REPAIR OF THE VALVE MITRAL
Solution to the problems of cardiac valves without changing them. 

Our heart in one of the most perfect and complex machines that exists.  It is capable of working continuously during more than 80 years, without stopping beating form more than 3 seconds.  No machine has been invented yet that is capable to carry out a similar task without being necessary to substitute its pieces as they wear off.

The heart on the other hand is capable of working in these hard conditions without need of repairs.  Nevertheless, in some circumstances by illnesses, or simply by the passing of time, the valves of the heart can be damaged in an irreversible form, being necessary action on this damage.

How do the cardiac valves function? 

The heart is a bomb designed to push the blood toward the lungs, and from there to remainder parts of the body.  So that this can happen, the blood should advance in the correct direction, and not go back once pushed out of the heart.  This happens thanks to the four valves of the heart: aórtica, mitral, pulmonary and tricuspid.  Each one of them is in charge that the blood moves from a place to another without going back to none of the four cameras that are in  the heart: two atriums and two ventricles. 

The valves have two positions: closed, that is the one that they adopt to stop the blood going back; and open, when the cavity contracts, so that the blood can leave the cavity.  If they fail on the  positioning the problems are valvular.  A shortage is produced when a valve is not capable of closing completely and the blood escapes backwards.  An estenosis is produced when the valve instead of being opened completely remains half closed, and the blood passes with difficulty through it. 

Replacement of valves.   

One of the forms to solve the problem of a damaged valve  is to substitute it for another.  Various types of valves exist, and inside them there are several modalities.  In general, we can distinguish two large groups of valves replacements : 

"Biological" valves , obtained from tissues of animals.  Its advantages are that as they are living beings tissues, the body tolerates them very well.  The disadvantage is that its parts are soft, and with time they start to break down a lot more faster than a human natural valve.  In general, a valve of this type is expected to last between 10 and 15 years, depending on the circumstances.

"Mechanical"  valves , are artificial valves made of very strong chemical components.  The advantage is that they are so hard that they are practically impossible to break.  Most of the ones that exist currently would be capable of functioning during more than 600 years without problems.  Nevertheless, they are artificial substances and our body is not comfortable with them.  The blood reacts with it and can coagulate as it enters in contact with its surface.  Due to this reason, these valves require of medicines (anticoagulants) all the life to stop this occuring.

The two options are magnificent solutions for the valves problems,  but both have the objections indicated above.  Although more the mechanical valves than the biological valves, because of their form and because they lack living cells to defend them, they have more risk to contract infections of the heart ("endocarditis").  In practice, due to the biological valve being damaged with time, or because the mechanics produce problems of coagulation, or because both can be infected, it is not infrequent that a patient with an artificial valve has to be intervened again after some years to replace the valve.   

Repairing of valves. 

For all these reasons, the best solution is to repair the valve of the own patient.  A valve repaired does not cause coagulation of the blood, because it is not an artificial surface.  Neither it has a greater risk of infection that a natural valve, because once repaired the valve continues alive and is capable defending itself better than an artificial valve of the germs that can attack it.  As for the duration, variable.  We know that a valve repaired does not last as much as  a healthy valve, and that is habitual that a good number of patients have to be operated again in the time spread of some years. 

Nevertheless, although it is not the final solution and although we know that can it fail again, we the specialists agree  to that a valve repaired is the best option for a patient, because we know that he/she will have a longer life, with less problems, and will need of less medicines.  Unfortunately, not all the valves can be repaired.  In many occasions, as occurs with the rheumatic fever, the valve is  object of a severe attacks by an illness, that has left it almost useless.  In others, as it occurs often with the aortic valve in  people of more than 70 years, the passing of time has done to much damaging, and habitually the valves present too many zones aged and hardened which will not function again, for which is better to substitute them. 

The mitral valve. 

The good news are that the mitral valve is not normally damaged in a irreversible way.  In almost half of the cases it is possible to repair it.  This will depend, of course, of many factors: the age of the patient, the cause that has caused the failure, and where is situated that failure.  In some cases the repair is so simple that an intervention will not be necessary: the same cardiologist will be able to repair it by means of a procedure called valvuloplastia by catheterism.  This procedure is employed in valves that have remained closed for a long time and that which are not capable of opening with normality, this situation is called mitral estenosis. 
In the cases in which repairing would be much too complex, it is necessary a surgical intervention to correct it.  If what happens is that the valve is not capable of closing, we are looking at a mitral shortage.  These cases should be repaired by the surgeon. 

The intervention of repair.

Currently almost all the heart valves repair interventions require the utilization of an artificial system ("bomb of extracorporeal circulation ") that substitutes the function of the heart, and can only be carried out by heart surgeons.  In most cases, it would be necessary as well to stop the heart.  During the time in which the heart is stopped, which can be at most 3 or 4 hours, the surgeon should analyze what fails in the valve, repair it, put it again in motion, verify that all functions correctly, and if is necessary to stop it again and to carry out additional repairs.  When the patient leaves the surgery room, the valve problem  should be finally solved in a way or another. 

In all the cases it is very important to verify during the  intervention that the repair is correct.  For that a test called ultrasound is carried out transesofágica or epicárdica.  This test is similar to the one which is used to diagnose the failure of the valves in the prior phases to the surgery, it is carried out in the same surgery room once the repair has been performed, and before removing finally the bomb of extracorporeal circulation.

In some cases the ultrasound will show that the repair has not been satisfactory.  In this case, the surgeon will decide according to his/her experience and the time that has been consumed in the intervention, if it is possible to do another attempt of repair using the same intervention, or if it is necessary to substitute the ill and irreparable valve by an artificial valve. 

What type of life is carried out after the repair? 

The repair returns the normal functioning to the valve, for which once surpassed the phase of recovery, habitually of 1 month to carry out the physical recovery, and of 3 months for completion of the cycle of pharmacological processing, the patient can continue with the same life that he/she carried out before the illness.  The fatigue, very common in the patients with illnesses of the mitral valve, normally disappears in a few months, permitting to carry out all kinds of activities, including sport.  In the case of women, they can be pregnant and maintain a normal maternity.

The only precaution that should be followed by the patients with the valve repaired is to carry out a cardiological monitoring of the valve, with visits and eventually ultrasounds once a year, to periodically verify that the repair continues functioning with normality. 

In the long-term, it is possible that the valve fails again.  We should not forget that in this surgery the valve is not changed, but is repaired.  The same illnesses that caused it to fail once can cause it to become ill again, increasingly if the cause is genetics like in the case of patients with very weak tissues.  In these cases the surgeon will evaluate the situation and he/she will decide if is possible another repair, or if he/she must proceed to change finally the valve.  Fortunately this new intervention, in the event that did happen, has much less risk that if it was a matter of changing an artificial valve that has failed. 

Exists a form to repair the valve without opening the chest? 

Yes. In the cases in which the size and the age of the patients permits it, it is possible to carry out what is called "videoscópica surgery ".  In this procedure no opening of the chest with an injury along all the sternum is carried out , but is accessed to the valve through small orifices in the axils or near the chest.  This technique employs special devices, and requires an also specific training of the surgical team.  It can be seen more information of this technique in the chapter of valve surgery  by minimal access and robotic surgery.