Heart Valve Reconstruction: Information & Specialists

When is heart valve reconstruction necessary?

The human heart has four heart valves.

Two of these valves—the semilunar valves—are located between the atria and separate them from the ventricles:

• the tricuspid valve on the right and
• the mitral valve on the left.

Two other heart valves, the sac-shaped valves, close the openings from the ventricles to the major arteries:

• the aortic valve (on the left) to the aorta and
• the pulmonary valve (on the right) to the pulmonary artery.

All four heart valves can become diseased and, when they do, very often require treatment through heart valve surgery.

Essentially, there are two major heart valve diseases:

• valvular stenosis and
• valvular regurgitation.

The four heart valves: The semilunar valves are located on the outside, and the two semicircular valves are on the inside © Martin | AdobeStock

In heart valve stenosis, the heart valve does not open wide enough. As a result, less blood flows through it. This causes a rise in pressure in front of the valve (inside the heart).

If the heart valve does not close properly, this is referred to as heart valve insufficiency. This means that blood flows back into the chamber after passing through the heart valve. The result is what is known as regurgitation.

Both stenosis and regurgitation place a greater strain on the heart. To generate more force, the heart enlarges—that is, the heart muscle thickens and the heart chambers expand.

Once the wall reaches a certain thickness, the heart muscle is no longer adequately supplied with blood, putting the patient at risk of heart failure. To prevent this, doctors may recommend heart valve reconstruction.

Heart Valve Reconstruction via Open-Heart Surgery

In the majority of cases, heart valve reconstruction is performed via open-heart surgery. During the procedure, the surgeon opens the chest directly above the sternum and exposes the heart. To treat the heart valve, the heart must be stopped. A heart-lung machine takes over circulation while the heart is not beating.

During heart valve reconstruction surgery, the patient is under general anesthesia and is asleep throughout the procedure.

The surgeon has several options available for heart valve reconstruction:

• the valve opening can be enlarged by removing tissue,
• deposits in the area of the heart valve can be removed,
• the ligaments that control the semilunar valves can be repaired and, for example, reattached to the heart valve.

In addition, it is possible to strengthen the valve base (annulus) by adding tissue or placing an annulus band.

Once the surgeon has restored the heart valve, the patient is disconnected from the heart-lung machine. The heart begins beating on its own again, and the surgical incisions from the heart valve reconstruction are sutured closed.

This is followed by a few days in the intensive care unit, where the patient is monitored. This allows medical staff to detect any complications more quickly after the heart valve reconstruction is complete.

The human heart © Peter Hermes Furian | AdobeStock 

Minimally Invasive Heart Valve Reconstruction

In some cases, it is possible to perform heart valve reconstruction on a beating heart. Through a procedure known as minimally invasive surgery, the surgeon gains access to the heart and the damaged heart valve.

Mitral valve reconstruction is particularly well-suited for a minimally invasive approach.

To do this, the surgeon makes incisions about five to six centimeters long on the right side of the chest along the sternum. Cutting through the sternum is not necessary for minimally invasive heart valve reconstruction.

Minimally invasive surgery can also be performed for aortic valve replacement whenever possible. In this procedure, the sternum is cut only in the upper region and only partially. The length of the incision for the procedure has thus been reduced from 20 to 30 centimeters to less than eight centimeters.

The minimally invasive procedure primarily reduces

• postoperative pain following heart valve reconstruction,
• scarring, and
• recovery time.

This method offers significant improvements, particularly in terms of wound healing. Wound healing complications are avoided. As a result, the surgical scar heals faster than with conventional heart valve reconstruction. Because there is less strain on the sternum, the patient experiences less pain. This makes it easier for them to breathe in.

Today, the minimally invasive method is being used more and more frequently precisely because of these advantages. In Germany, however, this form of heart surgery is currently available only at a few select cardiac centers.

Mitral Valve Reconstruction

One of the most common causes of mitral valve regurgitation is the prolapse of the posterior mitral leaflet. In this case, the chordae tendineae that control the leaflet have torn. This results in a loss of connection between the heart valve and the papillary muscles, which control valve function. The papillary muscles are always located beneath the heart valve and originate from the muscle of the respective ventricle.

With each heartbeat, the ventricular muscle contracts, and so do the papillary muscles. This causes the mitral leaflets to open and close again after the blood has been ejected.

A leaky mitral valve can be treated using various state-of-the-art techniques, depending

• on the severity of the valve damage as well as
• the quality of the tissue

.

In all surgical methods, the heart valve must be stabilized using a metal ring. This ring keeps the valve leaflets open and ensures that they close properly. This prevents blood from flowing backward (regurgitation).

Overstretched or torn chordae tendineae are routinely attached to the papillary muscle using pre-manufactured Gore-Tex sutures. At the same time, the perforated leaflet of the valve is sutured to prevent it from perforating again. These Gore-Tex threads fully take over the function of the former chordae tendineae, thereby restoring the valve’s original function.

