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Degenerative mitral valve disease is a condition in which the valve between the left chambers of the heart becomes structurally worn and cannot close completely, allowing blood to leak backward. Interventional cardiology approaches used in the treatment of this medical condition refer to non-surgical treatment options developed as alternatives to open-heart surgery. Innovative methods such as percutaneous repair and transcatheter valve replacement aim to repair the damaged valve from within or replace it with a new valve by advancing through the groin vessel without opening the chest. These minimally invasive procedures, planned individually through meticulously conducted clinical decision-making mechanisms, help reduce the excessive workload on the heart and allow patients to return to their daily routines more comfortably.
| Definition | It is a heart valve disease in which mitral valve function deteriorates due to aging, connective tissue changes, or structural degeneration and most commonly leads to mitral regurgitation. |
| Main Characteristic | As a result of thickening, loosening, or prolapse of the valve leaflets, or elongation or rupture of the cords (chordae tendineae), the valve cannot close completely and some blood flows back from the left ventricle into the left atrium. |
| Most Common Causes | Age-related degeneration, fibroelastic deficiency, myxomatous degeneration (Barlow disease), mitral valve prolapse, connective tissue diseases (Marfan syndrome, Ehlers-Danlos syndrome), and age-related advanced valve calcification. |
| Risk Factors | Advanced age, family history, mitral valve prolapse, connective tissue diseases, hypertension, and male sex (more common in advanced cases requiring surgery). |
| Prevalence | It is one of the most common causes of mitral regurgitation, and its prevalence increases particularly in older age groups. |
| Development of the Disease | Deterioration in the valve structure may progress over time. It may not cause symptoms initially, but in later stages, increasing mitral regurgitation may lead to enlargement of the heart chambers and deterioration of heart function. |
| Symptoms | Shortness of breath on exertion, easy fatigue, palpitations, reduced exercise capacity, chest discomfort, and in advanced stages, leg edema and nighttime shortness of breath. |
| Early-Stage Findings | Mild palpitations, shortness of breath during exertion, and sometimes a completely asymptomatic course. |
| Advanced-Stage Findings | Symptoms of heart failure, atrial fibrillation, pulmonary hypertension, and significant exercise intolerance. |
| Physical Examination Findings | A systolic murmur at the apex of the heart, a midsystolic click in mitral valve prolapse, and findings of heart failure in advanced cases. |
| Possible Complications | Progression of mitral regurgitation, atrial fibrillation, heart failure, pulmonary hypertension, loss of left ventricular function, and rarely, risk of infective endocarditis and stroke. |
| Diagnostic Methods | Physical examination, transthoracic echocardiography (the primary diagnostic method), transesophageal echocardiography, electrocardiography (ECG), chest X-ray, cardiac MRI (when necessary), and cardiac catheterization (in selected cases). |
| Importance of Echocardiography | It is the most important imaging method for evaluating valve anatomy, prolapse or leaflet sagging, the severity of regurgitation, left ventricular function, and surgical suitability. |
| Severity of the Disease | It is evaluated as mild, moderate, or severe mitral regurgitation according to the amount of blood flowing backward and echocardiographic measurements. |
| Treatment Goals | The goals are to reduce symptoms, preserve heart function, prevent progression of mitral regurgitation, and plan intervention or surgery at the appropriate time. |
| Medication Treatment | Diuretics for symptoms, hypertension treatment, rate control if atrial fibrillation develops, and anticoagulant therapy in suitable patients may be used. Medications do not correct the valve disorder but contribute to symptom control. |
| Interventional Treatment | Transcatheter mitral valve repair, such as edge-to-edge repair methods, may be performed in selected patients with high surgical risk and suitable anatomy. |
| Surgical Treatment | Mitral valve repair is the preferred option in suitable patients. Mitral valve replacement may be performed when repair is not possible. |
| Timing of Surgery | It is considered in cases of severe mitral regurgitation, development of symptoms, deterioration of left ventricular function, significant enlargement of the heart chambers, or development of pulmonary hypertension. |
| Follow-Up | Regular cardiology examinations and echocardiography at intervals determined according to the severity of the disease are recommended. |
| Lifestyle Recommendations | Keeping blood pressure under control, planning regular physical activity according to the physician’s recommendations, avoiding smoking, maintaining a healthy diet, preserving an ideal weight, and controlling cardiovascular risk factors are recommended. |
| Pregnancy | Mild cases are generally well tolerated. Pre-pregnancy cardiological evaluation is recommended for women with severe mitral regurgitation. |
| Conditions Requiring Emergency Admission | Sudden severe shortness of breath, chest pain, fainting, rapid or irregular palpitations, and symptoms of acute heart failure. |
| Prognosis | The course of the disease depends on the degree of degeneration and the severity of mitral regurgitation. Long-term outcomes are generally successful with valve repair or replacement performed at the appropriate time. |
| Prevention | Although age-related degeneration cannot be completely prevented, controlling hypertension, reducing cardiovascular risk factors, and regular cardiological follow-up may help reduce the adverse effects of the disease. |
What Is Degenerative Mitral Valve Disease?
