Heart valve disease occurs when heart valves fail to open and close properly. Left untreated, valve disease may lead to arrhythmias and congestive heart failure.
Heart valve treatment options include medication; valve repair, in which physicians attempt to fix a malfunctioning valve; and valve replacement, in which physicians install a new heart valve.
The decision to repair or replace a heart valve depends upon whether the valve is diseased, whether the valve is narrowed or leaky, and the degree of any calcium buildup.
Lifestyle choices that a person makes after valve surgery can dramatically affect the performance of a repaired or replaced heart valve.
The valves in the heart are susceptible to disease, and some people are born with defective valves. Valvular stenosis is a narrowing or obstruction of a valve that prevents the valve from opening properly, impeding blood flow. Valvular regurgitation occurs when a valve does not close properly between heartbeats, allowing blood to regurgitate, or spill back.
Managing symptoms through medication may be the first line of treatment for valve disease. When medication cannot control symptoms caused by valve disease or when heart function continues to suffer, surgery may be necessary. Heart valve surgery is common, with more than 1 million valve replacements having been performed in the last 30 years.
WHEN IS IT INDICATED?
Common valve surgeries include valve repair and valve replacement.
Valve repair has been shown to lower death rates resulting from the operation, improve left ventricle function, and creates less frequent need for anticoagulation therapy, or anti-clotting medication, when compared to valve replacement. Valve repair surgery is not commonly performed when a person has a diseased aortic valve.
Most valve repair is done as open-heart surgery, although a minimally invasive treatment called percutaneous transluminal balloon valvuloplasty can repair a stenotic mitral valve. Balloon valvuloplasty is typically not performed in people with one or more of the following:
Severely calcified and blocked valves;
Very large valve surfaces;
Problems with the structures under the valve;
Severe mitral valve regurgitation;
Endocarditis, a heart infection; or
Serious coronary artery disease.
Valve replacement has traditionally been open-heart surgery in which the surgeon removes the entire defective valve and sews in a new valve. Minimally invasive valve replacement surgery has become more popular since the late 1990s. These procedures feature smaller incisions, which offer less pain and quicker healing time than the open versions. Valve replacement is necessary in most cases of aortic valve disease, or when the mitral valve is severely stenotic or deformed.
Pre-surgery tests to identify any health risks for the procedure include:
Chest x ray;
Blood and urine tests; and
People scheduled for surgery cannot take any drugs containing aspirin for 2 weeks before the surgery. People who take blood thinners such as warfarin (trade name Coumadin) are advised when to stop taking those drugs.
WHAT TO EXPECT
On the day of the operation, the person's chest is shaved and disinfected. An intravenous line, or IV, is placed in one or both of the arms to administer fluids and medication during and after the surgery.
To begin the open operation, the surgeon makes an incision through the breastbone. In minimally invasive techniques, the surgeon can either cut through the breastbone, but with a much smaller incision, or by making several small incisions between the ribs to gain access to the heart. Once the surgeon has gained access to the heart, the heart is stilled, and a heart-lung machine is used to maintain blood circulation through the body.
After a valve has been repaired or replaced, the physician ensures that no blood will leak past the new valve. The physician closes any incisions and stimulates the heart with pacing wires so that it resumes contracting normally.
If a balloon valvuloplasty is to be performed, a site on the leg or arm where the catheters will be inserted is cleaned and numbed and the physician makes a tiny incision in the skin to access the vein. Other than a sedative, people undergoing a balloon valvuloplasty may not receive any other drugs.
A retractable sharp tip on a catheter makes a hole in the wall of muscle, called the septum, which separates the right atrium from the left atrium. The physician then threads 1 or 2 balloon-tipped catheters through this hole. Once the balloon catheter is inserted into the valve opening, the physician inflates the balloon. The balloon presses the mitral valve leaflets apart to widen the valve. When the physician removes the catheters, the small hole in the septum heals naturally.
The first 2 or 3 days following the open operation are spent in an intensive care unit where heart functions can be monitored constantly. The average hospital stay is about 1 week. For the minimally invasive version, the patient may be discharged within 48 hours of the procedure. The incision made in the breastbone usually heals completely within 4 to 6 weeks. The physician may also plan a course of physical activity that will help the person recover from the surgery and enable the person to begin resuming normal activities within a few weeks after the operation. Two months should be allowed for complete recovery.
Approximately 1 month to 6 weeks after valve replacement surgery, a follow-up visit is usually scheduled.
Though rare, complications do arise during valve repair or replacement.
In valves repaired with balloon valvuloplasty, some degree of leakage, also known as valve insufficiency or regurgitation, may develop. People who experience any of the following symptoms at the site of the catheter insertion should call their physician as soon as possible:
Bleeding or swelling;
Other, more rare complications of catheterization include:
Infection at the site of sheath insertion;
Damage to the artery and surrounding veins near the insertion point;
Perforation of blood vessels or of the heart muscle;
Arrhythmia (disturbance in the heart's rate or rhythm);
Kidney damage or kidney failure;
Stroke caused by dislodged plaque; and
Open-heart surgery is a major medical procedure and serious complications, while uncommon, are possible. Complications that can arise during or immediately following valve replacement surgery include:
Blood clots in legs;
Malfunction, blocking, or loosening of the prosthetic valve;
After the surgery, it is common to experience pain, soreness, itching, bruising, and redness from the incision into the breastbone. People who take anticoagulants may experience bleeding from the wound.
The lifestyle choices that a person makes can dramatically affect the performance of a repaired or replaced heart valve and on the management of any remaining heart-failure symptoms. Recommended changes include: