Heart valve replacement: what are my options?

When you hear the words “heart valve replacement,” open-heart surgery might first come to mind. And that thought can be scary. It’s one reason some people may choose to delay treatment for heart valve disease.

But waiting on treatment can allow the condition to worsen and cause permanent heart damage, says Michael Firstenberg, MD, a cardiothoracic surgeon in Beachwood, Ohio.

Open-heart surgery is how surgeons have traditionally repaired or replaced damaged heart valves. But other, less invasive alternatives for valve replacement are available.

One such option is called transcatheter aortic valve replacement (TAVR), also known as transcatheter aortic valve implantation (TAVI). This minimally invasive technique uses a thin tube called a catheter to access the heart. The method was originally approved by the U.S. Food and Drug Administration as an option for high- and intermediate-risk patients who are unable to have major surgery. In 2019, the FDA expanded its decision to include patients at low risk for death or major complications associated with open-heart surgery.

The procedure can decrease the risk of complications and death for some people. Since the procedure was first introduced in the early 2000s, outcomes have improved for people who have undergone TAVR. Over the years, surgeons have gained experience in using this technique. There have also been advances in valve technology and surgical equipment as well as improvements in identifying people who may best benefit from the procedure.

An analysis of 23 studies published in the Journal of Cardiothoracic Surgery in 2021 covering a total of over 66,000 people showed that rates of stroke and death one year after valve replacement were similar for TAVR and open-heart surgery for low- and intermediate-risk patients. For high-risk patients, these outcomes were better with TAVR than with open-heart surgery.

Another study published in the Journal of the American College of Cardiology in 2019 looked at how long these valves lasted in 241 people who had undergone TAVR. Results showed that 91 percent of these people did not experience valve degeneration five to ten years after TAVR.

If you need a heart valve replacement, you may have preconceptions about what is best. It’s important to understand that this is a complex decision based on many individual variables. Your healthcare provider (HCP) and other specialists on your heart-care team will help you determine the best therapy for you.

Dr. Firstenberg offers insights about heart valve replacement and about some of the risks and benefits of existing treatment options.

What are alternatives to open-heart surgery for patients who need valve replacement?

Many people may be familiar with traditional open-heart surgery, which involves getting into your chest, putting you on a heart-lung machine, temporarily stopping your heart, opening it up, and either repairing or replacing a valve to deal with the problem. But catheter-based therapies that require smaller incisions have also been developed. These include TAVR.

This approach typically involves accessing a faulty or diseased valve through some of the larger arteries and veins in the body. A replacement valve is secured to the end of a catheter, which is threaded through a blood vessel that leads to the heart. Use of this minimally invasive technique is partly driven by the desire to make any type of intervention as safe as possible.

Aside from how you access the heart, how is TAVR different from open-heart surgery?

A fundamental difference between the two procedures is that during traditional open-heart surgery, you go in and you take out the existing diseased valve. You clean it out, and you put a new valve in. During TAVR, you basically put a valve in whatever residual hole there is and expand it. So, the old valve isn’t taken out. It just gets pushed to the side.

Are there any concerns about leaving an “old” heart valve in place?

One issue that people get very concerned about are paravalvular leaks, which can occur when there is a space between the existing heart tissue and the replacement valve. When you put these transcatheter valves in, and you just expand them against the existing valves, there clearly is an increased risk of having leaks in those areas. These leaks are not exactly benign and may cause problems down the road.

There is also a significantly increased risk for needing a permanent pacemaker due to problems with the electrical system of the heart. The short- and long-term risks of needing a pacemaker are also not minor.

Are there any other specific risks associated with catheter-based therapies?

One obvious question involves the durability of transcatheter valves. We're starting to get longer-term data, but it’s still somewhat limited.

Accessing a heart valve through the femoral vessels, or the arteries and veins in your groin, also isn’t risk-free. There's risk of injury to the vessels. There are nerves in those areas that could also be bruised for a while. These are all part of the trade-offs and that's why each case needs to be individualized.

We are also still trying to understand some of the additional risks and benefits of each procedure, including bleeding, infections, heart attacks, the need to be readmitted to the hospital and strokes—not only during the first few weeks or months after the initial procedure, but also years down the road.

Some people assume that a less invasive procedure is always better. Is that always the case?