It is possible to think of the heart as a perfect pump with four chambers that works continuously without stopping. The upper chamber on the left side is responsible for collecting blood that has been oxygenated in the lungs. This oxygenated blood then passes into the lower chamber, from where it is pumped throughout the body with a powerful contraction. The mitral valve acts as a critical one-way door located between these upper and lower chambers. As blood passes downward, this door opens fully, and when the lower chamber contracts forcefully to send blood to the body, the door closes tightly to prevent blood from flowing backward. The leaflets of this door are attached to the walls of the lower chamber by thin but extremely durable fibrous connections called “chordae.” These cords can be compared to the strings of a parachute; they allow the leaflets to withstand pressure and prevent them from turning inside out.
In degenerative mitral valve disease, this perfect mechanism begins to deteriorate over time. The valve leaflets stretch, thicken, or the strong parachute-like cords holding the valve may suddenly rupture. Because the door cannot close completely, each time the lower chamber contracts, a significant portion of the blood flows backward into the upper chamber instead of going where it belongs, namely to the body. This creates a serious workload on the heart. Over time, the backward-flowing blood begins to accumulate in the lungs and increases pressure in the pulmonary vessels. The heart has to exert more effort each time to provide the blood the body needs. This continuous state of overwork eventually causes the heart muscle to tire, the chambers to enlarge like balloons, and ultimately lays the foundation for a broader problem known as heart failure.
What Causes Degenerative Mitral Valve Disease and Which Subtypes Does It Include?
In the past, the most common factor damaging heart valves was rheumatic fever experienced during childhood. Today, with the advancement of modern medicine and the extension of average life expectancy, “degenerative” diseases related to tissue aging and wear are seen more frequently. These structural deteriorations mainly present in three different forms, and the underlying mechanism of each is different.
The first condition encountered is usually fibroelastic deficiency, which affects older individuals. Just as our skin loses elasticity and wrinkles with advancing age, the connective tissues forming the heart valve also weaken over time. As a result of this thinning and weakening, sudden ruptures may occur in the fibrous structures that hold the valve in place. A person may have no complaints and then suddenly need to seek medical attention due to severe shortness of breath.
Another subtype is Barlow disease, which is more commonly observed in young and middle-aged individuals. In this condition, the valve leaflets become much thicker, spongier, looser, and more wavy than normal. When the valve attempts to close, the loosened leaflets bulge and sag toward the upper chamber like a balloon. These patients have a much more widespread deformity of the valve, and stretching of the cords is observed over time. A third subtype develops as a result of genetically inherited connective tissue disorders such as Marfan syndrome. In this syndrome, in which all connective tissues in the body are congenitally defective, serious structural deterioration tends to occur at a very early age in the aorta and mitral valve, in addition to differences in skeletal and eye structures.
What Symptoms Does Degenerative Mitral Valve Disease Cause in Our Body?
In the early stages of the disease, the heart generally tries to adapt to this new condition, and the body establishes a compensatory mechanism that suppresses complaints. During this period, the leakage is mild or moderate, and people generally do not feel a significant problem in their daily lives. However, as the structure of the valve deteriorates further over the years and the amount of blood flowing backward increases, the heart muscle becomes unable to carry this extra load. As the heart’s compensatory mechanisms begin to become exhausted, various complaints that deeply affect daily life and reduce quality of life start to appear.
