Surgeon Insights: Minimally-Invasive Mitral Valve Repair with Dr. Marc Gerdisch
Written By: Adam Pick, Patient Advocate & Author
Medical Expert: Dr. Marc Gerdisch, Chief of Cardiac Surgery at Franciscan Health
Page last updated: April 27, 2021
For patients needing mitral valve repair surgery, a key consideration in selecting your medical team may be the surgical approach utilized to access the heart. With so many options available to patients, I wanted to answer several patient questions I recently received about minimally-invasive mitral valve repair surgery.
To help you learn more, I interviewed Dr. Marc Gerdisch, the Chief of Cardiac Surgery at Franciscan Health in Indianapolis, Indiana. Dr. Gerdisch is long-time supporter of HeartValveSurgery.com who has performed successful heart valve surgery on over 100 patients in our community. So you know, this video became an instant “patient-favorite” at YouTube. In just a few weeks, this video has been watched over 8,000 times.
Key Learnings from Dr. Gerdisch
For patients with mitral regurgitation, the key learnings that Dr. Gerdisch shared during our interview are actionable and beyond helpful. For that reason, I wrote down several important points below.
- Dr. Gerdisch is a heart valve expert who has performed over 4,000 heart valve repair and replacement operations. Dr. Gerdisch is so committed to the study, research and treatment of valvular disorders, his wife got him a license plate that reads “HRT VALV”. At HeartValveSurgery.com, Dr. Gerdisch has over 100 patient testimonials.
- Mitral valve disease is global term for anything that effects the mitral valve and changes the valve itself or the shape of the heart. Those changes, often in the architecture of the heart, can impact the performance of the mitral valve. The mitral valve can be compromised due to infection (endocarditis), disease (rheumatic), and calcification of the valve as patients age. The most common mitral valve disorder is a leaking mitral valve that is known as mitral regurgitation.
- Mitral valve prolapse is a precursor to substantial mitral valve disease which is relatively common.
- While symptoms (fatigue, shortness of breath, gaining fluid weight, chest pain, palpitations) can be triggers for incremental monitoring and treatment, they are not always obvious. The “insidious” nature of mitral valve disease progression is often confused for aging.
- Risks associated with mitral regurgitation can be an enlarged heart, atrial fibrillation, pulmonary hypertension, left atrium enlargement, and, most importantly, left ventricle damage.
- The ejection fraction is the fraction of blood that leaves the left ventricle when the heart squeezes. A normal ejection fraction is 55% to 60%. Patients with mitral valve regurgitation should have a higher ejection fraction because the heart is sending additional blood back out the left atrium.
- Dr. Gerdisch considers the opportunity of timing mitral valve repair surgery as a “golden moment” for patients and their medical teams. When timed right, a mitral valve repair surgery can return a patient to normal life expectancy. Dr. Gerdisch states, “If you have mitral regurgitation and we fix it at the right time, you will live just as long as somebody who never had mitral regurgitation. That is beautiful.”
- Leaking mitral valves should almost always be repaired not replaced. A mitral valve repair procedure is one of the few procedures in medicine that return a patent to a normal life curve. A mitral valve replacement is a very good operation for damaged valves that will extend patient lives, improve hemodynamics through the valve, but there are risks associated with the replacement device as it is a foreign body inside the cardiac muscle.
- Finding a mitral valve repair specialist can be challenging for patients who are looking for an experienced surgeon and medical team. On average, a cardiac surgeon performs only five mitral valve repair procedures a year. In comparison, Dr. Gerdisch performs over 100 mitral valve repair surgeries each year.
- The most important consideration for a patient is NOT the incision made my a physician. Dr. Gerdisch states, “I would stress for every patient, the absolute most important thing is not the incision. It is a perfect operation. It is a perfect repair. It is a complete operation.”
- Minimally-invasive techniques have evolved over many decades of research and development specific to ports, camera utility, incision size, instrument capability and medical devices. The minimally-invasive mitral valve repair approach used by Dr. Gerdisch typically leverages one small incision on the side of the patient’s chest.
