Kalp Kapağı Ameliyatı Nedir? Riskleri, Türleri ve Ameliyatsız Seçenekler

What are heart valve diseases?

Problems with heart valves generally occur in two types: there is either an issue with the opening or the closing of the valve. If there is a problem with the opening, it is called valve stenosis (e.g., aortic valve stenosis, mitral valve stenosis); if there is a problem with the closing, it is called valve insufficiency or regurgitation (e.g., aortic valve insufficiency, mitral valve insufficiency). Sometimes, stenosis and leakage can coexist in the same valve.

Note: In common language, the terms “valve” and “leaflet” (kapakçık) are often used interchangeably. Similarly, the terms “insufficiency,” “failure,” or “leakage” developing in a valve all mean the same thing.

The problem in the valve can be mild, moderate, or severe. Mild or moderate issues do not cause any symptoms in the patient and do not require intervention; therefore, it is sufficient for the patient to remain under medical supervision. If there is a severe problem—that is, serious valve stenosis or insufficiency—the valve is usually intervened upon. Intervention occurs either through valve surgery or non-surgical methods. In surgery, the valve is either replaced or repaired. In non-surgical methods, interventions on the valve are performed without cutting the chest cage or stopping the heart. Which treatment is appropriate for which patient varies from patient to patient.

Now, let’s briefly look at heart valve replacement surgery, heart valve repair surgery, and non-surgical methods in order.

How is heart valve replacement surgery performed?

During heart valve replacement surgery, the patient is first connected to a ventilator and put under general anesthesia. The chest cavity is opened by making incisions in the skin, subcutaneous tissues, and sternum. The heart is stopped. While the heart is not beating, a heart-lung machine takes over the functions of pumping and oxygenating the blood. Next, the left atrium is incised for the mitral valve and the aorta is incised for the aortic valve to access the valve. The old valve is cut out and removed, and a new artificial valve is sutured into place. At the end of the surgery, the patient is disconnected from the heart-lung machine, and the chest cavity is closed with metal wires. This is the classic surgical method.

What is closed-heart valve surgery?

Thanks to advancing technology, new methods have emerged as alternatives to the traditional surgery I described above. For example, the procedure can also be performed through a small incision made on the side of the ribcage. This method, known as minimally invasive surgery, allows for both valve replacement and repair. It is commonly referred to as “closed surgery” or “surgery with a small incision.” In fact, this is also a type of “open” surgery. Another method involves performing the surgery using a robot (robotic surgery). In this method, several small holes are made in the chest, and the robot’s arms are inserted into the chest through these holes. The surgeon does not touch the patient directly; instead, they perform the surgery by controlling the robot’s arms from a corner of the operating room. These alternative methods result in a shorter recovery time and leave a smaller, more aesthetically pleasing scar. However, the surgeon performing these procedures must be a physician who has received training in these techniques and has sufficient experience.

Heart Valve Surgery

Mitral kapak ameliyatında büyük kesi ile küçük kesi yara izlerinin karşılaştırılması

What is heart valve repair surgery?

When surgery is required for heart valves (particularly the mitral and tricuspid valves), valve repair is preferred over valve replacement if the valve anatomy is suitable and the surgeon has sufficient experience. This is because, with repair, the patient retains their natural valve after surgery and is not required to take strong blood-thinning medication for the rest of their life. However, this is not always possible. In such cases, the valve must be replaced. Various techniques can be used in valve repair. For example, if the ligaments holding the valve in place have torn, artificial ligaments can be sutured in their place; if the natural ring to which the valve is attached has dilated, it can be narrowed using ring-like materials; or if there is excess tissue in the valve structure, it can be excised and removed.

Video 1. Aortic valve replacement (AVR)

Video 2. Mitral valve surgery (MVR and mitral valve repair)

Are there non-surgical methods for heart valve treatment?

