Valve Repair / Replacement

Valve Repair / Replacement - What it is

A valve is a structure in the body that allows fluid to move along the body. The main heart valves are the aortic, pulmonary, tricuspid and mitral valves. These valves work in coordinated movements, so that while the mitral and tricuspid valves open to allow blood to flow into the heart for example, the aortic and pulmonary valves remain closed. This ensures one-directional blood flow for proper blood circulation.

Valve repair or replacement is a major operation that is performed to treat patients with diseased valves that are no longer functioning correctly. Examples of dysfunctional valves are when they are stenotic (narrowed) or incompetent (leaky), causing blood to leak back into the heart when it should flow out of the heart. It is crucial that faulty valves are repaired because untreated valve disease can lead to heart disease and mortality.

Pathway of blood flow through the various chambers and valves in the heart.

To repair or replace damaged valves

Valve repair (also called valvuloplasty) is a procedure whereby the surgeon fixes a faulty valve. The mitral valve is the most commonly repaired valve, but the aortic and tricuspid valves may also undergo some of these repair techniques. During surgical repair of valve defects, such as mitral incompetency, the surgeon reconstructs the valve so that it can close properly, which can include:

Fixing holes in a valve
Reconnecting valve leaflets
Separating valve leaflets that have fused together
Removing excess valve tissue
Replacing chords supporting the valve
Strengthening and tightening the valve with a synthetic ring

It is important to note that valve repair is only suitable for selected patients. If the valve is severely damaged, replacement of the valve will be necessary. In valve replacement surgery, the patient’s heart valve is replaced by an artificial valve which can be made of metal (mechanical valve), or biologic animal tissue (bio-prosthetic valve). The following shows the advantages and disadvantages of mechanical and bio-prosthetic valves respectively:

Type of Valve	Advantage	Disadvantage
Mechanical valves	Can last for 30 years or more.	May cause blood clots and hence, patients with mechanical valves need to take lifelong anticoagulation medication.
Bio-prosthetic valves	Do not cause blood clots and hence, patients with bio-prosthetic valves do not need to take anticoagulation medication.	Only last an average of 10 years and need to be replaced when they wear out.

Your doctor will make recommendations based on the severity of your condition and medical history.

How is a valve repair or replacement done?

Valve repair surgery is typically done though open-heart surgery.

Traditionally, heart valve surgery is conducted through open-heart surgery via a median sternotomy, which involves splitting the sternum (breastbone). As such, the patient will be given general anaesthesia before the surgeon cuts open the chest. The patient will then be connected to the heart-lung bypass machine which performs the heart’s pumping functions.

A Transesophageal Echocardiogram (TEE) is conducted to monitor the functions of the patient’s valves both before and after the procedure. An echo probe will be inserted down the oesophagus which is behind the heart and thus should not interfere with the surgery.

One or more plastic chest drains may be left in the chest to drain any excess fluid. Pacing wires may be left in the heart temporarily to control the heart rhythm when necessary. The breastbone is then wired together and wounds are closed with absorbable sutures.

Minimally invasive valve repair or replacement techniques

In suitable patients, minimally invasive heart surgery for valve repair or replacement may be an option. These involve smaller surgical incisions and can potentially lead to a faster recovery.

Percutaneous transcatheter valve repair or replacement techniques

In patients not suitable for open-heart surgery, percutaneous transcatheter valve repair or replacement techniques may be an alternative. These involve small needle punctures and incisions to insert wires and catheter-based instruments. Some of these treatments include:

TricValve®
TriClip™
MitraClip
Transcatheter Aortic Valve Implantation (TAVI)

Who will need a valve repair or replacement?

Valve repair or replacement can help improve various symptoms caused by diseased valves such as:

Chest pain (angina)
Breathlessness
Dizziness or fainting
Swelling at the legs or abdomen
Palpitations

What are the advantages of valve repair compared to valve replacement?

Compared to valve replacement, valve repair is associated with:

Lower risk of infection
Decreased need for life-long blood thinning medication
Preserved heart muscle strength
Reduced risk of stroke and increased long-term survival

Possible complications of valve repair or replacement

Heart valve repair or replacement is a major surgery and in some cases, might result in certain complications, including:

Abnormal heart rhythms (arrhythmias): Up to 30% of patients might experience a rapid irregular rhythm called atrial fibrillation (AF), but this is usually controlled with medications.
Chest discomfort or breathlessness: This could be a temporary or permanent side effect that occurs after the surgery.
Dysfunction of repaired or replaced valves: The repaired or replaced valve(s) might not be effective. In these cases, additional procedures might be needed.

