Heart Valve Repair and Replacement

Overview

Cedars-Sinai has a long history of innovation in heart valve surgery. In 1978 Cedars-Sinai became the second program in the United States to implant the St. Jude valve. We continue that innovative tradition with a wider spectrum of valve replacement procedures.

The decision to repair versus replace a valve is based on complex factors.

At Cedars-Sinai a repaired valve is expected to have a life of at least 10 years (comparable to the minimum expectation for a bioprosthesis). If the repaired valve is not projected to last at least that long, the valve is replaced rather than repaired. Optimally a repaired valve should last a lifetime.

The decision is based on factors unique to each patient. These include the anatomy of the aortic valve and nature of the tissue. When a normal trileaflet aortic valve is present, there is greater potential for repair. Particularly during surgery for ascending aortic dissection involving a normal aortic valve, lifetime durable repairs are often possible.

Careful scrutiny is required for bicuspid aortic valves. In young patients where the bicuspid valve functions well with little calcification, or where there is a problem with only one leaflet, a durable repair may be possible. However, about 75% of bicuspid aortic valves cannot be repaired with the expectation of lasting for an acceptable period of time. In these cases, replacement is preferable.

When the doctor determines that a patient's heart valve cannot be repaired, it must be replaced. Surgeons at Cedars-Sinai have extensive experience with all types of valve replacement surgery, including aortic valve replacement, mitral valve replacement and pulmonic (lung) valve replacement.

Several different kinds of artificial valves are used for replacement surgery, including:

• Mechanical valves
• Ross procedure
• Tissue valves
• Homograft valves

Before surgery, patients need to complete all dental work. Dental infections can allow bacteria to enter the bloodstream and infect the new heart valve - a condition that is very hard to treat.

After surgery, patients need to:

• Take a blood thinner
• Take antibiotics about an hour before going to the dentist
• Report any skin, foot or hand infections to the doctor so that they can be treated aggressively to prevent spreading the infection to the blood or the heart valve
• Report fevers that are high, last a long time or keep coming back because fevers may indicate an infection that could spread to the blood or new heart valve

The most common type of valve used in the United States is the St. Jude valve. In more than 20 years of experience using the St. Jude valve, surgeons at Cedars-Sinai have never had a mechanical valve fail.

While a mechanical valve has an unlimited life, its disadvantage is that patients must take blood thinning medicine (often warfarin) for the rest of their lives and have a blood test done every four to six weeks.

Mechanical valves are recommended for patients:

• With long expected life spans
• With a mechanical valve already in place at a different site than the new valve
• In kidney failure, on hemodialysis or with hypercalcemia (high blood calcium)
• Already taking blood thinners because of a risk of a blocked blood vessel
• Older than 65
• Undergoing valve re-replacement for a blocked tissue valve
• Who can take blood thinners

The Ross procedure replaces a diseased aortic valve with another of the patient's own heart valves, the pulmonic valve. The pulmonic valve is in turn replaced by a homograft valve (a pulmonic valve donated by another person). The benefits of this procedure are that the patient does not need to use blood thinners, has less chance of infection and receives a valve that works like a normal human valve.

The Ross procedure is often used in children so that the new aortic valve can grow as the child grows.

Although this is a more complicated operation, surgeons at Cedars-Sinai have extensive experience with the Ross procedure.

Because this procedure requires extensive surgery, not all patients are candidates for the Ross procedure. Patients with serious infections or who are experiencing organ failure as a result of infection are not candidates for this procedure.

The Ross procedure is more complex and technically challenging than a single valve surgery. Some patients will require another operation within 10 to 15 years if the homograft degenerates. This procedure is appropriate in selected young patients who do not have Marfan Syndrome or a connective tissue disorder.

Several tissue valves are currently used at Cedars-Sinai. The Carpentier-Edwards pericardial valve and the St. Jude Toronto Stentless Porcine valve are the most common.

These valves offer less resistance to the blood flowing through it and patient do not need to take blood thinners. The disadvantage is that these valves usually only last about 15 years.

Tissue valves are recommended for patients who:

• Cannot or will not take blood thinners
• Are younger than 65 years old and need aortic valve replacement but do not have risk factors for blocked valves or who are younger than 70 years old and need mitral valve replacement
• Need to have a blocked mechanical valve replaced
• Are in kidney failure, on hemodialysis or have hypercalcemia (high blood calcium)
• Who are in adolescence and still growing

Homograft valves are donated human aortic valves that are used in select cases. These valves may result in less risk of infection, but the operation is more complex than standard valve replacement.

Homografts are the most resistant to infection, making this the preferred technique for treating aortic root infection and endocarditis at Cedars-Sinai.

The major disadvantages of a homograft include issues with the longevity, the size and the length. Since homografts depend on human donor availability, there is no assurance that there will be enough valves of the right size and length when needed.

Because our bodies try to reject foreign objects - even when they are present to help, such as replacement valves - severe calcification of the aortic wall may occur, stiffening the leaflets, making the valve less effective. The leaflets of the aortic valve also may degenerate.

Homografts may be considered for elderly patient with a life expectancy less than 15 years who are being treated for a heavily calcified (porcelain or egg shell) aorta. In such cases, a homograft would be done in lieu of other types of aortic valve replacement and endarterectomy of the aorta.