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Surgery options for your heart condition

Heart surgeon Simon Kendall explains the different kinds of conditions that can affect your heart, and the surgical procedures that can be carried out as treatment.

Click on the accordion that describes your condition for information about it and how it's treated. For example if you have a problem with your aortic valve, click on the accordion heading 'Aortic valve repair and replacement'.

Details

  • Aortic valve repair and replacement Aortic valve repair and replacement

    About your aortic valve

    Your aortic valve is one of four valves in your heart. Its job is to stop the blood falling back into the heart (specifically, into the left ventricle) after each heartbeat.

    The aortic valve is around the size of a 50p piece and is made up of three leaflets arranged so that they meet in the middle and look a bit like a Mercedes sign. They are as thin as cling film.

    Usually, your aortic valve lasts a lifetime. However, things can happen to it that may mean you need to have treatment or surgery.

    Aortic stenosis

    Aortic stenosis (narrowing) is when the leaflets become thickened and stiff so that the flow of blood out of your heart becomes more and more obstructed. This makes your heart work harder, especially when you exercise.

    If aortic stenosis causes symptoms, your valve will need to be replaced – this is called aortic valve replacement (AVR). Occasionally, even if there are no symptoms, you may still need surgery. This might be the case if you’re having another heart operation (such as a coronary artery bypass graft), or if you have an exercise test that shows a problem.

    The treatment you’re offered will depend on your symptoms, how serious your condition is, how well you are, and what the risks are for you during and after treatments. Your surgeon will talk with you about what the risks are and explain why they are recommending a particular procedure for you.

    If you need a new artificial valve, it will be either a mechanical valve or a tissue valve. See ‘Mechanical and tissue valves for aortic valve replacement’ for further information about the available valves.

    Your valve can be replaced in three ways.

    1. Conventional aortic valve replacement. This involves an open-heart operation called a complete median sternotomy and is the main way aortic valves are replaced. Your breastbone (sternum) is divided along its length so your surgeon can get to your heart. Your valve is then replaced. You’ll be under general anaesthesia (asleep and feel no pain) for this operation. 
    2. Minimal access aortic valve replacement. This is when a surgeon gets to your heart through a smaller incision (cut), by dividing only the top part of the sternum, or a small cut to the right side of the breastbone. Your valve is then replaced. You’ll be under general anaesthesia. As yet, there’s no evidence (proof) to show which of these approaches (conventional or minimal) is the better or safer approach. 
    3. Transcatheter aortic valve implantation (TAVI) is a completely different way of getting the new valve to your heart. The artificial valve is inserted into the artery at the top of your leg and negotiated back along the artery to your heart. It is then expanded to fit within your own thickened aortic valve. If the artery at the top of your leg isn’t suitable, the valve can be inserted through a small incision below your left breast. The procedure can be done under general anaesthesia or local anaesthesia.

    TAVI isn’t as invasive as conventional surgery, and recovery is quicker so you can go home earlier. However, the long-term results from this procedure aren’t known. Because of this, TAVI is only recommended as an alternative if you’re not well enough to have conventional surgery.

    Aortic regurgitation

    Aortic regurgitation (leaking) occurs when the valve leaflets don’t meet properly in the middle and the blood falls back into your heart after each heartbeat. Your heart has to work harder to get enough blood around the body.

    Aortic regurgitation may not necessarily give you symptoms. Your heart can tire and show signs of strain without you feeling unwell. It’s important to have regular echocardiography to detect signs of heart strain. Your cardiologist will arrange these tests with you. Aortic valve surgery is recommended if you’re having symptoms or if tests such as echocardiography show that your heart is tiring.

    If you need surgery for aortic regurgitation, you’ll have your valve replaced. Your new artificial valve, may be either a mechanical valve or a tissue valve. See ‘Mechanical and tissue valves for aortic valve replacement’ for further information about the available valves.

    Your valve can be replaced in two ways.

    1. Conventional aortic valve replacement. This involves an open-heart operation called a complete median sternotomy and is the main way aortic valves are replaced. Your breast bone (sternum) is divided along its length so your surgeon can get to your heart. Your valve is then replaced. You’ll be under general anaesthesia (asleep and feel no pain) for this operation. 
    2. Minimal access aortic valve replacement. This is when a surgeon gets to your heart through a smaller incision (cut), by dividing only the top part of the sternum, or a small cut to the right side of the breastbone. Your valve is then replaced. You’ll be under general anaesthesia. As yet, there’s no evidence (proof) to show which of these approaches (conventional or minimal) is the better or safer approach. 

    Transcatheter aortic valve implantation (TAVI) is a treatment that is sometimes used for aortic stenosis, but it isn’t an option for aortic regurgitation. This is because it isn’t possible to expand the new valve into a secure position.

