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The average heart beats 2.5 billion times in a lifetime, and in most people, the valves will continue to function properly throughout your lifespan. However, when they misbehave, they can become narrower which restricts blood flow, or they can leak, which causes backflow of the blood. There are 4 valves in the heart: Aortic, Mitral, Tricuspid and Pulmonary. In adults, the pulmonary valve is the least likely to malfunction.
Heart valve replacement is a serious surgery, however with new innovations and less invasive techniques, there are more options available that allow a quicker recovery time post-operation. Dr Iqbal Malik, Consultant Cardiologist at OneWelbeck Heart Health, explains the choices.
What symptoms might I have?
Narrowed valves cause symptoms at an early stage. Depending on which valve is affected, you can suffer from chest pain, breathlessness, dizziness and blackouts, or palpitations.
What treatments are available?
In general treatments fall into 3 groups:
- Tablets – this is generally advised as a primary course of action, before any surgical procedures are looked at. If your heart rate needs to slow down you may be prescribed betablockers. You may need water pills to remove excess water that is building up. Indeed you may have a weaker heart and tablets such as ACE inhibitors (most end in “-pril”) ARBs (most end in “-artan”) and even Entresto (another heart failure tablet) will be needed. In addition, your blood may need to be thinned with warfarin or other oral anti-coagulant. None of these actually treat the valve itself. They are not a cure.
- Cardiac Surgery – open-heart surgery with valve replacement or repair, with varying sizes of cuts, and the need for cardio-pulmonary bypass (CPB)
- Percutaneous procedures– with small incisions, and valves placed without the need for CPB, and thus faster recovery (although not all patients are suitable for this)
Are there different types of surgical valves?
Surgical valves for the heart were first developed in the 1950s. Needless to say, research and technology has come a long way since then. The main two types used today are:
- From humans – reengineered from a cadaver to be used again.
- From the patient – your pulmonary valve might be put into the aortic position to provide benefits for the more important valve.
- From animals – usually pigs or cows.
Reconstructed valves – Prosthetic valves
- Tissue valves – normally made from a bovine (cow) or porcine (pig) pericardium (the lining of the heart), which is shaped and stitched into the correct size and shape for the patient.
- Mechanical valves – metal and plastic of varying types, but mainly initially ball and gauge, and there are now tilting disc designs on offer as well.
What about Percutaneous, less invasive treatments?
For younger patients, the pulmonary valve has been treated for some time with a balloon mounted valve – expanded in position and held in position without sutures and put in without the need for open heart surgery. This was the Melody Valve.
Over 10 years ago, TAVI (Transcatheter Aortic Valve Intervention, or TAVR) was developed to treat the aortic valve, which is a much more common problem in adults. TAVI is becoming the standard of care for more and more patients with severe symptomatic aortic stenosis. (SSAS).
The Mitral valve treatments that don’t involve open heart surgery are less well-developed but the Mitraclip to reduce mitral leak has evidence behind it in patients that can’t have surgery.
The tricuspid valve is even more challenging: a leaking tricuspid valve is hard to treat both with surgery and with percutaneous treatments.
In terms of recovery, open heart surgery will generally mean a one-week stay in hospital and four-to-six weeks of recovery at home. With the newer treatments such as TAVI, your time in hospital can be reduced down to no more than three days, and at-home recovery would be two-to-three weeks.
How do I choose a treatment for my Aortic Valve?
If you have SSAS, then treatment is urgent. If you are young (<65) and have a congenitally abnormal (Bicuspid) valve, or need bypass surgery or other valves need treating, have surgery. The choice of valve will be made with the surgeon, cardiologist and you jointly. Metal valves last longer, but they need you to take powerful blood thinners.
If you are older (>75) or have significant other medical issues that increase the risk of surgery, opt for the TAVI procedure, if you are suitable after all your tests.
If you have a leaky aortic valve (Aortic regurgitation), then surgery is still the first option, but TAVI may be suitable also.
How do I choose a treatment for my Mitral valve?
If you have a narrowed mitral valve (mitral stenosis) then a balloon treatment might hold off the need for definitive surgery, but eventually surgery will be needed.
If you have a leaky mitral valve (Mitral Regurgitation), then surgery will probably be the best option. The surgeon may be able to repair the valve rather than replace it. If you are not suitable for this, a Mitraclip may be an option.
Valve disease is complex. Knowing how the heart has been over the last 5 years helps in deciding what to do. With valves that have moderate or more narrowing or leak, close follow-up is needed by your cardiologist.
Written by Dr Iqbal Malik, Consultant Cardiologist and Director of Cardiology OneWelbeck Heart Health, specialising in coronary artery disease and the TAVI procedure.