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Heart Valve Surgery
Written with A. Marc Gillinov, M.D.

Heart valve surgery is a procedure used to repair or replace diseased heart valves. Over the past few years, there have been great advances in the surgical treatment of diseased heart valves by heart valve surgery. The diagnostic tests your heart doctor orders help to identify the location, type and extent of your valve disease. The results of these tests, the structure of your heart, your age, and your lifestyle will help your cardiologist, surgeon, and YOU decide what type of heart valve surgery procedure will be best for you.

Valve disease can be treated by protecting your valve from further damage, taking medications, seeing your doctor for regular visits and having heart valve surgery.

Cleveland Clinic continues to perform the largest number of valve procedures in the United States. In 2006,  Cleveland Clinic surgeons performed 2,127 valve procedures — 1,524 primary operations and 603  reoperations.
Heart Valve Surgery

Traditional heart valve surgery

During traditional heart valve surgery, a surgeon will make an incision down the center of your sternum (breastbone) to get direct access to your heart. The surgeon then repairs or replaces your abnormal heart valve or valves. While this approach remains in use, today most patients with isolated valve disease can be treated with minimally invasive techniques.

Minimally invasive heart valve surgery
Minimally invasive surgery is a type of surgery performed through smaller incisions. This type of surgery reduces blood loss, trauma, and length of hospital stay. Heart valve surgery is the most common minimally invasive procedure. Your surgeon will review your diagnostic tests prior to your surgery to see if your are a candidate for minimally invasive valve surgery. Click here to learn more about minimally invasive heart surgery

Chest wall incisions used for heart surgery

traditional incision

Traditional heart surgery incision: median sternotomy

minimally invasive

Minimally invasive approach: partial upper sternotomy

Minimally invasive approach: small right thoracotomy incision

Often, the heart surgeon and cardiologist will use transesophageal echocardiography during the operation to help determine the functioning of the valve before and after surgery.

There are two types of heart valve surgery: valve repair surgery and valve replacement surgery

Heart valve repair surgery
Valve repair allows the surgeon to fix your faulty heart valve, often without the use of artificial parts. The advantages of heart valve repair are:

  • lower risk of infection
  • decreased need for life-long blood thinner medication
  • preserved heart muscle strength

The mitral valve is the most commonly repaired valve, but the aortic and tricuspid valves may also undergo some of these repair techniques.

Common valve repairs include:

Commissurotomy
Mouse over illustration to view repaired opening

Commissurotomy
Fused valve leaflets are separated to widen the valve opening.

Decalcification
Calcium deposits are cleaned off the valve leaflets, allowing them to be more flexible and close properly.

 

Triangular resection
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. Click here to learn more.

Triangular Resection Mitral Valve Repair
Ruptured chords at free edge of posterior leaflet. Region to be resected is indicated.
Abnormal segment has been removed. Leaflet edges are sewn together
Annuloplasty completes the repair.

Annulus support
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 or synthetic material.

Patched leaflets
Mouse over illustration to view repaired leaflet

Patched leaflets
The surgeon may patch leaflets with tears or holes with tissue patches.

 

Click here to learn more about mitral valve repair

Annulus support
Mouse over illustration to view repaired aortic valve
When you have aortic or pulmonic valve disease, heart surgery most often requires replacement of the valve. In some cases, the aortic valve can be repaired.

Bicuspid aortic valve repair
If you have a bicuspid aortic valve (two leaflets instead of three), the surgeon may be able to repair the valve by reshaping the aortic valve leaflets, allowing the valve to open and close more easily.

Heart valve replacement surgery
If valve repair is not an option, your surgeon may choose to replace the valve. The native valve is removed and a new valve is sewn to the annulus of your native valve. The new valve can either be mechanical or biological.

Mechanical valve replacement

Mechanical valves are made totally of mechanical parts which are tolerated well by the body. The bileaflet valve is used most often. It consists of two carbon leaflets in a ring covered with polyester knit fabric. There are advantages and drawbacks to mechanical valves.
St. Jude Medical® Mechanical Heart Valves
St. Jude Medical® Mechanical Heart Valve
SJM Regent® Valve

The St. Jude Medical® Regent valve is available for aortic valve replacements, and the standard St. Jude Medical® valve is used in the aortic and mitral valve positions.

The St. Jude heart valve was the first bileaflet mechanical heart valve (St. Jude Medical® (SJM)). This valve has a track record spanning 3 decades of excellent results. This bileaflet mechanical heart valve is designed and manufactured of pyrolytic carbon.