Thanks to developing technology in recent years, it has become possible to treat heart diseases with non-surgical methods as an alternative to surgery. The reason these methods are called “non-surgical” is that, unlike surgery, the chest cage is not cut and the heart is not stopped during the treatment. In other words, all stages are performed while the heart continues to beat. Since the heart is not stopped and therefore there is no need to be connected to a heart-lung machine, the risks in these procedures are generally lower compared to surgery. Since no incision is made in the chest, the recovery process is faster. Pain and stress are also reduced. There are no aesthetic concerns as there are no surgical scars on the chest. These procedures are performed with the help of long, flexible tubes (catheters) sent to the heart through a small vessel entry point, usually in the groin, which is thinner than a pen. The most typical example is the non-surgical replacement of the heart’s aortic valve (TAVI). A similar method is applied for the heart’s pulmonary valve as well. For the other two valves of the heart (mitral and tricuspid valves), this method is not yet suitable due to anatomical challenges. However, studies are ongoing, and it is predicted that these valves will also be replaceable non-surgically within 10 years. Still, in modern medicine today, mitral valve stenosis can be widened with a balloon in suitable patients (mitral balloon) or mitral valve regurgitation can be partially or completely corrected using the clipping method (MitraClip / Pascal) procedure. All these non-surgical methods are performed by interventional cardiologists (whereas surgeries are performed by heart surgeons).

Prof. Dr. Şükrü Akyüz is an interventional cardiologist. His field of expertise is the treatment of heart diseases using non-surgical methods. He is a proctor (instructor) and consultant for structural heart disease procedures, including the clipping method and TAVI.

Is a biological valve better, or a mechanical valve?

There are two types of artificial heart valves: biological (tissue) valves and mechanical valves. Whether a biological or mechanical valve is more suitable for a particular patient is determined on a case-by-case basis, as both have their own unique advantages and disadvantages. Heart Valve Surgery

Bioprosthetic (Biological) valves are manufactured from the pericardium of cattle or pigs and resemble a natural valve. They wear out earlier compared to mechanical valves. Specifically, they deteriorate even sooner in relatively younger individuals (due to the heart working more vigorously and the faster blood flow putting more strain and pressure on the valve). Therefore, biological valves are preferred in older individuals, taking into account the patient’s estimated natural life expectancy.
Mechanical valves are typically made of carbon and metal and operate on a hinge principle. They are preferred in younger people because they do not wear out easily. However, since this valve is not biological in nature, the body attempts to form clots much more aggressively against this valve, which it perceives as a foreign substance. If a clot develops, the valve hinges may become blocked and fail to function. For this reason, a strong blood-thinning medication called warfarin must be used for life with mechanical valves (according to the most current data, unfortunately, no other blood thinner can replace warfarin). This is a cumbersome medication to use. While using it, the tendency to bleed increases, it interacts with certain foods—primarily green leafy vegetables—and other medications (meaning its effect either increases or decreases), and the effectiveness of the drug (i.e., how “thin” the blood is) must be monitored every month with a blood test (INR). For biological valves, a milder blood thinner like Aspirin, which is easier to use, is sufficient, and therefore the problems seen with warfarin are mostly avoided.

Note: In non-surgical methods (e.g., TAVI), only biological valves can be implanted; mechanical valves cannot be used because they are not flexible and cannot be compressed and miniaturized inside a catheter. Additionally, a biological valve is usually preferred for a woman planning a pregnancy. This is because the blood thinner called warfarin, which must be used with mechanical valves, has the potential to harm the development of the fetus and lead to birth defects.

How long do patients who have had a heart valve replacement live?

It is not possible for a doctor to precisely know how long a patient in relatively good general condition will live. Based on experience, they can only make a prediction for patients in very critical condition or, based on statistics, provide the average life expectancy of similar patients for a certain period. In summary, to give a general idea:

Since mitral valve surgeries are riskier than aortic valve surgeries, the average life expectancy is also shorter.
Life expectancy is shorter for those with weak heart pumping power compared to those with normal pumping power.
Those with serious problems in other vital organs (brain, lungs, liver, or kidneys) live shorter lives compared to those without such issues.
As expected, those who undergo surgery at an older age live shorter lives compared to those who have surgery at a younger age.
Most importantly, those whose surgery is delayed for too long live shorter lives compared to those who undergo surgery on time.

