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Valvular SurgeryEdit

Valvular surgery encompasses a range of procedures aimed at correcting diseases of the heart valves, most commonly the aortic and mitral valves, but also the tricuspid and pulmonary valves. Techniques include open-heart operations such as repair or replacement performed with cardiopulmonary bypass, as well as catheter-based and minimally invasive approaches. The overarching goal is to restore proper valve function, alleviate symptoms like shortness of breath and fatigue, prevent deterioration of cardiac performance, and improve long-term survival and quality of life.

Valvular disease arises from degenerative changes, congenital defects, rheumatic disease, infection, or ischemic injury. Degenerative calcific aortic stenosis and functional or degenerative mitral regurgitation are among the most common indications for surgery in adults, particularly as the population ages. When a valve fails to open fully (stenosis) or to close properly (regurgitation), the heart has to work harder, which can lead to heart failure, reduced exercise capacity, arrhythmias, and other complications. Surgical intervention is usually considered when nonoperative treatments are insufficient and symptoms are present, or when there is a high risk of adverse outcomes if the valve problem is left untreated.

Indications and patient selection

Valvular procedures are guided by the type and severity of valve disease, the patient’s symptoms, comorbid conditions, and life expectancy. Classic indications include:

  • Severe aortic stenosis causing symptoms or evidence of reduced heart function
  • Severe mitral regurgitation with symptoms or signs of adverse remodeling
  • Severe tricuspid or pulmonary valve disease in the context of other cardiac problems
  • Valve dysfunction related to congenital abnormalities or prior disease

Decision-making typically involves a multidisciplinary heart team that weighs surgical risk against expected benefits from valve repair or replacement. In many cases, patients with favorable anatomy may be steered toward valve repair rather than replacement, given advantages in durability and avoidance of long-term anticoagulation in some valve types. Key terms that describe the disease process include aortic valve disease, mitral valve prolapse, and valvular regurgitation.

Techniques and approaches

Valvular surgery falls along a spectrum from conventional open surgery to catheter-based and minimally invasive methods.

Open-heart valvular surgery

Historically the standard approach involves sternotomy (opening the chest) with cardiopulmonary bypass to stop the heart temporarily while the valve is repaired or replaced. In summary, common maneuvers include:

  • Valve repair: reshaping or reconstruction of the native valve to restore competence, often favored when anatomy permits and especially for the mitral valve.
  • Valve replacement: removing the diseased valve and implanting a prosthetic valve, either mechanical or bioprosthetic.

The choice between repair and replacement depends on valve anatomy, tissue quality, patient age, and anticipated durability. Mechanical valves are durable but require lifelong anticoagulation, while bioprosthetic valves avoid routine anticoagulation but have a finite lifespan.

Transcatheter and minimally invasive approaches

Advances in percutaneous techniques have expanded options for patients who are high-risk for open surgery or who prefer less invasive routes. Notable catheter-based therapies include:

In selected cases, less invasive approaches to the aortic and mitral valves can reduce hospital stay, accelerate recovery, and provide meaningful symptom relief for appropriately chosen patients. The role of catheter-based therapies continues to evolve as technology and outcomes data accumulate.

Valve types and considerations

  • Mechanical valves: highly durable prostheses that typically require lifelong anticoagulation to prevent thromboembolism.
  • Bioprosthetic (tissue) valves: derived from animal tissue, generally do not require long-term anticoagulation but have a finite durability that can be a consideration for younger patients.
  • Valve repair techniques: aim to preserve the patient’s own tissue and geometry, often associated with better long-term outcomes in suitable cases.

Key procedures and concepts include mitral valve repair, aortic valve replacement, and valve durability. Cardiopulmonary bypass and myocardial protection are integral to most open-valve procedures and are described in cardiopulmonary bypass.

Outcomes and risks

Outcomes after valvular surgery depend on disease severity, comorbidity, and the chosen intervention. General considerations include:

  • Symptom relief and improved functional capacity are common, with many patients reporting meaningful improvements in daily activity.
  • Survival benefits may follow timely intervention, particularly in severe aortic stenosis and certain forms of mitral regurgitation.
  • Complication risks include bleeding, infection (including prosthetic valve endocarditis), stroke, renal dysfunction, and a need for reoperation or valve replacement in the future.
  • Anticoagulation management is a central consideration for mechanical valves and influences bleeding risk and management of other health conditions.

Durability is a major determinant of long-term outcomes. Mechanical valves generally offer decades of function but require ongoing anticoagulation, while bioprosthetic valves avoid routine anticoagulation but may degenerate after 10–20 years in many patients.

Controversies and debates

As the field progresses, several areas of debate warrant careful consideration to optimize patient-centered care:

  • Repair versus replacement: When feasible, valve repair is often favored for its potential preservation of native tissue and avoidance of prosthetic material, but not all valves are amenable to durable repair. The balance between immediate surgical risk and long-term durability guides decisions.
  • Anticoagulation versus bleeding risk: Mechanical valves confer longevity but require lifelong anticoagulation, which increases bleeding risk and complicates management of other health issues. Bioprosthetic valves lessen or eliminate long-term anticoagulation but may necessitate reoperation or valve-in-valve procedures as they degenerate.
  • Catheter-based therapies versus open surgery: TAVR and related approaches broaden options for high-risk patients and those with certain anatomic features, but questions persist about long-term durability, suitability in lower-risk populations, and applicability across valve types. Some patients may undergo staged or combinational strategies involving both approaches.
  • Age and lifestyle considerations: Younger patients face longer anticipated valve life spans and different risk profiles for reoperation, which influences valve choice and the role of future interventions.
  • Access, cost, and equity: The availability of advanced valvular therapies varies by region and health system, raising debates about cost-effectiveness, allocation of resources, and ensuring patients have access to appropriate treatments regardless of background or location.

See also discussions in valvular heart disease guidelines and related literature on balancing risk, durability, and quality of life.

See also