Mitral Valve Surgery: Why We Operate on the Heart from the Right Side

The launch of our new minimally invasive mitral valve surgery print ad, which has appeared in many publications, including The Washington Post Magazine, has generated several e-mails and blog posts from people questioning the accuracy of the image, which features a chest with the incision location – under the right breast – highlighted.

Dr. James Gammie, a UMMC  cardiac surgeon who specializes in mitral valve repair, said patients are surprised to learn the incision site is under the right, and not the left, breast.

So what’s the story? The heart’s mitral valve is located in the center of the chest, and Dr. Gammie said the best way to approach the valve is through the upper chambers of the heart, which are on the right side of the chest.

Dr. Gammie also talks about his passion, and the benefits to patients, of repairing vs. replacing the mitral valve, which UMMC does more than 90 percent of the time. As for the comments about the incision location, he says he encourages patients to ask questions, and that the more informed patients are the better.

Virginia Woman Shares Story of Her Successful Mitral Valve Repair

Virginia resident Elizabeth Norris never suspected anything was wrong with her heart. However, the results of an echocardiography test and cardiac catheterization indicated she had severe mitral valve regurgitation and needed surgery to correct the problem. Her physician referred her to Dr. James Gammie at the University of Maryland Medical Center, an expert in mitral valve surgery, who was able to successfully repair her leaking valve.  Visit our Web site to read her story.

Mitral Valve Surgery Patient Shares His UMMC Experience

By David Kubiatowicz

Editor’s Note:  This post features excerpts from a post David — shown at right with his wife, Rose — published on his own blog on May 11.

It was 4 years ago today (May 11) that I went under the knife at the University of Maryland Medical Center in Baltimore for “minimally invasive mitral valve repair” under the skilled hands of heart surgeon James Gammie, MD and a skilled staff of OR personnel.

My mitral valve (separating the heart’s left atrium from the left ventricle) was prolapsed, which is defined in Wikipedia as: “Mitral valve prolapse (MVP) is a valvular heart disease characterized by the displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole. There are various types of MVP, broadly classified as classic and nonclassic. In its nonclassic form, MVP carries a low risk of complications. In severe cases of classic MVP, complications include mitral regurgitation, infective endocarditis, congestive heart failure, and — in rare circumstances — cardiac arrest, usually resulting in sudden death.”

This was a condition which I inherited at birth and which only worsened as the years rolled by. Because of excess tissue in the valve flaps, my mitral valve did not close completely when my left ventricle contracted to squeeze oxygenated blood into my body. Consequently blood leaked into my left atrium (regurgitated) and back toward my lungs from whence it came. This leakage causes a “murmur” sound picked up by the physician or cardiologist listening to the heart.

I had been a runner since 1985 (age 43). My internist said I would be able to subjectively judge my mitral valve worsening by slowing of running speed and technically judge it by results of yearly cardiac ultrasound scans. In 1985 I was able to run a 10K race in under 7 min/mile and a 15K race in about 7.5 min/mile. By 2004 my average running time per mile was up to over 9 min and cardiac ultrasound scans showed worsening leakage of my mitral vale to the point of “severe.”

In addition my heart was in full-time “atrial fibrillation,” manifesting as fast and/or irregular heartbeat. This was caused by disorganized electrical impulses originating in the atria and resulted in the atria behaving like a squiggling bag of worms according to Baltimore heart surgeon James Gammie, MD. Normal behavior was a slight but steady contraction of the atria as the ventricle filled with blood during the resting phase of each cardiac cycle.

The lack of incomplete atrial draining could cause pooling of blood in the atria (especially in the left atrial appendage, which I liken to an appendix) with the potential of clot formation and subsequent stroke. To reduce the risk of stroke, I was prescribed a daily dose of Coumadin, which slowed blood clotting time. Blood concentration of the drug was important so a monthly test was necessary to monitor Coumadin level and adjust the dose if necessary. I always had to be careful with sharp objects for fear of prolonged bleeding if cut.

My clinical symptoms and cardiac ultrasound tests convinced my internist and cardiologist that heart surgery would be a prudent choice for me in the very near future. My options included mitral valve repair or mitral valve replacement with an artificial valve. There would be no promise that surgeons could repair my valve. In addition, radio frequency “ablation” (destruction of tissue generating erroneous electrical impulses) could be done at the same time to eliminate or at least minimize my full-time atrial fibrillation.

Back at home while searching the Internet to assess my options, I found a February 3, 2004 video presentation of a minimally invasive mitral valve repair procedure developed at the University of Maryland Medical Center by surgeon James Gammie, MD and others.

