What the future holds for heart valve surgery

Why do more people need heart valve surgery?

As a practising surgeon, I’m interested in how we can improve the whole treatment journey for people who need their heart valve repaired or replaced.

Every year, more than 15,000 people in the UK need heart valve surgery. This figure has risen significantly in the last 10 years – and it’s likely to keep increasing.

This is partly because heart valve disease is being detected earlier as more people are aware of the symptoms. Tests for other health problems, such as CT scans, often pick up heart valve problems by accident too.

At the same time, more of us are living longer and as heart valves naturally weaken over time, it means more people are going to need treatment.

Can a heart valve be repaired or replaced without open heart surgery?

Traditionally, it requires open-heart surgery, where the breastbone is split and the rib cage opened up to allow the surgeon to operate on the heart.

The 2 alternatives are robotic-assisted surgery and keyhole surgery.

Robotic surgery

One exciting advancement is robotic heart surgery. NHS England aims to carry out half a million robotic operations by 2035, to cut waiting times and shorten recovery periods. Robots currently assist with many types of operation – such as prostate removal surgery - but not routinely on the heart because it needs very specialised equipment.

Professor Akowuah talking with a colleague in theatre next to a surgical robot, at The James Cook University Hospital in Middlesbrough.

Robots specially designed for heart surgery are due to arrive in the UK in 2026. With a surgeon guiding its arms using a 3D screen and controllers, a robot makes it possible to perform procedures through tiny cuts less than 1cm long in the side of the chest - offering a new minimally invasive alternative to open heart surgery.

Using them routinely for heart operations would be a gamechanger.

For heart valve patients, this could mean waking up sooner after surgery and not needing to stay on an intensive care unit. You could go home within a day and even return to work within a week. It’s likely that robotic assistance will also make heart surgery faster, meaning more people can be treated and waiting lists shortened.

Remote robotic surgery (also called telesurgery) could also become commonplace and eventually used for heart valve procedures. This technology allows a surgeon to operate on a patient without needing to be in the same room – or even the same country. It’s exciting because it means more people can access specialist care, no matter where they live.

Keyhole surgery

This is where small incisions are made in the chest, arm or groin. Tiny cameras and specially designed instruments are used to treat the valve through these openings. This is called minimally invasive surgery.

My research, funded by British Heart Foundation, looks at how well 2 particular types of keyhole procedures work in the long-term compared to open heart surgery. These types are:

• Transcatheter edge-to-edge repair - TEER
  Used to repair a leaky mitral valve. A tube is guided to your heart through an artery in your leg and a special wire is used to place a clip on the leaky valve to help it function as it should.
• Valve-in-valve transcatheter aortic valve replacement - ViV-TAVR
  Used to treat people who have already had their aortic valve replaced with a biological one, but this valve has begun to wear out. It’s similar to TEER in that a tube is pushed through an artery to get to the heart. But then a special wire is used to attach a new biological valve inside the old one. It’s sometimes called the ‘Russian Doll’ technique because you end up with several valves each sitting inside the one before.

What other innovations in care are there?

Another area of innovation is around the materials that replacement heart valves are made from. At the moment, there are 2 types:

• mechanical (man-made, usually from carbon)
• biological (from human, pig or cow tissue).

Mechanical valves can last forever but you have to take blood-thinning medicines for life with this type to prevent blood clots, while biological valves are not as durable, meaning you may need multiple procedures.

Researchers in the UK are looking at new types of plastics, called SEBS (styrene-ethylene-butylene-styrene) polymers as an alternative. These are highly durable, flexible and non-toxic, meaning they could be ideal for making the prosthetic heart valves of the future.

The operation itself is not the only area we could improve. Aftercare has a big effect on people’s lives once they return home from hospital and there are no doctors around them.

For example, people who opt for a mechanical valve replacement currently have to take blood-thinning medicines, like warfarin, for life. But these medicines can increase your risk of bleeding, so people who take them need regular blood tests to check how fast their blood clots.

Research like the ongoing AFFECT trial can help us find out which blood-thinning medicines will give the best balance of safety and effectiveness. This will affect not only people having valve surgery in the future, but also the many people who have had mechanical valves implanted in the last 10 years who must continue to take blood-thinners.

Why does heart valve surgery need improving?

So that we can help people to choose the treatment that’s right for them, have a faster recovery, reduce their risk of problems after the procedure, and help ease pressure on the NHS by reducing waiting lists.

At the moment, it can take about 4 months from being diagnosed to having an operation, going through to recovery and completing cardiac rehab. It’s important we try to reduce that so that people can get back to their lives sooner.

We also want to reduce the number of procedures a person needs on their heart valve in their lifetime by finding more durable materials and better understanding the benefits of using keyhole procedures compared to open heart surgery. Research can help get us there.

How might research lead to better heart valve surgery?

Research plays a vital role because it helps us answer the questions that matter most to people when they are deciding which heart valve treatment to have: How long will it take to recover? Will this operation last a long time? Will I need to take medicines afterwards? What are the chances I’ll get problems again?

We know that keyhole procedures, like TEER and ViV-TAVR, have many benefits. The wounds are smaller meaning there’s less pain, less chance of infection and you recover faster. But it’s not clear whether these procedures work as well in the long-term, so might not be the best option for everyone.

My research involves long-term monitoring of people from across the UK, Germany and the United States of America who have agreed to take part in the study and been randomly allocated either a keyhole procedure or open heart surgery. They will have regular scans and appointments up to 5 years after their heart valve treatment to see if they develop issues later on or need additional procedures.

Once we have this data, it will give us the evidence we need to better help patients choose the option that’s right for them. It could also impact the way doctors all over the world treat heart valve problems.

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