What are open surgery procedures for heart valve disease?

Surgery involving the heart valves is a treatment option reserved for patients with severe heart valve disease. Normally, the heart valves should ensure that the blood only flows in one direction, i.e. from the atria to the ventricles, and from there either to the lungs or to the rest of the body. In cases where these valves have become narrowed (stenosis) or leaky (regurgitation), the heart muscle has to work much harder in order to be able to pump a sufficient amount of blood around the body. This excess strain on the heart often leads to heart failure. Heart valve surgery may become necessary in order to prevent heart failure from developing, and in order to preserve the patient's quality of life.

The purpose of heart valve surgery is to either repair or replace defective heart valves. If a defective heart valve has to be replaced with a prosthetic heart valve, this can be done by using either mechanical or tissue valves. Today, the repair or replacement of a defective heart valve can also be performed using catheter-based procedures.

What conditions are treated with this procedure?

• Aortic valve stenosis - a narrowing of the valve situated between the left ventricle and the aorta - is the most common type of heart valve disease found in industrialized nations, and so is a typical reason for why a patient might have to undergo heart valve replacement surgery.
• Heart valve surgery may also become necessary if the aortic valve becomes leaky (aortic valve regurgitation).
• Damage to the mitral valve, which is situated between the left atrium and the left ventricle, is also a common reason for heart valve surgery.
• In contrast, there are significantly fewer patients who require heart valve surgery as a result of damage to the tricuspid valve, which is the valve situated between the right atrium and the right ventricle. A procedure involving the tricuspid valve, if required, may at times be combined with a procedure to treat damage to the mitral valve.
• Damage to the pulmonary valve, which is situated between the right ventricle and the pulmonary artery, is generally rare. Damage of this type may have been present since birth, and in some cases requires surgery early in life.

Surgical strategies

There are two different surgical strategies available:

Heart valve reconstruction

In patients whose valves have become distended and leaky, it is sometimes possible to reconstruct the valve using tissue from the patient's own valve as well as specialist surgical techniques in order to restore its function. Ideally, this procedure will preserve the patient's own valve, and restore it to near-normal function. This strategy has proved particularly useful in the treatment of patients with leaky mitral valves (mitral regurgitation). In certain cases, valve reconstruction may also be suitable in the treatment of patients with aortic regurgitation.

In certain cases, a heart valve may be able to be repaired rather than replaced, the obvious advantage being that the patient's own valve tissue is preserved. This type of procedure can only be performed by a highly experienced surgeon, who is able to determine during surgery whether valve repair is likely to result in adequate valve function being restored. If valve repair is unlikely to restore adequate valve function, the procedure is neither viable nor advisable and, if this is the case, valve replacement surgery is the safer alternative.



The majority of procedures involve the aortic valve, which is situated between the left ventricle and the aorta, and the mitral valve, which is situated between the left atrium and the left ventricle. It is much rarer for this type of procedure to involve the tricuspid valve, i.e. the heart valve situated between the right atrium and the right ventricle. While it is rare for this particular heart valve to require replacement, it is possible for the valve to suffer as a result of a mitral valve defect which leads to an increase in blood pressure in the lungs. When this occurs, it may become necessary to carry out a procedure to tighten the tricuspid valve in order to improve its seal upon closing.

Heart valve replacement

The second surgical procedure involves the replacement of the affected heart valve. Heart valve replacement is the standard approach to the treatment of patients with either valve regurgitation or stenosis, and can involve the use of either mechanical or tissue valves. Although mechanical valves - which are made of metal and synthetic materials - have almost unlimited durability, they also have one main disadvantage, namely that patients have to take anticoagulant medication for life in order to prevent the formation of dangerous blood clots. Tissue valves, in comparison, which are made from either pig (porcine) or cow (bovine) tissue, do not require patients to be on life-long medication. However, they only last for approximately 10 years. The decision as to which type of prosthetic valve is best for a particular patient therefore requires careful consideration. More

Surgical procedures

There are two different surgical strategies that are available, with selection dependent upon the individual patient's requirements:

Conventional heart valve surgery

Conventional heart valve surgery is typically performed on an open heart, therefore requiring both sternotomy (separation of the breastbone) and cardiopulmonary bypass (a heart-lung machine). This particular approach requires the heart to be stopped, and is only ever preformed under general anesthesia.

Minimally-invasive heart valve surgery

Minimally-invasive procedures are becoming increasingly important in the treatment of heart valve disease. Many procedures involving the mitral valve, for instance, do not require any more than a small incision in the side of the chest, while a connection to the cardiopulmonary bypass machine can be established using the blood vessels in the groin. In some cases, aortic valve replacement can be performed using a catheter-based procedure, therefore removing the need for cardiopulmonary bypass. More