Treating Heart Valve Disease

Your physician will determine when your valve disease is serious enough to require treatment. The type of treatment that is recommended for you will depend on several factors, including the type of valve disease, the severity of the damage, your age and medical history.

Heart valve disease is a mechanical problem, and surgery may eventually be needed to repair or replace the damaged valve. Often, the surgeon may not know whether repair is possible until he or she can actually see the valve during the procedure.

In 1996, Cleveland Clinic surgeon Delos M. Cosgrove, MD, performed the world's first minimally invasive heart valve surgery. Since that time, improvements in the type of incision and surgical techniques have led to a proven, successful minimally invasive approach to valve surgery. Today, nearly 95 percent of valve surgeries performed here are done with minimally invasive techniques.

Valve repair

When possible, most surgeons prefer to repair the native valve, particularly in women of child-bearing age. Although valve repair is a technically difficult procedure, it has a lower risk of infection compared with replacement, does not require long-term use of anti-clotting medicine and has better long-term functional results than a replacement valve. At Cleveland Clinic, 95 percent of operations for mitral valve prolapse are repairs.

Valve replacement

When a valve cannot be repaired, it must be replaced. The choices are a mechanical (prosthetic) valve or a tissue (bioprosthetic) valve from an animal source. They both are available in different styles and sizes from various manufacturers. Making the decision of which type of valve can be difficult because both types have advantages and disadvantages. A recent study by the Cleveland Clinic Department of Cardiothoracic Anesthesia comparing outcomes of valve replacement in women and men found that women have a greater risk for cardiac complications – but not death - compared with men. Earlier studies suggested that women had a higher mortality rate than men following aortic valve replacement.

Mechanical Valves

Mechanical valves are constructed of high performance carbon and titanium. They are extremely durable so the chance that you will need a future re-operation to replace the valve is small. But, if you choose a mechanical valve, you will have to take medication to prevent clots from forming on the valve that would block blood flow to the brain or other organ systems. Because of the need for anti-coagulation medication, a mechanical valve is not an appropriate choice for women of childbearing age.

Tissue Valves

Tissue valves are native valves that are harvested from a pig or cow, then treated and processed to make them safe for human use. In some cases, a tissue valve may be retrieved from a human donor, but these are rare.

Tissue valves are an excellent choice for older people and women of childbearing age because they do not usually require anticoagulant therapy. The downside of these valves is that they tend to degrade over time and may require a re-operation.

At Cleveland Clinic, our surgeons prefer tissue valves in patients over the age of 60 years and mechanical valves under the age of 50. Healthy women in their 50s should consider mechanical valves since many can expect another 30 years of life.

Valve Surgery Without Large Incisions

Heart surgery does not always mean a large incision. Minimally invasive surgery is performed through a small incision, often using specialized surgical instruments. The incision is about 3 to 4 inches instead of the 8- to 10-inch incision required for traditional surgery. Keyhole approaches or port-access, and robot-assisted techniques are also available for some types of valve surgery. These approaches allow for minimal scarring, and other benefits, such as decreased length of stay, reduced risk of infection, and less blood loss.

Repairing valves without surgery

Percutaneous balloon valvotomy has revolutionized the treatment of mitral valve stenosis. More than 80 percent of all patients who undergo balloon valvotomy for mitral stenosis are women. This non-surgical technique involves passing a deflated balloon through the femoral artery to the mitral valve. At the valve, the balloon is inflated against the valve ring to widen the opening.

This is an effective option for pregnant women with mitral valve stenosis because it is safer for the baby than open heart surgery, which requires cardiopulmonary bypass. However, radiation exposure during the procedure is a concern, and appropriate shielding of the uterus must be used. As an alternative to X-ray guidance, the procedure can be performed with transesophageal echocardiographic guidance, which reduces radiation risk.

Older patients may have less improvement in function after Percutaneous balloon valvotomy compared with younger women, but it is a well-tolerated option for those who cannot undergo open heart surgery.

Cardiologists and surgeons are currently researching other percutaneous approaches to treat both mitral and aortic valve disease. Investigators are hopeful that these procedures may increase options for patients with valve disease in the future.

When selecting a center for treatment of heart valve disease, experience counts. Surgeons at large, busy heart centers treat more patients and are more likely to have the skill and experience necessary to perform a valve repair so that you will not need a replacement. At major heart centers, only about 5 percent of operations for mitral valve prolapse are replacements.

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