Valve Repair/Replacement

Valve repair or replacement is open-heart surgery that fixes or swaps out one or more of the heart's four valves when they can no longer open and close properly.

Your heart has four valves — the mitral, tricuspid, aortic, and pulmonary valves — that act like one-way doors, keeping blood flowing in the right direction with every heartbeat. When a valve becomes too narrow (a condition called stenosis) or leaks backward (a condition called regurgitation), the heart has to work much harder to pump blood around the body. In a repair, the surgeon reshapes or rebuilds the damaged valve using the patient's own tissue. In a replacement, the damaged valve is removed and swapped for either a mechanical valve made of durable materials or a biological valve made from animal or donated human tissue.

This surgery is considered when a diseased heart valve causes serious symptoms or begins to put lasting strain on the heart muscle, and when less invasive treatments are unlikely to be enough.

• Severe aortic stenosis (dangerous narrowing of the valve between the heart and the main artery)
• Mitral regurgitation (the mitral valve leaks blood backward into the upper heart chamber)
• Mitral stenosis (narrowing of the mitral valve, often caused by rheumatic fever in earlier life)
• Aortic regurgitation (the aortic valve does not close fully, allowing blood to flow back into the heart)
• Tricuspid valve disease causing significant leakage or narrowing
• Infective endocarditis (a serious infection that has damaged the valve tissue)
• Congenital valve defects (valve abnormalities present from birth) that have become symptomatic
• Valve damage caused by heart disease or previous heart surgery

This surgery may not be suitable for every patient. Your cardiologist (heart specialist) and cardiac surgeon will assess your overall health before recommending it. It is generally avoided or approached very cautiously in the following situations.

• Very advanced age combined with severe frailty or multiple serious illnesses that raise surgical risk significantly
• Severely reduced heart pumping function that makes open-heart surgery too dangerous
• Active, uncontrolled infection elsewhere in the body before surgery can be safely performed
• Terminal illness from another cause where surgery would not improve quality of life
• Blood clotting disorders that cannot be managed safely around the time of surgery

Like all open-heart surgery, valve repair or replacement carries recognised risks; your surgical team will discuss which of these apply most to your specific situation.

• Bleeding during or after the operation, sometimes requiring a return to the operating room
• Irregular heart rhythm (arrhythmia), most commonly atrial fibrillation (a rapid, uncoordinated heartbeat), in the days after surgery
• Infection at the chest wound, in the lungs, or, rarely, on the new valve itself
• Stroke (a blockage or bleed in the brain) caused by small blood clots forming during or after surgery
• Kidney problems, including temporary loss of kidney function, related to the time spent on the heart-lung bypass machine
• Breathing difficulties requiring a longer time on a breathing machine (mechanical ventilator) after surgery
• Heart attack during or shortly after the procedure
• For mechanical valves specifically: lifelong need for blood thinners (anticoagulant medicines) to prevent clots forming on the valve
• For biological valves specifically: the valve may wear out over time and need to be replaced again in the future
• Rare but serious: complete heart block (the heart's electrical system fails to coordinate beats) requiring a permanent pacemaker

Preparation for this surgery usually begins days to weeks before the planned date and involves both lifestyle adjustments and a series of medical tests. Your care team will give you a personalised checklist, but the steps below reflect what most patients can expect.

Lifestyle and medication adjustments in the days before surgery typically include the following. Smoking should be stopped as early as possible, because smoking reduces the ability of the lungs and heart to recover. Alcohol intake is usually stopped at least a few days before. Blood thinners, anti-inflammatory medicines, and certain diabetes medicines are commonly paused before surgery — the exact timing is decided by your doctor, not a standard rule. Fasting (no food or drink) is required for a number of hours before the operation; your team will give you a specific time to stop eating and drinking.

Before surgery is confirmed, most patients undergo a range of assessments to build a complete picture of heart function and overall health.

