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Overview

The valves in your heart are small, but very important. They control how blood flows into and out of the heart. If they don’t work properly, it will be difficult for your heart to function as it should and your health may suffer. Some heart valve problems are congenital (present at birth), some are caused by infection, and some just develop for no apparent reason. Because heart valve problems are most common in older people, some experts think age is a factor.

Heart valve problems are one of the things your doctor is looking for when he or she listens to your chest with a stethoscope. A murmur, like a swishing sound, is a common tip-off that a patient may have a heart valve defect. In cases where heart valve changes have occurred over time, symptoms like fatigue or shortness of breath may be the first clue that something is amiss.

“Treatment of heart valve disease has changed dramatically over the last 10 years. Multidisciplinary approaches to the diagnosis and management of valve disease aim to offer the best possible treatment for each patient. This includes transcatheter treatment, minimally invasive or “key-hole” surgery, as well as standard open heart operations for valve repair or valve replacement,” says Arnar Geirsson, MD, chief of Yale Medicine Cardiac Surgery.

What are heart valves and how do they work?

The heart is a pump that keeps blood flowing throughout your body. At different points, the blood flows through valves. Each valve has “leaflets,” or flaps that act like small gates. These leaflets open to let blood flow into the heart’s chambers or to the body’s arteries, and close to keep the blood from flowing backward. Altogether, there are four valves in the heart. Defects in these valves can be critical, because they can inhibit the blood’s flow, leading to blood clots, heart attacks, and strokes.

Two valves—the aortic and mitral valves—are the most common ones that need repair or replacement surgery. Defects are less common in the two other valves, but they can also develop problems that require surgery.

Aortic valve: This is located between the heart’s lower left pumping chamber and the aorta, which is the largest artery in the body. The aorta carries blood out of the heart and regulates its flow to the rest of the body. Because of the aorta’s size, it is the most likely place for a valve defect to develop. Valve replacement is a common surgery for patients who have aortic stenosis, a narrowing of this valve. Aortic valve surgery also may be done to treat aortic regurgitation, a condition in which the valve doesn’t close tightly. (This condition is also called a “leaky valve.”) A leaky aortic valve can sometimes be repaired instead of being replaced. 

Mitral valve: This valve also is located on the left side of the heart, between the heart’s left atrium and the left ventricle. Usually the solution to a problem with the mitral valve involves repair, not replacement. A common condition affecting this valve is mitral valve prolapse, in which the leaflets don’t close tightly. Valve repair surgeries include ring annuloplasty, which involves repairing a ring-like area around the valve; or shaping or rebuilding one of the leaflets. At Yale, the mitral valve is often repaired using minimally invasive techniques. 

Tricuspid valve: This valve separates the heart’s two upper and lower chambers on the right side of the body. Though not as common as with the aortic and mitral valves, surgeons sometimes need to repair the tricuspid valve.

Pulmonic valve: Located between the right ventricle and the pulmonary artery, this valve is necessary for healthy blood flow between the heart and the lungs. Problems with the pulmonic valve are uncommon. While surgeons prefer to repair problems because there is less risk of infection, some people may need replacement surgery for pulmonic valve problems.  

What are the signs and symptoms of a valve problem?

The primary sign that you have a valve problem is a heart murmur, or unusual heartbeat, that a doctor can hear when he or she listens to your heart with a stethoscope. However, having a heart murmur doesn’t necessarily mean you have a valve problem.

Other symptoms of heart valve disease include fatigue, dizziness, fainting, shortness of breath, sudden weight gain, and swelling in the ankles, neck veins, and other areas of the body.

Is surgery necessary for heart valve disease?

Some people can delay heart valve surgery with the help of lifestyle changes and medications. However, many will eventually need surgery, depending on such factors as age, health, and symptoms that are becoming severe.

What is surgery like to repair or replace a heart valve?

Cardiac surgeons use a variety of approaches to repair or replace heart valves. A procedure may be minimally invasive, meaning it’s performed through small incisions or through a catheter in the skin rather. 

Minimally invasive procedures are often possible if you have a mitral valve defect, and sometimes with problems involving the aortic valve. The surgeon will typically make a 2- to 4-inch incision between the ribs. If you are having robotic heart surgery, the surgeon will work at a video display monitor, where he or she can watch their progress while manipulating instruments connected to a robot.

For some problems, open heart surgery may be the best treatment option. This involves opening the chest bone so the surgeon has direct access the heart. A team of specialists—cardiologists, cardiac surgeons, anesthesiologists, and others—will work together to determine the best approach for your situation.

Heart valve surgery typically requires general anesthesia and use of a cardiopulmonary bypass, also known as a “heart-lung machine.” This is an artificial system that temporarily diverts blood from the heart so that the surgeon can operate. 

One surgical innovation that surgeons expect will gradually result in fewer invasive procedures on the aortic valve is called percutaneous valve replacement. (Percutaneous means “through the skin.”) Another name for this procedure is transcatheter aortic valve replacement (TAVR). Using this technique, doctors make a small incision in the groin to send a catheter through the blood vessels to the site where the repair is needed. This technique is far easier for patients to recover from than open or even minimally invasive heart surgery.

What are heart valve replacements made of?

There are two types of heart valve replacements:

Mechanical heart valves: These valves are created from man-made materials, which can be ceramic or metal. Because they are considered to be the most durable, these valves are often used for younger patients. People who have a mechanical valve must take blood-thinning medications such as warfarin. They are also at higher risk for thrombosis (a blood clot). Though this is rare, it is a serious complication that is more likely to occur with a mechanical valve.

Tissue valves: While a tissue valve does not require long-term use of blood-thinners (although some patients may need them for another condition), and they are less likely to be associated with thrombosis, they are also less durable. Most will need to be replaced in 12 or 15 years. The tissue can be taken from animals or cadavers.

A third option is the Ross procedure, a surgery that uses the patient’s own pulmonic valve, then replaces that with a new artificial valve. 

How will I feel after surgery?

After heart valve repair or replacement surgery, patients begin their recovery in an intensive care unit, and are later transferred to a specialized care unit. They typically go home from the hospital in three to seven days.

It’s important for patients to continue to follow up with their surgeon, who can check for any related problems that may develop or monitor a new valve that eventually may need to be replaced.

How is Yale Medicine unique in its approach to heart valve replacement and repair?

Yale Medicine cardiac surgeons working at Yale New Haven Hospital (YNHH) have treated every type of valve disorder. More mitral valve operations and transcather aortic valve replacements are done at YNHH than at any other hospital in Connecticut. For patients who need it, we have a special mitral valve repair program that uses a robot. We also offer aortic valve repair aimed at treating leaking aortic bicuspid and tricuspid aortic valves, a procedure that can be performed in conjunction with aneurysm surgery.

At the Yale New Haven Hospital Heart & Vascular Center, our cardiac surgeons and our cardiologists collaborate to determine the best options for each patient, whether it’s open heart surgery, minimally invasive surgery, or transcatheter procedures.

“Patients generally experience significant improvement in symptoms following valve surgery and should expect near normalization of their life expectancy. Yale is one of the few cardiac surgery programs in the U.S. that has three-star ratings from the Society of Thoracic Surgeons for both aortic valve and mitral valve procedures with or without concomitant coronary artery bypass procedure,” says Dr. Geirsson.