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         Valve surgery

If the obstruction or leaking of valves is severe, medicines alone may not be enough to keep the heart working properly. If this happens, you may be advised to have valve surgery before there is any permanent damage to the heart. At this stage, you may not even have many symptoms..

Balloon treatment’ or mitral valvuloplasty
People with mitral stenosis (disease of the mitral valve) may be advised to have ‘balloon treatment’. This is also called mitral valvuloplasty. Balloon treatment for other valves is possible but less common.
Balloon treatment involves putting a catheter (a very fine, hollow tube) into an artery in the groin. The catheter is then passed into the heart until its tip reaches the narrowed valve. A sausage-shaped ‘balloon’ on the end of the catheter is then gently inflated to stretch the valve. This procedure is carried out during cardiac catheterization. The main advantage of this procedure is that it avoids having to have an operation. However, the mitral valve may become narrow or leak again and need more attention later.

Valve surgery
If your valves are severely affected, you may be advised to have valve surgery. This can get rid of, or greatly improve, your symptoms and allow you to lead an almost normal life.
There are two types of valve surgery – valve replacement and valve repair.

• Valve replacement is when the diseased valve is replaced with another valve. The most
common types of replacement valves are manufactured valves (also called ‘mechanical
valves’), or animal valves (also called ‘tissue valves’ or ‘biological valves’). In some cases, a
preserved human valve (a homograft) may be used. In a very small number of patients, the
aortic valve is replaced by the patient’s own pulmonary valve, and the pulmonary valve is
replaced by a preserved human valve.

• Valve repair is most often used for mitral valves which leak but are not seriously damaged.
Other valves can be repaired too, but they are more often replaced. Whether you have a replacement or repair will depend on the cause of your problem. For example, if you had rheumatic fever as a child (a condition that is rare these days), you are more likely to need to have the valve replaced.

Generalised wear and tear through age responds reasonably well to a repair, but not in all cases. If you are having aortic valve surgery, the valve is usually replaced rather than repaired as this valve is under great pressure as the blood leaves the heart.

In most valve operations the surgeon reaches the heart by making an incision (cut) in the front of the chest and then cutting the breast bone lengthways. The heart is stopped and the blood circulation is kept going by a heart-lung bypass machine. The surgeon then opens up a heart chamber to reach the affected valve.

In a very small number of cases, a new type of valve surgery called minimally invasive surgery is used for valve surgery operations. This involves making a much smaller incision in the chest, to reduce the amount of discomfort after the operation. In some cases specially designed telescopes are used so that the incision can be even smaller. The breastbone does not need to be cut. Findings so far suggest that, with these new methods, there may be fewer complications such as bleeding, pain and breathing problems, and patients recover more quickly and return to work and other activities earlier than with conventional surgery. However, because the heart is less exposed, surgery can be difficult. Ongoing research is improving techniques all the time. If you are offered this type of surgery, you can discuss the advantages and disadvantages of it with your surgeon.

What sort of replacement valves are used?
There are two main types of replacement valves – mechanical valves and tissue valves.

Mechanical valves
Mechanical valves are artificial, manufactured valves. They are sometimes called ‘metal valves’ or ‘plastic valves’, although they are actually made of carbon fibre. There are many different types and all have been put through strict tests for function and wear. This is very important as the valves have to open and close about 40 million times a year!

Mechanical valves are made of hard materials, so many of them make a ‘clicking’ sound. Most people soon get used to this. In some cases, even if the person with the valve is aware of the clicking, other people will not be able to hear it. However, sometimes partners say that the clicking sound is very noticeable to start with, especially at night!

Some people find that the clicking may disturb their sleep if they are very light sleepers. Because these valves are made of artificial materials and are lying in the bloodstream, there is a greater risk of a blood clot developing on the surface of the valve. To help prevent this, you will have to take drugs called ‘anticoagulants’ for the rest of your life.

Tissue valves
Some tissue valves are made from animal tissue (xenografts), mainly from pigs (porcine valves) but also from cows (bovine valves). Other tissue valves are fresh or preserved human valves (homografts).
Because these valves are made from natural tissue, you do not always have to take anticoagulants. However, powerful anticoagulants are often recommended for the first few weeks after surgery, until the valve has settled in. After that you will need to take aspirin to reduce the risk of blood clots forming.
Tissue valves have been specially treated so that they are not rejected by the human body.

Advantages and disadvantages of mechanical valves and tissue valves
There is little difference in the long-term survival of patients between mechanical or tissue valves. The advantages of tissue valves are that they do not make any clicking noise, and you do not need to take anticoagulants for the rest of your life. The disadvantage is that, in  younger people who do more physical activity, the stresses placed on a tissue valve will cause the valve to wear out sooner than a mechanical valve, and a second replacement might be needed. However, in older people who do less vigorous activity, either a tissue valve or a mechanical valve will often last a lifetime. For this reason, tissue valves are usually used for older patients. Valves do tend to wear out, but 8 out of 10 tissue valves are still working after 12 to 15 years.

 If you need a replacement valve, you can discuss with your surgeon the type of valve that would be most suitable for you, taking into account your views and preferences, and your condition.

What are the risks of valve surgery?
Overall, 95 in every 100 people having valve surgery have a successful operation. But valve surgery, like any other surgery, is not risk-free. If you are about to have valve surgery, your surgeon will discuss your risk with you. Your risk will depend on your age, your current state of health, the degree of valve disease,which type of valve is affected, and whether or not you are also having coronary artery bypass grafts done at the same time as the valve surgery. Surgery on the mitral valve carries a slightly greater risk than surgery on the aortic valve, and the risk is also greater if you are having a valve replaced rather than repaired. With so many factors involved, it is important that you discuss with your specialist all the factors affecting you. The surgeon will discuss with you both the risks and the benefits of the treatment.

Once you have recovered from your operation, problems are rare. However, no replacement valve is perfect. Having a ‘foreign’ valve in the circulation can sometimes cause problems. Both mechanical and tissue valves may become infected. To reduce the risk of infection, all patients with valve replacements should have antibiotics when having dental treatment or surgery.

Also, blood clots may form, particularly on mechanical valves, and especially if it has been difficult to control anticoagulation. And any type of valve can wear out or become damaged, although this is more likely with tissue valves in young people.

      Doctor Tips
Angina is an uncomfortable feeling or pain in the chest.
It usually feels like a heaviness or tightness.
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