Prof. Dr. med. Alexander Albert is an outstanding cardiac surgeon who is internationally recognized for his expertise in minimally invasive bypass surgery, mitral valve surgery, heart transplantation, and artificial heart implantation. Since fall 2019, he has headed the Department of Cardiac Surgery at Klinikum Dortmund, one of Germany’s largest hospitals; he has developed it into a center for cardiac surgery of supraregional significance.
With 30 years of professional experience, including more than twenty years in leadership positions, Prof. Dr. Albert has had an impressive career. Previously, he served for ten years as Deputy Director of Cardiac Surgery at the University Hospital of Düsseldorf and played a key role in expanding the department into a major cardiac and transplant center. His previous positions—including as a senior physician at the Lahr/Baden Heart Center and specializations at renowned European hospitals such as the Cantonal Hospital of Basel and the University Hospital of Leuven—underscore his extensive experience and international reputation.
Under his leadership, the Dortmund University Hospital offers an exceptionally broad range of cardiac surgical procedures, thereby enabling personalized care for patients. Prof. Dr. Albert places great emphasis on ensuring that diagnostic and therapeutic decisions are discussed within an interdisciplinary team, with the patient and their family always involved in the process. This patient-centered approach ensures that the gentlest yet most effective treatment methods are selected. Prof. Dr. Albert’s team is structured so that each surgeon has a specific area of expertise, which guarantees high quality even for rare and complex procedures.
The clinic’s range of services includes, in particular, minimally invasive bypass and heart valve procedures, innovative aortic surgery, complex endocarditis surgeries, as well as mechanical cardiac support using ECMO, Impella, and artificial hearts. Of particular note is Prof. Dr. Albert’s specialization in off-pump surgery and minimally invasive bypass surgery, fields in which he is regarded as one of the world’s leading experts. His commitment to advancing minimally invasive techniques is evident in his role as director of Medtronic’s European Training Center for Minimally Invasive Bypass Surgery in Dortmund.
A central aspect of his philosophy is the preservation of the heart’s natural, biological structures whenever possible. For example, in Dortmund, a heart valve is preferably repaired and replaced with a prosthesis only when no other option is available. This also applies to other procedures where biological and reconstructive solutions take precedence. Prof. Dr. Albert is not only a renowned surgeon but also a dedicated researcher and educator. He has made it his mission to train young doctors and instill in them his passion for cardiac surgery.
His goal is for every procedure to be not only immediately successful but also as gentle and sustainable as possible for the patient. Patients at the Heart Center in Dortmund can be confident that they will be treated using the latest minimally invasive methods and that their individual needs will be the top priority. Prof. Dr. Albert and his team are fully committed to achieving the best possible quality of life for their patients by using innovative and minimally invasive techniques. The editorial team of the Leading Medicine Guide had the opportunity to speak with him specifically about “minimally invasive mitral valve surgery.”
Minimally invasive mitral valve surgery has become established in a few select clinics for the treatment of mitral valve diseases and has replaced open-heart surgery. It offers patients a less invasive alternative to traditional open-heart surgery. Smaller incisions and state-of-the-art surgical techniques reduce risks and recovery time, leading to a faster recovery and a higher quality of life. This advanced method enables surgeons to work precisely and effectively while minimizing the burden on the patient. Minimally invasive mitral valve surgery thus represents a significant advance in cardiac surgery and expands the treatment options for patients with mitral valve problems.
“The mitral valve acts as an inlet valve for the left ventricle. It allows oxygen-rich blood coming from the lungs to flow into the left ventricle, from where it is then pumped into the body at high pressure. During the pumping cycle, when the left ventricle is filled and the heart muscle contracts and builds up pressure, the mitral valve closes so that the blood cannot flow back toward the lungs,” explains Prof. Dr. Albert at the beginning of our conversation, before going on to discuss the main diseases affecting the mitral valve: “There are mitral valve diseases caused by untreated or late-treated infections in the body, such as tonsillitis or other infections in the throat. This is no longer very common here in Germany, but it still occurs in North Africa, further south, and also in Eastern Europe. Untreated inflammation attacks the mitral valve and destroys the delicate valve leaflets, which then clump together and lead to a narrowing, or stenosis. We are also familiar with this type of narrowing in the coronary arteries, and the mitral valve can similarly become narrowed and calcified. In such cases, the only option is to remove the old valve and implant a new one. Fortunately, these cases of mitral valve stenosis are rare in our practice these days; what we see more frequently is a leak in the mitral valve, known as insufficiency. This occurs when the left ventricle contracts and builds up high pressure; in cases of insufficiency, a greater or lesser amount of blood is pumped in the wrong direction toward the lungs; the blood then no longer drains properly from the lungs and backs up there, which can cause shortness of breath; in advanced cases, fluid can even be forced into the lungs, a condition known as pulmonary edema.”
Causes of mitral valve regurgitation can include valve degeneration, enlargement of the valve annulus, endocarditis, or a heart attack.
