Valve repair surgery
During valve repair surgery, the surgeon fixes the damaged or faulty valve, often without the use of artificial parts.
The mitral valve is the most commonly repaired valve, but repair surgery can also be used to treat problems with the aortic and tricuspid valve.
The potential advantages of heart valve repair versus valve replacement are:
- Lower risk of infection
- Less need for life-long anticoagulant (blood thinning) medication
- Preserved heart muscle strength
Common valve repairs
Commissurotomy (aortic valve shown)
Fused valve leaflets are separated to widen the valve opening
Before: Aortic valve leaflets are fused, causing stenosis
After: Valve leaflets are separated, widening the valve opening
Quadrangle Resection of Leaflet (mitral valve shown)
If a portion of the mitral valve leaflet is flail (floppy), and bows back into the left atrium, a segment may be cut out and the leaflet sewn back together, allowing the valve to close more tightly.
Learn more about mitral valve repair.
Before: A portion of the mitral valve leaflet is floppy (flail) and bows back into the left atrium. A rectangular-shaped section is cut out.
After: The leaflet is sewn back together, allowing the valve to close more tightly.
Annulus Support (mitral valve shown)
If the valve annulus is too wide, it may be reshaped or tightened by sewing a ring around the annulus (annuloplasty). The ring may be made of tissue, cloth or metal with a clot covering. It acts like a belt supporting the valve and bringing the leaflets together.
Before: Valve annulus is too wide; the leaflets lack support and do not close tightly. This causes the valve to leak.
After: The leaflet is reshaped or tightened by sewing a ring around the annulus (annuloplasty)
Patched leaflets (mitral valve shown)
The surgeon may patch leaflets with tears or holes with tissue patches.
Before: Valve leaflet has a hole or tear
After: Tissue patches are used to repair the hole or tear.
Bicuspid aortic valve repair (aortic valve shown)
When you have aortic valve disease, heart surgery most often requires replacement of the valve. In some cases, the aortic valve can be repaired.
Before: A bicuspid aortic valve has two leaflets instead of the normal three. The valve may not open fully (stenosis) or may not close tightly (regurgitation)
After: The aortic valve leaflets are surgically reshaped allowing the valve to open and close more easily.
Heart valve replacement surgery
Valve replacement surgery is performed when valve repair surgery is not a treatment option. valve replacement surgery is most often used to treat patients with aortic valve disease, particularly aortic stenosis. However, the aortic valve can sometimes be repaired instead of replaced.
Valve replacement surgery involves removing the faulty valve (native valve) and replacing it with a biological or mechanical valve that is sewn to the annulus of the native valve. All valve replacements are "biocompatible,"which means your new valve will not be rejected by your immune system.
Types of Valve Replacement Surgeries
Biological valves (also called tissue or bioprosthetic valves) are made of cow tissue (bovine), pig tissue (porcine) or human tissue (allografts or homografts). Biological valves may have some artificial parts to give the valve support and to make placement easier.
A homograft (also called allograft) is a human heart valve that comes from a donor after death. It is frozen and preserved under sterile conditions. A homograft is most often used to replace a diseased aortic valve in children or young adults, especially when the aortic root is diseased or there is infection (endocarditis). The homograft can also be used to replace the pulmonic valve during the Ross Procedure.
The Ross procedure involves switching your pulmonary valve to the aortic valve position and then placing a pulmonary homograft. This is a very complex procedure; however it has many benefits, especially for young patients with aortic valve disease. Techniques, such as the Ross Procedure are examples of innovative ways surgeons are able to treat valve disease while protecting the heart's natural functioning. Learn more about aortic surgery options in the young adult.
There are advantages and drawbacks to biologic valves.
Advantages: Most patients do not need to be on lifelong blood-thinner medication, unless they have other conditions (such as atrial fibrillation) which warrant it.
Drawbacks: Traditionally, biological valves were not considered as durable as mechanical valves, especially in younger people. Previously available biologic valves usually needed to be re-replaced after about 10 years However, recent studies show these valves often last 15 - 20+ years without a decline in function.
