written by Mustafa Ahmed MD and David Mcgiffin MD
Mitral Valve Replacement vs Mitral Valve Repair – When should the mitral valve be repaired and when should the mitral valve be replaced?
Decision making in valvular heart disease is complex. Operation may be required for mitral regurgitation, mitral stenosis, or both. Mitral regurgitation is a leaky mitral valve. Mitral stenosis is a tight mitral valve. The key is that all decisions regarding operations on the mitral valve be discussed with dedicated specialists with a proven track-record of successful mitral valve surgeies. Unfortunately, in the US many valves that could be repaired are replaced, simply because of a lack of experience and interest in mitral valve repair by the surgeons involved. In many circumstances, there is a clear advantage of mitral valve repair over replacement. There are cases; however, where mitral valve replacement will be the preferred method. Again, the key is that cardiologists and cardiac surgeons with a special interest in mitral valve disease make these decisions.
Should I get a metallic or a tissue mitral valve?
Many factors need to be taken in to account before deciding on the type of prosthetic heart valve. It’s important to take in to account the preference of the patient and how the choice will affect lifestyle. For example, a tissue valve does not require long-term blood thinning medication, whereas a metallic valve does. Therefore, patients with a lifestyle that may include sports or other activities that would preferably avoid blood-thinning medication may benefit from a tissue valve.
There are advantages and disadvantages to both types of valve. Metallic valves have the advantage of lasting a long time and are generally not subject to wear and tear over time. This of course means that the chance of needing a further operation is low. The major disadvantage to a metallic mitral valve replacement is the need for blood thinning medication, typically in the form of a Coumadin blood thinner. Patients with metallic valves need their blood to be 2-3 times thinner than usual to avoid the risk of clot formation on the valves. Formation of a clot can lead to stroke or valve dysfunction. Of course when the blood is thinner, there is an increased risk of bleeding.
Tissue valves have the advantage of not requiring long-term blood thinner. The major disadvantage of tissue valves is the fact that they will wear and tear over time and eventually require further mitral valve surgery. This may not be a concern for an 80 year-old, as it is not even known if they will be suitable for reoperation when they are over 90 years old. It is, however, an issue for someone in their 40’s, who would be in their 50’s when another valve is required.
The whole decision of tissue vs. metallic mitral valve replacement is getting even more interesting given the development of minimally invasive techniques such as TAVR by which a valve replacement can be performed without the need for open heart surgery. These valves can be placed inside existing tissue valves, but not metallic valves. As of now, this is still early technology and shouldn’t influence decision-making regarding the choice of mitral valve replacement. Even more interesting is the development of super minimally invasive techniques such as the mitraclip for mitral regurgitation.
The current guidelines make some general recommendations that can be helpful.
- The choice of mitral valve replacement needs to be a shared decision between patients and specialists with multiple medical and lifestyle factors taken in to consideration.
- Patients who cannot tolerate or for some reason do not want to consider the use of blood thinning medication should have a tissue mitral valve replacement recommended.
- In general, in patients below 60 years of age, who are able to tolerate blood-thinning medication, a mechanical mitral valve replacement is reasonable. In patients over 70 years of age, a tissue valve is considered reasonable. In those between 60-70, either is considered reasonable.
Even though the valve has been replaced, it’s important to realize that mitral valve replacement patients have significant heart disease and require close follow-up care and attention to detail after the mitral valve replacement. Many patients undergoing mitral valve replacement have accompanying problems such as heart failure, other valve disease, and pulmonary hypertension (high pressures in the lung arteries) that will require ongoing management.
How often will valve replacement patients have to see their heart doctor?
This depends on factors such as other ongoing health issues, the type of valve and other factors that will be determined by the MD or DO in charge of your care. After the surgery and the hospital discharge, patients will follow up with the surgeon in the 1-2 weeks after the mitral valve replacement to ensure there are no immediate problems from the surgery and that everything is going well. Moving forward the cardiologist may see patients in weeks to months after the surgery. If all is well, mitral valve replacement patients typically are seen on a yearly basis.
Patients with metallic valves will require check for effect of blood thinning medications.
For those patients with metallic valves, it’s important to pay close attention to blood tests such as the INR, that monitor the response to Coumadin blood thinner. This is important, because it prevents the valve from developing clots that can lead to strokes or valve failure.
How often do metallic mitral valve replacement patients need imaging studies?
