Treatment of Heart Valve Disease

People with congenital heart valve defects may need treatment with drugs. Some valve defects may need to eventually be repaired with surgery. Typically, heart surgery is accomplished through a larger incision down the center of the chest.  Traditional open surgery has a number of inherent drawbacks caused primarily by the large incision required, splitting of the breastbone and spreading the ribs to access the thoracic space. Recovery time is typically 8-12 weeks before a return to normal daily activities. A new alternative to traditional open-chest surgery is da Vinci Mitral Vavle repair. This option provides the surgeon access to the heart through the ribs and potentially offers a number of clinical advantages.

Most people with defective heart valves will need to take antibiotics before certain dental or surgical procedures likely to cause bleeding. This will prevent endocarditis, an infection of the heart's lining or valves. Only a doctor familiar with a patient's condition can determine whether that person needs antibiotics.

Heart Valve Disease Definitions

Aortic Regurgitation

Aortic regurgitation (aortic incompetence, aortic insufficiency) is leakage of the aortic valve each time the left ventricle relaxes.1

Aortic Stenosis

Aortic stenosis is a narrowing of the aortic valve opening that increases resistance to blood flow from the left ventricle to the aorta.2

Mitral Regurgitation

Mitral regurgitation (mitral valve regurgitation, mitral incompetence, mitral insufficiency) is leakage of blood backward through the mitral valve each time the left ventricle contracts.3

Mitral Stenosis

Mitral stenosis (mitral valve stenosis) is a narrowing of the mitral valve opening that increases resistance to blood flow from the left atrium to the left ventricle.4

Mitral Valve Prolapse

Mitral valve prolapse is a disorder in which the valve cusps bulge into the left atrium when the left ventricle contracts, sometimes allowing leakage (regurgitation) of small amounts of blood into the atrium.5

Pulmonary Stenosis

Pulmonary stenosis, also known as pulmonic stenosis, is a narrowing of the pulmonary valve opening that increases resistance to blood flow from the right ventricle to the pulmonary arteries.6

Tricuspid Regurgitation

Tricuspid regurgitation (tricuspid incompetence, tricuspid insufficiency) is leakage of blood backward through the tricuspid valve each time the right ventricle contracts.7

Tricuspid Stenosis

Tricuspid stenosis is a narrowing of the tricuspid valve opening that increases resistance to blood flow from the right atrium to the right ventricle.8

Heart Valve Repair

Heart valve repair is performed in a hospital setting by a cardiac surgeon. During valve repair surgery, the patient's heart is stopped, and his/her blood is circulated outside of the body through a heart-lung machine. This “extracorporeal” circuit consists of tubing and medical devices that take over the function of the patient's heart and lungs during the procedure. As blood passes through the circuit, carbon dioxide is removed from the bloodstream and replaced with oxygen. The oxygenated blood is then returned to the body.

Below are summaries of three of the main surgical procedures for heart valve repair:

Valvulotomy

In cases of valve disease where the leaflets have become fused together, a procedure known as a valvulotomy is performed. In valvulotomy, the leaflets of the valves are surgically separated, or partially resected, with an incision to increase the size of the valve opening. The surgeon may also make adjustments to the chordae, the cord-like tissue that connects the valve leaflets to the ventricle muscles, to improve valve function.

Valvuloplasty

Another valve repair technique, balloon valvuloplasty, is used in patients with pulmonary, aortic, and mitral valve stenosis to force open the valve. Valvuloplasty is similar to a cardiac angioplasty procedure in that it involves the placement of a balloon-tipped catheter into the heart. Once inserted into the valve, the balloon is inflated and the valve dilates, or opens. Valvuloplasty does not require a bypass circuit.9

Annuloplasty

Annuloplasty is a technique to repair the annulus, which is fibrous tissue at the base of the heart valve. An enlarged annulus enables blood to back up into the atrium. To repair this, sutures are sewn around the ring to reduce the opening. This creates a purse string effect around the base of the valve and helps the leaflets meet again when the valve closes. When repairing the annulus, it may be necessary for the surgeon to implant an annuloplasty ring.10

Heart Valve Replacement

There are four main types of artificial valves used in heart valve replacement surgery. They are:

  • Mechanical Valves
  • Tissues Valves
  • Homograft Valves
  • Ross Procedure11

Mechanical Valves

While a mechanical valve has an unlimited life, its disadvantage is that patients must take blood thinning medicine (blood thinners) for the rest of their lives and have a blood test done every four to six weeks.

