Surgery is the standard treatment for mitral regurgitation.
However, in Japan, MitraClip has been reimbursed from April 2018 for so-called high-risk patients who are elderly, have extremely poor heart function, and have many illnesses.
At our hospital, Surgery, we perform Mitra Clip for patients who are more suitable for this treatment. The treatment, Surgery of hospital stay compared to surgery is short features.
High risk of surgery, treatment for the elderly, short hospital stay
Less burden on the body
MytraClip, which is a catheter treatment, is a treatment that is inserted from a vein in the groin (base of the crotch) and clipped from the right atrium to the left atrium to the regurgitation part of the mitral valve.
Since there are no scars left on the chest, recovery from surgery is quick and the burden on the body is small. First, to those who benefit of surgery is large, Surgery surgery (valvuloplasty, replacement) recommends. However, even among patients who have had difficulty undergoing surgery due to their age, comorbidities, and extremely poor cardiac function, if the anatomical fit on the transesophageal echograph (described later) is satisfied, this is the case. The hospital recommends Mitra Clip.
From insertion to placement of MitraClip ®
What is mitral regurgitation?
It is one of the heart failure that causes blood to flow back, which causes heart failure.
The heart is mainly divided into four rooms. Each room has a total of 4 doors (valves) to prevent blood from flowing back. Blood oxygenated in the lungs is first collected in the left atrium and then filled in the left ventricle, a pump that pumps blood throughout the body. The mitral valve is located between these left atrium and left ventricle. In most mitral regurgitation, the string (chordae tendineae) that connects the valve to the left ventricle is partially cut, the left ventricle itself becomes larger, the valve is pulled, and the mitral valve frame expands. This results in the valve not closing properly and the blood flowing back from the left ventricle to the left atrium.
Mitral valve Mitral valve with insufficiency
There are two main types of mitral regurgitation, "organic (primary) MR" and "functional (secondary) MR".
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Organic (primary) MR
The chordae tendineae (the string connecting the mitral valve and the left ventricle) on the left ventricular side of the mitral valve break or stretch for some reason, causing the mitral valve itself to become unfit (joint failure) and blood. Is in a state of regurgitation to the left atrium.
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Functionality (secondary) MR
The left ventricle becomes sluggish due to ischemic heart disease such as myocardial infarction, dilated heart disease, etc., or the heart itself expands, causing the string (tendon cord) that connects the mitral valve to be pulled, or the mitral valve. As the heart becomes larger, the mitral valve itself becomes less fit (joint failure), and blood flows back into the left ventricle.
Current status of mitral regurgitation
Valvular heart disease is a disease that increases with age and age. Among them, mitral valve disease is the most common valvular heart disease and accounts for a large part of all valvular diseases.
According to US statistics, it is reported to be present in 9.3% of people aged 75 and over (Fig. 1).
The number of operations for valvular heart disease in Japan is also increasing with the aging society (Fig. 2).
Figure 1: US Population Based Survey
Figure 2: Survey of Olmsted County, Minnesota, USA
* Nkomo VT, et al. Burden of valvular
heart diseases: a population-based study.
Lancet. 2006; 368: 1005-11.
Comparison of treatment methods
How to treat mitral regurgitation
If you have mild illness, you can relieve the symptoms with medicine or follow up.
Severely ill patients need surgery to replace or repair the valve, but for elderly people and patients with complications who have been unable to perform surgery due to the heavy burden on the body, MitraClip.
