Physicians and Public Can See Innovative Procedure from Home or Office
A Webcast showing cardiac surgeons at the University of Maryland Medical Center performing innovative, minimally invasive mitral valve repair can now be seen on the Internet. During the February 4, 2004, operation, surgeons used tiny instruments and a video camera, placed through a two-inch "keyhole" incision, to perform the same repairs that have traditionally required open-heart surgery.
The patient, 52-year-old Andrew Copeland of Baltimore County, says he had no hint of heart problems until last winter, when he was shoveling snow. He became short of breath, began sweating profusely, and then blacked out. His doctor found that while his heart was in good condition, his mitral valve needed repair.
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The mitral valve normally permits blood flow in only one direction. But Mr. Copeland's valve leaks, allowing some blood to flow in the wrong direction, toward his lungs, causing congestion and difficulty breathing.
Mr. Copeland leads a very active life with his wife, Ruth, their three children and six grandchildren. He does a lot of walking on his job as a car auction coordinator in Elkridge. Mr. Copeland says he likes the fact that this was a minimally invasive operation.
"It's the perfect operation to be done through a small incision," says James S. Gammie, M.D., a cardiac surgeon at the University of Maryland Medical Center and assistant professor of surgery at the University of Maryland School of Medicine, who described the surgery shown during the Webcast. "This procedure reduces the amount of blood loss, eliminates the need for a breastbone incision, minimizes the chance of infection and allows patients to resume normal activities sooner."
Surgeons at the University of Maryland Medical Center performed the first minimally invasive, "videoscopic" mitral valve repair in the Mid-Atlantic region in May 2003. The center is a leader in the surgical and medical treatment of mitral valve disease.
Bartley P. Griffith, M.D., chief of Cardiac Surgery at the University of Maryland Medical Center and professor of surgery and head of the Division of Cardiac Surgery at the University of Maryland School of Medicine, performed the surgery on Mr. Copeland.
"The videoscopic approach meshes well with our emphasis on mitral valve repair rather than replacement," says Dr. Griffith. "We prefer to fix a broken mitral valve rather than replace it, because a repair lasts longer and rarely requires another operation down the road."
The Webcast, the first in a series of four, originated from the University of Maryland Medical Center's new surgical facility, called the O.R. of the Future. The 19-room O.R., which opened in June, combines the most advanced video and other communications equipment with information technology to enhance patient safety and operational efficiency.
"In traditional mitral valve repair, the actual view of the surgery is hard to see for anyone but the surgeon," says Dr. Gammie. "But with the videoscope, we have a beautiful view on our flat panel monitors in our new operating rooms, so everyone involved in the operation can see what's going on." The Webcast adds a new dimension to that view, according to Dr. Gammie, extending it throughout the region, across continents and around the globe.
The mitral valve, shaped like a liturgical headdress worn by bishops and abbots called a miter, is the "inflow valve" for the left ventricle, the heart's main pumping chamber. Blood flows from the lungs, where it picks up oxygen, across the open mitral valve and into the left ventricle. When the heart squeezes, the two leaflets of the mitral valve snap shut and prevent blood from backing up to the lungs. Blood is directed out of the heart to the rest of the body through another valve, the aortic valve.
According to Dr. Gammie, there are two major problems that can occur with the mitral valve. "It can be too tight, so it doesn't allow blood into the main pumping chamber. Or, the valve can be leaky, so when the heart is squeezing, instead of sending blood where it's supposed to go, it backs up and goes in the wrong direction."
Dr. Gammie says that about 90 percent of patients who come to the University of Maryland Medical Center for mitral valve treatment have leaky valves, and their most common symptom is shortness of breath.
The goal during surgery, says Dr. Gammie, is to "expose the valve, get a good look at it, determine the exact problem, and perform the repair to create a valve that is water-tight and works perfectly."
Mitral valve surgery was first performed in 1960, when surgeons replaced the diseased, native valve with an artificial valve. For the next 20 years, valve replacement was the gold standard, using either a metal, mechanical valve or a valve made from cow tissue.
Dr. Gammie says neither device is as good as a patient's own valve. The metal valve tends to form blood clots, so patients must take a blood thinning medication for the rest of their lives, with the risk of bleeding. The tissue valves are less likely to cause clots, but they last only 10 to 15 years.
"Both of those are reasonable options," says Dr. Gammie, "and certainly better than not fixing a diseased valve. But we really like the idea of fixing a person's own mitral valve. We have a very high success rate of doing that."
According to nationwide data, about six percent of patients with a valve replacement do not survive the surgery. But Dr. Gammie says with a mitral valve repair, the chance of survival is about 98 percent.
Several factors influence those numbers. The risk of stroke during and after valve repair is extremely low compared to valve replacement. Artificial valves can cause infection, but infection is unlikely when the patient's own valve is repaired. Further, repairs are much more likely to last for the rest of the patient's life.
Despite the benefits of repair over replacement, only about 40 to 45 percent of mitral valves nationwide are repaired. In centers that specialize in mitral valve repair, such as the University of Maryland Medical Center, that rate has climbed to about 90 percent. "Not every valve can be fixed," says Dr. Gammie. "There are some that are too damaged and beyond repair. But we feel that a team approach focused on fixing the valve truly helps patients. And the ability to do the repair with a minimally invasive approach takes the patient benefits to an even higher level."
This Webcast activity has been approved for AMA PRA credit, which is sponsored by the University of Maryland School of Medicine.
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