Treatment for Heart Valve Disease
Mount Sinai's valvular heart disease experts take a proactive approach to assessing patients for heart valve repair or replacement surgeries. Paul Stelzer, MD, Professor of Cardiothoracic Surgery, counsels against waiting for symptoms to appear or worsen.
"Patients might be fine for a while," Dr. Stelzer says, "but we know that valve problems will ultimately impact ventricular function. When that happens, it can take years off people's lives."
Doctors began performing valve replacements in the 1960s, using mechanical prostheses or valves from animals or humans. While these remain viable options, they aren't perfect. Prosthetic valves require long-term drug treatment with resulting side effects, while biological valves can deteriorate over time.
Valvular Repair Now the Treatment of Choice
At Mount Sinai Heart, we concentrate on surgery to repair—rather than replace—heart valves. Both the American Heart Association and the American College of Cardiology recommend valvular repair over replacement. Both groups state that the surgery should be performed in a high-volume hospital, like Mount Sinai, where surgeons have the highest level of experience.
David H. Adams, MD, Professor and Chair of Cardiothoracic Surgery and Program Director of the Mitral Valve Repair Reference Center, says that despite the clear consensus, many patients still undergo the wrong operation. "Here at Mount Sinai Heart, we give people the most current information," Dr. Adams says. "We offer the best technical expertise and medical care for valve repair surgery."
Mount Sinai Heart has built an internationally renowned valvular heart disease surgical team. Our outstanding success rates and unparalleled performance records attract patients to New York from all over the world.
"We have a wealth of experience to offer patients, whether their problems are simple or complex," says Dr. Stelzer. "We have the depth of personnel to take patients from diagnosis to treatment and follow-up."
Mitral Valve Repair
Mount Sinai Heart surgeons have an outstanding record in mitral valve repair. Surgeons with particular expertise in mitral valve repair are called "reference mitral valve surgeons." Our mitral valve surgeons concentrate on preserving as much of the valve as possible. Opting for repair over replacement boosts long-term survival by maintaining the shape, volume, and function of the left ventricle.
The two main types of degenerative mitral valve disease are Barlow's disease and fibroelastic deficiency. Each has unique characteristics and requires a different surgical approach. For example, Barlow's disease causes large, billowing, hardened leaflets. Patients often have multiple complex lesions. High rates of repair are likely only at the hands of reference mitral valve repair surgeons.
The Method of Mitral Valve Repair
Surgeons use a variety of techniques to repair the mitral valve. For example, a common cause of mitral valve regurgitation involves a weakening of the mitral valve's posterior leaflet. This weakening causes the valve to swing back and forth like saloon doors, unable to shut properly. Removing the weakened portion of the leaflet may enable the valve to close normally and avoid leakage.
Sometimes surgeons perform more extensive reconstruction of the valve leaflets and may use sutures to support the valve. After fixing the leaflet, a special ring called an annuloplasty ring is implanted around the valve to reinforces the annulus. The annulus frames the valve much the same way a door frame supports a door. Annuloplasty rings help restore the annulus to its normal size and shape if it has become enlarged or distorted.
Dr. Adams is the co-inventor of several widely used annuloplasty rings, including the worldwide gold standard, the Carpentier-Edwards Physio II Annulplasty Ring. Learn more about Dr. Adams's contributions to mitral valve repair in Advances in Care.
Minimally Invasive Surgical Options for Valve Repair
Accomplished surgeons can now perform mitral valve repair in some patients with minimally invasive techniques. Surgeons use specifically designed instruments passed through a few tiny incisions and into the heart.
"We can provide the same high-quality valve surgery through smaller incisions, speeding recovery," says Joanna Chikwe, MD, Assistant Professor of Cardiothoracic Surgery. The technique minimizes pain and scarring for many patients. Dr. Chikwe has a particular interest in the practice. She is one of a handful of surgeons in the United States with advanced training in both reconstructive valve surgery and minimally invasive cardiac surgery techniques such as off-pump, video, and robotic-assisted surgery.
Tricuspid Valve Repair
At Mount Sinai Heart, we have demonstrated that tricuspid valve disease can be safely and effectively treated in a wide variety of patients. Our surgeons recommend assessing the need for surgical repair of the tricuspid valve at the time of mitral valve surgery, preferably using an annuloplasty ring.
