Heart Valve Replacement: Open Surgery, Port, Recovery

Heart valves keep blood flowing in the right direction between the heart’s four chambers. If a valve, such as the aortic or mitral valve, is diseased or faulty, it may require repair or, sometimes, replacement if repair is not an option or fails.

Open-heart surgery is the traditional way of replacing a heart valve. It involves making a large incision (cut) in the middle of the chest wall to expose the heart and replace the valve.

Alternative options for valve replacement are minimally invasive surgeries, which avoid a large incision and typically allow for a less painful and shorter recovery.

Heart Valve Replacement Based on Affected Valve

Heart valve replacement is surgery that replaces one or more of the heart’s valves when repairing them has failed or is not an option.

There are four heart valves. They include:

• The tricuspid valve is between the right atrium (upper chamber) and right ventricle (lower chamber).
• The mitral valve is between the left atrium (upper chamber) and the left ventricle (lower chamber).
• The pulmonary valve is between the right ventricle and the pulmonary artery (the lung’s main artery).
• The aortic valve is between the left ventricle and the aorta (the main artery carrying oxygen-rich blood away from the heart to the body).

The two main reasons a valve may need to be repaired or replaced are:

• Stenosis is when a valve narrows, obstructing blood from flowing forward (in the right direction) through the heart.
• Regurgitation is when a valve leaks, causing blood to backflow (in the wrong direction) within the heart.

In all valve replacement cases, the damaged heart valve is replaced with either of the following:

• Mechanical valves are made of sturdy, durable materials like titanium and carbon.
• Bioprosthetic valves are animal-derived heart valve tissue taken from a pig, cow, or horse. Sometimes, they are taken from a donor’s human heart.

The choice of a valve depends on numerous factors.

While mechanical valves last longer than bioprosthetic valves—20 years vs. 10 to 15 years—they require a person to take a blood thinner (anticoagulant) lifelong to prevent blood clots from forming on the artificial valve.

Heart Valve Open Surgery vs. Other Procedures

Open-heart surgery is the traditional option for all valve replacements.

Alternative options include minimally invasive valve replacement surgeries and catheter-based surgical procedures. These techniques involve making smaller incisions (cuts) near the ribs to access the heart or using a catheter (tube) containing the compressed “new valve” and threading it into the heart via a blood vessel.

The choice of valve (mechanical vs. bioprosthetic) and the replacement approach (surgical vs. minimally invasive procedure) requires a thorough and careful decision-making process between the patient and a multidisciplinary heart valve team.

This multidisciplinary heart valve team often consists of the following:

• Cardiologists (doctors specializing in heart disease)
• Interventional cardiologists (cardiologists that treat heart conditions using catheter-based techniques)
• Cardiothoracic surgeons (surgeons who perform operations on organs within the chest)
• Cardiac anesthesiologists (doctors who manage a person’s care before, during, and after heart surgery)

Open-Heart Surgery

Open-heart surgery, performed by a cardiothoracic surgeon in a hospital under general anesthesia, is the traditional treatment for heart valve replacement.

During open heart surgery, a surgeon makes a 6- to 8-inch cut (incision) down the middle of the chest wall, followed by cutting the breastbone (sternum) and opening the rib cage to expose the heart.

Next, the patient is placed on a heart-lung bypass machine, which performs the heart’s job (pumping blood) while the surgeon replaces the diseased valve.

Once the new valve is placed, the surgeon removes the person from the bypass machine and ensures the heart beats correctly.

The breastbone is then sewn back together with small wires, and the muscles and skin on the chest wall are closed with sutures.

Minimally Invasive Heart Surgery

A cardiothoracic surgeon performs minimally invasive heart valve replacement surgeries in a hospital under general anesthesia.

Similar to open-heart surgery, individuals are temporarily placed on a heart-lung bypass machine during the operation. However, small incisions called “ports” are made to access the damaged valve instead of a large incision within the chest.

The two main types of minimally invasive heart valve replacement surgeries are:

• Mini thoracotomy involves making a 2- to 3-inch incision between the ribs.
• Mini sternotomy involves making a 3-inch incision at the upper part of the breastbone.

During these surgeries, surgeons insert a long, thin instrument with a small video camera attached inside one of the small incisions to visualize the heart. Other tools inserted through the same or additional incisions are used to replace the valve.

In some cases, the surgeon uses robotic instruments to perform the surgery. With this minimally invasive surgery, the surgeon uses a computer with special controls that guide the robot’s small arms, which have a camera and special instruments attached to them.

Catheter-Based Procedures

Catheter-based procedures are also a minimally invasive approach to heart valve replacements.

They are performed by an interventional cardiologist or a cardiac surgeon in a hospital under general anesthesia or twilight sleep.

Catheter-based procedures include:

• Transcatheter aortic valve replacement (TAVR), also called transcatheter aortic valve implantation (TAVI), can replace a narrowed (stenosis) aortic valve. It’s role has also expanded and continues to progress in the treatment of native aortic regurgitation.
• Transcatheter mitral valve replacement (TMVR) is a minimally invasive procedure for replacing a narrow (stenosis) or leaky (regurgitation) mitral valve.
• Transcatheter pulmonary valve replacement (TPVR) is typically used to treat individuals with certain congenital (born with) heart diseases, such as tetralogy of Fallot.
• Transcatheter tricuspid valve replacement is still under investigation, although it’s starting to be performed at select locations in the United States.