If all goes well after surgery and the patient is doing well without issues, there is usually a yearly follow up to assess how the patient is clinically doing. After surgery there will be an echocardiogram performed to ensure normal valve functioning. This is usually done in the weeks to months after mitral valve replacement and is also important to establish a baseline. Stable patients don’t require routine follow-up imaging. After this point, imaging is only typically required if there is a change in the clinical status, i.e. development of symptoms, or a new finding on the physical exam such as an increasing murmur.
How often do tissue (i.e. animal) mitral valve replacement patients need follow up imaging?
This is slightly different for patients with metallic valves. Tissue valves are subject to degeneration over time. Degeneration isn’t likely in the first 10 years after a tissue mitral valve replacement. But, afterwards this it is increasingly likely to occur with each year that passes. For this reason it is recommended that after 10 years, even if there are no symptoms or clinical signs of concern, that an echocardiogram is performed to assess the valve. It is very important that patients with tissue mitral valve replacement are educated to report signs and symptoms such as shortness of breath, dizziness, swelling etc. so they can be evaluated in a timely fashion.
What tests are needed before mitral valve replacement surgery?
Typically most patients have had an ultrasound scan of the heart known as an echocardiogram before they are sent to a surgeon. For patients with risk factors for coronary artery disease, and in general those over 35-40, a coronary angiogram will be performed to ensure there are no heart artery blockages that need bypassing at the time of valve replacement.
How long will the mitral valve replacement operation take?
In general the whole process in and out the operating room takes 2-4 hours. It also depends on whether there are other things being fixed, such as additional valve or bypass surgery. The usual time from stopping the heart to getting the heart beating again is around 45 minutes. After that the various tubes are removed, and the heart is check to ensure there is no bleeding. Finallu, the chest is closed.
How long do patients need to stay in hospital?
A lot depends on the patient and how quickly they are up walking. If things go well and the patient is up and walking within a few days, the usual hospital stay will be roughly 5 days.
When can patients go back to work after a mitral valve replacement?
This of course depends on the job. Most patients can be driving within 2 weeks of leaving hospital. If they are involved in heavy manual work, then it’s advised they avoid any type of heavy work for 8. If it’s a desk job, for example, then patients can basically go back to work whenever they feel like it, although its advised not to start with a full day. With robotic heart surgery the recovery time is likely to be more rapid.
Are there any special restrictions after mitral valve replacement?
Patients with valve replacement should be sure to ask about antibiotic prophylaxis before certain procedures to help prevent infection from reaching the heart. Also in patients with metallic valves who are taking blood-thinning medicines, activities with more than an ordinary risk of injury should be avoided due to the risk of hemorrhage.
I have had two heart valves replaced so far two times . First time I selected tissue valve for the Mitral and Aortic Valves. No trouble and no issues. Have had some noses bleeds for 11 years. Recently in 2013, due to nose bleed, a different doctor decides to replace the valves with Mechanical Valves. Started to have complication of poking sensation since the surgery. Doctors told me it was post surgery complications will take time to heal. Anyways a little after a year, approximately 9 inches of a wire poked out of my left sternum went to emergency room, got that taken out. Had x-ray and was told I have additional wires in my chest cavity. Still had poking sensations, doctors recommended to take the wires out. So after a surgery they removed two more wires which turn out to be the epi-cardial wires left inside after the surgey. Total of three wires maybe still have more. Now I am having cramps almost all the times in my chest however no more poking pain. My question to you all good doctors, is this normal to leave multiple wires in the chest after a heart surgery without letting the patient know.
I am worried about my sister she had a heart problem rwcieved an implant that she thinks is a camera to detect leaks in the aorta it was to be removed in 3 yes is there such a procedure or did she misu derstand the Dr she’s had it for 5 yes she says it hurts where the implant is there’s a lumpp she says is the camera now she’s having problems her heart tried to drowned giving her double pneumonia she keeps diareah all the time she has protein in her urine and is acting crazy at times I’m wondering if the oxygen. To her brain is not sufficient causing her confusion and mood swings we really do not know what to do about her she does not want to shower we fight to get her to take a shower a .month she wears depends because of her runny stools and not holding her urine long enough to get to the bathroom so she literally stinks bad she says she doesn’t feel like it
It must be something else, there is no camera implanted to detect leaks in the aorta.
Two years ago in December I had my mitral valve replaced. Just after Christmas I went into a-fib, had to get jump started. The following Christmas, blood clot was found on the new mitral valve. Am now on blood thinners. Was not put on blood thinners after valve replaced until blood clot was found. Is this normal?
Was it a mechanical or an animal valve?