    Some surgeons have the knowledge, experience and expertise to repair a leaking valve. In this case, you wouldn’t need to have a new valve – your own valve would be repaired instead, either by conventional or minimal access surgery.

    Mixed aortic valve disease

    Mixed aortic valve disease is when aortic stenosis (narrowing) and aortic regurgitation (leaking) happen together. The leaflets of the aortic valve have thickened so the flow of blood becomes obstructed (aortic stenosis). At the same time, the leaflets don’t meet in the middle so blood falls back into your heart after each heartbeat (aortic regurgitation).

    The treatment you’re offered will depend on your symptoms, how serious your condition is, how well you are, and what the risks are for you during and after treatments. Your surgeon will talk with you about the risks and explain why he or she is recommending a particular procedure for you.

    Your new artificial valve may be either a mechanical valve or a tissue valve. See ‘Mechanical and tissue valves for aortic valve replacement’ for further information about the available valves.

    Your valve can be replaced in three ways.

    1. Conventional aortic valve replacement. This involves an open-heart operation called a complete median sternotomy and is the main way aortic valves are replaced. Your breastbone (sternum) is divided along its length so your surgeon can get to your heart. Your valve is then replaced. You’ll be under general anaesthesia (asleep and feel no pain) for this operation. 
    2. Minimal access aortic valve replacement. This is when a surgeon gets to your heart through a smaller incision (cut), by dividing only the top part of the sternum, or a small cut to the right side of the breastbone. You’ll have this operation under general anaesthesia. As yet, there’s no evidence (proof) to show which of these approaches (conventional or minimal) is the better or safer approach. 
    3. Transcatheter aortic valve implantation (TAVI) is a completely different way of getting the new valve to your heart. The artificial valve is inserted into the artery at the top of your leg and negotiated back along the artery to your heart. It is then expanded to fit within your own thickened aortic valve. If the artery at the top of your leg isn’t suitable, the valve can be inserted through a small incision below your left breast. The procedure can be done under general anaesthesia or local anaesthesia.

    TAVI isn’t as invasive as conventional surgery, and recovery is quicker so you can go home earlier. However, the long-term results from this procedure aren’t known. Because of this, TAVI is only recommended as an alternative if you’re not well enough to have conventional surgery.

  • Mechanical and tissue valves for aortic valve replacement Mechanical and tissue valves for aortic valve replacement

    Mechanical valves 

    Mechanical valves are very reliable. There are various models made by different companies but essentially they’re very similar. They’re made from carbon and metal.

    Mechanical valves will last your lifetime but your normal blood will want to clot (build up and stick) on the valve. Therefore, if you choose to have a mechanical valve, you’ll need to take an anticoagulant medicine called warfarin everyday of your life to keep your blood thin.

    Taking warfarin means you’ll need to have blood tests every week, or more frequently. These can be done at your GP surgery, anticoagulation clinic or at home if you purchase a home testing kit. If you have to have another operation such as a hip replacement, you would need to stop the warfarin and change to heparin at the time of the procedure. This is because warfarin can cause bleeding problems such as stomach ulcers and nose bleeds.

    Mechanical valves make a slight clicking noise – like an electric clock in a quiet room. You’ll almost certainly not notice it, but family and friends might hear it in a quiet situation. If you do notice it, it can be a bit disconcerting, but it’s nothing to worry about.

    Mechanical valves tend to be the preferred choice of:

    • younger people (younger than 65) as this will lessen the chance of needing another valve operation because the valve will last for a lifetime 
    • people who are at risk of a replacement tissue valve deteriorating quickly 
    • people who are already taking anticoagulation medicines for other reasons 
    • people who would be at risk if another valve operation were needed

    Mechanical valves have the same risk of infection as tissue valves.

    Tissue valves 

    Tissue valves are also very reliable. They are either made from the valve of a pig (porcine valve) or created from the sac encasing a calf’s heart (bovine pericardium). These valves perform well and out of every 100 implants, 80 will last at least 15 years. This means that 20 out of 100 implants will begin to fail in that time.

    If this happens to you, you’ll need a further procedure. This will either be another aortic valve replacement or possibly a TAVI procedure if your tissue valve is big enough to allow a TAVI valve to be inserted inside it.

    The big difference between mechanical and tissue valves is that with tissue valves, you don’t need to take a blood-thinning medicine (warfarin) for the rest of your life. However, a tissue valve won’t last as long as a mechanical valve.

    Tissue valves tend to be the preferred choice of: 

    • older people (older than 70) as they may not need another valve operation in their lifetime 
    • people who have a risk of bleeding and don’t want to take warfarin 
    • people who have other major surgery planned and don’t want to have blood-thinning drugs 
    • people who are planning to have children and avoid the risk of warfarin in pregnancy

    Tissue valves have the same risk of infection as mechanical valves.