“The mitral valve has two leaflets that open when blood flows into the ventricle and close when pressure builds up. There are conditions in which the leaflets themselves are normal, but the surrounding heart structures are diseased. For example, when the left side of the heart is damaged as a result of heart attacks; in this process, heart muscle tissue dies and is replaced by connective tissue and scar tissue; the heart lacks muscle and becomes flaccid and enlarged. As the heart enlarges, the supporting apparatus to which the mitral valve is attached also stretches apart. The two leaflets of the mitral valve are pulled apart and no longer meet in the middle, creating a gap in the center. As a result, the valve leaks. Consequently, blood flows back toward the lungs at high pressure. This impairs breathing, and the patient experiences shortness of breath. If this condition persists, the lungs change—they become stiffer—and the resistance to blood flow through the lungs increases; eventually, the right side of the heart—which must pump oxygen-poor, deoxygenated blood from the body’s organs to the lungs to reoxygenate it—is also affected. It becomes increasingly difficult to overcome the rising resistance. Then the right heart also enlarges, and much like with the mitral valve, the corresponding valve in the right heart—the tricuspid valve—begins to leak,” explains Prof. Dr. Albert.
Acute mitral valve regurgitation is a sudden and severe form of regurgitation, often caused by an acute event such as a heart attack, endocarditis, or trauma. Endocarditis, an infection of the heart valves, can damage the mitral valve and also lead to regurgitation. Finally, rheumatic heart disease, a consequence of rheumatic fever, can cause scarring of the mitral valve, causing it to narrow or leak.
Prof. Dr. Albert explains: “It is not the case that every form of mitral valve regurgitation requires surgical treatment. In particular, the functional mitral valve regurgitation described above can resolve with appropriate therapy—as the heart shrinks back to its normal size. The mitral valve annulus then also shrinks again, and the two leaflets close together in the middle once more. Drug therapy, in particular, is constantly improving, so that functional mitral valve regurgitation can often resolve on its own with the right medications. In older patients, a clip inserted via a cardiac catheter also works very well. Sometimes it is also advisable to treat the underlying conditions with a stent or, less commonly, bypass surgery. Pacemaker therapy is also often helpful. Certain pacemakers can positively influence the heart’s pumping function and thereby also improve mitral valve function (e.g., CRT systems). What we see more frequently in surgery is a primary disease of the mitral valve leaflets or of the apparatus to which the leaflets are attached (papillary muscles and chordae tendineae). This can also affect very young patients who are very active in sports. It is not possible to say whether the defect is caused by overuse. Sometimes this defect is also congenital.”
Prof. Dr. Albert explains: “The cause of primary mitral valve regurgitation can be a weakness in the connective tissue, in which the suspensions (chordae) to which the mitral valve leaflets are attached become stretched out; this causes the leaflets to prolapse when pressure is applied. This is referred to as prolapse, and almost always the posterior of the two leaflets is affected. It slips past the anterior leaflet and then flips into the left atrium, meaning that the posterior and anterior leaflets no longer meet, and the valve no longer closes. Some people have had a prolapse since early adolescence, though it almost never causes symptoms at that stage. Over the years, this prolapse then becomes larger. Those affected notice this as shortness of breath during exertion or increased heart rhythm disturbances. Fluid may also accumulate in or around the lungs. However, patients often do not notice this until very late in the course of the disease. In patients who are still very young and athletic, this may manifest as a decline in physical performance. It is also possible for a doctor to discover the prolapse incidentally during a routine physical examination.
More complicated is what is known as Barlow syndrome, in which there is an abnormal contraction of the ventricle. The moment the left ventricle contracts, the mitral valve annulus opens slightly—instead of contracting, as it normally would. This places a high degree of stress on the leaflets, which in turn respond by increasing in size: they grow larger and larger and billow out like the sails of a sailing ship. As a result, the force acting on the leaflets becomes increasingly stronger and eventually reaches a point where the supporting ligaments begin to tear. Patients can live for a long time with a prolapse and even with severe mitral valve regurgitation. However, action should be taken at the latest when the heart is visibly affected by this leakage and the resulting increased workload. Due to the pressure of blood flowing in the wrong direction because of the leak, the left ventricle must pump significantly harder to compensate for the abnormal flow. In addition, the heart’s atria slowly enlarge because they are not designed to handle the high pressure at which blood is ejected from the left ventricle. And if the left atrium, located in front of the mitral valve, is already enlarged, one should not wait too long to undergo surgery. However, if the patient has few symptoms and the changes in the heart are minimal, surgery can still be postponed. The condition of the heart deteriorates gradually. There is no major risk. The worst that can happen is that the mitral valve’s supporting ligaments tear further. Then the patient will experience increased shortness of breath, feel their heartbeat (due to arrhythmias such as atrial fibrillation), and fluid may accumulate in the lungs. Nevertheless, even then, surgery can still be planned effectively, and there is no time pressure.”
Heart Surgery Without Sternotomy!
