What heart valve operation is best?

Submitted by Dr T on November 7, 2013 – 5:04pm

The question is not what mechanical heart valve is best. That’s your surgeon’s decision, and it depends on his personal experience.  The real question is whether a mechanical valve is preferable  over a tissue valve, or whether a repair is possible. 

The first questioon is about what valve needs to be fixed, the mitral or aortic valve. 

There are a lot of considerations about the treatment of aortic valve or mitral valve disease, and especially mitral insufficiency and aortic insufficiency:

1. An aortic valve repair or mitral valve repair should be considered first. If possible, this is the best solution, but it requires an experienced surgeon.
2. For both mitral and aortic valve replacement the choice between tissue vs. a metal valve depends first of all on
   1. Whether there are cardiac arrhythmias such as atrial fibrillation that requires long-term anti-coagulation with a blood thinner such as Coumadin.
   2. Is an adequate size valve prosthesis possible (a tissue valve requires more space), and if not, can the area be enlarged to accommodate a larger prosthesis?
   3. A metal valve prosthesis has a smaller diameter (thus fits easier) and lasts forever, but is more prone to the risk of an infection and requires a blood thinner for the rest of your father’s life – an issue if he is involved with activities that may expose him to injuries and thus bleeding.
   4. A tissue valve is larger (thus a good size sometimes not possible without additional surgery), lasts about 15-17 years and will need to be replaced eventually if your dad lives long enough. Blood thinners in someone with a normal rhythm usually only need to be taken for about 6 months.
3. Is there associated coronary artery disease for which Coronary artery bypass grafting is needed?
4. How physically active and healthy is your father? 
5. What is his normal life expectancy once his valve has been fixed?

With all that in mind, I’d probably recommend a tissue valve if repair is not possible, because if could avoid long term blood thinner use and the risk of a future replacement of the prosthesis is relatively small in an otherwise healthy person. A new procedure called trans catheter aortic valve implantation (TAVI) has recently been developed for patients who are otherwise too sick to survive convential open heart surgery. Hope this helps,