The most commonly observed symptoms when valve leakage progresses are as follows:
- Palpitations
- Weakness
- Easy fatigue
- Shortness of breath
- Dry cough
- Nighttime awakenings
- Swelling in the ankles
- Abdominal swelling
The mechanism by which these symptoms appear is directly related to the disrupted dynamics of the heart. Particularly during activities requiring exertion, such as walking uphill or climbing stairs, the muscles need more oxygen. However, because sufficient blood cannot be pumped to the body due to the valve leakage, the person suddenly loses energy and becomes tired quickly. The pooling of backward-flowing blood in the lungs makes breathing especially difficult in a horizontal position. Patients often state that they wake from sleep at night with a feeling of suffocation and have to increase the number of pillows to sleep comfortably. This slowing of blood circulation and increase in backward pressure eventually lead to fluid accumulation in the lower parts of the body, also due to the effect of gravity.
What Do Traditional Surgical Methods Offer for Degenerative Mitral Valve Disease?
The traditional method used in the treatment of advanced structural deterioration and leakage of the valve is repair of the valve through open-heart surgery. Surgical repair allows the anatomical structure to be reshaped by directly intervening in the heart tissue. These operations are generally performed by cutting the breastbone down the middle or, in some cases, through smaller incisions made under the arm.
During the operation, the functions of the heart and lungs must be completely stopped. During this process, the patient is connected to an advanced extracorporeal system called a “heart-lung machine” to maintain the body’s blood circulation and oxygen needs. After the heart is stopped by cooling it with special fluids, the surgeon opens the relevant chamber of the heart and reaches the defective valve directly. New supporting cords made of durable Teflon material are sutured in place of the ruptured cords, excessively loose tissues are removed, and special support rings are placed to narrow and reinforce the frame in which the valve sits.
This surgical approach is a highly effective treatment option in terms of providing long-term anatomical improvement. However, due to the nature of the operation, the physiological burden it places on the body is quite substantial. Opening the chest, stopping the heart, and transferring circulation to a machine create significant stress on the tissues. While young individuals in good general health may tolerate this process more easily, recovery usually takes weeks, and healing of the breastbone may take months.
What Are the Advantages of Non-Surgical Interventional Methods in the Treatment of Degenerative Mitral Valve Disease?
Although traditional open surgery is effective, opening the chest may carry very high risks for elderly individuals or people with additional health problems such as chronic lung disease or impaired kidney function. For patients whose bodies are too fragile to withstand such major surgical trauma, the most important alternative offered by medicine is transcatheter, catheter-assisted non-surgical methods performed within the field of interventional cardiology. The basic philosophy of these methods is to reach the valve through vascular pathways and repair it from within without stopping the heart or making large incisions.
Some potential advantages these innovative approaches offer patients are as follows:
- No cutting of the breastbone
- No stopping of the heart
- Short hospital stay
- Rapid recovery process
- Low risk of bleeding
- Reduced post-procedural pain
These catheter-based procedures begin by entering a large vein in the groin with thin needles. Because there is no large incision in the body, the risk of infection is lower, and patients can begin walking independently shortly after the procedure. The physical restrictions lasting for weeks after open surgery are generally absent with this method; most patients can be discharged within a few days and quickly return to their daily routines, loved ones, and social lives. In addition, if a new valve problem develops in later years, while a second open-heart surgery is considered very risky, the possibility of repeating procedures performed through the groin with a lower risk profile provides a major advantage.
How Is the Clipping (MitraClip) Procedure Performed Step by Step in Cases of Degenerative Mitral Valve Disease?
One of the most common and groundbreaking methods that comes to mind when non-surgical valve repair is mentioned is the clipping procedure, medically known as Transcatheter Edge-to-Edge Repair (TEER). This procedure is performed in the angiography laboratory. The patient is usually placed under general anesthesia to ensure comfort and safety.