The risks associated with valve repair or replacement procedure varies according to each patient’s specific conditions and medical history. Please discuss any concerns you might have with your surgeon beforehand and provide him/her with all the necessary information.

Valve Repair / Replacement - Symptoms

Valve Repair / Replacement - How to prevent?

Valve Repair / Replacement - Causes and Risk Factors

There are various reasons why one might need a valve repair or replacement, such as:

Degenerative valve disease (degeneration due to wear and tear)
Rheumatic heart disease (as a complication of rheumatic fever whereby the heart valve can be inflamed and scarred over time)
Infective endocarditis (due to bacterial or fungal infection of the heart valves)

Valve Repair / Replacement - Diagnosis

Valve Repair / Replacement - Treatments

Valve Repair / Replacement - Preparing for surgery

Preparation for valve repair or replacement

Consent for surgery

The surgeon will explain the nature of your condition and the procedure you will be undergoing, before obtaining your written consent for the surgery. Please feel free to discuss any concerns you might have with your doctor.

Precautions for the patient to take

It is important to inform your doctor if you have:

Any other medical illnesses
History of allergy or reaction to any medications, drugs or food
History of bleeding or clotting disorders
Current drugs or herbs that you are taking as these medications or herbs might affect blood clotting and increase the risk of bleeding.

Smoking

If you smoke, please stop smoking as soon as possible because this will help with smoother recovery and improve your health.

Valve Repair / Replacement - Post-surgery care

After a valve repair or replacement surgery

After the surgery, you will be closely monitored in the intensive care unit (ICU) for any signs of infection. Devices like intravenous tubes may be used to administer fluids and medications while chest drains and a urinary catheter will be used to drain excess urine and fluids. When you are fit to be transferred to a High Dependency Unit or general ward, these devices will be removed according to your doctor’s instructions.

Upon your discharge, you will be advised on how to care for your wounds and how to monitor yourself for infections. You will also be advised to adhere to the prescribed medications which will be reviewed at each outpatient visit.

Recovering from valve repair or replacement surgery

Typically, patients who have undergone valve surgery will only be hospitalised around a week. However, full recovery is expected to take about two months. Patients recovering from major heart surgeries, such as valve repairs and replacements, should take note of the following for quicker recovery:

1) Engage in light physical activity
You can start with light activities such as doing chores and taking strolls. This can be beneficial to patients who face difficulties with sleeping after the surgery. However, within the first two months, you should avoid:

Lifting, pushing or pulling heavy objects (depending on your level of fitness)
Driving a car

If it is possible, patients going back to work should start with reduced working hours and workloads before gradually increasing these back to normal. This prevents excessive strain on the body.

2) Care for your wound(s)
Keep the wounds and the surrounding areas dry. Clean the wound using soap and warm water only. Please visit your doctor immediately if you notice any signs of infection such as:

Pus
Fever more than 38º C
Tenderness and redness around the wound(s)
Opening up of the wound(s)

3) Take note of cognitive and emotional changes
Patients might experience slight decreases in their cognitive functions though this is usually temporary. To cope with this, patients should avoid any stressful or mentally taxing tasks within the first few weeks of surgery.

Some patients might also experience an onset of low moods or even depression after the surgery. However, patients’ moods should generally improve over the period of recovery. Patients could also speak with their family and friends to cope with these emotions.

You should also make healthy lifestyle changes to sustain the improvements made through the surgery. This could include eating a healthy diet, exercising regularly, quitting smoking and managing your stress levels.

Cardiovascular Rehabilitation & Preventive Cardiology (CVR & PC) Programme

You are encouraged to attend the Cardiovascular Rehabilitation & Preventive Cardiology Programme that will enable and encourage you on the road to recovery.

Cardiovascular rehabilitation is a process that assists you in making the transition from a state of illness back to a state of health and normal function. It is a lifelong process and begins from the time of diagnosis. The four basic features of the programme are behavioural counselling, aggressive risk factor modification, health education and exercise training.

Cardiac Rehab Programme

Valve Repair / Replacement - Other Information

Alternatives to valve repair or replacement

For patients who are unfit for surgery, there are alternatives such as:

Medical therapy
Percutaneous intervention

Please seek your doctor’s advice on the most suitable form of treatment for your condition.

Overview

Cardiothoracic Surgery,

Aortic Valve Repair,

Mitraclip Procedure,

Transcatheter Aortic Valve Implantation (TAVI)/Percutaneous Aortic Valve Replacement (PAVR),

TriClip,

TricValve,

Valvular Heart Disease

Article contributed by Department of Cardiothoracic Surgery, National Heart Centre Singapore

The information provided is not intended as medical advice. Terms of use. Information provided by SingHealth

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