Tissue valve
From what I read on other sites, seems I should have taken blood thinners first few months after tissue valve replacement
doctor says mitrail valve problem in2015
but there is no much symptoms.littele breathing problem or couth
no pain in chest
or it is compulsary a valve surgery
please give sir some advice
What did the echocardiogram say, and what was the advice from the cardiologist?
My father has undergone a mitral valve replacement surgery. It’s been a year now. His mitral valve was replaced with mechanical valves. Now he is showing symptoms of blood clot over the new valve’s surface. He has not yet visited the doctor. Before he goes to meet one, he’d like to know about curing this.
Im assuming the leaflet function is impaired and thats why clot is suspected? Often higher doses of blood thinning medication are used to see if the clot can dissolve.
I had a mitral valve replacement 11 weeks ago bovine valve was used, my
Doc changed my me after a two monthly visit I am on Nebicard -h 2.5mg but I find my eyes are bloodshot in the mornings I have niggling headaches at odd times of the day my blood pressure has gone upto 130/90 and the swelling in my feet comes up every second day,also extreme fatigue on some days and shortness of breath if I climb two flights of steps I walk around 6 km in a day I am 56 and have always been slim but I find weight has come up around my middle should I be concerned?
I suggest you get evaluated by your treating cardiologist, the symptoms of fatigue, shortness of breath, and weight around the middle are not normal and could represent heart failure.
Given the large amount of people we have been able to help here, we are starting a twitter to help keep heart patients up to date with advances and relevant information. Mine can be followed at @MustafaAhmedMD
Good day i am going in for mitral valve replacement they gona put mechanical in. Im currently using blood thinner. Must i stop or not. Im terrified of the operation
I recommend you call the operating surgeons office to clarify as certain ones may need stopping prior to surgery.
I had mitral valve repair with an annuloplasty ring back in 2013. It has been over 4 years. They put ring in because i have enlarged heart and my mitral valve was floppy and causing regurge. Now echocardiagram shows that the ring is not opening like it was. Am having a tee in couple weeks but am anxious. Is it normal for your ring to work fine and then become too tight? I really want to avoid them replacing the whole valve in general as im only 30.
It would be possible but not likely if the original operation was for regurgitation. See what the TEE shows. I advise the involvement of a valve specialist if any intervention is proposed.
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TEE showed that I have a lot of scar tissue around the annuoplasty ring which is what has caused it to not let my mitral valve open like it should. They advised repair or even replacement. Have to meet with surgeon in few weeks. Since the ring only lasted 4 years roughly would you suggest that I just opt for the replacement if they say they want to repair again. I thought that the repair should have lasted longer than 4 years. also I am following on your twitter. thanks for that.
BP normal for me is 159/90…..doctor says have to get it below 130/80 to replace mitral valve which is flapping in the wind for years….born with heart murmur……on 3 BP meds…feet swollen….all the side effects……at what level does my BP have to be to get surgery…been suffer for too long cant work nothing complete lifestyle change….57 years old and 5 11 190lbs
I have never heard of someone having to get a blood pressure below a certain level for mitral valve replacement. The only exception would be someone with heart dysfunction and where there is thought that the disease can be improved and surgery be avoided, or if the pressure is an emergency i.e over 200.
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Dear Dr A:
I had MVR surgery 4 yrs ago. They thought it would be a repair but probably due to radiation treatments for breast cancer, they ended up replacing it with a bovine valve (didn’t think I could tolerate metal clicking sound or Coumadin). 3-4 wks post-surgery, I suffered from extreme exhaustion, falling asleep, barely able to move. After 1-1/2 yrs, they determined I was desatting at night so now I use cpap w O2. Feeling better but am anemic and no one knows why. My heart is also beginning to be irregular and flutter off and on, otherwise things seem normal. Does this sound like the valve may be leaking or are the irregular beats normal please? I’m 60 and dread another open heart surgery which will most likely be inevitable? (My surgery took 6+ hours) Thank you
One consideration to take in to the account is in post valve replacement patients with anemia and fatigue there is the possibility of a paravalvular leak. If there is evidence of a hemolytic anemia then a leak should be considered and searched for.
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Dr A
I have a severe mitral valve leak, enlarged atrium, moderately enlarged heart and normal heart function. I am fit, walk 8 kms most days and am up and down stairs. My cardiologist has taken a wait and see approach. I am wondering if people felt better or worse after their mitral valve surgery? I have a second opinion with a Cardiothoracic surgeon who said I have an 80% chance of a repair so not sure which path to take.
Thanks for your help.