Much less frequently, parts of or the entire anterior mitral leaflet perforate, which also leads to mitral valve insufficiency. The new method of chordae replacement has the major advantage that the affected leaflet can be reattached over a large area.

If heart valve reconstruction is not possible using this method, the tried-and-true Carpentier procedures are used as an alternative. In this procedure, the affected segment is excised and the remaining valve segments are sutured together. This results in a smaller but still functional posterior mitral valve leaflet.

Primarily in very difficult, specialized cases, a “double-orifice” technique—named after the Italian cardiac surgeon Alfieri—is used. In this procedure, the surgeon sutures the anterior and posterior leaflets together over a short distance so that they open and close in unison.

In addition, a plastic ring (annuloplasty ring) is routinely implanted. This ring encircles the actual valve after heart valve reconstruction and reduces the size of the implanted valve ring.

The plastic ring is very important for ensuring the long-term success of the heart valve reconstruction. The use of an annuloplasty ring requires prophylactic blood-thinning with Marcumar for approximately three months following heart valve reconstruction. After three months, the implanted ring has become integrated with the surrounding tissue and no longer poses a risk of embolism.

Thanks to the successful options available for heart valve reconstruction, valve replacement is now necessary only in very rare cases.

Heart Valve Reconstruction and Statistics

Older patients in particular, who very often already suffer from heart failure, experience problems with heart valve reconstruction.

When the ventricle expands again due to the correction of the “heart defect,” the sutured mitral valve ring also expands. Since the mitral valve leaflets are attached to this ring, the leaflets can no longer close properly in the center, resulting in what is known as functional mitral regurgitation.

If the heart valve leaks again, the backflow of blood places a greater strain on the ventricle once more. The left ventricle enlarges so that the heart can regain the necessary pumping capacity. The ring eventually stretches out, and the mitral valve leaks more and more.

As the heart grows larger, the blood supply to the heart muscle reaches its limits, causing the heart to beat comparatively weaker and weaker. Pumping capacity decreases. The patient experiences

• rapid exhaustion,
• shortness of breath, and
• cardiac arrhythmias

.

Complete replacement of the mitral valve is necessary only if the valve is severely calcified or destroyed by inflammation.

According to statistics from the German Society for Thoracic, Cardiac, and Vascular Surgery (DGTHG), approximately 5,500 patients underwent mitral valve surgery at all German cardiac centers in 2012.

Of these, 3,600 underwent mitral valve repair, and in 60% of those cases, the procedure was performed using minimally invasive techniques. Thanks to mitral valve reconstruction, the mortality rate for mitral valve regurgitation was halved between 2000 and 2012.

Germany ranks among the international leaders in terms of both the volume and quality of heart valve reconstructions. Early surgery and heart valve reconstruction can also improve quality of life and life expectancy for those affected.

Percutaneous clip implantation for inoperable patients

The surgical risk of heart valve reconstruction increases

• in cases of advanced mitral valve regurgitation and
• in the presence of concomitant age-related conditions 

. For such patients, doctors currently favor the minimally invasive percutaneous implantation of a mitral valve clip.

This is a catheter-based heart valve repair procedure in which a clip is inserted into the left atrium. This clip is used to staple the two valve leaflets together, thereby restoring function.

The randomized EVEREST II study compared mitral valve clip implantation with standard surgery. It clarified which method would yield better results and under what circumstances. The EVEREST II study enrolled 279 patients with mild to moderate mitral regurgitation.

One group underwent open-heart surgery, while the other underwent percutaneous mitral valve repair using a clip. In 20% of the patients who received a mitral clip, valve insufficiency worsened over the course of 6 months. In contrast, 80% showed good results that remained stable in the long term.

Overall, the percutaneous valve repair procedure was found to carry a lower risk. However, open-heart surgery is significantly more effective and is therefore the superior option for such patients.

These study results brought about a very lasting change in the surgical landscape for mitral valve insufficiency in Germany. Today, the percutaneous method is primarily used to treat patients in poor health who are at high risk for complications.

Conclusion on Heart Valve Reconstruction

Mitral valve regurgitation is the second most common form of heart valve disease among German adults.

The treatment of choice is heart valve reconstruction. Significant progress has been made in recent years in the field of minimally invasive heart valve reconstruction. This surgical method offers clear advantages in terms of

• the complication rate,
• the healing process, and
• pain management following surgery.

At the same time, novel catheter-based treatment methods are being developed and tested. These include, for example, percutaneous mitral valve reconstruction via the insertion of a mitral clip. This procedure has been medically evaluated in studies and tested for its broad applicability.

Heart valve reconstruction is increasingly preferred over heart valve replacement. In Germany, more than 50% of all mitral valve defects are now treated using valve-preserving heart valve reconstruction.