The nuances of each catheter-based technique are complex. However, the general steps of the above approaches include:

• A tiny incision is made in the groin area to access the femoral artery.
• A catheter (thin, hollow tube) containing the crimped “new” valve is threaded through the femoral artery into the heart.
• The new valve is positioned within the damaged valve, expanded, and secured in place.

Does Valve Replacement Prolong Life Expectancy?

Research suggests that valve replacement improves life expectancy, although it’s still lower overall than in the general population.

Factors like surgical risk, age, and possibly the type of valve surgery performed can affect the estimation of life expectancy after a valve replacement.

Post-Op Effects and Expectations

After a heart valve replacement, a person will likely spend a day or two in the cardiac intensive care unit before being transferred to a regular hospital cardiac care floor. To minimize the risk of complications, people are encouraged to move around and eat as soon as possible after surgery.

Healing from a heart valve replacement is a slow process requiring support, effort, grit, and a positive mindset.

During recovery, you can expect some of the following:

• A decrease in appetite that can last for several weeks
• Difficulty sleeping due to discomfort and/or limited activity
• Constipation due to pain medication side effects and limited activity
• Incision site tenderness and swelling (this should be mild; contact your provider if there is redness or worsening swelling/pain)
• Mood changes like feeling frustrated or down (this should be mild; contact your provider if feeling depressed or anxious)

After being discharged home, following your heart valve care team’s instructions is crucial. They will include detailed information about the following:

• How to care for your incision site(s) and when to seek medical attention for worrisome symptoms/signs
• What medications (e.g., blood thinners) to take, and what alarming side effects to look for
• The time frames for when you can lift, shower, drive, have sex, or return to work
• Guidelines on balancing rest with the appropriate exercises, which often involve walking

Recovery and Rehabilitation

Each person’s overall recovery from a heart valve replacement and how smooth and speedy it goes are unique. Many variables play into the healing process.

Some of these variables include:

• How the valve was replaced (e.g., open surgery vs. minimally invasive approach)
• The health status and activity level of the person before the surgery
• Whether any complications occurred during or after the surgery (e.g., bleeding, infection, or postsurgical depression)

According to the American Heart Association, a full recovery from a heart valve replacement generally takes four to eight weeks. However, his time frame may be shorter if a minimally invasive technique was performed.

Keep in mind that after you leave the hospital, your heart valve care team will likely advise you to join a cardiac rehabilitation program as a critical step in your recovery.

Cardiac rehabilitation is a medically supervised program that provides exercise training and counseling on healthy lifestyle habits. The overall purpose is to optimize your recovery timeline, well-being, endurance, and level of support.

Complications, Risks, and Continuous Monitoring

The possible complications associated with heart valve replacement surgery depend on the type of valve implanted, the kind of surgery performed, the surgeon’s experience, and whether the person has underlying health issues.

While not a complete list, examples of potential complications include:

• Bleeding
• Infection at the incision site(s)
• Infection in the new valve (endocarditis)
• Pneumonia (lung infection)
• Blood clots may form on the new valve. They can travel to other organs (e.g., the brain) and cause damage (e.g., stroke).
• Arrhythmias (abnormal heart rhythms)
• Death

Attending your scheduled follow-up appointments with your provider or surgeon after a heart valve replacement is vital. They can closely monitor your heart using various tests to help prevent potential complications or address them before they get too serious.

Seeing your heart valve care team has the added benefit of providing comfort and support and ensuring that you feel your best physically and mentally.

Life After Valve Replacement

Research has found that heart valve replacement improves quality of life. If you (or a loved one) undergo a heart valve replacement, you should experience a more fulfilling and active lifestyle with fewer symptoms, more energy, and enhanced emotional well-being.

To maximize your surgical results, remain committed to a heart-healthy lifestyle. Follow your provider’s guidelines for diet and exercise, take your medications as prescribed, and attend your follow-up appointments.

Summary

Heart valve replacement is a treatment option for a diseased or damaged valve. It involves replacing the faulty valve with either a manufactured one made of durable materials like titanium or one made of animal and, less commonly, human donor tissue.

Open-heart surgery, which involves making a large incision (cut) down the chest to expose the heart, has traditionally been used to replace heart valves.

However, less invasive surgeries that involve smaller incisions near the ribs or using a thin, hollow tube (catheter) to thread the new valve into the heart have emerged. These minimally invasive techniques, which are still progressing and evolving, allow for less pain and a shorter hospital stay.

Choosing the right surgical approach for replacing a valve and the type of valve is a complex decision that requires a careful conversation between the patient and their multidisciplinary heart valve care team.

Recovery from heart valve replacement surgery is a gradual, step-by-step process that lasts between four and eight weeks and requires close monitoring, support, and detailed attention to self-care and the surgeon’s instructions.