Mechanical valves are recommended for patients

  • With long expected life spans
  • With a mechanical valve already in place at a different site than the new valve
  • Who are experiencing kidney failure, including patients on hemodialysis
  • Who are already taking blood thinners
  • Who are older than 65
  • Who are undergoing valve re-replacement for a blocked tissue valve
  • Who are able to take blood thinners12

Tissue Valves

Tissue  valves offer less resistance to the blood flowing through it and patient do not need to take blood thinners. The disadvantage is that these valves usually only last about 15 years.

Tissue valves are recommended for patients who

  • Cannot or will not take blood thinners
  • Are younger than 65 years old and need aortic valve replacement but do not have risk factors for blocked valves or who are younger than 70 years old and need mitral valve replacement
  • Need to have a blocked mechanical valve replaced
  • Are in kidney failure, on hemodialysis or have high blood calcium
  • Who are in adolescence and still growing13

Homograft Valves

Homograft valves are donated human aortic valves that are used in select cases. These valves may result in less risk of infection, but the operation is more complex than standard valve replacement.

The major disadvantages of a homograft include issues with longevity, size and length. Since homografts depend on human donor availability, there is no assurance that there will be enough valves of the right size and length when needed.

Because our bodies try to reject foreign objects—even when they are present to help or replace existing body parts—severe calcification of the aortic wall may occur. The leaflets of the aortic valve also degenerate.14

Ross Procedure

The Ross procedure replaces a diseased aortic valve with the patient's own lung (pulmonic) valve. The pulmonic valve in turn is replaced by a homograft valve (a pulmonic valve donated by another person).

The benefits of this procedure is that the patient does not need to use blood thinners, has less chance of infection and receives a valve that works like a normal human valve.

The Ross procedure is often used in children so that the new aortic valve can grow as the child grows.

Because this procedure requires extensive surgery, not all patients are candidates for the Ross procedure. Patients with serious infections, or who are experiencing organ failure as a result of infection, are not candidates for this procedure.15

  1. For further information, see: "Aortic Regurgitation," Merck, www.merck.com. URL: http://www.merck.com/mmhe/sec03/ch028/ch028e.html
  2. For further information, see: "Aortic Stenosis," Merck, www.merck.com. URL: http://www.merck.com/mmhe/sec03/ch028/ch028f.html
  3. For further information, see: "Mitral Regurgitation," Merk, www.merck.com. URL: http://www.merck.com/mmhe/sec03/ch028/ch028b.html
  4. For further information, see: "Mitral Stenosis," Merck, www.merck.com. URL: http://www.merck.com/mmhe/sec03/ch028/ch028d.html
  5. For further information, see: "Mitral Valve Prolapse (MVP)," Merck, www.merck.com. URL: http://www.merck.com/mmhe/sec03/ch028/ch028c.html
  6. For further information, see: "Pulmonic Stenosis," Merck. www.merck.com. URL: http://www.merck.com/mmhe/sec03/ch028/ch028i.html
  7. For further information, see: "Tricuspid Regurgitation," Merck. www.merck.com. URL: http://www.merck.com/mmhe/sec03/ch028/ch028g.html
  8. For further information, see: "Tricuspid Stenosis," Merck. www.merck.com. URL: http://www.merck.com/mmhe/sec03/ch028/ch028h.html
  9. "Heart Valve Repair," St. Jude Medical. SJM.com. URL: http://www.sjm.com/procedures/procedure.aspx?name=Heart+Valve+Repair
  10. "Heart Valve Repair," St. Jude Medical. SJM.com. URL: http://www.sjm.com/procedures/procedure.aspx?name=Heart+Valve+Repair
  11. Gosta Pettersson, M.D., "Aortic Valve Surgery in the Young Adult Patient: Repair, Replacement and Ross Procedure," Cleveland Clinic, www.clevelandclinic.org. URL: http://www.clevelandclinic.org/heartcenter/pub/guide/disease/valve/youngvalve.htm.
  12. "Mechanical Valves," Cedars-Sinai Heart Center, www.csmc.edu. URL: http://www.csmc.edu/8607.html
  13. "Biological or Tissue Heart Valve," Cedars-Sinai Heart Center, www.csmc.edu. URL: http://www.csmc.edu/8606.html
  14. Ibid.
  15. "The Ross Procedure," Cedars-Sinai Heart Center, www.csmc.edu. URL: http://www.csmc.edu/8608.html

While clinical studies support the effectiveness of the da Vinci® System when used in minimally invasive surgery, individual results may vary. Surgery with the da Vinci Surgical System may not be appropriate for every individual. Always ask your doctor about all treatment options, as well as their risks and benefits.