There are a number of approaches physicians can take to repair defective heart valves. The best approach depends on the nature of the valve problem, and the unique medical condition of the patient. In some cases, existing heart valves can be repaired. If they cannot be repaired, they can be replaced. Heart valve replacements are either biological, such as those from an animal or human donor, or mechanical. Heart valve procedures can be accomplished during open-heart surgery, or in some cases, through minimally invasive techniques, including minimally invasive surgery and catheter-based procedures.

In 2003, an estimate 95,000 heart valve repair or replacement procedures were performed. The types of valvular heart disease most often addressed by heart valve procedures are narrowed valves (stenosis) or improperly closing valves that allow blood to leak back in the wrong direction (regurgitation).

For some forms of valvular heart disease, neither heart valve repair nor replacement is an option, such as valvular atresia. Other surgeries may be necessary in the treatment of this condition, in which a valve is totally closed at birth.

Heart valve repair is a procedure that corrects a defective heart valve. In 2003, an estimated 95,000 heart valve repair or replacement procedures were performed. The majority of these procedures are accomplished through open-heart surgery, although researchers are making steady advances with catheter-based heart valve procedures.

The conditions most often treated by heart valve repair include narrowing (stenosis) or leaking (regurgitation) of one of the heart’s four valves:

A number of strategies may be used to repair a defective heart valve. They include:

• Percutaneous balloon valvuloplasty
• Valvotomy
• Decalcification
• Annuloplasty ring
• Complex mitral valve repair

The percutaneous balloon valvuloplasty is a nonsurgical procedure to treat stenosis. During the procedure, a cardiologist uses a local anesthetic to numb the area of the body (usually the groin) where an incision will be made for the insertion of a thin, flexible tube called a catheter. The catheter is then inserted into the blood vessel and fed all the way up to the heart. Upon reaching the damaged valve, a balloon at the tip of the catheter is inflated. The inflated balloon stretches, widens and separates the narrowed valve.

This procedure may be an alternative for patients who cannot undergo open–heart surgery because of failing health or other reasons. There is a risk that the valve will re–narrow (restenosis) or that it will no longer be able to close properly, allowing blood to leak back in the wrong direction (regurgitation).

A valvotomy (also known as a valvulotomy) is a type of open–heart surgery in which the surgeon cuts into a valve to repair valvular damage. One such type is a commissurotomy, a procedure in which narrowed valve leaflets are widened by carefully opening the fused leaflets or commissures with a scalpel.

For repairing either the mitral or the tricuspid valve, surgeons may also implant an annuloplasty ring at the point where the leaflets meet the fibrous ring (annulus). An annuloplasty ring is designed to help support the valve so the leaflets can come together properly.

During a decalcification procedure, the surgeon removes built-up calcium deposits from the surface of the valve leaflet. Calcium deposits can affect the function of the valve by making it stiffer and by preventing the valve from closing properly.

A complex mitral valve repair may involve a number of techniques including:

• Partial removal (resection) of a faulty valve flap (or leaflet)
  
• Shortening of a faulty valve chord and/or repositioning of the chord
  
• Insertion of artificial chords (chordae tendineae)
  
• Reducing the size of the valve ring through a special surgical process (annular plication)
  
• Annuloplasty ring implantation (to reinforce the above)

In some cases, these operations can be performed through smaller incisions, resulting in less surgical trauma to the patient. This type of surgery is known as minimally invasive heart valve surgery. First performed in 1996, these procedures can be used to perform surgery on either the aortic or mitral valves. During a minimally invasive procedure, a smaller incision is made in the sternum (partial sternotomy) or in the side, between the ribs (a thoracotomy incision). Although smaller, these incisions allow the surgeon to work with specialized equipment and successfully complete the surgery.

Although these minimally invasive strategies involve the patient spending more time in surgery as these delicate procedures are performed, they offer a lower risk of surgical trauma, a shorter recovery time and reduced pain. They are being performed with greater frequency on patients with selected valve diseases, particularly those involving the aortic and mitral valves.

Heart valve replacement is an open-heart surgery in which a defective valve that cannot be repaired is replaced with one of two basic types of valves. This type of procedure is typically used on heart valves that leak or on those that have thickened, hardened or stretched. The two basic types of artificial valves used are:

The open-heart surgery necessary for a valve repair or replacement is described in more detail in the following sections.

Before surgery, the patient will undergo a number of tests, which may include:

Depending on the procedure, a patient may also be advised to visit a dentist prior to the surgery to check for any infections.