Mitral Valve Replacement
In some valvular heart disease, the valves are significantly calcified or damaged by infection. The tissue can no longer be manipulated and repaired, and replacement is the treatment of choice.
Surgeons can use either mechanical devices or biological valves, called heterografts, that are made from animal tissue and strengthened with metal frames.
Replacement valves are subject to various risks:
- Valves can deteriorate, causing openings to narrow or leak
- Blood clots can form near the new valves and break off
- Anticoagulant medications, given to prevent clots, can cause bleeding
- Infection, such as endocarditis, can develop
- Structural valve failure may require repeat surgery
Aortic Valve Replacement
Mount Sinai Heart surgeons are expert at replacing aortic valves. Unlike the mitral or tricuspid valves, the aortic valve is under high pressure and usually cannot be repaired.
Ross Procedure: Replacing an Aortic Valve
The Ross Procedure is a surgical technique in which a patient's diseased aortic valve is replaced with his or her own pulmonary valve, rather than an artificial valve. The procedure is based on the principle that blood flows more easily through a human valve than an artificial one.
During the Ross Procedure, the surgeon removes the diseased aortic valve and replaces it with the patient's own pulmonary valve, which is anatomically similar. The relocated pulmonary valve is then replaced with a donor heart valve. Within a few months the pulmonary valve becomes thicker and stronger and begins to behave like an aortic valve.
Paul Stelzer, MD, Professor of Cardiothoracic Surgery, is one of only a handful of physicians who have performed more than 450 Ross Procedures. Patients come to Mount Sinai Heart from all over the world to have this procedure.
"The valve we use to replace your aortic valve is your own, live pulmonary valve, which can live a normal life span," explains Dr. Stelzer. "That's the beauty of the Ross Procedure."
Although the Ross Procedure was designed as a long-term solution for younger, active patients, some older adults have benefited from this technique. Very young patients, whose hearts are not fully developed, can be treated through other means until their valves are a suitable size, usually around age 10. At that point, they may undergo the Ross Procedure.
Valvuloplasty: Opening Narrowed Heart Valves
Valvuloplasty, also known as percutaneous balloon valvotomy, is a procedure used to open a narrowed heart valve. In valvuloplasty, doctors thread a catheter carrying one or more balloons through an artery. Once at the narrowed valve, the doctor inflates the balloons. The balloons fracture hardened deposits, increasing the size of the opening and helping the valve move more freely.
Mount Sinai Heart doctors perform more than 100 valvuloplasties annually, including more aortic valvuloplasties than any other center nationwide. Led by Samin K. Sharma, MD, Professor of Cardiology and Director of the Cardiac Catheterization Laboratory, Mount Sinai Heart cardiologists are trailblazers in this minimally invasive procedure.
Valvuloplasty is a treatment of choice for many people with significant mitral valve stenosis, or narrowing. For aortic stenosis patients, valvuloplasty is often an option for older patients who are not healthy enough to undergo valve replacement surgery. The procedure is also used as a "bridge" to valve replacement surgery in young adults and adolescents.
When to Have Heart Valve Surgery
"We really try to minimize the number of times in a patient's life that they need an operation. Once would be great," says Dr. Stelzer. "You want the surgery to be as successful as possible with the lowest risk, and you want to be able to maintain that benefit for the longest possible time."
Deciding when to perform valve surgery depends on a combination of factors:
- The amount of regurgitation, or blood flowing back into the atrium
- The function of the affected portions of the heart
- The size of the heart chambers
- The presence of atrial fibrillation, a type of abnormal heart rhythm
- Symptoms of pulmonary hypertension, or elevated blood pressure in the arteries supplying the lungs
For people experiencing symptoms with evidence of advanced disease, surgery is clearly necessary. But even for patients with no symptoms, the field is moving toward early valve intervention. Surgeons experienced in valvular heart disease and practicing at a valve reference center with a high success rate, like Mount Sinai Heart, tend towards operating before heart damage or symptoms occur.
Surgeons are mindful of these important factors:
- Will the surgery pose undue risk of stroke or other complications?
- Will the repair be 100 percent effective?
- Will the repair last a long time?
Experienced valvular heart disease surgeons can easily assess the feasibility of doing a repair. Success depends not only on the severity of the valve's lesions, but also the experience of the surgical team and the team's mastery of repair techniques.