Valvular Surgery at Stony Brook University Hospital

Basic Facts

• 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.

Heart valve disease occurs because the valves in the heart are susceptible to disease and are wearing out as they open or close hundreds of thousands of times over the course of one's life. Valve disease may often affect the aortic valve, which allows blood to leave the heart, or the mitral valve, which prevents blood from backing up into the lungs. Sometimes the tricuspid valve may not work properly, which causes blood to back up into the system's circulation, causing swelling and other problems through the body. In some cases, 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 (insufficiency) 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 hundreds of thousands of heart valve operations performed annually in the United States alone.

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 heart function, and creates less frequent need for anticoagulation therapy, or anti-clotting medication, when compared to valve replacement. Valve repair surgery is rarely performed however when a person has a diseased aortic valve.

Most valve surgery is done either as open-heart surgery or by a minimally invasive treatment through a small incision between the ribs.

Valve replacement traditionally is performed typically for aortic valves or mitral valves that cannot be repaired. The surgeon removes the entire defective valve and sews in a new valve and typically uses a tissue valve from a pig or one that is harvested from the a cow's heart. As opposed to mechanical valves, which rarely wear out, tissue valves in general are expected to last 15-20 years, which means another procedure could be needed in the future.

PRE-TREATMENT GUIDELINES

Pre-surgery tests to identify any health risks for the procedure include:

• Chest x ray;
• Blood and urine tests;
• Electrocardiography (ECG);
• Echocardiogram; and
• Cardiac Catheterization.

People are often instructed not to take any drugs containing aspirin or blood thinners such as warfarin (trade name Coumadin) for 5 days before the surgery.

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.

POST-TREATMENT GUIDELINES

To reduce the chances of developing more disease in the future, the physician will advise the patient certainly to stop smoking and reduce intake of fat and cholesterol. The physician will also recommend that the patient walk or do another form of physical activity to help regain lost strength.

Patients can typically resume driving and other normal activities of daily life by 2 to 4 weeks after surgery. Sexual activity may be resumed in 3 to 4 weeks after surgery.

People with jobs requiring limited physical exertion can typically return to work in 4 to 6 weeks; those with more physically demanding jobs may have to wait longer.

POTENTIAL COMPLICATIONS

There is a small risk of complications from this procedure that includes (but is not limited to):

• Infection;
• Bleeding;
• Heart Failure;
• Breathing problems;
• Blood clots; and
• Stroke or brain damage.

Sometimes a pacemaker may be needed after surgery if the heartbeat is too slow.

LIFESTYLE

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:

• Quitting smoking;
• Eating a diet low in salt and cholesterol;
• Losing weight;
• Exercising; and
• Using alcohol in moderation.

Medical Review Date: October 16, 2007