DEAR MAYO CLINIC: My dad's cardiologist told him he may need complex heart valve surgery. What makes heart valve surgery "complex," and how do doctors decide whether a valve should be repaired or replaced? 

ANSWER: Heart valve surgery can range from a straightforward repair or replacement of one valve to a more complex operation involving multiple heart problems. Surgery may be considered complex when more than one valve needs treatment, a valve is severely damaged, you've had previous heart surgery, or another heart procedure needs to be performed at the same time. 

Less invasive or catheter-based procedures are good options for many patients, but they aren't appropriate for everyone. Your valve anatomy, extent of disease, age, overall health and other heart conditions help determine which approach is best. Sometimes open surgery provides the best opportunity to repair the valve and address other heart problems during one operation. 

Complex cases can involve severe mitral or tricuspid valve disease, disease affecting multiple valves, infection, significant calcium buildup, congenital valve abnormalities, or problems with a previous valve repair or replacement. Some patients also need coronary bypass surgery, treatment for an aortic aneurysm or surgery for an abnormal heart rhythm. 

When can a heart valve be repaired instead of replaced?

Whenever possible, surgeons consider whether your valve can be repaired rather than replaced. Repair can have important advantages for certain valves and conditions, particularly degenerative mitral valve disease. Aortic valve repair also may be possible for selected patients, including some people with bicuspid aortic valves. 

However, the goal isn't simply to repair a valve. The repair needs to be one that's expected to work well over the long term. If a durable repair isn't possible, valve replacement may be the better option. 

Detailed imaging, particularly echocardiography, helps your care team understand what's causing the valve to malfunction and whether repair is possible. Other tests may include a transesophageal echocardiogram (TEE), CT scan, cardiac MRI, cardiac catheterization or coronary angiography. Your care team also will consider your heart and lung function, kidney function, other medical conditions, and overall health. 

Heart valve disease symptoms can include:

• Shortness of breath.
• Fatigue.
• Decreased ability to exercise.
• Swelling in the legs or abdomen.
• Heart palpitations.
• Chest discomfort.
• Dizziness or fainting.

Sometimes the first sign is simply that activities you once did comfortably are becoming more difficult. 

But you don't necessarily have to feel sick to have serious valve disease. The heart can compensate for a damaged valve for a long time, and you may gradually reduce your activity without realizing it. Meanwhile, the heart can enlarge or weaken, pressure in the lungs can increase, or abnormal heart rhythms can develop. 

That's why the timing of surgery is important. Ideally, severe valve disease is treated before some of these changes become permanent. Your care team weighs the risks of treatment against the risks of allowing the disease to progress. 

Can complex valve surgery be minimally invasive?

Some valve operations can be performed through smaller incisions or with robotic assistance. These approaches can be good options for selected patients, but the safest approach depends on your anatomy and the complexity of the operation. The quality and durability of the repair or replacement always come first. 

Complex valve surgery also requires a team approach. Surgeons work with cardiologists, imaging specialists, anesthesiologists, intensive care specialists, nurses and other healthcare professionals to plan your care and manage recovery. If you have multiple valve problems, previous heart surgery, a valve that's difficult to repair, a valve infection or several heart problems requiring treatment, evaluation at a center with extensive valve experience can be valuable. A second opinion also can help when several treatment options are available. 

What is recovery like after heart valve surgery?

After surgery, most patients initially recover in an intensive care unit. As you improve, breathing tubes and monitoring lines are removed, and you'll begin eating, walking and gradually becoming more active. 

Recovery varies depending on the operation and your overall health. Many patients begin walking soon after surgery and gradually increase activity over the following weeks. Cardiac rehabilitation can provide a supervised way to rebuild strength and endurance, exercise safely, and regain confidence. 

After recovery, the goal is to return to an active, fulfilling life. Continue protecting your heart by not smoking, staying physically active, eating a heart-healthy diet, maintaining a healthy weight, managing conditions such as high blood pressure, high cholesterol and diabetes, taking medications as prescribed, and keeping follow-up appointments. 

Finally, understand why surgery is recommended, what your care team plans to do and what recovery will involve. Ask questions and involve family or loved ones in the process. Being informed and having good support can make an important difference as you move through surgery and recovery. 

Gabor Bagameri, M.D., Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota

Related Articles