| Method of treatment | Follow-up or medication | Surgery surgery | MitraClip (MitraClip) Percutaneous mitral valve insufficiency repair |
|---|---|---|---|
| severity | Mild to severe | Severe | Severe |
| Treatment content | I take several kinds of medicines. Medications remove excess water, dilate blood vessels, reduce pulse and blood pressure to rest the heart and increase the contraction of the heart. | The regurgitated mitral valve is surgically repaired or replaced with an artificial valve. | It is a treatment that uses a medical tube called a catheter to pinch the mitral valve with a clip to improve regurgitation. |
| merit | You can do it in the hospital, but you can also do it mainly at home. The burden on the body is the lowest treatment, except for the side effects of the drug. | If there are no abnormalities in the valve or the surrounding tissue, radical treatment is possible. | It can improve mitral valve regurgitation without surgery (open heart surgery) and is considered to be less risky than surgery. |
| Demerit | It is not a radical cure for mitral regurgitation. The disease can get worse over time. | Since it is an operation that stops the movement of the heart (open heart surgery), it may increase the burden on the body and cause serious complications. | It can cause complications specific to this treatment. It is not a radical treatment for mitral regurgitation. |
Main symptoms and test methods
Mitral regurgitation is difficult to show initial symptoms, and if it progresses without symptoms, shortness of breath, dyspnea, swelling, etc. will appear, so caution is required, such as undergoing regular medical examinations.
Mitral regurgitation (functional MR), which is associated with chronic heart failure, is said to affect the exacerbation of symptoms and prognosis of life, and requires regular echocardiographic observation.
Inspection methods
| Echocardiography (Trans-chest wall echocardiography) |
Use ultrasound to observe the shape and function of the heart and blood reflux. |
|---|---|
| Transesophageal echocardiography (Transesophageal echocardiography) |
With the side facing, an ultrasonic probe with a diameter of about 1 cm is placed in the esophagus like a gastrocamera, and the heart is examined by ultrasound from the back side. Compared to transthoracic echocardiography, the lungs and ribs do not get in the way, so it is possible to observe the valves and reflux of the heart more clearly. Especially MitraClip is, mate Ya length of the valve, because there are restrictions on the width (anatomical adaptation), all of the patients who get accepted, you must receive this inspection prior to surgery. |
| Stress echocardiography | Exercise stress echocardiography may be performed. This test involves riding a bicycle while lying down and straining the heart to see what happens to the movement of the left ventricle and whether blood regurgitation from the valve increases. |
Target patients
Patients with symptomatological severe mitral regurgitation (class 3 or 4) and any of the following:
- The danger of heart surgery
Those who are said to be expensive - Elderly people
- Those with impaired cardiac function
- Heart and chest Surgery surgery
Those who have a history - People with cirrhosis
- Such as emphysema
Those with respiratory illness - On the chest
Those who have a history of radiation therapy
Safe and advanced treatment environment
This can only be achieved at the Tobu Hospital
The treatment environment unique to general hospitals is in place.
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Reliable team structure
Supported by a "heart team" that transcends the boundaries of clinical departmentTobu Hospital has formed the "Heart Team" and started at the end of 2012. Rather than prioritizing the treatment method of the clinical department to which the doctor in charge belongs, doctors and staff will discuss with each other across the boundaries of the clinical department The Heart Team will continue to support you after treatment.
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One of the few in Yokohama
Hybrid catheter roomIt is an integrated operating room and angiography device, and refers to an operating room that can perform high-quality fluoroscopy and 3D imaging. Since the operating room is the basis, consideration is given to prevent infection, and lighting equipment necessary for surgery, such as surgical lights, is also installed. This makes it possible to use catheter treatment in combination with areas that are difficult to reach with surgery alone, or to perform surgery at the same time for lesions that cannot be treated with catheter alone. In addition, for the complications that occurred during catheter treatment, Surgery There are also benefits that can be quickly migrated to surgery. By performing hybrid surgery using this hybrid operating room, we aim to provide patients with minimally invasive, effective and safe treatment.
Forefront of treatment for mitral regurgitation
For each patient
Tailor-made treatment
In our hospital Cardiovascular Surgery feel working as a physician, internal medicine and Surgery of the fence is low, is that the airy smooth cooperation can be taken. Share patient information and exchange frank opinions from each professional standpoint at the conference. That leads to the best treatment choice. At this hospital, catheter treatment (TAVI, MitraClip), minimally invasive heart surgery (MICS) with right small thoracotomy, and normal thoracotomy can all be performed in the treatment of valvular disease. We will provide tailor-made treatment for each patient from all options, so if you are concerned about valvular disease, please feel free to consult us as soon as possible.