Most people do not want surgery. That's understandable. I think that there's a lot of fear and apprehension. There is a natural tendency to think that because something is less invasive, it is inherently safer or better. I think it's important to keep in mind that this is not always the case for each and every person. The key is that you have to get the therapy that's going to be best for you in the short and long term. All of these therapies have advantages and disadvantages. Nothing is perfect.

How do you decide which valve replacement procedure is best for you?

If you need to visit your HCP with a valvular problem, there will be a whole team of specialists—very similar to what's done in the cancer world—participating in a workup. In other words, the team will collect data, analyze it, and determine what, if anything, needs to be done. The members of this heart team will then strategize and make treatment recommendations based upon their areas of expertise. It's our obligation to provide you with as much objective data as possible so that you can make a good decision.

What are some of the variables that go into this treatment decision?

First, your HCP will look at whether your anatomy is suitable for valve replacement. In addition to ultrasounds and cardiac catheterizations, you may undergo CAT scans, which provide a picture of your arteries and veins. These images help determine the course of treatment.

We will also investigate your other medical problems and how those play into decision-making. The current line of thinking is that if somebody is at very high risk for surgery then there is a trend toward offering those patients catheter-based therapies. Factors that put someone at high risk include if they've had previous open-heart surgery, they are frail, they’ve had cancer and radiation to the chest, or they have other major health concerns which would make recovery after surgery difficult.

Are there unique considerations for younger adults who need valve replacement?

Valvular disease, for a variety of reasons, affects people of all ages. I recently did two valve replacements. One of them was in a 70-year-old and the other was in a 34-year-old.

For someone who’s a little bit younger with a life expectancy that could be measured in decades, I think it’s important to be honest with them about therapies that have stood the test of time, like open-heart surgery. Although we only have limited data, some of the complications that we see with the transcatheter valves are not trivial. When you start extrapolating that risk over a younger person’s lifetime, they could be potentially significant. That's why I think there's a reluctance to be very aggressive with newer types of procedures in younger people who may have a reasonable life expectancy to begin with.

What are the different types of replacement valves available?

Mechanical valves have the advantage of durability. While nothing lasts forever, for most patients they will last the rest of their lives. The downside is that these patients will have to take a blood thinner every day afterwards. That's usually a medication called warfarin (Coumadin). And there are concerns and risks associated with being on a blood thinner for the rest of your life.

On the other side of the coin, tissue valves are limited by their durability. These are predominantly made out of pig or cow tissue. You do not necessarily have to be on a blood thinner for a tissue valve, but the offset is that these types of valves may wear out over time.

Younger people tend to wear out their valves sooner than older people and may need another surgery or valve replacement later on. So if someone is 70 years old, a tissue valve may last ten years but that same valve may only last six or seven years for someone 20 years younger.

Complicating matters, the risks of complications associated with valve replacement are additive, so they increase with each additional procedure. That's why the early decision-making process is so important. These are lifelong decisions, and people need to make sure that whatever they decide right now is something that they can live with down the road.

Following a heart valve replacement, what can people expect during recovery?

Recovery varies by the individual. It also depends on how healthy the patients are going into the procedure. Most people who have TAVR can leave the hospital within one day, while many people may spend five to seven days in the hospital after open-heart surgery.

There's no doubt that open-heart surgery can be a little bit more painful. You also have to let the bones heal. A week or two down the road, we talk to all patients—including those who had a transcatheter valve replacement—about getting into a cardiac rehabilitation program. If they're doing well, people also usually start to drive within a couple weeks, and then we start negotiating with them about when they can get back to work. We really try to get patients back to a quality of life as quickly as possible.

Are there consequences for putting off valve replacement?

There are patients out there who, for a variety of reasons, say, "You know what? I can live with this shortness of breath. It doesn't bother me. I'm just going to wait." What they don't realize is that shortness of breath and chest pain indicate that their heart is struggling for oxygen and blood. Over time, that can result in substantial damage. Some of that damage is irreversible. You don't want to be in denial because these problems don't go away. They just get worse.

The longer you wait to treat the condition, the greater the impact it will have on your longevity and the quality of your life. Heart valve disease is almost like “cancer of the heart.” The longer you wait, the worse it gets, and the more damage it can do to your body.

Editor’s note: Dr. Firstenberg has disclosed ties to Medtronic, a medical device company that researches and develops heart valves. He has reported that he provides education about some of Medtronic’s replacement valves.