- The advantages of minimally-invasive mitral valve repair operations, according to Dr. Gerdisch, are the psychological benefits of a smaller incision, a faster recovery, accelerated mobility, and a shorter hospital stay. Some of Dr. Gerdisch’s patients leave the hospital on day 2 or day 3 after surgery.
- Dr. Gerdisch has implemented a unique Rapid Recovery Protocol that is minimizing or eliminating pain for patients. In particular, Dr. Gerdisch leverages the use of cryoanalgesia. Here are several wonderful examples of Dr. Gerdsich’s patients who have benefitted from Franciscan Health’s Rapid Recovery Protocol.
- For patients with tricuspid valve disease, Dr. Gerdisch will often repair their leaking tricuspid valve during a mitral valve repair procedure using the same minimally-invasive approach. There are two important considerations for a tricuspid intervention. Dr. Gerdisch states, “We’re looking for two things. We’re looking for if the tricuspid valve leaks of course. We’re also looking at the dimensions of the tricuspid annulus which is the fibrous structure that the leaflets attach to.”
- The addition of a tricuspid valve repair does not add a significant amount of time or complexity to a mitral valve repair procedure if the operation is performed by a specialist.
- Atrial fibrillation is an abnormal heart rhythm that can lead to a 5X greater risk of stroke for patients, according to the American Heart Association. Up to 35% of patients with mitral valve disease have atrial fibrillation which is under-treated. Research shows that only 38% of mitral valve repair patients get an Afib treatment at the time of their mitral valve procedure. For that reason, Dr. Gerdisch performs concomitant procedures, using surgical ablation (also known as the Maze procedure), to treat atrial fibrillation at the time of mitral valve repair surgery.
- Dr. Gerdisch’s top advice for mitral regurgitation patients are (i) determine if you can get a mitral valve repair and (ii) find a surgeon and medical team that you are comfortable and has extensive experience performing repairs.
Many Thanks to Dr. Gerdisch & Franciscan Health!!
On behalf of our entire patient community, many thanks to Dr. Gerdisch for sharing his clinical experience and research with our community! Also, many thanks to the Franciscan Health team for taking such great care of heart valve patients.
- Cryoanalgesia & Heart Surgery Pain: What Should Patients Know?
- Top 5 Facts About Dr. Gerdisch’s Rapid Recovery Protocol
- AFib & Heart Valve Disease Patient Education Center
Keep on tickin!
P.S. For the hearing impaired members of our community, I have provided a written transcript of my video interview with Dr. Gerdisch below.
Adam Pick: Hi, everybody, it’s Adam with HeartValveSurgery.com. This is a special surgeon question and answer session all about minimally invasive mitral valve repair surgery and tricuspid valve surgery. I am thrilled to be joined by Dr. Marc Gerdisch, who is the Chief of Cardiac Surgery at Franciscan Health in Indianapolis, Indiana. During his extraordinary career, Dr. Gerdisch has performed over 4,000 heart valve operations. He is a long-time supporter of HeartValveSurgery.com, where he has performed over 100 successful operations on patients in our community. Dr. Gerdisch, are you there?
Dr. Marc Gerdisch: I am here. Hello, Adam, good afternoon.
Adam Pick: Hey, Dr. Gerdisch. Thanks for being with us today. We’re going to get to this really fascinating topic about minimally invasive mitral valve repair and tricuspid valve surgery, but first, I have a true/false question for you. I understand that your commitment to heart valve disease goes beyond the operating room all the way to your license plate. I’ve recently learned, again, I’m going to ask you to confirm this, that your license plate may be H-R-T-V-A-L-V. Is that true, Dr. Gerdisch?
Dr. Marc Gerdisch: That is true.
Adam Pick: It leads me to this question for you, which is your dedication, your commitment, your research, and your innovation in heart valve therapy, what is it about this segment of cardiac that is so attractive and exciting to you?
Dr. Marc Gerdisch: Adam, it is all I do as far as my profession goes. It is a little bit of an obsession because I spend my spare time studying or doing research in heart valve disease. It’s been a very fulfilling career for me. It does dominate my life outside of my family. It’s true, it’s made its way over to my license plate. That was actually my wife, Lori Ann’s concoction, but we enjoy it. It simply symbolizes what my life is about.
