What is heart valve surgery?

Heart Valve Surgery: Types, Procedures, and Considerations

Heart valve surgery is a surgical procedure that repairs or replaces damaged or diseased heart valves to restore proper blood flow through the heart chambers and improve cardiac function, reduce symptoms, and extend life expectancy. 1

Types of Heart Valve Surgery

Valve Repair

• Mitral Valve Repair: Preferred technique when feasible due to lower mortality and better long-term outcomes 1

  • Most successful for degenerative mitral regurgitation with segmental valve prolapse 1
  • Less consistent results with rheumatic lesions, extensive valve prolapse, or calcification 1
  • Techniques include annuloplasty, leaflet repair, and chordal preservation/reconstruction

• Aortic Valve Repair: Less common than replacement but may be performed for certain types of aortic regurgitation

  • Techniques include decalcification, commissurotomy, and leaflet repair

• Tricuspid Valve Repair: Usually performed alongside other valve procedures

  • Conservative surgery preferred over balloon commissurotomy for isolated tricuspid stenosis 1

Valve Replacement

• Mechanical Valves:

  • Structurally stable with virtually zero primary failure rate 2
  • Require lifelong anticoagulation with warfarin 1
  • Typically used for younger patients 2
  • Types include single tilting disc and bileaflet valves 1

• Biological Valves (Bioprostheses):

  • Do not require long-term anticoagulation unless other indications exist 1
  • Subject to structural valve deterioration over time 1
  • Typically used for older patients 2
  • Types include:
    • Stented and stentless xenograft valves (porcine, bovine, or equine) 1
    • Homografts (human donor valves) 1
    • Pulmonary autografts (Ross procedure - using patient's own pulmonary valve) 1

Transcatheter Valve Procedures

• Transcatheter Aortic Valve Implantation (TAVI):

  • Performed percutaneously for patients with severe symptomatic aortic stenosis 3
  • Now approved for all surgical risk categories 3
  • Uses balloon-expandable or self-expanding valves 3

• Transcatheter Mitral Valve Repair:

  • Edge-to-edge repair (MitraClip) for high-risk patients with degenerative or functional mitral regurgitation 3
  • Significantly reduces hospitalizations for heart failure compared to medical therapy alone 3

• Valve-in-Valve Procedures:

  • Used for failed bioprosthetic valves in high-risk patients 4
  • Provides immediate hemodynamic improvement without reoperation 4

Surgical Considerations and Outcomes

Surgical Approach

• Traditionally performed through median sternotomy incision 1
• Minimally invasive approaches (partial sternotomy) gaining acceptance 1
• Requires cardiopulmonary bypass to isolate the heart from circulation 1

Mortality and Complications

• In-hospital mortality for isolated aortic valve replacement: 2.9-3.6% 1
• Combined valve and CABG procedures: 6-7% mortality 1
• Experienced centers report mortality rates of <1-2% for isolated valve procedures 1
• Early postoperative complications occur in approximately 26.6% of patients 5
  • Valve-related events
  • Postoperative arrhythmias
  • Worsening function of repaired valve
  • General complications

Risk Factors for Complications

• Advanced age
• Diabetes mellitus
• Hypertension
• Poor functional capacity
• Multivalve disease 5

Decision-Making for Valve Surgery

Repair vs. Replacement

• Valve repair is preferred when feasible due to:

  • Lower operative risk
  • Better preservation of left ventricular function
  • Avoidance of long-term anticoagulation
  • Reduced risk of endocarditis 6
  • Better long-term durability for mitral valve 6

• Factors favoring mechanical valve:

  • Younger patient age
  • Need for long-term durability
  • Already requiring anticoagulation for other reasons 1

• Factors favoring bioprosthetic valve:

  • Older patient age
  • Inability to manage anticoagulation
  • Limited life expectancy
  • Women of childbearing age 1

Timing of Surgery

• Early intervention is recommended before irreversible ventricular dysfunction occurs 1
• For asymptomatic severe mitral regurgitation, surgery is indicated with:
  • Left ventricular dysfunction (LVEF ≤60% or LVESD ≥45 mm) 1
  • New-onset atrial fibrillation or pulmonary hypertension 1
  • High likelihood of successful repair 1

Future Developments

• Continued refinement of transcatheter valve technologies 3
• Development of tricuspid valve transcatheter therapies 3
• Improvements in valve durability and design
• Advanced imaging for procedure planning and guidance 3

Heart valve surgery has evolved significantly with advances in surgical techniques, prosthetic valve design, and transcatheter approaches, providing effective treatment options for patients with valvular heart disease across all risk categories.