‘Mitral valve insufficiency’, which is painful to breathe, can be treated even in patients in their 80s with heart failure

Reporter Shin Eun-jin, Health Chosun

As we get older, we tend to take it for granted that we get short of breath easily and have a lot of coughing and phlegm. These symptoms, taken lightly, could be signs of the unfamiliar mitral regurgitation. Mitral valve insufficiency is such a painful disease that it is difficult to even breathe while lying still. It occurs frequently in the elderly and patients with heart failure, but they often have to give up treatment because of the burden of surgery. Fortunately, ‘percutaneous mitral valve surgery (TEER)’ using a clip appeared in Korea several years ago, giving hope to patients with high risk of surgery. We met Professor Kim Dae-hee and Professor Kang Do-yoon of the Department of Cardiology at Asan Medical Center, who performed the first clip-based percutaneous mitral valve plastic surgery in Korea, and heard about the latest treatment for mitral regurgitation.

―What kind of disease is mitral regurgitation?

Professor Kim Dae-hee: The heart has four structures called valves that act as doors. Among them, mitral valve insufficiency is a disease caused when the mitral valve, which serves as the door between the left atrium and the left ventricle, does not function properly. When the door opens and closes properly, blood does not flow backwards. The main cause is aging. In the past, Korea had many rheumatoid valve diseases, but with the westernization, 50% of mitral valve regurgitation is degenerative mitral regurgitation caused by aging. The severity of mitral regurgitation is divided into stages 1 to 4, and according to US data, patients with moderate or severe mitral regurgitation of stage 3 or higher account for 3% of the population over the age of 65.

―It is a degenerative disease, but is there any treatment?

Professor Kim Dae-hee: If mitral insufficiency is not treated, severe breathing difficulties appear that make it impossible to sleep while lying down, leading to an emergency room visit. There are usually no symptoms in the early stages. Difficulty breathing when climbing stairs or walking quickly. In the case of the elderly, they think that they are out of breath because of their age and do not think that they have a disease. However, over time, shortness of breath appears even at rest.

―How is the treatment?

Professor Kim Dae-hee: In principle, mitral regurgitation is treated in 4 stages. At first, drug treatment is given, and if the drug does not respond, surgery or procedure is performed. The timing and method of treatment depend on the type of mitral regurgitation. Mitral regurgitation is largely divided into primary mitral regurgitation and secondary mitral regurgitation, and primary is a problem with the mitral valve itself. Secondary is when there is no major problem with the mitral valve itself, but heart failure or other left ventricular function problems cause mitral regurgitation. Primary mitral regurgitation is basically a problem called mitral valve prolapse due to degenerative change of the mitral valve, so it is a principle to treat it when there are severe symptoms. However, recently, there are many data that suggest that surgery is good even if there are no symptoms, and valve plastic surgery is performed early.

―What is the difference between surgery and procedure?

Professor Kang Do-yoon: Surgery for mitral insufficiency refers to open thoracotomy, and the procedure mainly refers to percutaneous mitral valve plastic surgery. Percutaneous mitral valve surgery is a technology that has been used for about 10 years and was introduced in Korea in 2020. Most patients are included in the surgical target. In the case of primary mitral regurgitation, surgery is recommended first because there are still many relatively young patients and the surgical results are good. The procedure is recommended for very elderly patients or patients with secondary mitral regurgitation who have mitral regurgitation due to a broken heart muscle. However, among patients with primary mitral regurgitation, high-risk groups such as the elderly over 80 are treated.

―What kind of people are high-risk groups who need surgery?

Professor Kim Dae-hee: When calculated with the ‘STS Score’, a system that evaluates the risk of heart surgery for patients from the United States, the high-risk group is defined as patients with a postoperative mortality rate of 8% or higher. In this case, there is a high possibility of problems after surgery, so the procedure is recommended. The next high risk factor is age. Even if there are no other comorbidities, it is often difficult to open the chest for various reasons in the elderly over 80 years of age. Even patients in their 60s and 70s who find it difficult to undergo surgery due to other comorbidities can undergo the procedure.

―What is the prognosis of percutaneous mitral valve surgery?

Professor Kang Do-yoon: Percutaneous mitral valve surgery has been approved by the US FDA and has become a standard treatment. If you do the procedure in the morning, you can eat in the afternoon and walk around in the evening. The quick recovery period is the biggest advantage of the procedure. Most patients are discharged 2 to 3 days after the procedure.

―Are there any precautions after surgery/procedure?

Professor Kang Do-yoon: Medication should continue. Even if mitral regurgitation is cured, basically, the heart of a patient with this disease is already weakened, and heart failure is accompanied by continuous management after the procedure.

―Please say something to patients with mitral regurgitation and those who hesitate to seek treatment because they are in the high-risk group.

Professor Kim Dae-hee: Usually, when I recommend a procedure to a patient in her 80s, they say, ‘I’ve lived as long as I’ve lived and I don’t want to be indebted to my children, so I’ll just live as it is’, but after the procedure, they are very satisfied. Mitral regurgitation is never a disease that makes death easy. It is a disease that becomes more and more painful, and later makes it impossible to lie down and sleep, and to stay up all night with breathless eyes. must be continuously managed.

Professor Kang Do-yoon: Many people give up on surgery because of their age and comorbidities, but now a new treatment has emerged. Do not give up and visit the hospital because you can be treated very safely and recover quickly. However, it is currently not covered by insurance, so the patient’s cost burden is high.