Adam Pick: Dr. Gerdisch, I am thankful that you have that obsession and so are so many people in our community who are doing so well thanks to the care that you’re providing to them there in Indianapolis at Franciscan Health. Let’s now shift gears and get to the topic at hand, all about mitral valve defects and how you go about repairing them. Let’s just maybe start for patients who are perhaps newly diagnosed and learning all about mitral valve disease. Can you explain what mitral valve disease is?
Dr. Marc Gerdisch: Adam, that’s a very important question because so many people are told they have something and about their mitral valve: their mitral valve prolapsed, they have a leaking mitral valve, they have changes in the valve. Mitral valve disease is a global term really for anything that affects the function of the valve, the performance of the valve. That can be something that changes in the valve itself, the actual tissue of the valve, or it can be something that changes about the shape of the heart, the left ventricle, because the mitral valve and the left ventricle work in synergy. As the heart squeezes, the mitral valve moves with it. Changes in the architecture of the heart will also change the performance of the valve.
It’s a very global term in that sense. There can be destruction of the valve for example from endocarditis, infection, or from rheumatic disease when people have rheumatic fever when they’re young, or they can have calcification of the valve as they age. The most common disorder of the mitral valve though is a leaking mitral valve from what we call degenerative disease.
Adam Pick: Dr. Gerdisch, is mitral valve disease common?
Dr. Marc Gerdisch: People are often told they have something going on with their mitral valve. As much as probably between 2 and 4% of the people in the world have mitral valve prolapse, so people will say, I have mitral valve prolapse. That’s fairly common. It doesn’t cause any major problems, but it is a precursor to more substantial mitral valve disease. If you have it, it puts you a little bit more increased risk of having more substantial leakage of the valve. If we did echocardiograms on 100 people, random people, 20 of them are going to have some leak of the valve.
Adam Pick: Thanks for the structural overview and the description of the commonality of this problem, Dr. Gerdisch. I guess if I’m a patient and I’ve been newly diagnosed, I’m curious to know what are some potential symptoms of this disease that I should be looking out for, if anything? Can you talk about that?
Dr. Marc Gerdisch: It’s very important in all of valve disease that we recognize that although symptoms are key elements, they are triggers for reaction, they also aren’t always obvious. When people have valve disorder, sometimes it’s a very insidious, slow process. They think that they’re just aging or they put on a couple of pounds. That’s why they’re not as active as they were before. They feel more fatigued, but they don’t recognize that it’s related to their valve.
Often, we’ll have someone with substantial mitral valve disease who isn’t fully aware of it, but when we stress them, let’s say we put them on a treadmill or we talk to them about climbing stairs, well, I haven’t climbed stairs in a long time, we’ll go climb a flight of stairs, then they notice a difference. The other thing is that people that are a little more in tuned to it, their own physiology, they’ll notice it as something like that. In other words, well, six months ago, I was running up the stairs; now, I have to saunter a bit to take my time. I know there’s something different. It has a little bit to do with psychology and a little bit to do with the patient’s baseline level of activity when we talk about symptoms.
Symptoms can be shortness of breath, fatigue, gaining fluid weight, maybe some swelling in the ankles or just retention of fluid, palpitations, the feeling of fluttering in the chest that can signal an irregular heart rhythm like atrial fibrillation or just some brief episodes of rapid heart rate. People can have chest pain, too. It’s not impossible to have pain from a mitral valve. It’s a little unusual, but people will have atypical chest discomfort from a mitral valve disorder.
Adam Pick:Dr. Gerdisch, I love the way you describe this as an insidious cardiac disease because I talk to so many patients who say, I feel fine; yet, their heart might be getting more and more damaged as the disease progresses. I’m curious to know what are some of the risks for patients out there from something like mitral regurgitation?
Dr. Marc Gerdisch: Mitral regurgitation, the understanding of the disease and the impact on the person has evolved along with our ability to repair the valve. The story if you look at it over several decades is an interesting one in the sense that in the past, we waited. In general, the medical community waited until people had real symptoms or their heart enlarged. Now, as over the last 30 years, we’ve developed our acumen to the point where we repair essentially every leaking mitral valve. The threshold has fallen because we want to be able to get to the patient before they have any permanent or irreversible change in the heart.
