Treatment Guide: Heart Valve Repair and Replacement

Local options for keeping your ticker ticking

The heart has four valves — gate-like leaflets of tissue that open and close with each heart beat. Their job is to prevent blood from flowing backward as it travels through the heart. When the valve isn’t functioning properly, blood leaks back to where it came from instead of moving forward. You can be born with a valve that has anatomical defects or you can develop trouble from an infection or as a consequence of aging. The most common valve problems are aortic stenosis and mitral valve prolapse.

[sidebar]Most people with mitral valve prolapse have no symptoms and their tiny leaks aren’t threatening. However, a minority may develop palpitations, shortness of breath or arrhythmias that require valve repair. Aortic stenosis symptoms tend to progress as the condition worsens, and signs like chest pain, fainting, fatigue and shortness of breath, if untreated with valve replacement or bypass, can lead to heart failure and sudden death. In the last two years, special cardiac MRIs and CT scans have come on the market to help doctors make the decision when to operate.    

Types of heart valves:
One of the earliest open heart surgeries in 1960 was a valve replacement using a mechanical valve tested to far outlast any human life span. Despite their high-level performance, they require patients to be on blood thinners their entire lives so they aren’t very popular. Most people opt for a variety of biological tissue valves, usually from a pig and sometimes from a donor cadaver. But these last at the most 20 years, meaning another surgery may be needed in the future.

Mitral valve prolapse repair: Since the mid-1990s, the standard mitral valve replacement has become obsolete, and more than 95 percent of these valves are repaired instead. Nearly all of the valve operations done by Dr. Scott Goldman, chairman of the department of surgery at Main Line Health, are repairs, which he prefers because it isn’t necessary to open the patient’s chest to do them. Using a minimal incision technique, he makes a small cut under the right arm and a few tiny openings for the instruments. “Recoveries,” he says, “are four times faster.”

Aortic Stenosis Options

Replacement: Conventional aortic valve replacement required open-chest surgery and a stint on the heart lung machine while the diseased valve was removed and a mechanical or tissue valve inserted in its place. Then came the minimal incision variation, which Penn cardiac surgeon Joseph Bavaria declares will soon be yesterday’s news. His department is one of six sites nationwide participating in an FDA study of a dramatic new procedure that makes no cuts in the chest at all. Using the concept of balloon stent technology, a catheter carrying a tissue valve as wide as a pencil is threaded up the artery from the leg to the aortic valve, where it positions the new valve over the damaged one. “This is radical,” Bavaria declares excitedly. “We are doing valve replacements with a beating heart without opening the chest.” He has done 20, but only in patients who are at very high risk for surgery or who wouldn’t even have been considered before. The valves presently have a five- to 10-year life span but the safety data is good and they’re working well after one year.

This very complex surgery is about four years old, and Penn’s Dr. Bavaria was one of the pioneers. Patients with leaky valves come to him from all over the world, many of whom are young and athletic and likely to outlive a standard valve’s durability. In this procedure the doctor opens the chest, repairs the leaflets of the valve and reshapes the root. Because patients keep the valves they were born with, there is no risk of implant infection, no need for blood thinner and no risk of mechanical malfunctions.    

There is currently resurgent interest in this 30-year-old procedure (also known as percutaneous therapy) as an alternative to valve replacement in high risk, elderly patients. It uses a keyhole incision to place a graft with an artificial valve that bypasses the damaged valve and carries blood from the heart to the aortic artery.