Heart valve repair or replacement for mitral valve regurgitation or prolapse

Surgery Overview

---

Surgery is required for severe mitral valve regurgitation (MR).

Surgery for MR is recommended when you have symptoms of heart failure, or when your ejection fraction drops below 60% and/or your left ventricle is larger than 40 mm at rest.¹

Generally, surgery for mitral valve prolapse (MVP) is only done if you have mitral valve regurgitation. Valve repair or replacement are the two types of surgery available to treat these conditions.

Both valve repair and replacement are typically open-heart surgeries. Minimally invasive types of surgery may be another option. This section describes open-heart surgery.

During valve surgery, you are given general anesthesia. Surgery typically lasts about 3 to 5 hours. Your doctor makes a large incision in your chest. You are placed on a heart-lung machine during the surgery. Blood is circulated outside of the body and oxygen is added to it using a heart-lung (cardiopulmonary bypass) machine. To protect the heart muscle from damage during surgery to replace the heart valve, the heart may be cooled to slow or stop the heartbeat. The damaged mitral valve is either repaired or removed and replaced with an artificial (prosthetic) heart valve.

The decision between repairing or replacing the valve depends on the type of damage to the mitral valve. For instance, repair is more successful if there is limited damage to certain areas of the mitral valve flaps (leaflets) or to the tough fibers that control movement of the mitral valve leaflets (chordae tendineae). But replacement is usually preferred for people who have a hard, calcified mitral valve ring (annulus) or widespread damage to the valve and surrounding tissue.

Torepair the heart valve, the surgeon may:

• Reshape the valve by removing excess valve tissue.
• Add support to the valve ring by adding tissue or a collarlike structure around the base of the valve.
• Attach the valve to nearby cordlike heart tissues (chordal transposition).

Heart valve replacement surgery involves the removal of the badly damaged valve. The valve is replaced with a plastic or metal mechanical valve, or a bioprosthetic valve, which is usually made from pig tissue. The damaged valve is cut out, and the new valve is sewn into place.

People who receive a mechanical heart valve are more likely than those who receive a bioprosthetic heart valve to develop blood clots in the heart. The clots may break loose, travel to the brain, and cause a stroke. So if you have received a mechanical heart valve to treat severe MR, you will need to take medicine for the rest of your life to prevent clots from forming (anticoagulant medicine).

In some cases, a plastic or metal valve may be preferred if you are already taking anticoagulants for other reasons, such as atrial fibrillation.

What To Expect After Surgery

---

Recovery from heart valve surgery usually involves a few days in an intensive care unit (ICU) of a hospital. Full recovery from heart valve surgery can take several months. Recovery includes healing of the surgical incision, gradually building physical endurance, and exercising.

After you have an artificial valve, your heart function and your life will largely return to normal. You should feel better than before you had the surgery if you had symptoms before surgery. For example, you should no longer experience shortness of breath and fatigue. But if your heart was already severely affected before your surgery, you may continue to experience complications of heart disease.

You should be able to resume most of your normal activities, although you will have to continue to monitor your condition. You need to watch out for symptoms of blood clots and infections.

An artificial valve may need to be replaced after a period of time, so it is important to see your doctor regularly. Bioprosthetic valves last for about 8 to 15 years.

Why It Is Done

---

Surgery to repair or replace the mitral valve is often required in MR. Surgery is generally done for mitral valve prolapse (MVP) only when MR is present. The recommendations for surgery for both conditions are generally the same.¹

Conditions that are most likely to require surgery include:

• Sudden (acute) MR.
• MR with symptoms of heart failure.
• MR with mild-to-moderate left ventricular dysfunction (ejection fraction less than 60% and/or an enlarged left ventricle more than 40 mm at rest).

Conditions that may require surgery include:

• MR with an irregular heartbeat (atrial fibrillation) but no symptoms and no signs of functional damage to the left ventricle.
• MR with elevated blood pressure in the lungs (pulmonary hypertension) but no symptoms and no signs of functional damage to the left ventricle.
• MR with mild to severe left ventricular dysfunction, no symptoms, and a high likelihood of preserving some of the related structures of the mitral valve.

Conditions that are less likely to require surgery include:

• Chronic MR with no symptoms and no signs of functional damage to the left ventricle, even if surgical repair of the mitral valve is likely to be successful.
• MR with MVP and no signs of functional damage to the left ventricle but with recurrent ventricle arrhythmias despite treatment.

How Well It Works

---

If mitral valve repair is done before the heart is severely damaged by the faulty valve, most people have excellent short- and long-term results.¹

The outcome of mitral valve replacement depends on a person's overall health, including other health conditions.

• Mechanical valves, which are made of metal or plastic, tend to cause more clotting than those made of animal tissue. But mechanical valves generally do not have to be replaced and usually do not require additional surgery. A plastic or metal valve may be preferred if you are already taking long-term anticoagulants for other reasons.
• Artificial valves cause less blood clotting than mechanical valves. But you will likely take aspirin for the rest of your life to lower the chance of clotting.
• Bioprosthetic valves last for about 8 to 15 years.

Risks

---

The exact risks of mitral valve surgery vary depending on the person's specific condition and general health prior to surgery. In general, the risks include:

• Effects from the operation itself (such as bleeding, infection, and risks associated with anesthesia). These risks are low.
• Blood clotting caused by the new valve. Replacement with a mechanical valve requires lifelong treatment with medicine to prevent blood clots (anticoagulant).
• Infection in the new valve. Infection is more common with valve replacement than with valve repair.
• Failure of the new valve. Valve failure is more common with valve replacement than with valve repair. Bioprosthetic valves last for about 8 to 15 years.

What To Think About

---

Repair versus replacement

Repair of the heart valve usually is the preferred and more common type of surgery for MVP.

When the mitral valve is seriously damaged, heart valve replacement may be recommended. Examples of serious damage or complicated conditions that might lead to mitral valve replacement include:

• Extensive ballooning of the mitral valve (rather than a single flap that puffs up).
• Severe hardening (calcification) of the valve.
• Prolapse (bulging) of the valve at an unusual location.
• Damage to the valve from infection (endocarditis).

The decision regarding whether to repair or replace a valve is based on many things, including the person's general health, the condition of the damaged valve, the presence of other health conditions, and the expected benefits of surgery. In some cases, the decision clearly may be in favor of repair or replacement.

Complete the surgery information form (PDF) (What is a PDF document?) to help you prepare for this surgery.

References

---

Citations

1. Bonow RO, et al. (2006) ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease). Circulation, 114(5): e84–e231.

Credits

---

Author	Robin Parks, MS
Editor	Kathleen M. Ariss, MS
Associate Editor	Pat Truman, MATC
Primary Medical Reviewer	E. Gregory Thompson, MD - Internal Medicine
Specialist Medical Reviewer	Stephen Fort, MD, MRCP, FRCPC - Interventional Cardiology
Last Updated	March 27, 2008