  • Mitral valve repair and replacement Mitral valve repair and replacement

    About your mitral valve

    Your mitral valve is one of four valves in your heart. It stops the blood going back into the left atrium (in your heart) and the blood vessels from your lungs after each heartbeat. It’s around the size of a plughole in a basin and consists of two thin leaflets that meet in the middle.

    Usually, your mitral valve lasts your lifetime. However, things can happen to it that may mean you’ll need treatment or surgery.

    Mitral stenosis

    Mitral stenosis (narrowing) is when the leaflets and ribbons of tissue that hold them in place (chordae tendineae) become thickened and stiff so that the flow of blood from the left atrium into the left ventricle is obstructed. This condition is most often caused by rheumatic fever – an illness that is now very uncommon. Mitral stenosis causes a variety of problems including breathlessness, heart failure, swollen ankles and fluid retention.

    If you have significant mitral stenosis, your mitral valve will need to be replaced. This operation is called mitral valve replacement (MVR).

    If you need a new artificial valve, it will be either a mechanical valve or a tissue valve. See ‘Mechanical and tissue valves for mitral valve replacement’ for further information about the available valves.

    Your valve can be treated in three ways.

    1. Conventional mitral valve replacement. This involves an open-heart operation where your breastbone (sternum) is divided along its length so your surgeon can get to your heart. Your valve is then replaced. You’ll be under general anaesthesia (asleep and feel no pain) for this operation. 
    2. Minimal access mitral valve replacement. This is when a surgeon gets to your heart through a smaller incision (cut), just below the right breast. Your valve is then replaced. You’ll be under general anaesthesia. As yet, there’s no evidence (proof) to show which of these approaches (conventional or minimal) is the better or safer approach . 
    3. Balloon valvotomy. This procedure is done under local anaesthesia. A balloon is expanded within the thickened valve to open (widen) it. Balloon valvotomy may be advised if your condition is severe and your heart valve is in a suitable condition to have the procedure. It’s also called percutaneous mitral commissurotomy.

    Mitral regurgitation

    Mitral regurgitation (leaking) occurs when the valve leaflets don’t meet properly in the middle and the blood leaks back into the left atrium after each heartbeat. Your heart has to work harder to get enough blood around the body.

    Mitral regurgitation may not necessarily give you symptoms. Your heart can tire and show signs of strain without you feeling unwell. It’s important to have regular echocardiography tests to detect signs of heart strain. Mitral valve surgery is recommended if you’re having symptoms or if tests such as echocardiography show that your heart is tiring.

    For this condition, repairing your mitral valve is recommended wherever possible. Repairing your mitral valve rather than replacing it means that you won’t need to take blood-thinning medicine (warfarin) for the rest of your life.

    If you do need an artificial valve, it may be either a mechanical valve or a tissue valve. See ‘Mechanical and tissue valves for mitral valve replacement’ for further information about the available valves.

    Your valve can be repaired or replaced in two ways.

    1. Conventional mitral valve surgery. This involves an open-heart operation where your breastbone (sternum) is divided along its length so your surgeon can get to your heart. Your valve is then repaired or replaced with either a mechanical or tissue valve. You’ll be under general anaesthesia (asleep and feel no pain) for this operation. 
    2. Minimal access mitral valve replacement. This is when a surgeon gets to your heart through a smaller incision (cut), just below the right breast. Your mitral valve is then repaired or replaced. You’ll have this operation under general anaesthesia. As yet, there’s no evidence (proof) to show which of these approaches (conventional or minimal) is the better or safer approach.  

    Mixed mitral valve disease

    Mixed mitral valve disease is when mitral stenosis (narrowing) and mitral regurgitation (leaking) happen together. The leaflets of the mitral valve become thickened and obstruct blood flow (mitral stenosis). At the same time, the leaflets don’t meet in the middle so blood leaks back into the atrium (mitral regurgitation).

    If you need a new artificial valve, this will either be with a mechanical valve or a tissue valve. See ‘Mechanical and tissue valves for mitral valve replacement’ for further information about them.

    Your valve may need to be replaced in one of the following two ways.

    1. Conventional mitral valve replacement. This involves an open heart-operation where your breastbone (sternum) is divided along its length so your surgeon can get to your heart. Your valve is then replaced with either a mechanical or tissue valve. You’ll be under general anaesthesia (asleep and feel no pain) for this operation. 
    2. Minimal access mitral valve replacement. This is when a surgeon gets to your heart through a smaller incision (cut), just below the right breast. Your mitral valve is then replaced. You’ll have this operation under general anaesthesia. As yet there’s no evidence (proof) to show which of these approaches (conventional or minimal) is the better or safer approach. 
  • Mechanical and tissue valves for mitral valve replacement Mechanical and tissue valves for mitral valve replacement

    Mechanical valves 

    Mechanical valves are very reliable. There are various models made by different companies but essentially they’re very similar. They’re made from carbon and metal.