Mechanical valves are made of metal or carbon and are designed to work just like a patient's native valve. Mechanical valves, are well-tolerated by the body, very durable and designed to last a lifetime. The bileaflet valve is the most common type of mechanical valve. It is made up of two carbon leaflets mounted in a ring covered with polyester knit fabric.
There are advantages and drawbacks to mechanical valves.
Advantages: Mechanical valves are very durable. They are designed to last a lifetime.
Disadvantages: Due to the artificial material involved, patients who receive these valves need to take a blood-thinning (anticoagulant) medication lifelong. Blood-thinners are medications (such as warfarin or Coumadin) delay the clotting action of the blood. They help prevent clots from forming on the replaced valve, which can cause a heart attack or stroke. If you take Coumadin, you will need to have regular blood tests to see how well you are responding to the medication and if you need a change in dose.
Some patients who have a mechanical valve replacement hear the valve make a clicking noise at times. This is the sound of the valve leaflets opening and closing.
The choice is up to you.
The decision whether to choose a bioprosthetic or a mechanical valve is based on a number of choices - including patient choice. In younger patients, the patient may weigh issues such as the inconvenience and risk of bleeding related to taking a blood thinner (coumadin) with the risk of work or lifestyle related injury, or the possibility of reoperation during their lifetime. In patients more than 60 years of age, the bovine pericardial valve will probably last for the duration of the patient's life.
Valve Surgery Techniques
Traditional Surgical Approach
Traditional heart surgery involved an incision (6-8 inches) through the breastbone. This allows the surgeon to open the chest and see the heart and arteries. The surgeon will use the smallest possible incision to perform the surgery.
Minimally Invasive Surgical Approach
Minimally invasive heart valve surgery is performed using smaller incisions than those in traditional heart valve surgery. Other techniques include endoscopic or keyhole approaches (also called port access, thoracoscopic or video-assisted surgery) and robotic-assisted surgery. There are many minimally invasive approaches based on the type of valve surgery you need.
The benefits of minimally invasive surgery include a smaller incision (3-4 inches or smaller) and smaller scar. Other possible benefits include:
- A lower risk of infection
- Less bleeding and trauma
- Shorter hospital stay
- Shorter recovery
Valve surgeries, including valve repair and valve replacement are the most common minimally invasive procedure. Your surgeon will be able to tell you if you are a candidate for minimally invasive surgery.
Percutaneous Valve Procedures
Transcatheter Aortic Valve Replacement (TAVR)
a) Balloon catheter with valve replacement positioned in diseased valve;
b) Balloon inflation to secure the valve;
c) Valve in place
Transcatheter aortic valve replacement is a treatment option for some patients with severe aortic stenosis who are too ill to have traditional, open-heart surgery to replace the aortic valve.
The doctor uses a catheter to replace the diseased valve with a biologic valve. The catheter is inserted into an artery in the groin (transfemoral approach) or an incision in the chest (transapical, subclavian and direct aortic approaches).
Not all patients are candidates for TAVR. If you are interested in this procedure, talk to your doctor.
Transcatheter Mitral Valve Repair
MitraClip in Place; used with Permission Abbot Vascular
The MitraClip is a treatment option for some patients with severe symptomatic mitral regurgitation (leaky vale) who are too ill to have tradition, open heart surgery to repair the valve.
The doctor uses a catheter to place the MitraClip on the valve leaflets. This helps them close more tightly. The catheter is inserted into an artery in the groin or an incision in the chest.
Not all patients are candidates for MitraClip procedure. If you are interested in this procedure, talk to your doctor.
The Miller Family Heart & Vascular Institute at Cleveland Clinic surgeons and cardiologists specialize in the treatment of valve disease. Cleveland Clinic heart surgeons have developed many innovations in valve repair and replacement surgery. Often times, valve surgery may be combined with other procedures (bypass surgery or procedures to treat atrial fibrillation) to fully treat the patient's heart disease. The team approach at the Cleveland Clinic Heart Center insures that patients receive the best care before, during and after their valve procedure.
Learn about our surgical outcomes.