The most recent and comprehensive scientific research on life expectancy concerns aortic valve replacement (Surgical and TAVI) (See References). According to this, it was found that for those who undergo surgery before the age of 50, their lifespan is approximately 4 years shorter than the average lifespan of healthy individuals. For those who have surgery after the age of 80, life expectancy is almost the same as their healthy peers. After a surgery performed without delay and with a good surgical technique, if the patient also takes good care of themselves—meaning they use their medications regularly and adhere to a healthy lifestyle such as proper nutrition and walking—the probability of living a normal or near-normal duration is quite high. For example, a current and comprehensive study on life expectancy after repair surgery for degenerative mitral valve disease concluded that: “When mitral valve repair is performed by experienced surgeons and in a timely manner, these patients live as long as healthy people” (See References). Our experience suggests that the outcomes for patients whose mitral valve has been replaced are not as good as those who have undergone mitral valve repair; however, we do not have sufficient and reliable data to provide specific figures on this matter.

What happens if I don’t have heart valve surgery?

When there is severe narrowing or leakage in the heart valves, the heart cannot fully perform its function; consequently, it cannot supply the body with the blood—and therefore the oxygen—it needs. To compensate for this, the heart is forced to work harder, and over time, it becomes fatigued, leading to a decrease in its pumping capacity—that is, heart failure develops. Although the timeline varies from patient to patient, eventually the severe shortness of breath associated with heart failure reaches an irreversible stage, and the patient dies.

Is heart valve surgery risky?

Heart valve surgery is a major operation and certainly carries serious risks such as stroke and death. However, the risk of surgery must be compared with the question: “What is the risk if I do not have the surgery?” There are risk tables or software created based on scientific data to calculate these risks. Risk is assessed by entering the patient’s data. Examples of these data affecting the risk include: the patient being elderly (specifically, the level of frailty in the patient’s general condition, i.e., biological age), concomitant organ diseases (Alzheimer’s, chronic kidney failure, cirrhosis, COPD, etc.), low heart pumping power, concomitant cardiovascular disease (i.e., a combination of valve and bypass surgery), etc. Let us not forget: choosing not to have surgery out of fear of these risks leads to the start of an exhausting process that remains untreated for most patients and ultimately results in death. For example, let’s say the risk is calculated as 5%. This means that out of every 100 patients undergoing surgery, only 5 are predicted not to survive the operation or to develop another serious complication like a stroke; read conversely, it is predicted that 95 patients will successfully complete the surgery. In this case, someone who refuses surgery out of fear of the 5% probability explained by the doctor—perhaps not immediately, but eventually—would be choosing the option with a certain outcome (100% death). Undergoing surgery later when the disease has progressed further, because the heart’s pumping power has significantly decreased, requires a riskier operation compared to a few years prior. Sometimes the surgical risk is indeed very high, but there is a possibility of a solution through non-surgical methods. In such cases, it is more appropriate to prefer less risky non-surgical methods (TAVI, MitraClip, etc.). At other times, the disease may have progressed so far that a solution cannot be provided through either surgical or non-surgical methods. In this process, called palliative treatment, the focus is on treatments that allow the patient to breathe as comfortably as possible for the remainder of their life, rather than curing the disease.

When is heart valve surgery performed?

The presence of new symptoms (signs or symptoms) in a patient is an indication that the disease has progressed and that it is time for surgery. For example, the onset of symptoms such as shortness of breath, chest pain, or palpitations while walking or climbing hills is significant. However, it should not be forgotten that these symptoms may also be caused by other conditions, such as anemia or COPD. The timing of symptom onset varies from patient to patient. In some patients, symptoms appear relatively early in the course of the disease, while in others, symptoms develop only when the disease has progressed to a very advanced stage. In other words, even if symptoms have not yet appeared, serious heart problems may have already begun, and the time for surgery may have arrived. For this reason, the patient must be monitored at regular intervals using various tests, primarily an echocardiogram (heart ultrasound). During these follow-ups, the detection of enlarged heart chambers or a decrease in the heart’s pumping capacity indicates that the time for surgery has come, even if the patient has no symptoms.