    Mechanical valves will last your lifetime but your normal blood will want to clot (build up and stick) on the valve. Therefore, if you choose to have a mechanical valve it means you’ll need to take a medicine called warfarin everyday of your life to keep your blood thin.

    Taking warfarin means you’ll need to have blood tests every week or more frequently. These can be done at your GP surgery, anticoagulation clinic or at home if you purchase a home testing kit. If you have to have another operation such as a hip replacement, you would need to stop the warfarin and change to heparin at the time of the procedure. This is because warfarin can cause bleeding problems such as stomach ulcers and nose bleeds.

    Mechanical valves make a slight clicking noise – like an electric clock in a quiet room. You’ll almost certainly not notice it, but family and friends might hear it in a quiet room. If you do notice it, it can be a bit disconcerting, but it’s nothing to worry about.

    Mechanical valves tend to be the preferred choice of: 

    • younger people (younger than 65) as this will lessen the chance of needing another valve operation because the valve will last for a lifetime 
    • people who are at risk of a replacement tissue valve deteriorating quickly 
    • people who are already taking anticoagulation medicines for other reasons 
    • people who would be at risk if another valve operation were needed

    Mechanical valves have the same risk of infection as tissue valves.

    Tissue valves

    Tissue valves are also very reliable. They are either made from the intact valve of a pig (porcine valve) or created from the sac encasing a calf’s heart (bovine pericardium). These valves perform equally well and out of every 100 implants, 80 will last at least 10 years. This means that 20 out of 100 implants will begin to fail in that time. If this happens, you’ll need a further operation.

    The big difference between mechanical and tissue valves is that with tissue valves, you don’t need to take a blood-thinning medicine (warfarin) for the rest of your life. However, the valve won’t last as long as a mechanical valve.

    Tissue valves tend to be the preferred choice of:

    • older people (older than 70) as they may not need another valve operation in their lifetime 
    • people who have a risk of bleeding and don’t want to take warfarin 
    • people who have other major surgery planned and want to avoid blood-thinning drugs. 
    • people who are planning to have children and avoid the risk of warfarin in pregnancy

    Tissue valves have the same risk of infection as mechanical valves.

  • Coronary artery bypass graft (CABG) Coronary artery bypass graft (CABG)

    Coronary heart disease

    Coronary heart disease happens when fat and cholesterol in your blood build up in your coronary (heart) artery walls and form a plaque (atheroma). This process is known as atherosclerosis.

    Atherosclerosis narrows the artery and reduces the blood flow so that your heart muscle doesn’t get all the oxygen it needs. This can damage your heart muscle and lead to a range of symptoms, which can be serious.

    Coronary artery bypass graft surgery (CABG)

    Coronary artery bypass graft (CABG) surgery is a procedure to improve the blood flow to your heart. It’s used to treat coronary heart disease. You may well hear CABG pronounced as ‘cabbage’. Having a CABG procedure can relieve your angina symptoms, and may also reduce your risk of having a heart attack.

    In this procedure, your surgeon will take an artery or vein from your leg, arm or chest to use as a graft or grafts. You may just have one graft, or there may be several. To reach your heart, your surgeon will make a cut down the middle of your breastbone (sternum) and open your chest. This is known as open-heart surgery. Your surgeon will then attach the graft(s) in the correct place(s) to bypass the narrowed parts of your coronary arteries. After attaching the graft(s), your surgeon will restart your heart (if it was stopped in the operation). You’ll be under general anaesthesia (asleep and feel no pain) for CABG.

    CABG can also be done with keyhole surgery – this is when the cuts are smaller and the operation is minimally invasive. In this case, your breastbone won’t need to be cut. However, keyhole surgery for CABG is still being tested by surgeons and isn't yet widely used. It isn’t suitable for everybody – your surgeon will advise you if it's appropriate for you. If you do have keyhole surgery, there's a chance your surgeon may need to convert to open surgery if it's impossible to complete the operation safely using the keyhole technique.

    What happens to the place in the leg where the vein was taken away?

    After a vein in your leg has been taken away to use as a graft, the fat layer and the skin layer are stitched together over the length of the surgical wound. The veins in the leg that are used in this way run under the skin. They are an ‘extra’ and aren't essential for taking the blood from your leg back up to your heart. The veins that are really important in returning blood to your heart are deep within your leg muscles. This is because although gravity would make all the blood pool in your feet, every time you move your leg muscles, the deep veins in your muscles are squeezed so the blood goes upwards towards your heart. The veins under the surface of your skin help in this process. They have little valves to help stop the blood falling back towards your feet, but are not so important as the deep veins. Your blood flow will work perfectly well if a small section is taken away for a graft.

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