Patients undergoing open-heart surgery to either repair or replace a defective valve should prepare in advance for a hospital stay of four to six days.

Eight hours before surgery, all patients are placed on NPO (non per os; nothing by mouth) status. That means they are not permitted to eat, drink or take anything by mouth until after their surgery. Smokers will have been advised to completely avoid smoking for at least two weeks before their surgery to prevent problems in breathing, reduce secretions and facilitate necessary coughing. Certain medications may need to be reduced or stopped temporarily, so patients should discuss their medication schedules with their cardiologist before surgery.

Immediately before surgery, the patient will be given specific pre-operative medications and then “prepped” for surgery. First, the chest area is shaved. Next, the surgical team provides a sterile environment by swabbing the patient’s chest with an antiseptic solution and covering the patient in sterile surgical drapes. An intravenous (I.V.) line will also be started, usually in the forearm or back of the hand.

The patient is then given a sleep-inducing medication through the intravenous (I.V.) line. The patient will continue to breathe a mixture of oxygen and anesthetic gas (general anesthesia) to make sure that he or she remains asleep throughout the entire surgery.

This section applies to heart valve procedures completed through an open-heart surgery. After the patient is asleep, a device called the Swan-Ganz catheter is often inserted into the jugular vein (in the neck) and threaded to the pulmonary artery (which goes from the heart to the lungs). The catheter can be used to give medication, measure the oxygen levels in the blood and measure pressures in the heart. A breathing tube (endotracheal tube) will also be inserted into the mouth and guided down the windpipe (trachea) to maintain an airway. A urinary catheter is also inserted and connected to a collection bag to measure the patient’s urine output.

An incision is made through the chest and breastbone (sternum). The functions of the heart, including blood flow and oxygenation, are rerouted through a heart-lung machine via tubes (cannulas) that are placed in the body. While this machine takes care of the heart’s functions, the heart can be carefully stopped with a cardioplegic solution so the surgeon can perform the very delicate work. While stopped, some surgeons further protect the heart by decreasing its temperature (hypothermia). The heart will remain stopped for about 30 to 90 minutes during surgery.

Next, the surgeon will either repair or replace the damaged valves. Once the procedure is completed, the heart incision is closed and the heart is restarted. When the surgical team is satisfied that the heart is beating strongly again, the patient is weaned from the heart-lung machine and the chest incisions are closed. The procedure may take up to five hours.

Blood transfusion may be needed during any type of open-heart surgery, including a heart valve repair or replacement. Blood banks test blood to make sure it is free from any diseases, such as hepatitis or AIDS.

After open-heart surgery, the patient will be transferred to a cardiac intensive care unit, where he or she will be monitored continually. The patient will be on a respirator. Once the patient is awake and able to breathe independently, the breathing tube and respirator will be removed.

Family may be able to visit at this time, but should be aware that the patient is likely to be groggy and somewhat disoriented. The site of incision in the chest may be sore, so painkillers may be administered. Blood samples will be taken and electrocardiogram (EKG) monitors will continuously record the electrical activity of the heart.

Patients usually stay in the hospital for five days to a week. During this time, stitches will be removed from the chest and more tests will be done to assess and monitor the patient’s condition. The cardiologist will discuss further medical treatment, including the use of pain medications, antibiotics and/or anticoagulants. He or she will also update any medications that the patient had already been taking.

After leaving the hospital, cardiologists usually encourage patients to better protect themselves from complications by:

• Eating healthy
• Avoiding smoking
• Losing any excess weight
• Exercising regularly under a physician's guidance

The prognosis after heart valve surgery is good, and most patients can expect to resume normal activities within a few months. A successful surgery will restore proper valve functions in the heart. Signs such as heart murmurs or enlarged heart chambers should be resolved, as well as any symptoms that the patient may have been experiencing (e.g., fatigue).

However, the resumption of normal activities and energy levels can take six months to a year in some patients, particularly if they have lung-related conditions such as pulmonary hypertension. As long as their echocardiogram after surgery is normal, patients are generally encouraged to keep pushing themselves throughout the recovery process, striving to be as active as usual.

Although a successful surgery will restore proper valve functions in the heart and eventually resolve both signs (e.g., heart murmurs) and symptoms (e.g., fatigue) of valvular heart disease, there are a number of potential complications that could arise during or after the operation. They include:

As with any invasive procedures, surgical risk increases with:

Though the risk of death following valve replacement is small, risk may increase when more than one valve is being replaced during the same procedure. In addition, research has suggested that shorter patients (under 5 feet, 1 inch tall) are at higher risk following an aortic valve replacement procedure.