“The gold standard for treating mitral valve prolapse and Barlow’s syndrome is repair. A successful repair lasts a lifetime. Plan B is replacing the mitral valve with a prosthesis. For older patients over 70, this involves fewer drawbacks and is often a good solution. If reconstruction isn’t possible, a biological prosthesis would be implanted, which lasts 15–20 years. Once it has worn out, a new prosthesis can be easily implanted using catheter-based techniques without the need for another surgery. For younger patients, replacement with a prosthesis is not the optimal solution because biological prostheses do not last as long in younger patients, and we naturally want to avoid a second surgery. A mechanical prosthesis lasts significantly longer, but has the disadvantage that the patient must then take a blood thinner (Marcumar) for life. Therefore, I always strive for reconstruction, especially the younger the patient is. I now even perform mitral valve reconstruction in cases of endocarditis or functional mitral valve insufficiency; for these, I use very specialized techniques.
As a general rule, with very few exceptions—whether repair or replacement—all procedures are performed using minimally invasive techniques at our facility. Only if the patient has severe calcifications, an enlarged aorta, or coronary artery disease—requiring additional bypass grafts—would we perform open surgery, i.e., from the front, which involves opening the chest (sternum) (sternotomy). This applies to about 5% of our patients. A clean repair—that’s the challenge; the minimally invasive approach is standard. “Before the operation, I study the echocardiogram very carefully; that way, I already know how to repair the valve, and I’ve also developed a special formula that I use to decide which ring to choose for the best possible repair of the mitral valve,” says Prof. Dr. Albert.
During mitral valve surgery, an annuloplasty ring is often sutured around the valve annulus to stabilize and reduce its size. This causes both leaflets to meet again in the center, allowing the valve to close properly and resolving the regurgitation. The ring thus corrects the shape of the annulus and restores the function of the mitral valve, preventing blood from flowing back into the heart. In cases of prolapse, when the supporting cords are stretched out or torn, they are replaced with Gore-Tex cords, known as neo-chordae. For Barlow’s disease, there are various techniques used depending on the stage of the disease. There are also more specialized techniques, for example, for endocarditis or functional regurgitation, where the leaflets are reconstructed using special patches.
Prof. Dr. Albert sees a clear advantage in minimally invasive surgery: “For me, minimally invasive surgery—which takes between 2.5 and 3.5 hours—is the standard of care. The procedure can be easily performed through a small incision below the right breast, through which the mitral valve can be clearly visualized and repaired. This is actually simpler than open-heart surgery, which requires opening the sternum and then viewing the heart from the front. To access the mitral valve during open-heart surgery, the heart must be pulled upward and rotated. Once you’ve learned to perform the procedure minimally invasively from the side, you won’t want to go back to the other method. You need a good teacher who can teach you the standards and guide you through the process step by step. A solid understanding of echocardiography is also important for planning the surgery effectively from the outset. I’m currently training a younger surgeon, but I still perform about 100 surgeries a year myself, from the incision to the suture.”
For patients for whom surgery is too risky due to their age, an alternative treatment can be used. A clip can be guided via a catheter through the femoral vein to the mitral valve. This clip connects the valve leaflets, thereby reducing regurgitation. The procedure is performed under general anesthesia and ultrasound guidance. Once the cardiologist is satisfied with the placement of the clip, the catheter is removed, and the patient remains in the hospital for 1–2 days for monitoring. Follow-up treatment with blood thinners is usually prescribed to minimize the risk of blood clots.
“After mitral valve surgery, the patient stays in the hospital for about a week and has no restrictions afterward. The patient is completely healthy. It takes about three months for the ring to fully integrate. Patients are prescribed a blood thinner during this time. But they can fully resume their normal lives, whether that includes competitive sports or heavy physical labor,” explains Prof. Dr. Albert.
In the field of minimally invasive mitral valve surgery, there are various innovations and future developments that could expand the range of treatment options and further improve outcomes for patients.
One of the most promising developments is the improvement of minimally invasive access routes and instruments. Future developments could introduce new access routes that are even less invasive, thereby reducing tissue trauma and enabling faster recovery. These include robot-assisted procedures, which could allow for more precise movements and finer manipulation within the surgical field. “It is already possible today to perform mitral valve surgery with robotic assistance. Personally, I don’t use this method and prefer to look directly at the valve. We film every surgery, and the team can follow the procedure on a monitor, but I prefer to make the incisions and sutures under direct visualization and with a sense of the tissue—I still consider that safer and more precise at this time. The incision may be just a little bit larger, but the tactile sensation is simply better. You have a feel for the tissue, which is especially important with the mitral valve because the stitches required to position the ring must be anchored at a specific depth within the cardiac skeleton. The sutures must be precisely placed; otherwise, the ring could tear out if they’re placed too shallowly, and conversely, coronary arteries and other structures could be damaged if the sutures are placed too deeply. “Perhaps someday, when the robots have improved, I’ll look into it,” comments Prof. Dr. Albert, adding at the end of our conversation: “Continuously perfecting one’s own surgical technique is always a goal in order to become even better. In the field of mitral valve surgery, the current state of the art is very good. Nevertheless, it’s important that mitral valve treatment continues to improve. I think the main innovation will take place not in cardiac surgery but in cardiology—that we’ll make further progress, especially with older patients, and be able to replace valves, for example, via cardiac catheterization; and, of course, drug therapy—there’s a lot happening in that area right now.”
Thank you very much, Professor Dr. Albert, for this fascinating insight into mitral valve surgery!
