Aortic Valve Replacement Video Transcript

Introduction to Heart Valves

There are four heart valves. The blood returns to the heart and enters the right atrium (shown here).   From the right atrium it goes into the right ventricle and in order to do so it goes across the tricuspid valve.

From the right ventricle, the blood is going to go to the lungs into the pulmonary artery across what is known as the pulmonary valve.   So the first valve is the tricuspid valve, the second valve is the pulmonary valve.

After the blood goes back to the lungs and returns to the heart, it enters the left atrium and goes across the mitral valve. From the mitral valve in the left ventricle, it goes out across the aortic valve to the pulmonary artery.

So, the four valves of the heart are the tricuspid valve, the pulmonary valve, the mitral valve and the aortic valve.

Now what valves do is that they open and close so that when the heart beats, the blood goes forward.   If it weren't for valves, what would happen is the heart would beat and the blood would go forward and backwards.   So what valves do is they allow blood to go forward in the heart.  

Who Develops Heart Valve Disease

Patients who develop heart valve disease may not have any symptoms at all and that's why it's important for patients to see their primary care physicians on a regular basis.   However when patients do develop symptoms, it's often signs such as shortness of breath , sometimes feeling tired, they may get chest pain and in severe cases patients may black out (we call that syncopy) or develop heart failure.

Now, there are two fundamental problems that you can have with valves: the failure to open all the way or the failure to close all the way.   When a valve doesn't open all the way we refer to that as stenosis, for example aortic stenosis is the most common of all heart valve disease.   For reasons that are complex, the valve may become scarred or develop calcium - little blocks of rocks that are on the leaflets so the valve has trouble opening.

On the other hand, sometimes the valves are just weak and they don't close properly so the valve prolapses and the blood goes backwards in the heart. Most patients are familiar with the term mitral valve prolapse and that's a very common disorder where the valve simply doesn't close correctly sometimes because a portion of the valve is so weak that it even tears.

Diagnosing Heart Valve Disease

Well the most common way that we know there is something going on with a patient's valves is with a physical examination.   The old-fashioned stethoscope is as important as any diagnostic tool.

We listen to the heart and we hear what is often recognized as a murmur.   A murmur is just the turbulence, the sounds you hear as the blood is going across a valve that isn't working well.

The greatest tool of all is the echocardiogram.   The echocardiogram is an ultrasound study where they take a probe and put it onto your chest, looking between your ribs, where you can see pictures of the heart valves and decide if the heart valves are working correctly or not.   A very fancy type of echocardiogram is known as trans-esophageal echocardiogram or TEE.   This is a probe that is put down your throat with your being sedated and you don't really feel this being done and you can get really wonderful pictures of the heart.

Treating Your Heart Valve Disease

Many, many patients with heart valve disease can be treated medically so long as they are getting routine physical exams on a yearly basis with their primary care physician and, if need be, a cardiologist they can often be treated medically for a long time.   Once it gets to the point where the valve disease is actually negatively impacting the heart, for example the heart is starting to enlarge or the patient is developing symptoms that aren't allowing them to live a normal lifestyle.   They may not be able to exercise well or they get tired or they are having chest pain then we may need to do something surgically.

Lehigh Valley Health Network's Heart Valve Center

Well it turns out that Lehigh Valley Heart Network, we have one of the largest heart programs in the state and along with that, we have one of the largest valve centers in the state of Pennsylvania. Our valve center is very unique because we work as a team, a collaborative team, of cardiologists, cardiac surgeons, vascular surgeons, nurse practitioners - all working together in a multi-disciplinary way to treat our patients so that you get three, four practitioners in one when you are treated at our Valve Center.

On the surgical side of things we are very fortunate because we have five cardiac surgeons who are all board certified and exceptionally trained in all aspects of valve disease, including minimally invasive approaches to heart valve surgery.   We work as teams for these complex procedures.

It turns out that in Pennsylvania we're very lucky because our cardiac surgeons are under great scrutiny.   We have a report card that comes out once a year.   It's known as the Pennsylvania Health Care Cost Containment Council Report or PHC4.   For example in valve surgery, we have significantly lower than expected mortality rates in the state of Pennsylvania.   Now, keep in mind that only two, maybe three centers in the entire state of Pennsylvania have that and we actually have the best results of any of them.

