Valve Surgery — How It Works, Benefits & Recovery — Procedure Guide, Recovery & Risks | MyMedicPlus

Cardiac valve surgery encompasses procedures to repair or replace diseased heart valves — most commonly the aortic and mitral valves — when their dysfunction causes haemodynamically significant stenosis (obstruction to blood flow) or regurgitation (backward leakage), leading to cardiac remodelling, heart failure, and reduced life expectancy. The heart contains four valves that maintain unidirectional blood flow: the aortic and pulmonary valves (semilunar, with three leaflets) and the mitral and tricuspid valves (atrioventricular, with two and three leaflets respectively). Degenerative valve disease (calcific aortic stenosis, mitral valve prolapse with regurgitation) is the most common aetiology in high-income countries; rheumatic heart disease, endocarditis, and functional regurgitation secondary to ventricular dilation are also prevalent worldwide. Surgical treatment strategies include valve repair (valvuloplasty — preserving the native valve structure using annuloplasty rings, leaflet reconstruction, or chordal techniques), valve replacement with a mechanical prosthesis (highly durable, requiring lifelong anticoagulation), or valve replacement with a bioprosthetic (tissue) prosthesis from porcine or bovine pericardial material (limited longevity of 10-15 years but without mandatory anticoagulation). Transcatheter approaches — TAVI for aortic stenosis, MitraClip for mitral regurgitation, TMVR for mitral replacement — are established alternatives for high and intermediate surgical risk patients, revolutionising the management landscape of valvular heart disease.

Surgical or transcatheter valve intervention is indicated for patients with severe symptomatic valvular heart disease confirmed on echocardiography with evidence of haemodynamic compromise, symptoms attributable to the valve lesion, or declining ventricular function. For severe aortic stenosis — the most common valvular lesion requiring intervention — symptoms of syncope, angina, or dyspnoea on exertion indicate an average survival of 1-3 years without treatment. TAVI or surgical aortic valve replacement (SAVR) is recommended for all symptomatic severe aortic stenosis patients with a suitable anatomy. Severe mitral regurgitation warrants repair or replacement when symptomatic (dyspnoea, reduced exercise tolerance), or when asymptomatic but with evidence of left ventricular dysfunction (LVEF below 60%), left ventricular dilatation (LVESD above 40 mm), new-onset atrial fibrillation, or pulmonary hypertension. Mitral valve repair is strongly preferred over replacement where technically feasible (most cases of degenerative MR), given its superior long-term outcomes and avoidance of anticoagulation. Severe mitral stenosis typically from rheumatic aetiology is treated by percutaneous balloon mitral valvuloplasty (PBMV) if valve anatomy is suitable (Wilkins score 8 or below), or surgical mitral valve replacement if commissurotomy or repair is not feasible.

Conventional open cardiac valve surgery is performed through a median sternotomy (full midline sternal division) or a minimally invasive approach (right mini-thoracotomy for mitral valve, upper hemi-sternotomy for aortic valve) under general anaesthesia. Cardiopulmonary bypass (CPB) — the heart-lung machine — takes over the functions of the heart and lungs: venous blood is drained via cannulas, oxygenated and pumped back to the aorta, maintaining perfusion of all organs while the heart is arrested. Cardioplegia — a cold potassium-rich solution — is injected into the aortic root to arrest the heart in diastole, providing a still, bloodless operative field. For aortic valve surgery: the aorta is cross-clamped and opened transversely. The diseased valve leaflets are excised; the annulus is sized with graduated sizers; the prosthetic valve is seated and secured with multiple interrupted sutures. The aortotomy is closed and the aortic clamp released, allowing the heart to resume sinus rhythm after cardiac defibrillation if needed. For mitral valve surgery: the mitral valve is accessed through a left atriotomy (or trans-septal approach). The pathology determines the repair strategy: posterior leaflet prolapse is corrected by quadrangular resection of the prolapsing segment and reapproximation of the leaflet; anterior leaflet prolapse uses artificial chordae (expanded PTFE sutures); annular dilatation is corrected with an annuloplasty ring (rigid, semi-rigid, or flexible) secured around the annulus. If repair is not feasible, the native valve is replaced with a mechanical or bioprosthetic prosthesis. TAVI for aortic stenosis is performed in a cardiac catheterisation laboratory under general or local anaesthesia plus sedation: a balloon-expandable (Edwards SAPIEN) or self-expanding (Medtronic Evolut) transcatheter valve mounted on a catheter is delivered via the transfemoral route (groin) in over 90% of cases, positioned across the calcified native valve under fluoroscopic and TEE guidance, and deployed.