• Echocardiogram (an ultrasound scan of the heart) to measure exactly how badly the valve is affected and how well the heart muscle is pumping
• Electrocardiogram or EKG (a recording of the heart's electrical activity) to detect any rhythm problems
• Chest X-ray to check the size of the heart and condition of the lungs
• Coronary angiography (a dye-based X-ray of the heart's own blood vessels) to check whether any arteries are blocked — this is important because blocked arteries may be treated at the same time as the valve
• Blood tests including full blood count, kidney and liver function, blood group and cross-match, and clotting tests
• Lung function tests if there is any history of breathing problems
• Dental check — any tooth infection should be treated before surgery to reduce the risk of bacteria reaching the new valve

On the day of surgery, here is what typically happens, step by step. The exact number and order of steps can vary between hospitals and individual patients.

• The patient is admitted and identity, allergies, and consent are confirmed by the nursing and surgical team.
• An intravenous (IV) line is placed in the arm or hand for fluids and medicines.
• The chest and sometimes the groin are shaved and cleaned to reduce infection risk.
• The patient is taken to the operating theatre and general anaesthesia (medicine that causes deep, controlled sleep) is given.
• A breathing tube is placed into the airway and connected to a ventilator to breathe on the patient's behalf throughout surgery.
• A heart-lung bypass machine is connected, usually via tubes placed in large blood vessels. This machine takes over the work of the heart and lungs so the heart can be stopped temporarily and worked on safely.
• The surgeon opens the chest by cutting through the breastbone (sternum). In some patients, smaller incisions may be used — your surgeon will explain which approach is planned for you.
• The damaged valve is repaired or removed and replaced. For repair, the surgeon may cut, reshape, or reinforce the valve leaflets (the flaps that open and close). For replacement, the old valve is removed and a new one is sewn into place.
• The heart is restarted and the bypass machine is disconnected.
• The breastbone is closed with wires, and the skin is closed with stitches or staples.
• The patient is moved to the intensive care unit (ICU) to be closely monitored as the anaesthesia wears off.

Recovery from valve repair or replacement is gradual and happens in stages — first in the ICU, then on the general cardiac ward, and finally at home. The pace of recovery varies from person to person depending on the type of surgery, the valve involved, and the patient's overall health before the operation.

• ICU monitoring: Most patients spend at least one to a few days in the ICU with continuous monitoring of heart rhythm, blood pressure, and breathing. The breathing tube is usually removed within hours of surgery once the patient is awake and breathing well on their own.
• Hospital ward stay: After the ICU, patients move to a cardiac ward for further recovery. The total hospital stay is typically several days to one to two weeks, though this varies.
• Chest wound care: The sternal wound (cut through the breastbone) needs to be kept clean and dry. The care team will give specific instructions. Signs of infection — redness, swelling, discharge, or fever — should be reported immediately.
• Activity restrictions: Heavy lifting and strenuous physical activity are avoided for a number of weeks while the breastbone heals. Walking is usually encouraged early, but the pace is increased gradually under guidance.
• Driving restrictions: Most patients are advised not to drive for several weeks after surgery, as the healing breastbone cannot safely absorb a sudden impact.
• Blood thinner management: Patients with a mechanical valve will take blood thinners (anticoagulant medicines) for life and will need regular blood tests to ensure the medicine is working safely. Patients with a biological valve may take blood thinners for a shorter period — your doctor will decide the duration.
• Cardiac rehabilitation: A supervised exercise and education programme (cardiac rehabilitation) is usually recommended to help the heart recover safely and to support lifestyle changes.
• Follow-up appointments: Regular check-ups with the cardiologist will include echocardiograms to monitor the repaired or replaced valve. The frequency is decided by the treating team.
• Dental hygiene: After valve surgery, any dental procedure — even a routine cleaning — carries a small risk of bacteria entering the bloodstream and infecting the valve. Patients are usually advised to inform their dentist of their heart history and may need antibiotics before dental work.
• Lifestyle: A heart-healthy diet, not smoking, managing weight, and controlling conditions such as high blood pressure and diabetes all help protect the valve and the heart long term.