heart is identical. Only the route in changes. Benefits can include less pain, less blood loss, a lower risk of wound infection, a shorter stay, and an earlier return to driving and work.

Not everyone is a candidate, and these operations need a team that does them often. A smaller scar is never worth a less complete repair. Our page on minimally invasive and robotic heart surgery covers the trade-offs.

The catheter clip option

For people whose risk from an operation is too high, a cardiologist can reduce the leak with a small clip delivered through a leg vein. The procedure is called transcatheter edge-to-edge repair, or TEER, and many people know it by the brand name MitraClip. The result is usually less complete than a surgical repair, but for the right patient it eases symptoms without surgery. A Heart Team of surgeons and cardiologists should weigh these options with you.

Recovery after mitral repair

Recovery follows the usual pattern: a short stay in intensive care, a few days on the ward, then several weeks at home. Atrial fibrillation is common after mitral surgery because the upper chamber has been under strain. It is usually treated with medicine and settles. If you notice a racing or irregular heartbeat at home, call your surgical team that day. Many teams prescribe a blood thinner or aspirin for a few months while the ring heals into place, then stop. Ask what applies to you and when the valve will be checked with an echocardiogram.

If your repair went through the breastbone, most teams ask for sternal precautions for about six to eight weeks and no driving for about four to six, and only once you are off opioid pain medicine. If it was done between the ribs or robotically, you usually need fewer precautions and these numbers can be shortened. Teams are also developing systems that allow reduced sternal precautions and earlier driving, but you must check with your own practitioner. Let pain be your guide. If something hurts, stop what you are doing and allow the bone to heal. Our week-by-week recovery page describes the general course.

Protecting your repaired valve

A repaired valve can still become infected. Look after your teeth and gums and tell every dentist about the valve. Because most repairs include a ring, your team may advise an antibiotic before certain dental work, so ask. Routine dental treatment is usually postponed for about three months after surgery.

Call your surgical team about fevers you cannot explain, night sweats, or a flu-like feeling that will not go away, which can point to an infection on the valve. Call 911 or seek emergency care for chest pressure, severe breathlessness, fainting, or signs of a stroke. Our warning signs page lists the rest.

Learn more in The Cardiac Surgery Playbook

Chapter 4 explains the mitral valve, repair versus replacement, and the catheter clip. Chapter 8 covers the minimally invasive and robotic approaches, and Chapter 11 lists the questions to ask, including a surgeon's repair rate.

Go deeper in the book. Chapter 4: Valve Surgery; Chapter 8: Minimally Invasive and Robotic Cardiac Surgery; Chapter 11: What to Ask Your Surgeon and Team. Written by a cardiac surgeon, a cardiac surgery nurse and an infectious disease physician, with worksheets you can fill in for your own care.

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This page is general education, not medical advice. Your own surgeon and care team know your situation best. If you think you are having a medical emergency, call 911.

More questions before heart surgery