You’re right, because the human body, because the heart is such a brilliant organism, and because we have this capacity to compensate, there’s compensatory changes we call them where the heart enlarges in order to deal with extra volume and still delivers good cardiac output or blood flow to the body. At the same time, the heart is enlarging. That means there are changes to the muscle, that means there are changes in the architecture of the heart, and that there can be fibrosis in the heart muscle.
Now, we look for essentially anything that could be a potential trigger. One would be obviously if you have symptoms. That would include if you have atrial fibrillation or irregular rhythm related to the leaking valve, if you have an evaluation in the pressure in your lungs, pulmonary hypertension, if the left atrium is enlarging, the upper chamber of your heart. That actually should be a trigger because that means that extra volume is being delivered back and forth across the mitral valve. The upper chamber is enlarging. There’s consequence to that.
Probably the most important trigger, although we don’t like to wait for it, is if we see changes in the shape or dimensions of the left ventricle because that’s the powerhouse that generates your blood pressure. That’s a thick, hearty muscle. If that starts to falter, we know that we’re pretty far along in the process when we see changes in the left ventricle.
Adam Pick: Dr. Gerdisch, I get lots of patient questions about the ejection fraction. What should patients know about the ejection fraction specific to mitral regurgitation?
Dr. Marc Gerdisch: If someone has moderate or severe mitral regurgitation, the amount of blood that they squeeze out of the heart every time it beats should be greater than normal. Let’s say people hear the term ejection fraction. That’s the fraction of blood that leaves the left ventricle when it squeezes to go out to your body. A normal person, 55-60% because the heart squeezes, the mitral valve closes, the blood goes out to the body. If the mitral valve leaks, you’re sending a lot of blood back into the left atrium and blood out to your body. You could imagine there with that path of least resistance up in the left atrium that now the heart initially is going to go from squeezing 60% out to 70% or 75% out because it’s sending blood back out into the left atrium.
When we see a “normal” ejection fraction, 55%, 50% in someone who has mitral regurgitation, we’re actually concerned because it should be higher. It’s very important that when somebody has a leaking mitral valve that there are – there’s a person who can study it and really realize what the factors are for that patient. Indeed, many people don’t need anything done; they don’t need anything done then and they may not need anything done for a long time. You just don’t want to miss the golden moment, the opportunity to intervene for the heart.
Adam Pick: Dr. Gerdisch, let’s talk about how you and your team in those golden moments go ahead and help your patients avoid those risks with different forms of therapy. Can you talk about – I know you referenced mitral valve repair a little earlier. Can you talk about the treatments you use to treat mitral regurgitation?
Dr. Marc Gerdisch: Of course. A mitral valve repair is the most important – this titular line. That’s the thing that you have to focus on with a leaking mitral valve. Above all else, the mitral valve when it’s leaking should be repaired.
Again, this has been demonstrated over 30 years ago initially by Dr. Carpentier with whom I spent time in Paris when I was in training, that if a mitral valve can be repaired, you can restore the person back to their normal life curve. It’s one of the few things in medicine where we can put somebody back to the normal life curve. In other words, if you have mitral regurgitation and we fix it at the right time, you will live just as long as somebody who never had mitral regurgitation. That is beautiful. The most important thing for us is timing and then to be sure that we get every opportunity to repair the valve. The vast majority of people with leaking mitral valves can be repaired. Number One, repair the valve.
Adam Pick: Dr. Gerdisch, can you talk about the differences between mitral valve repair and mitral valve replacement?
Dr. Marc Gerdisch: Sure, again, a very important difference. Mitral valve replacement still a very good operation. In someone who has a damaged or very sick mitral valve, the replacement is better than leaving them with their damaged, sick valve. Mitral valve replacement is a good thing for folks who cannot be repaired because we know that we will extend their lives relative to their damaged valve. If we can repair their valve, we can restore them to a normal life curve.
If we replace their valve, the replacement valve will give them back good hemodynamics, blood will flow through well, it will go in the right direction, but there’s a little bit of risk attached to a replacement valve no matter what kind of valve we use. If it’s a tissue valve or a mechanical one, it doesn’t matter; there is a little bit of risk attached to that device because it’s a foreign body inside the heart. A mitral valve replacement is still good, is still helpful when we have to do it, but we try to repair it in every situation that we can.