Photographs posted with permission from St. Jude Medical®

The CarboMedics Prosthetic Heart Valve (CPHV™)
Photographs posted with Permission from CarboMedics

Top Hat™ Supra-Annular
Aortic Valve
Standard Mitral Valve

CarboMedics manufactures a variety of bileaflet mechanical heart valves. The Top Hat Supra-Annular valve is used for aortic valve replacement and the standard valve in the mitral position. A third valve, the Reduce R Aortic Valve may also be used for aortic valve replacement.

The valve housing and leaflets are made of Pyrolite carbon, a unique form of carbon which Carbomedics engineers discovered in the sixties. Attached to the carbon housing is a reinforcing band of titanium and attached to the titanium band is a suture ring of PET fabric. A metallic nitinol wire holds the titanium ring to the housing with an interference groove system. Pyrolite is biocompatible.

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 require lifelong treatment with a blood-thinning (anticoagulant) medication. Blood-thinners are medications (such as warfarin or Coumadin) that delay the clotting action of the blood. They help prevent clots from forming on the mechanical valve, which can cause a heart attack or stroke.

Tissue valves (also called biologic or bioprosthetic valves):

Tissue valves (also called biologic or bioprosthetic valves) are made of human or animal tissue. Some valves may have some artificial parts to help give the valve support and to aid placement.

There are three types of tissue valves: pig tissue (porcine), cow tissue (bovine), and human (allografts or homografts).

Porcine stented valve


Information and photographs posted with permission from Edwards Lifesciences®

The porcine stented valve was the first generation of porcine tissue valves. They have been available for more than 30 years.

The valves are made from natural porcine aortic valves, but may be used for aortic or mitral valve replacement. They are trimmed and then fixed in buffered glutaraldehyde at high pressure. The valves are mounted on flexible stents (frames). The bottom of the valve is covered with a seamless knitted polytetrafluoroethylene cloth. This material helps to facilitate the healing and ingrowth of tissue around the implanted valve.


Porcine stentless valve


Information and photographs posted with permission from Edwards Lifesciences®

 

The porcine stentless valve is used for aortic valve replacement. The valve is made from a natural porcine aortic valve and is fixed in buffered glutaraldehyde solution at a low pressure.

No stents or synthetic sewing rings are used. Therefore, these valves are very similar to the homograft valve (see below).

These valves are technically more difficult to implant but are useful in patients with small hypertrophied hearts.

 


The Carpentier-Edwards PERIMOUNT Pericardial Bioprosthesis


Information and photographs posted with permission from Edwards Lifesciences®

Heart valves built to last

This valve is made of bovine pericardial tissue (tissue from a cow heart) that has been preserved in a buffered glutaraldehyde solution and mounted on a flexible frame and a sewing ring of molded silicone rubber, which allows the surgeon to sew the valve to the patient. Both the frame and the sewing ring are covered with a knitted polytetrafluoroethylene (PTFE) cloth.

The aortic pericardial bioprosthesis has been implanted internationally since 1981, and in the United States since 1991. In the summer of 2000, Carpentier-Edwards released a PERIMOUNT valve for the mitral position.

The benefit of this valve is enhanced durability, which is related to the use of pericardium and the specific bioengineering involved in the valve design. Click here to learn more about the durability of these valves.

Click here to view a movie of aortic valve replacement with a biologic valve:
(takes a few minutes to load)


Aortic Valve Allograft - the Homograft Valve


Information and photographs posted with permission from CryoLife®, Inc


A homograft (also called allograft) is a valve that has been removed from a donated human heart, preserved and frozen under sterile conditions.

Homografts are ideal valves for aortic valve replacement, especially when the aortic root is diseased or there is infection. The heart's natural anatomy is preserved and patients do not need to be on any blood-thinner medications. Although the limited availability is a drawback in some settings, we maintain a large supply and have extensive experience with these valves.

 

.

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. Click here to 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: Biologic valves, traditionally, 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 on the PERIMOUNT aortic valve, show that these valves may last at least 17 years without decline in function. This represents a new milestone in durability of biologic valves.

The decision whether to choose a bioprosthetic or a mechanical valve is based on patient choice. In younger patients, the patient may weigh the inconvenience of taking a blood thinner (coumadin) versus 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. .

The Cleveland Clinic Heart and Vascular Institute 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. Click here to learn about our surgical outcomes.

More information:

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This information is provided for education purposes only and is not intended to replace the medical advice of your doctor or health care provider. While we strive to keep our website current, medical practices sometimes change quickly. Please consult your health care provider for advice about a specific medical condition or contact the Cleveland Clinic if you would like an appointment.