If a biological valve is used, the patient may be prescribed anticoagulants for a few months to reduce the risk of blood clots. The condition of a biological valve should be reassessed annually because it has a tendency to deteriorate over time. After about 10 years, a second replacement procedure may be necessary. If a mechanical valve is used, patients will continue taking anticoagulants for the rest of their lives because they are at greater risk of blood clots.

In some rare circumstances, abnormal heartbeats (arrhythmia) may develop after the surgery. These can usually be controlled with the temporary use of medication, but occasionally permanent medication use or the implantation of a pacemaker is necessary.

Researchers continue to explore new ways to repair or replace heart valves. Currently available replacement valves last between 10 and 30 years. Though they may last a lifetime for older patients, younger patients may need several replacement procedures over time. Therefore, one focus of research is to create longer-lasting replacement valves, particularly for patients with congenital heart disease. Two areas of research have shown potential toward this goal: stem cell research and the use of endothelial cells.

Stem cells are immature cells that can grow to become any one of a variety of different body cells. They are found in bone marrow, lymphatic tissue and in embryos. Studies have demonstrated success in isolating and culturing stem cells toward growing into specific heart valve tissue cells. Catheter-based procedures are also being developed for certain heart-valve replacement surgeries.

Endothelial cells make up the lining of blood vessels and play an important role in communication between body cells. Researchers have successfully grown endothelial cells on a valve “scaffolding” created by stripping a human or pig valve of all its living cells. The patient’s own endothelial cells were then grown over the scaffolding in a laboratory before the valve was used in a replacement procedure. By incorporating a patient’s own cells into the replacement valve, researchers hope to lessen the rate of deterioration and reduce the need for multiple replacement procedures in younger patients.

Researchers are also exploring nonsurgical approaches to the treatment of some heart valve disorders, such as aortic stenosis, which may offer significant benefit. One such approach deals with the problem of calcification on the valve's surface. Calcium deposits that form on the valve leaflets decrease mobility in the valve, thus restricting blood flow through the valve. This calcification is similar to the calcium build-up that can affect arteries during atherosclerosis. Because statin therapy is common in the treatment of high cholesterol, which contributes to atherosclerosis, researchers are exploring the effectiveness of such medications in slowing the progression of aortic stenosis. The therapeutic effect of statins on aortic stenosis is still undergoing evaluation.

Other research has suggested that statin use following any major surgery may decrease the risk of death. Though more investigation is needed, the use of these medications may eventually become more common for people following heart valve procedures.

A number of new technologies are being explored to allow patients who formerly would need an open-heart surgery to have a less-invasive procedure. For instance, the use of a tiny metallic clip is being studied for the treatment of mitral regurgitation to help the valve close properly.

The heart has four valves: the pulmonic valve, the mitral valve, the aortic valve and the tricuspid valve. Each of the four valves has its own set of gates or flaps. In a normally functioning heart, these flaps swing open to let blood flow from one area to the next, then neatly close again until the next cycle begins. Thus, blood should flow smoothly in only one direction and only when the valves are open.

Any restriction or narrowing (stenosis) of the valve opening limits blood flow. Any leaking of the blood back in the wrong direction (regurgitation) could lead to more serious problems (e.g., heart failure) if left untreated.

The routes traveled by oxygen-rich and oxygen-poor blood through the heart and its valves are described below:

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to heart valve procedures:

1. How do I know if I need a heart valve procedure?
   
   
2. What sorts of procedures are available to a person in my condition?
   
   
3. Am I taking any medications that might interfere with the surgery?
   
   
4. Do I need to make any special preparations prior to the procedure?
   
   
5. How likely is it that I will need a follow-up procedure?
   
   
6. Is there a chance that I will need to undergo this same procedure again someday?
   
   
7. How often will I need to visit my doctor after the surgery?
   
   
8. What type of artificial valve are you using to replace my valve? A mechanical valve or biological valve?
   
   
9. What are the advantages and disadvantages to the kind of artificial valve I'm receiving?
   
   
10. Will I need to take anticoagulant medications after the procedure? For how long? What is their purpose?
    
    
11. Which valve will you be performing the procedure on?
    
    
12. Will having this procedure affect my pregnancy?