Balloon mitral valvuloplasty
This is a procedure performed for patients with a condition known as mitral stenosis which is a thickening of the heart valve where the valve does not open normally. Usually only valves that are thickened due to underlying rheumatic fever are suitable for this technique.
It is a keyhole procedure which is usually performed via a vein in the neck or the leg. This can be performed under local or general anaesthetic. A tube is introduced into the vein and moved up to the heart under x-ray guidance. The tube arrives in the blue blood chamber of the heart known as the right atrium and travels across a little membrane into the left atrium (red blood side of the heart). A balloon is then introduced through the tube and positioned across the mitral valve under x-ray guidance. The balloon is inflated and is able to stretch the mitral valve open.
In order to assess your suitability for this procedure you are likely to need a trans oesophageal echocardiogram in advance of the procedure. Sometimes a trans oesophageal echocardiogram is also used to help the operator guide the positioning of the balloon during the procedure. If this is the case your procedure will be done under general anaesthetic.
Transcatheter aortic valve implantation (TAVI)
What is a TAVI procedure?
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This is a keyhole procedure used to treat aortic stenosis which is a thickening of the main outlet valve of the heart known as the aortic valve. Occasionally a TAVI valve can also be inserted inside a worn out bioprosthetic (tissue/cow/pig) aortic valve replacement. This is known as a valve-in-valve TAVI.
Not everybody is suitable for a TAVI procedure. A cardiac CT scan will be performed in advance of the TAVI procedure to ensure that your anatomy is suitable for the procedure. As we do not have long-term durability data for the TAVI procedure this is usually only offered to people that are unsuitable for surgery due to other medical conditions, or for those that are in their 70s or 80s.
A TAVI keyhole procedure is most commonly performed via the groin. It can also be performed via an artery under the collar bone.
If the TAVI is performed via the groin then this usually under local anaesthetic with or without light sedation. A tube is introduced to the groin under x-ray guidance and fed up into the heart. The aortic valve is crushed out of the way and a new pig or cow valve which is introduced via the tube springs up in its place.
How long will it take me to recover from a TAVI?
You will usually be able to sit out of the bed the day following your procedure. There may be some discomfort in the groin where the puncture was performed. You are generally able to be discharged several days after your TAVI procedure. You may have pain in your groin for a few weeks after the procedure. Your heart will be monitored after the procedure via stickers on the chest to ensure that you not do not develop any heart rhythm disturbances.
What are the risks of a TAVI procedure?
It is a common perception that a TAVI procedure is lower risk than a surgical procedure because it is a keyhole procedure. Although the risks are different, a TAVI should still be considered a major invasive procedure. Risks include heart attack, stroke, death during the procedure, permanent pacemaker requirement following the procedure, bleeding from the arteries or damage to the arteries, infection, kidney problems following the procedure or the need for emergency open heart surgery. Every patient will have a different risk and this will be discussed with you at the outpatient clinic prior to consenting for the procedure.
What tests will I need prior to a TAVI procedure?
You will need an echocardiogram prior to a TAVI procedure to confirm that your aortic valve is severely narrowed and to understand how strong your heart muscle pump is (left ventricle). You will also need basic blood tests and will often have a chest x-ray. A special cardiac CT will be performed in most patients to assess their anatomical suitability for the procedure. Some patients will have an angiogram (cardiac catheterisation) prior to the procedure, especially if they present with chest pain/tightness or have angina.
Can I drive after a TAVI?
You should refrain from driving for 4 weeks following your TAVI. It is advisable to inform your insurance providers that you have had the TAVI procedure.
Mitral edge to edge repair (Mitraclip / PASCAL / TEER)
What is a mitral edge to edge repair?
A mitral edge to edge repair procedure is sometimes known as a TEER procedure or a MitraClip. When this procedure was put first performed the only company that made this type of procedure was known as MitraClip and this name seems to have stuck!
A mitral edge to edge repair procedure is designed to reduce the valve leak associated with mitral regurgitation. As it often does not abolish the leak on the heart valve it is considered only in patients that are not suitable for surgical mitral valve replacement or repair.
A mitral edge to edge repair procedure is a keyhole technique performed under general anaesthetic. A tube is inserted in the vein in the groin. This tube is passed up to the heart under x-ray guidance. There is a small membrane which connects the blue blood right atrium with the red blood left atrium and this is crossed during the procedure. A small clip is then introduced into the tube which is applied to the mitral valve to bring the edges of the two mitral valve leaflets together. This is often successful in reducing the degree of the leak on the mitral valve.
What are the benefits of a mitral edge to edge repair?
The main benefits of this procedure are to reduce symptoms such as shortness of breath, fatigue and leg swelling.
What are the risks of a mitral edge to edge repair procedure?
As with any invasive procedure there are risks. Sometimes due to technical difficulties, the amount of leak on the valve is not significantly reduced. This can occur relatively commonly, especially if your valve has a complex leak. Other risks are relatively small but generally there is a small risk of stroke, death, bleeding, collection of blood around the heart, disturbed heart rhythm, damage to the blood vessel, kidney damage and damage to the teeth or gullet caused by the trans oesophageal echocardiogram probe. Your healthcare professional will discuss these risks with you prior to you providing consent for the procedure.
What tests do I need prior to a transcatheter mitral edge to edge repair?
This technique is not suitable for everyone with mitral valve regurgitation. You will need a trans oesophageal echocardiogram prior to the procedure to check your suitability. You will also have baseline blood tests and may also have a coronary angiogram/cardiac catheterisation procedure in advance.
What happens after my MitraClip procedure?
After your procedure you will return to either the coronary care unit or the cardiology ward. A heart monitor will be placed on your chest to monitor your heart rhythm. You will have a small stitch in your groin and there may be some tenderness and bruising. You will generally be discharged from hospital a few days following your procedure provided you feel well. You will be seen as an outpatient following your procedure.
Percutaneous mitral valve implantation
The treatment of valve disease is a rapidly evolving field. Trials of new technology are happening all the time and the UK is often involved in these trials. Various manufacturers are developing keyhole mitral valve implantation procedures. At the moment these are in the experimental stages and would only be offered to if you were felt to be unsuitable for traditional heart valve surgery.
Percutaneous pulmonary valve implantation
This is a procedure designed for patients with a leaky pulmonary valve (pulmonary regurgitation), or for patients who have previously had surgery to replace the pulmonary valve and the replacement valve has worn out. Keyhole pulmonary valve replacement procedures have been provided routinely for over 20 years. In fact, they were the first type of keyhole valve replacement procedures to be developed.
They are usually performed under general anaesthetic. A tube is inserted into the vein in the groin and fed up to the heart under x-ray guidance. A pig, cow or horse valve is then positioned via this tube in the place of your worn-out pulmonary valve.
Tricuspid valve edge to edge repair (Triclip / PASCAL)
The treatment of tricuspid valve disease is a rapidly evolving field. Trials of new technology are happening all the time and the UK is often involved in these trials. Various manufacturers are developing transcatheter edge to edge repair devices that clip the tricuspid valve leaflets together to treat tricuspid regurgitation. This is a very challenging procedure technically, only available in very select centres and on a trial basis in the UK at the moment. Given that these procedures are in the experimental stage they would only be offered if you were felt to be unsuitable for traditional heart valve surgery.