The procedure is guided by a three-dimensional ultrasound probe placed in the esophagus, which provides a very clear view of the heart from directly behind it. A small entry is made through the vein in the groin, and a long, flexible, steerable tube (catheter) is advanced into the upper right chamber of the heart. The thin wall separating the right and left chambers of the heart (septum) is punctured at a very precise point using a special needle, allowing passage to the left side, where the mitral valve is located. Determining this crossing point with millimetric calculations is critically important so that the device can approach the valve at the correct angle.
After passing to the left side, the system with a small clip-like device at its tip is advanced through the catheter toward the valve. While the heart is monitored live on the ultrasound screen, the device is aligned directly over the area of the valve where the leakage is greatest. Inside the beating heart, the arms of the device are opened and lowered beneath the valve. When the heart contracts, the leaflets move toward the arms of the device; at that moment, the arms are closed and the leaking leaflets are attached to each other at their centers. Before the device is released, the extent to which the leakage has decreased is checked. If the reduction appears sufficient, the clip is left permanently in place and the procedure is completed, thereby largely preventing leakage in that part of the valve.
Who Is a Suitable Candidate for Non-Surgical Treatment of Degenerative Mitral Valve Disease?
Although the clipping procedure is a major achievement of medical technology, it cannot be considered a standard treatment for everyone with a heart valve problem. The decision regarding who should undergo the procedure is made through comprehensive evaluations by boards known as the “Heart Team,” which include cardiologists, surgeons, and anesthesiologists. The aim is to determine the method that will provide the greatest benefit and carry the least risk for the patient.
In general terms, individuals who do not respond to medication and are considered at very high risk for open-heart surgery due to advanced age or severe accompanying diseases are among the primary candidates for this procedure. However, high surgical risk alone is not sufficient; the anatomical structure of the valve must also be suitable for the device to attach. Large international medical studies have shown that this method can produce lifesaving results in patients whose valve leakage is disproportionately large compared with the size of the heart itself. The procedure is not performed if the valve is excessively calcified, if the valve opening is already too narrow, or if there are infectious clots inside the heart. Selecting the right patient is the most critical factor in treatment success.
What Approach Is Followed If Valve Stenosis Is Present Along with Degenerative Mitral Valve Disease?
Structural deterioration of the mitral valve does not always occur only as loosening and backward leakage; sometimes, due to years of wear, previous infections, or excessive calcium accumulation in the tissues, the valve leaflets may thicken and adhere to each other. In this case, the valve becomes unable to open sufficiently, let alone close completely. Blood has difficulty passing from the upper chamber into the lower chamber, and serious pressure accumulation develops inside the heart.
When stenosis is predominant but the leaflets have not yet become calcified to the point of hardening like stone, a non-surgical solution may still be possible. In this procedure, called “balloon valvuloplasty,” which is performed by entering through the groin vessel, a special deflated balloon is positioned in the narrowed valve opening with the help of a catheter. The balloon is suddenly inflated at the correct point, allowing the fused connection points of the leaflets to stretch and separate in a controlled manner. Through this mechanical widening, the valve opening area increases, blood flow improves, and a noticeable reduction in symptoms such as shortness of breath is generally aimed for, even while the patient is still on the procedure table.
Can Non-Surgical Valve Replacement (TMVR) Be Performed If Degenerative Mitral Valve Disease Is Advanced?
The clipping procedure focuses on repairing the existing valve from within while keeping it in place. However, in some patients, the valve structure may be too deformed to repair, excessively calcified, or anatomically altered completely due to previous surgeries. In such cases, no healthy tissue remains for the clipping device to attach to. While alternative treatment options for these patients were very limited in the past, non-surgical valve replacement technologies known today as transcatheter mitral valve replacement (TMVR) have become a major source of hope.
The aim of this procedure is to completely replace the patient’s nonfunctioning valve with a new artificial valve. A biological heart valve, folded and compressed into a very thin tube, is advanced through the groin into the heart. When it reaches the exact level of the old valve, the new valve opens like an umbrella, presses the old tissues toward the walls, and takes over their function. This method is generally used in patients who previously received an artificial valve made from animal tissue during open surgery but whose valve has deteriorated, by placing a new valve inside the old one. Similarly, when the valve frame becomes completely covered with calcium and hardens like stone, an important treatment alternative is created by using this concrete-like base to anchor the new valve in that area.