Mary
If the leak is truly severe, and the valve is repairable then in most cases, centers of excellence would recommend repair. I would recommend evaluation in a place with a large volume of valve repair and a designated center of excellence, with evaluation by a dedicated valve specialist. In our center, we don’t watchful wait in patients that are good candidates for valve repair and are good operative candidates with severe MR.
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Hi doctor,
Is there any possibility to get pregnant with mitral valve replacement? Currently m taking blood thinning medications…
Suggestion will be very helpful…
In general most would not advise it. If even considering pregnancy with a mechanical mitral prosthesis then you need to personally see a valve specialist and high risk pregnancy specialist that can perform the extensive counseling required to make an informed decision. There are risks associated with blood thinner, valve function and pregnancy that all need to be taken in to account.
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I am 81 years old, and have had a rheumatic heart since childhood. I have now been put in the waiting list for replacement mitral valve, which I have been informed is calcified. Should I go ahead with this operation and how high is the risk?
Bet
Depends on many factors regarding the risk. There are multiple different approaches, in our center we prefer a mini or a robotic approach due to accelerated recovery. Surgery should be performed depending on the severity of the disease and the presence of indications. My opinion is that mitral valve surgery should only be performed in a specialist mitral valve reference center.
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Hi sir, Vivek My mother was mitral valve replacement done in 2016, age 48.
But now patient having blooding problem in periods
Doctor suggesting PT-INR test . the test is normal. INR is 2.18 which is normal.
The gynecologist suggesting operation Is it possible or not ?.
Depends on the cause of bleeding and whether it is a mechanical or bioprosthetic valve. If mechanical then a cardiologist needs to be involved and there may be a need for heparin in the peri-operative period.
Hi sir, it is a mechanical valve . patient having bleeding 15 days form starting of periods and after 15 days it will stop automatic . The gynecologist suggesting operation , It is risky or not ?. & operation are successful or not ?.
When is the right time to have a Mitral valve replacement? I have moderate regurgitation and asymptotic. Would you recommend surgery or wait until the regurgitation worsens?
Firstly depending on the type of disease its important to realize repair is often far superior to replacement. For moderate disease there is typically no intervention, usually intervention is done on severe valves with symptoms or with evidence of heart failure, or severe valve without symptoms that can be repaired.
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20 yrs. ago my husband had endocarditis which also lead to two brain aneurysm surgeries and finally a new porcine mitral valve. He is one 68yrs.and he needs anot her mitral valvue He has has an embiloc stroke and seizures which are now mostly under control.. He is a middle risk for open heart surgery. The valve in valve seems safer for him but I am concerned about the durability and length of time until it has to be replaced. If it lasts 5-7 yrs, he will then need open heart and will be in his middle 70s. Can you give me any information on the durability and length of time of the valve in valve until it has to be replaced again. Any info on this subject would be helpful.
Hi my 73year father is having the mass of 13*9mm on posterior side of mitral valve..dr adviced to replace mitral valve with tissue valve .But he my father doesn’t hv any other issue and replacing valve will trigger some other issue .I have no clue on what decision I should take .Kindly guide
Not possible to comment without further information of the echo characteristics.
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Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
Dear sir
my wife have been faced heart valve problem in 2013 and got successfull MVR surgery
so my question is that my wife can born a baby after MVR surgery
in this case if my wife get perganant than how to handle in pregnancy days please give me some suggestions for born a healthy baby
It depends on the valve and the blood thinner used. In general these cases should be managed with the input of a cardiologist well versed in the situation and the input of an obgyn also well versed as there are a number of careful nuances that need consideration.
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Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
Have been diagnosed with severe mitral regurgitation caused by leaflet breakage. Age 69, good health otherwise and no symptoms. It seemed to be a sudden thing as doctors appointments prior to did not hear heart murmurs. All tests have been done and show that repair is probable.
Trying to decide between the right anterolateral minithoracotomy and robotic surgery. Are there any thoughts on disadvantages of either for this condition and any recommendation would be helpful.
Choose the surgeon, the experience and the results. This is more important than the operation choice. If all things were equal to that regard then minimally invasive may have some advantages with recovery.
You can follow our twitter at @MustafaAhmedMD
Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
I have had 2 open heart mitral valve replacements with bovine. Is it ok for me to take a one a day vitamin plus 2,500mcg daily?
I have a DVR open heart surgery about one and half year ago .now and have severe arotic stenosis and parvalvular leakage .which is best option re open heart surgery or tavi
Depends on age, risk and valve features. Needs a heart team approach with input from an experience surgeon and interventional cardiologist.
You can follow our twitter at @MustafaAhmedMD
Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.