済生会横浜市東部病院 心臓血管外科部長
MitraClip is a catheter treatment. The burden on the patient's body is less than in normal surgery, and the wounds are smaller, so there is less pain after surgery. However, MitraClip is basically Surgery Since it is a procedure that is difficult patients surgery is the object, or an elderly, with or have other diseases, is often where there is a risk to make a general anesthesia. Anesthesiology specialists are always in charge of surgery to manage the whole body of patients safely. Since it is necessary to adjust blood pressure and respiration during surgery to evaluate treatment policies and procedures, smooth communication with a Cardiology At our hospital, the Heart Team, which was formed in 2012, is still providing medical care with almost no change in the main staff, so I am confident in that respect. Please feel free to receive treatment at our hospital.
Saiseikai Yokohamashi Tobu Hospital Anesthesiology Medical Director
Flow from first visit to discharge
Tobu Hospital, we propose the most suitable medical environment for patients undergoing surgery and have an environment to back up their treatment.
Before surgery
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First visit outpatientThe doctor in charge will ask you about your current symptoms, activity of life, comorbidities, treatment history and oral medications. At the same time, blood sampling, chest X-ray, transthoracic echocardiography, etc. may be performed outpatiently.
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Preoperative examination
(Transesophageal echo, etc.)We will perform transesophageal ultrasonography (transesophageal echocardiography) at an outpatient clinic. In addition, if the doctor in charge deems it necessary, stress echocardiography and CT will be performed outpatiently. Patients with chronic heart failure may be hospitalized before surgery MitraClip for intravenous drip and drug adjustment.
After managing heart failure with drugs, transesophageal echo and coronary catheterization may be performed before discharge.
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Heart Team ConferenceBased on the interview and test results, Cardiology (catheter treating physician, echocardiography physician), Cardiovascular Surgery performed well, in the heart team made up of experts in each department, the selection of treatment appropriate for the patient's We will have a discussion.
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MitraClipAfter being hospitalized, we will perform a MitraClip in cooperation with the Cardiology (catheter treatment doctor, echocardiography doctor) and Anesthesiology
After surgery
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Postoperative treatmentIf you enter the intensive care unit (ICU) and the heart failure has subsided after postoperative management, you will be transferred to the general ward.
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RehabilitationIf the condition is calm, rehabilitation will start the day after the operation. The inguinal region (crotch) where the catheter is inserted is removed, and the Pharmacist 's medication guidance and discharge adjustment are started.
If the patient has passed without complications after surgery, he / she can be discharged from the hospital in about 5 to 7 days.
Treatment costs
MitraClip" (varies slightly depending on length of hospital stay and room charge)
| Target person | Medical expenses burden | High-cost medical treatment system | Actual counter burden (including meals) | |
|---|---|---|---|---|
| Active income earners | Ⅲ Taxable income of 6.9 million yen or more | About 360,000 yen | → | 291,220 yen |
| Ⅱ Taxable income of 3.8 million yen or more | 208,860 yen | |||
| Ⅰ Taxable income of 1.45 million yen or more | 124,470 yen | |||
| General | Taxable income less than 1.45 million yen | 20% burden about 240,000 yen 10% burden about 120,000 yen |
→ | 68,640 yen |
| Low-income earners | Resident tax exemption (low income I) | 35,640 yen | ||
| Resident tax exemption (low income II) | 26,040 yen | |||
| Target person | Medical expenses burden | High-cost medical treatment system | Actual counter burden (including meals) |
|---|---|---|---|
| Annual income of about 11.6 million yen or more | About 360,000 yen | → | 291,220 yen |
| Annual income of about 7.7 million yen to 11.6 million yen | 208,860 yen | ||
| Annual income of about 3.7 million yen to 7.7 million yen | 124,470 yen | ||
| Annual income of about 3.7 million yen or less | 68,640 yen | ||
| Resident tax exemption (low income II) | 46,440 yen |
* 1 [Low-income earners II]:
All household members are (1) tax exempt from municipal inhabitants tax, or (2) persons requiring nursing care under the Public Assistance Act, and those who do not need protection due to the reduction of Ceiling Amount of self payment
* 2 [Low-income earners I]: All household members fall under "low-income earners II", and their household income is below a certain standard.
