Designation from the American Heart Association, Mitral Valve Foundation recognizes high-volume programs that achieve excellent outcomes for repair surgeries

The American Heart Association (AHA) and the Mitral Valve Foundation recently designated Emory Saint Joseph’s Hospital as a Mitral Valve Repair Reference Center, a recognition awarded to hospitals that have shown excellence in clinical outcomes and performance in mitral valve repairs. Emory Saint Joseph’s is the first hospital in the southeast to receive the designation and one of only seven in the country.

The AHA and Mitral Foundation established the designation this year to increase the number of patients who undergo mitral valve repair where appropriate, rather than mitral valve replacement, which has been associated with higher rates of death or complications within five years after surgery.

To receive the designation, hospitals must perform at least 50 index mitral valve repair procedures per year for the most recent three years and have at least one surgeon who has performed a minimum of 25 index mitral valve repair procedures per year in the last two years. Emory Saint Joseph’s cardiovascular surgeons Douglas Murphy, MD, and Michael Halkos, MD, far exceeded the threshold for reference center designation. In just one year—2020—they performed 240 robotic mitral valve repair surgeries at Emory Saint Joseph’s.

“Overall 85% of patients with mitral regurgitation can be repaired. The US average is 50-60%. For degenerative disease the repair should approach 100%,” says Dr. Murphy, professor of surgery at Emory University School of Medicine and medical director of surgical robotics at Emory Saint Joseph’s. “Last year, our program’s repair rate for these patients was 100%, with no incidence of strokes or deaths. The reason to repair is important;

• Lower morbidity and mortality
• Less chance of a second operation being needed
• Cardiac function is better

The Impact of Subspecialization

At Emory Healthcare, cardiothoracic surgeons and surgery teams specialize in different segments of cardiac surgery, such as aortic disease, heart transplant, aneurysm and left ventricular assist devices. “To become proficient in even one of these areas requires years of experience and focus,” Dr. Murphy explains. “Our mitral valve surgery team includes surgeons, anesthesiologists, perfusionists, nurses and other clinical staff whose dedicated expertise makes it possible for us to achieve such strong outcomes.”

Emphasis on robotic surgery

Almost all mitral valve repairs at Emory Saint Joseph’s Hospital are done endoscopically with a surgical robot (the national average is about 11%). “We use the robot to perform the same surgery you would with a conventional sternotomy, accessing the valve through five tiny holes in the soft tissue rather than through bone,” Dr. Murphy says. “Instead of a two- to three-month recovery, most patients are back to their normal lives within three weeks.”

Dr. Murphy credits the robotic approach with better outcomes than sternotomy since it offers:

• Improved visualization with 10x magnification, compared to 3-4x for conventional magnification with a sternotomy.
• Lateral endoscopic approach. Using the robot, the surgeon enters the left atrium from the lateral cheSaint This reduces the need for septal retraction and minimizes distortion of the valve anatomy. Dr. Murphy and colleagues at Emory developed this technique, called the lateral endoscopic approach with robotics (LEAR), which is now widely used throughout the world by other robotic surgeons.
• Precise instrumentation of the valve. Cardiovascular surgeons perform mitral valve surgeries using robotic instruments alongside highly trained surgical assistants who use handheld instruments for certain elements of the surgeries. The technique leads to more precision and shorter surgery times. 

Since 2002, Dr. Murphy and his colleagues have completed over 2,500 robotically-assisted mitral valve surgeries, more than any other program in the world. They also perform many concomitant procedures with the mitral valve repair, including tricuspid valve repair/replacement, atrial ablation, closure of the left atrial appendage and repair of atrial septal defects.

When to Refer

Patients routinely travel from all over the United States to have their mitral valve surgery at Emory. Among those eligible for surgery include those who have already had a sternotomy and those with certain comorbidities, including obesity. Cardiologists typically refer patients who are experiencing any of the following:

• Severe mitral regurgitation
• Any enlargement of the left atrium or left ventricle
• Onset of atrial fibrillation when an echocardiogram detects a leaky mitral valve
• Shortness of breath

Because mitral valve degenerative disease occurs slowly, patients may wish to delay surgery until their symptoms are more severe. However, research shows that those who undergo surgery earlier have a normal life expectancy, unlike those who wait until they are more symptomatic.

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