Adam Pick: Dr. Gerdisch, if I’m a patient, I’m hearing about this restoration of the valve and the restoration of life expectancy to normal, mitral valve repair is high my list, the operation that I want to go and have performed on me. I’ve just got a question for you. Do all surgeons out there perform mitral valve repair therapies?
Dr. Marc Gerdisch: No, as it turns out, if we look across the entire nation, mitral valve surgery itself is a little bit sparse. We have centers like ours and other places where they do lots of mitral valve surgeries. I might do 100 mitral valves in a year. If we look at the median across the nation, it’s about five. It’s true that many surgeons don’t have the opportunity to be as invested in mitral valve therapy and so don’t see as much mitral valve disease to treat. Over the years, it has funneled down and focused into centers where surgeons are dedicated to the disease process, understand it, and are able to perform the operation.
Adam Pick: For the patients out there, finding a specialist is super important for this type of therapy. Dr. Gerdisch, what I know from you is that you’ve taken this specialty one step further. You’re using minimally invasive techniques to help your patients. Can you shine some light on what it is you’re doing there in Franciscan Health in terms of minimally invasive procedures for mitral valve repair?
Dr. Marc Gerdisch: Minimally invasive surgery was a bit of a journey for me. I think I came into heart surgery just at the right time because I’m not old and I’m not young. I was part of that – the genesis of minimally invasive surgery and was able to take advantage of each component as it came along. I would stress for every patient, the absolute most important thing is not the incision; it is a perfect operation; it is a perfect repair; it is a complete operation.
Over the last couple of decades, I progressed toward doing simple things, complicated things, multiple things to the point now where we’re very comfortable through a small incision doing an entire set of operations at one time for a patient, an entire set of procedures. We evolved to that safely, slowly, being sure that we could give them exactly the same operation. I think this is the most important component. If someone’s going to do a minimally invasive operation, they have to be able to deliver the same operation that they would through a larger incision. We drove toward that.
The other thing that we really learned was that we could take what were multiple little incisions that we might make for cameras and arms and things and we coalesce them into one small incision if we can do the entire operation through one small incision. We combine that with a technique for creating anesthesia at the site. We use a cryoprobe, a freezing probe that makes that area numb. We were able then to have a consistent operation that simply always works where we go through one small incision. The patient isn’t uncomfortable. We’ve been super pleased with it now for several years.
Adam Pick: Dr. Gerdisch, talk about how you’re using new technologies like cryoanalgesia to help your patients recover, smaller incisions. Does this help in the recovery of patients who are getting minimally invasive procedures?
Dr. Marc Gerdisch: The recovery is affected in a few different ways I think. First of all, again, I’ll say it’s the most important thing to have a perfect operation. We are able to do the operations through a small incision. The small incision has a few impacts. One is psychologically; it’s just nice not to have an incision, to have a small incision. Most people can’t even notice it after a bit.
Number Two, I have a lot of people that need to get back to work. Some of them have to do heavy lifting. I can get them back to it very quickly. Number Three, their mobility is rapid; in other words, they come out of surgery. I have people sometimes go home at Day Two or Day Three just because they feel fine and you want to get out of the hospital. It has that way of expediting the recovery. Certainly, for people who are physically active, it’s super nice because there really isn’t a limitation of their activity other than very heavy lifting for a little while.
Adam Pick: Specific to that recover, Dr. Gerdisch, I’ve talked to some of your patients. I’ve seen videos of them playing tennis and golf less than three weeks after the surgery. On all their behalf, I can’t thank you enough for your commitment to this space to take first off that safety is the key concern and then add into it all these additional layers to get to a minimally invasive safe procedure that enables a faster recovery.
If you’ve got time, I have one other question for you that comes up frequently with the patients in the HeartValveSurgery.com community, which is this idea of I’ve got mitral valve disease regurgitation. I’m going in for surgery. My surgeon says to me, hey, while I’m fixing your mitral valve, I may need to go ahead and fix your tricuspid valve as well. That often takes patients by surprise, which I’m really hopeful you can help patients understand the why and the how a tricuspid valve might need to be repaired during a mitral valve surgery.
