Heart valve repair or replacement for mitral valve regurgitation or prolapse
Surgery Overview
Surgery is required for severe mitral valve regurgitation (MR).
Surgery for MR is recommended when you have symptoms of heart failure, or when your ejection fraction drops below 60% and your left ventricle is larger than 45 mm at rest.1
Generally, surgery for mitral valve prolapse (MVP) is only done if you have mitral valve regurgitation. Valve repair or replacement are the two types of surgery available to treat these conditions.
Both valve repair and replacement are open-heart surgeries. You are given general anesthesia and placed on a heart-lung machine during the surgery, which usually lasts about 3 to 5 hours.
During valve surgery, the doctor makes a large incision in the chest. Blood is circulated outside of the body and oxygen is added to it using a heart-lung (cardiopulmonary bypass) machine. To protect the heart muscle from damage during surgery to replace the heart valve, the heart may be cooled to slow or stop the heartbeat. The damaged mitral valve is either repaired or removed and replaced with an artificial (prosthetic) heart valve.
The decision between repairing or replacing the valve depends on the type of damage to the mitral valve. For instance, repair is more successful if there is limited damage to certain areas of the mitral valve flaps (leaflets) or to the tough fibres that control movement of the mitral valve leaflets (chordae tendineae). Replacement, however, is usually preferred for people who have a hard, calcified mitral valve ring (annulus) or widespread damage to the valve and surrounding tissue.
To repair the heart valve, the surgeon may:
- Reshape the valve by removing excess valve tissue.
- Add support to the valve ring by adding tissue or a collar-like structure around the base of the valve.
- Attach the valve to nearby cordlike heart tissues (chordal transposition).
Heart valve replacement surgery involves the removal of the badly damaged valve. The valve is replaced with a plastic or metal mechanical valve, or a bioprosthetic valve, which is usually made from pig tissue. The damaged valve is cut out, and the new valve is sewn into place.
People who receive a mechanical heart valve are more likely than those who receive a bioprosthetic heart valve to develop blood clots in the heart. The clots may break loose, travel to the brain, and cause a stroke. Therefore, if you have received a mechanical heart valve to treat severe MR, you will need to take medication to prevent clots from forming (anticoagulant medication) for the rest of your life.
In some cases, a plastic or metal valve may be preferred if you are already taking anticoagulants for other reasons, such as atrial fibrillation.
What To Expect After Surgery
Recovery from heart valve surgery usually involves a few days in an intensive care unit (ICU) of a hospital. Full recovery from heart valve surgery can take several months. Recovery includes healing of the surgical incision, gradually building physical endurance, and exercising.
After you have an artificial valve, your heart function and your life will largely return to normal. You should feel better than before you had the surgery if you had symptoms before surgery. For example, you should no longer experience shortness of breath and fatigue. But if your heart was already severely affected before your surgery, you may continue to experience complications of heart disease.
You should be able to resume most of your normal activities, although you will have to continue to monitor your condition. You need to watch out for blood clots and infections.
An artificial valve may need to be replaced after a period of time, so it is important to see your doctor regularly.
Why It Is Done
Surgery to repair or replace the mitral valve is often required in MR. Surgery is generally done for mitral valve prolapse (MVP) only when MR is present. The recommendations for surgery for both conditions are generally the same.1
Conditions that are most likely to require surgery include:
- Sudden (acute) MR.
- MR with symptoms of heart failure.
- MR with mild-to-moderate left ventricular dysfunction (reduced ejection fraction and an enlarged left ventricle).
Conditions that may require surgery include:
- MR with an irregular heartbeat (atrial fibrillation) but no symptoms and no signs of functional damage to the left ventricle.
- MR with elevated blood pressure in the lungs (pulmonary hypertension) but no symptoms and no signs of functional damage to the left ventricle.
- MR with mild to severe left ventricular dysfunction, no symptoms, and a high likelihood of preserving some of the related structures of the mitral valve.
Conditions that are less likely to require surgery include:
- Chronic MR with no symptoms and no signs of functional damage to the left ventricle, even if surgical repair of the mitral valve is likely to be successful.
- MR with MVP and no signs of functional damage to the left ventricle but with recurrent ventricle arrhythmias despite treatment.
How Well It Works
If mitral valve repair is done before the heart is severely damaged by the faulty valve, most people have excellent short- and long-term results.2
The outcome of mitral valve replacement depends upon a person's overall health, including other underlying conditions.
- Mechanical valves, which are made of metal or plastic, tend to cause more clotting than those made of animal tissue. But mechanical valves generally do not have to be replaced and usually do not require additional surgery. A plastic or metal valve may be preferred if you are already taking long-term anticoagulants for other reasons.
- Bioprosthetic valves cause less blood clotting, but they tend to wear out in 8 to 10 years and thus may require repeat operations.
Risks
The exact risks of mitral valve surgery vary depending on the person's specific condition and general health prior to surgery. In general, the risks include:
- Effects from the operation itself (such as bleeding, infection, and risks associated with anesthesia). These risks are low.
- Blood clotting caused by the new valve. Replacement with a mechanical valve requires lifelong treatment with medication to prevent blood clots (anticoagulant).
- Infection in the new valve. Infection is more common with valve replacement than with valve repair.
- Failure of the new valve. Valve failure is more common with valve replacement than with valve repair. Pig valves tend to fail after about 8 to 10 years.
What To Think About
Repair versus replacement
Repair of the heart valve usually is the preferred and more common type of surgery for MVP because it is a simpler surgical procedure and has a lower risk of infection.
When the mitral valve is seriously damaged, heart valve replacement may be recommended. Examples of serious damage or complicated conditions that might lead to mitral valve replacement include:
- Extensive ballooning of the mitral valve (rather than a single flap that puffs up).
- Severe hardening (calcification) of the valve.
- Prolapse (bulging) of the valve at an unusual location.
- Damage to the valve from infection (endocarditis).
The decision regarding whether to repair or replace a valve is based on many factors, including the person's general health, the condition of the damaged valve, the presence of other health conditions, and the expected benefits of surgery. In some cases, the decision clearly may be in favour of repair or replacement.
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| Author: | Douglas Dana Kathe Gallagher, MSW | Last Updated: June 7, 2006 |
| Medical Review: | Adam Husney, MD - Family Medicine Caroline S. Rhoads, MD - Internal Medicine Stephen Fort, MD, MRCP, FRCPC - Interventional Cardiology | |
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| Topic Contents | |
| Surgery Overview | |
| What To Expect After Surgery | |
| Why It Is Done | |
| How Well It Works | |
| Risks | |
| What To Think About | |
| References | |