FAQ
- How long have you been in the hospital?
MitraClip may be hospitalized several days before the implementation of Mytraclip, and you may be required to adjust the drug and perform preoperative examinations. If there are no complications after the operation and the condition is stable, the patient can be discharged within a week, so the total length of hospital stay will be about 10-14 days. As mentioned above, you may be hospitalized for drug adjustment and preoperative examination purposes.
- Are there any patients who cannot receive the MitraClip
In transesophageal echocardiography examination, anatomically MitraClip patients who are not in adaptation, patients life expectancy is considered to be not long for the disease to complications is now, percutaneous mitral valve junction failure repair I cannot receive (MitraClip
- MitraClip if I wish?
Percutaneous mitral valve insufficiency repair (MitraClip) cannot be performed at the patient's request alone. The current standard treatment for mitral regurgitation is Surgery mitral valve repair / replacement. However, patients vary in age, comorbidities, and activity. First, this Surgery consider the advantages and disadvantages of surgery, in the case of then this remains observation in drug treatment risk, and is a minimally invasive MitraClip the benefits and disadvantages of, based on the results of the interview and the preoperative examination , Will be considered by the Heart Team.
- Is there any pain from the treatment?
We will perform general anesthesia and manage it appropriately so that the patient does not feel any pain. In principle, Surgery wound as surgery does not remain in the chest, there are rare cases that the catheter insertion portion of the base of the foot is sore after surgery. I try to minimize it with painkillers.
- What are the complications
There are the following complications.
Thromboembolism
It is a complication that when a catheter or clip is inserted into the body, blood clots are formed or bubbles are generated, which clog the blood vessels of the brain (embolism).
Heart tamponate / hemothorax
It is a complication caused by damage to the heart when inserting a catheter. Blood collects around the heart, which can cause a decrease in blood pressure and deterioration of respiratory status.
Clip dropout / embolism
It is a complication that the clip that grips the anterior and posterior leaflets of the mitral valve comes off and flows to other organs (embolism). There is also a complication of unilateral valve leaflet grasping, in which the leaflet on one side comes off the clip and the mitral regurgitation cannot be controlled.
Atrial septal defect (iatrogenic)
MitraClip inserts a catheter from the right atrium to the left atrium, but at that time, the hole remains in the atrial septum due to the thickness of the catheter. Through this hole, blood may move (shunt), and in rare cases, breathing may become difficult or the heart may be strained.
Mitral valve stenosis
MitraClip, it may be difficult to open the valve, which may cause mitral valve stenosis. During the operation, we will observe by transesophageal echocardiography and judge how much stenosis can be tolerated, taking into account the control of mitral valve regurgitation.
Esophageal ulcer
MitraClip is a general anesthesia, but during the operation, transesophageal echocardiography is placed in the esophagus for several hours and operated. This may result in an ulcer in the postoperative esophagus.
Puncture complications / infection
Hematoma, wound infection, or infection (infective endocarditis) may occur at the place where the catheter is inserted after surgery.
Consultation information
"Valvular disease / heart failure outpatient clinic"
弁膜症・心不全でお悩みの方は、
予約不要の弁膜症外来にお越しください。
毎週 水曜日 (受付 8:30～11:00) 担当医
毎週 木曜日 (受付 8:30～11:00) 担当医：本多
水・木曜日にお越しになれない方でも、平日毎日（受付 8:30～11:00）初診受付しております。
Consultation by phone
045-576-3000(Representative)
Reception hours 9:00-17:00 (Saturdays, Sundays, and holidays)
Please tell us "To the outpatient department of the Cardiovascular Center".