Dr. Marc Gerdisch: Great question, one that I talk to patients about all of the time. It’s frequently part of our conversation before surgery. There are really two conditions that are related to mitral regurgitation or mitral valve disease that often become an issue around the time of surgery. One is the tricuspid valve having some changes.
Now, it’s important to recognize in tricuspid valve disease when it’s secondary disease, especially when it’s related to the mitral valve. We’re looking for two things. We’re looking for if it leaks of course. We’re also looking at the dimensions of the tricuspid annulus which is the fibrous structure that the leaflets attach to. There is a strong body of evidence that when that annulus becomes enlarged and we’re not certain whether it is partly the same condition has affected the mitral valve or it’s just secondary to the mitral valve, but when that is enlarged even if the valve isn’t leaking much or maybe not even leaking that we should probably address it because it can leak later. It is very important to be alert to the tricuspid valve.
We even do a lot of valve surgery. We’ve all had patients that have come to us several years after their previous surgery where the mitral valve is still okay, but their tricuspid valve is leaking badly. Now, we have to treat that valve as a second operation. We’ve talked about golden moments of opportunity before. There is an opportunity.
When you’re doing the mitral valve surgery, it really doesn’t take much to add repair of the tricuspid valve and still be done through minimally invasive incision. It adds just a little bit of time at the end of the operation. You can address something that can become a problem later. If we see elevated pressures in lungs beforehand, if we see leaking of the valve, if we see it enlarged, it should be addressed.
I would add that second condition is atrial fibrillation. As you know, Adam, I’m – I’ve been very proactive about this. I think that it’s super important that people recognize that atrial fibrillation is never just a little atrial fibrillation. It’s a real condition that’s progressive and chronic. When patients are found to have atrial fibrillation as well, that has to be addressed at the time of your valve surgery. It definitely impacts their longevity, how well they live. It should be treated at the same time. That can be done minimally invasively as well.
Adam Pick: Dr. Gerdisch, this is fascinating. We’ve talked about mitral valve repair, we talked about tricuspid repair, A-fib as a condition that definitely needs treatment as well. I’m sure the patients out there are wondering, can all of this be treated at one time using minimally invasive techniques?
Dr. Marc Gerdisch: Yeah, I think we have to be super clear about that. Not only can they be, they should be. We cannot sacrifice any part of that operation, any procedure for – even for a small incision. Whereas I’m very comfortable treating all three through the small incision, someone else might not be. To be honest, they should move over to a sternotomy then and make sure the patient gets the full operation. Everything has to be addressed at that first operation.
Adam Pick: Dr. Gerdisch, the big question that I love to ask clinicians who dedicate their careers to this space is, what is your Number One piece of advice for a patient out there who’s considering mitral valve repair surgery right now?
Dr. Marc Gerdisch: Number one piece of advice would be to first establish that you’re with someone who can repair the valve. Second and maybe competitive with first, is it someone that you’re comfortable with? The relationship between a patient and a heart surgeon is completely unique. It’s pretty intense. You’ve decided on someone that’s going to do heart surgery for you and determine the path of the rest of your life.
Can the valve be repaired? Am I comfortable with the person who’s going to do it because I’m about to enter into a very serious relationship? The rest of it falls into place. We’ve talked about the other things, the valve repair, addressing the concomitant conditions, look at the entire experience, feel comfortable. Heart valve surgeries are rarely an emergency, so patients have time to study, to learn, to spend time talking to people, get second opinions, and be sure that they’re comfortable with what they’re going to have done.
Adam Pick: Dr. Gerdisch, that’s incredible advice. I hope all the patients out there really listen and learn from that. If you need to, press rewind to make sure you are best positioned for this procedure should you need it. Dr. Gerdisch, on that note, on behalf of all the patients at HeartValveSurgery.com, all the patients all over the world who are going to be watching this, I want to extend a tremendous thanks to you and the team there at Franciscan Health in Indianapolis for taking the time away from your very busy practice to share your clinical experiences and insights with us today. As we always say here at HeartValveSurgery.com, keep on ticking.
Dr. Marc Gerdisch: Thank you, Adam.