Future Heart Valve Treatment

On the horizon is a new technology known as percutaneous valve insertion or transcatheter valve insertion.   Now this is actually a procedure where you can have a valve replaced without open surgery - without conventional open surgery.   Just as certain coronary arteries can be opened with a stent, there are certain valves that can be opened with a valve placed on a stent.   It's truly remarkable.   Now this is a very new technology.   We expect that it's going to be FDA approved in the United States in the next year to fifteen months.

Repairing vs. Replacing Valves

It turns out that the valve that is most likely to be repaired rather than replaced is the mitral valve.   We make every effort to repair a mitral valve rather than replace it.    Mitral valve prolapse is a very common problem that people sometimes face.   They'll get palpitations and shortness of breath, their heart may become enlarged because the valve is no longer functioning correctly often because a portion of the valve is torn.   What we can do in that a situation is take out the portion of the valve that's torn and sew the remaining good portions of the valve back together again.   That is what we refer to as a valve repair.   The advantage of valve repair is that it's your own tissue, there's less susceptible to infection and you don't need to take any blood thinners.   So, if you have mitral valve prolapse, you should want to be at a center where they have expertise in mitral valve repair, such as we have here at Lehigh Valley Health Network.

Let's say your valve can't be repaired.   Well, that happens and sometimes your valve needs to be replaced for example the aortic valve, which is the most common valve to require heart valve surgery almost always needs to be replaced.   It's very rare that we can repair an aortic valve.

Metal vs. Tissue Valves

Well the question comes up - what kind of valve replacement should I have?   Should I have a metal valve or should I have a tissue valve.   I must say that neither valve is perfect, but let's talk about the differences between the two valves.

You have a metal valve (as shown here). The white part that you see is known as the sewing cuff.   That's actually where we place the sutures.  The black part (shown here) is the part that opens and closes.   Now metal valves are very easy to implant and they last, basically, forever.   There are two downsides to the metal valve.   One is you may hear it clicking.   The other disadvantage to the metal valve is that you require lifelong blood thinner therapy known as Coumadin, which is the drug that we use these days, and so you need to have your blood tested on a regular basis and there is about a one to two percent chance of bleeding complications per year if you're on Coumadin.

The biologic valves come in several varieties.   There are the "pig" valves, which we refer to as porcine valves, the "cow" type of valves, which is bovine and even cadaver human valves.   All three of these valves are easy to implant.   The nice thing about biologic valves is that they don't require Coumadin.   You do not need blood thinners for a biological valve.   The downside to a biological valve is that they do not last forever.

To compare the two valves we have a metal valve: the advantage is it will last a very long time, if not forever.   The disadvantage is you require a blood thinner and maybe another disadvantage is you may hear it clicking.   The biological valve has the advantage of not needing blood thinners, but it has the disadvantage of not necessarily lasting forever.

No doubt, the trend has been toward the biologic valves.   For one thing, patients do not want to be on blood thinner and they trust the technology as such that if they need a second procedure fifteen, twenty years down the road.   They'd rather have fifteen to twenty years of carefree life meaning not on blood thinners and accept the possibility of needing a second operation.   And also, as we mentioned, there are new technologies out there where valves may be put in with catheters and stents such that if you had a biologic valve, maybe twenty years from now you could have a valve placed inside a valve without needing a second operation.   So there is no doubt the trend has been more toward biological valves.

Second Opinions

I'm a physician and before I would have anything done to me, I would have a Second Opinion. Now the nice thing about second opinions today is that you can utilize the internet to get second opinions.   Of course, you have to be careful there because not all the information on the internet is good.   That's why going to sites such as the PHC4 site for the Pennsylvania Health Care Cost Containment Council Report because that gives a fair assessment of outcomes.   But, if you needed valve surgery, you might want to ask the surgeon, "How many years have you been doing the procedure?   How many procedures do you do?," and, "Would you mind if I get a second opinion?".   Quite frankly, if your surgeon doesn't want you to get a second opinion, you're probably in the wrong office.

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