Focus on: Heart valve surgery
Our heart valves are vital to making sure blood flows correctly in and out of our hearts. But what happens when they go wrong? Professor Olaf Wendler talks to Sarah Brealey about heart valve disease and the latest approaches to surgery.
What is heart valve disease?
There are different forms, but usually one of the valves in your heart either becomes narrowed or starts to leak. This means that the blood doesn’t flow properly through the heart, putting more strain on your heart muscle.
The two most common types are aortic stenosis and mitral regurgitation. Aortic stenosis is when the valve becomes narrowed because of calcium deposits building up in the valve cusps (the moving parts that make up the valve), making the valve stiff. Mitral regurgitation is when the valve starts to leak because the cusps do not close properly.
How would you know if you have heart valve disease?
It’s important to get diagnosed early because, without treatment, symptoms such as breathlessness will increase
Usually people get breathless, especially when they are doing something that makes the heart work harder, such as going up stairs or walking uphill. A heart murmur is also a sign.
It’s important to get diagnosed early because, without treatment, symptoms such as breathlessness will increase, and you are more likely to be admitted to hospital.
When would you need valve surgery?
If the disease is mild to moderate, people would need to take medicines to control the symptoms and we would monitor their condition regularly. We only recommend repairing or replacing the valve when the disease is advanced or severe. Both repair and replacement carry risks and benefits, so these are weighed up for each patient. For some people, it is the only option, as medication alone is not enough to improve their symptoms or stabilise their condition.
What does surgery involve?
If it is possible to repair the valve, the surgeon will do this rather than replace it. It’s usually possible to repair a leaky valve, and this is the most common treatment for a leaking mitral valve. In the past few years, techniques have also been developed to repair the aortic valve if it is leaking, although these are not available everywhere. Open heart surgery is more likely when this valve is narrowed, and is the only effective treatment for aortic stenosis.
Repair or replacement will take place at a specialist centre where a team of cardiologists, cardiac surgeons and cardiac imaging specialists is available, so this may not be your local hospital.
What are the pros and cons of different types of replacement valve?
Mechanical valves last a long time, so we usually recommend these to younger patients. Biological valves, such as a pig’s valve, can wear out over time, so we usually use those in patients who are over 65. The disadvantage of a mechanical valve is that people have to take warfarin for the rest of their life to reduce the risk of a clot forming on the valve and potentially causing a stroke. Each patient is assessed according to their individual needs.
What about modern keyhole techniques?
There are some patients who are not well enough to have conventional surgery – especially if they are very elderly or have other health problems – so we have developed techniques to avoid opening the chest.
If it is possible to repair the valve, the surgeon will do this rather than replace it
Transcatheter aortic valve implantation (TAVI) is a new technique where we go through a blood vessel in the groin or a keyhole in the chest to insert a prosthetic aortic valve. Using a stent – a tube of metal mesh on the end of a catheter – a new valve is put in and the existing valve is compressed open and left in place.
We can use this technique either to replace the patient’s original valve or if a replacement valve has started to fail. If it works, you can avoid the trauma of open heart surgery, including having to stop the heart and use a heart-lung machine. It is a new technique and, at the moment, we only use it for patients who are at high risk from conventional heart surgery – especially the over-80s.
For low- and medium-risk patients, conventional heart surgery is still low risk, and we know it has excellent long-term results.
Valve repair is always done through conventional surgery rather than keyhole, but it can be done with a smaller incision than in the past, leaving a smaller scar.
What is recovery like?
After conventional surgery, you would usually stay in hospital for about a week and you’d probably need about three months to get back to normal life. During that time, you would gradually increase your activity. Recovery is usually quicker after keyhole surgery or if the breastbone has not had to be cut open completely.
Read patient Henrietta Tye's account of her heart valve surgery