Which Advanced Technological Examinations Should Be Performed Before Treatment for Degenerative Mitral Valve Disease?
Whether the procedure involves repair or valve replacement, the success of non-surgical interventions depends on highly detailed planning performed beforehand. Because the inside of the heart is a closed box, devices placed from outside must be fully compatible with the heart’s unique anatomy. At this stage, high-resolution imaging technologies come into play.
The basic examinations that should be performed before the procedure are listed below:
- Transesophageal echocardiography
- Cardiac computed tomography
- Electrocardiography
- Blood tests
These tests make it possible to create a three-dimensional virtual map of the heart. Particularly when placement of a new valve is planned, computed tomography data are transferred to specialized software. The device is virtually simulated as if it had been placed inside the heart. The main concern is whether the structure placed from outside will put pressure on other parts of the heart; for example, if there is a risk that it may narrow the outflow tract through which blood travels from the heart to the main artery, that procedural method is not preferred. Millimetric measurements are critically important for minimizing risks and achieving positive outcomes from the procedures.
Which Simultaneous Procedures Are Performed When Degenerative Mitral Valve Disease Also Affects the Right Heart?
The circulatory system in our body works in an integrated manner, and a problem in one area gradually affects other areas as well. When deterioration of the mitral valve continues for many years, the high pressure created in the lungs by the backward-flowing blood gradually reflects toward the right side of the heart. As a result of this chronic burden, the frame of the tricuspid valve located on the right side of the heart begins to enlarge, and that valve also becomes unable to close completely and starts leaking blood. This condition worsens the patient’s health much more rapidly and causes severe fluid accumulation in the legs and abdomen.
Thanks to the technological capabilities offered by interventional cardiology, simultaneous interventions can be performed even in patients whose condition has progressed this far. When the patient’s general health and heart structure are considered suitable, clipping procedures may be applied to both valves in a single session using the same vascular access in the groin. First, passage is made to the left side and an attempt is made to reduce leakage of the mitral valve; immediately afterward, the procedure returns to the right side and a similar repair clip is attached to the leaflets of the tricuspid valve. In this way, the mechanical burden on both sides of the heart is reduced with a single procedure; this dual approach has been observed to be highly supportive in reducing patients’ shortness of breath and body swelling.
How Are Leaks That May Develop After Degenerative Mitral Valve Disease Treated?
In some patients who previously received a mechanical or biological valve through open-heart surgery, new problems may arise years after the operation. Even if the implanted artificial valve itself continues to function properly, weakening may occur in the tissues around the outer frame where it was sutured to the heart, or the sutures may loosen. In this situation, although the main door remains closed, leakage begins between the outer frame of the door and the wall. This is medically called a paravalvular leak. Blood cells forced backward through these narrow gaps under high pressure break apart, causing severe anemia and fatigue in the patient.
Performing a second open-heart surgery on these patients is a very demanding process. Instead, interventional methods are preferred, entering through the groin and passing through the small leaking tunnels with the help of thin wires. Special umbrella- or plug-like devices designed to completely close the tunnel are placed there. Once the device is positioned, the surrounding gap is closed and the leakage is intended to stop. This repair technique, which prevents the breakdown of blood cells and reduces symptoms of heart failure, helps improve patients’ quality of life by protecting them from the physiological burden of major surgery.
Frequently Asked Questions
Prof. Dr. Kadriye Orta Kılıçkesmez is one of the leading figures in the field of Turkish cardiology. She was born on January 24, 1974, in Tekirdağ. After completing her undergraduate education at Istanbul University Cerrahpaşa Faculty of Medicine, she chose cardiology as her specialty and received her specialist training at the Cardiology Institute of the same university. In 2015, she was appointed by the university to establish the Şişli Etfal cardiology clinic and Angio laboratory. Becoming a professor in 2017, Kadriye Kılıçkesmez established the cardiology clinic and Angio laboratory of Prof. Dr. Cemil Taşçı Hospital in 2020 and ensured that the clinic became a training clinic.