Isolated mitral valve repair carries operative mortality below 1% at experienced centres with high annual surgical volumes, representing the safest open cardiac operation performed. Long-term survival after successful mitral valve repair for degenerative mitral regurgitation is equivalent to the age-matched general population, demonstrating that timely surgery corrects the natural history of the disease. Mechanical valves provide structural durability exceeding 25 years without requiring re-intervention, making them the preferred choice for younger patients (typically under 60-65 years of age) who can safely manage lifelong anticoagulation. Bioprosthetic valves have a 10-15 year durability in adults, improving in older patients where the valve is implanted after the age of 70 — calcification of bioprosthetic leaflets is slower in older recipients because calcium metabolism is reduced. Transcatheter aortic valve implantation (TAVI) achieves equivalent or superior 1-2 year outcomes to surgery in intermediate and low surgical risk patients in landmark trials (PARTNER 3, Evolut Low Risk), with faster recovery, shorter hospital stay, and better quality of life at 30 days, though long-term durability data beyond 10 years are still accumulating. The TAVI advantage for rapid recovery makes it particularly beneficial in elderly patients with multiple comorbidities.

Perioperative risks of cardiac valve surgery include stroke (1-2% for isolated valve surgery, higher with combined procedures or calcific aortic disease), pericardial effusion requiring drainage, significant bleeding requiring re-exploration in theatre (2-5%), deep sternal wound infection (1-2%) — most commonly in obese or diabetic patients — and new-onset atrial fibrillation (20-40%), which usually resolves spontaneously but may require cardioversion or anticoagulation. Permanent complete heart block necessitating pacemaker implantation occurs in 3-5% of patients undergoing aortic valve surgery due to conduction system injury in the membranous septum near the His bundle. Prosthetic valve endocarditis — infection of the implanted prosthesis — occurs at an annual incidence of 0.5-1% and is a serious, potentially life-threatening complication requiring prolonged antibiotics and often reoperation. Mechanical valve thrombosis causing acute haemodynamic compromise is a surgical emergency and occurs in approximately 0.2% per patient-year despite therapeutic anticoagulation. Transcatheter TAVI-specific risks include significant paravalvular aortic regurgitation (PPM-mismatch), permanent pacemaker requirement (10-15% with newer-generation transcatheter valves), access-site vascular complications (1-2%), and coronary ostium obstruction from the deployed frame (under 1%).

After open cardiac valve surgery, patients are transferred to the cardiac intensive care unit (CICU) for 24-48 hours for haemodynamic monitoring, ventilator weaning, arrhythmia management, and chest drain surveillance. Extubation occurs within 6-12 hours in uncomplicated cases. Total inpatient stay is typically 5-8 days. Chest physiotherapy and early mobilisation begin on postoperative day 1-2 to prevent pulmonary complications and deep vein thrombosis. Sternal healing takes 6-8 weeks; sternal precautions — no pushing, pulling, or lifting greater than 5 kg with arms, and no driving — apply throughout this period. Cardiac rehabilitation — supervised exercise, education, risk factor modification, and psychological support — begins at 4-6 weeks and is associated with a 20-25% reduction in mortality and significant improvements in functional capacity and quality of life. Mechanical valve recipients require lifelong warfarin anticoagulation with a target INR of 2.5-3.5 (aortic) or 3-4 (mitral), with weekly INR monitoring until stable; self-monitoring home INR testing devices improve anticoagulation control and are supported by current guidelines. Bioprosthetic valve recipients receive anticoagulation for 3 months post-operatively then may discontinue if in sinus rhythm. After TAVI, most patients are discharged within 2-3 days; dual antiplatelet therapy (aspirin plus clopidogrel) is prescribed for 3-6 months.