You and your surgeon will need to decide which type of surgery is right for you and the type of prosthetic valve that will be implanted.
Types of surgery
Valve replacement surgery can be performed in two main ways: as open heart surgery or as minimally invasive surgery.
Open heart valve replacement surgery
In open heart valve replacement surgery, your surgeon will open your chest by cutting down through your sternum (breastbone). You’ll be put on a heart-lung machine so that your heart can be stopped during the valve replacement, and your body will be cooled to protect your vital organs. The surgeon removes the faulty valve and sews a new replacement valve into its place. Then your heart is restarted and taken off the heart-lung machine. Finally, the incision in your sternum is closed.
Minimally invasive valve replacement surgery
Minimally invasive surgery uses a smaller incision and sometimes robotic techniques – apart from this, it’s essentially the same as open surgery. The ‘mini’ incision will be made either in the sternum or on the right side of your chest to access the heart valve.
The benefits may include less pain, quicker recovery, less risk of bleeding or infection, reduced need for blood transfusions, shorter hospital stay, quicker return to normal activities and a smaller scar.
However, because it’s relatively new, there’s currently not enough evidence from clinical studies to confirm if the benefits outweigh the risks. The risks could include the surgeon’s reduced visibility and access to the valve, possibly affecting the outcome of your surgery.
Not all cardiothoracic surgeons are skilled in minimally invasive surgery. Talk to your surgeon about whether it would be suitable for you, and ask about their experience and results.
Minimally invasive and robotic surgery tends to cost more than open surgery, so you may be left with substantial out-of-pocket costs.
Sometimes, your surgeon may need to change from a minimally invasive procedure to an open procedure because of difficulties during your surgery.
Types of replacement valve
There are two types of replacement valves; mechanical or tissue, and there are pros and cons with both.
Mechanical valves are durable and usually last a lifetime. But as blood clots can lodge in the mechanical valve, you’ll need to take lifelong blood-thinning medication, such as warfarin. If a blood clot happens, the valve can malfunction and the clot can break off and travel through your bloodstream, putting you at risk of a heart attack or stroke. Warfarin helps to prevent this but has some unpleasant side effects. Because warfarin prevents your blood from clotting, if you injure yourself, you may bleed heavily. You may bleed from your gums when you brush your teeth, get swelling or pain at an injection site, and have heavy menstrual periods, with bleeding between periods. There are also more serious, but less common side effects of warfarin.
Mechanical valves can also make a clicking sound that some people notice and find annoying.
Tissue (bioprosthetic or biological) valves, which are made from pig, cow, horse or human tissue, usually only require you to take a daily aspirin and/or a short course of warfarin. But they tend to only last between 10 to 20 years, which means you may need another surgery later on.
In general, mechanical valves are recommended if you’re younger than 65 and tissue valves if you’re aged over 70. If you’re aged between 65 and 70, either type of valve may be recommended.
90% of 20 year-olds who have a tissue valve will need another operation. Whereas, only 10% of 70 year-olds will. There are many factors to consider and discuss with your surgeon when choosing the type of valve.
Women should discuss plans for future pregnancies with their surgeon as the risks of excessive bleeding during and after delivery are higher if you have a mechanical valve and take blood-thinners.
A few surgeons in Australia are trained to use the ‘Ross procedure’ to replace a failing aortic valve. In this procedure, your aortic valve is replaced with your own pulmonary valve (this is known as an autograft). Your pulmonary valve is then replaced with a valve from a human donor.
This is a longer and more complex surgery, requiring two valve replacements instead of one. However, it may combine the longevity of a mechanical valve with the benefit of not having to take blood-thinners for the rest of your life. This can make it attractive if you have a longer life expectancy and would otherwise face the prospect of having a tissue valve replaced at a later stage or taking blood-thinners for the rest of your life.
The drawback is that potentially, you would have two valves that could later fail, not just one.