I was impressed with the procedure (no midline incision), a shorter recovery time and the high likelihood that my valve would be repaired rather than replaced. At that time nation-wide valve repairs were about 45% and at Baltimore repair rates had climbed to 90%.

A key attitude for me that was expressed by Dr. Gammie near the front of the video was: “It’s better to keep your own valve than to get an artificial valve. No artificial valve is as good as the valve that you were born with. That God gave you.”

This sort of minimally invasive surgery was not available in the Minneapolis-St. Paul, MN area nor at the Mayo Clinic in Rochester, MN nor in nearby states. I ultimately received blessings from my internist and cardiologist (who performed a cardiac catheterization procedure to ascertain that blood vessels in and around my heart were not blocked) for the minimally invasive procedure. Fortunately, Dr. Gammie’s assistant, Mary J. Santos, PA-C, M.S. handled all requests for my medical information to insure that I fit their criteria for the minimally invasive procedure, and helped coordinate all arrangements for housing and the surgery. She was invaluable in this regard!!

Thus, on Monday May 8, 2006, I and my loving wife Rose travelled to Baltimore, MD so I could undergo a minimally invasive procedure during which my heart received a cryogenic (cold) MAZE (ablation) treatment for atrial fibrillation followed by mitral valve repair in which excess tissue was cut from the valve flap. At the same time as the valve repair, the left atrial appendage was tied off to reduce stroke risk from pooling blood if there were any residual atrial fibrillation. James Gammie, MD was the chief surgeon. My surgery was May 11, 2006 and we returned to St. Paul on Saturday May 20, 2006. It was an anxious time for me but more so for Rose, who did the worrying, communicated with family, lived in unfamiliar housing and negotiated an unfamiliar city. Looking back, we wondered how we did it all!

The cosmetic results of the surgery are shown below.

6 days Post Surgery Incision 6 cm just to right and above the right nipple.
Two other areas with “holes” were for draining tubes
8 weeks Post Surgery
5.9 months Post Surgery

You may be wondering how did Dr. Gammie get to my heart located in the center-left of my chest from an incision made to the right of the right nipple. I quote from the Operative Summary:

“An incision of 6 cm in length was made just below the right nipple. This was deepened and the chest [was] entered in the fourth intercostal space. The fourth rib was shingled [a 1 cm section was removed to facilitate tunneling into the chest cavity]. The pericardium was opened and tacked up. The cardiopulmonary bypass was initiated. A cross-clamp was applied. A liter of cold blood cardioplegia [intentional and temporary cessation of cardiac activity, primarily used in cardiac surgery] was administered. There was excellent diastolic arrest to the heart. [An] Interatrial groove was developed, and the left atrium exposed in the standard fashion. Exposure of the [mitral] valve was excellent…”

Note additions in [ ] are added by me. According to Dr. Gammie, tunneling through the chest wall like this to get at the heart with the aid of a tiny camera, affords a better view of the mitral valve than entering the chest cavity through a large incision down the breastbone (sternum).

Dr. Gammie’s studies showed that cessation of atrial fibrillation doesn’t occur until about 6 months after surgery. My cessation was about 2 years after my operation. Till then my heart was in and out of atrial fibrillation on a random basis and I took daily doses of Coumadin during this time. With cessation of atrial fibrillation today, 4 years later, I am left with a “tight” mitral valve according to cardiac ultrasound scans and with occasional (less than a day in duration) episodes of recurring atrial fibrillation.

Also with cessation of atrial fibrillation my resting heart rate reduced to a regular 45 beats per min (bpm). It should be 60 bpm, but when I exercise it increases normally. As a runner my heart beat was also about 45-50 bpm because of my good physical shape. I am not currently on any cardiac medications. My running has suffered but that’s not related to my heart. Today, just 4 years later, the minimally invasive procedure is much more common and is done in a number of medical centers. The research is yours to do.

Dr. Gammie’s view on mitral valve surgery, when a valve can be repaired rather than replaced, is that it’s better to have the repair done sooner than later. Better at age 50 rather than 60. By waiting the valve only gets worse, causing the heart to enlarge, which can result in the disruption of electrical signals and the onset of atrial fibrillation and other maladies. I, frankly, was afraid that with heart surgery, an artificial valve would replace my mitral valve. I would be on high doses of Coumadin for the rest of my life and there would be the constant worry of a malfunction of the mechanical valve. I waited longer than I should have. Then I found Dr. Gammie and his Team at the University of Maryland Medical Center!!

© Copyright 2010 David O. Kubiatowicz (used by permission)