Heart valve surgery today: indications, operative technique, and selected aspects of postoperative care in acquired valvular heart disease

Abstract

Background: Surgery plays a central role in the management of acquired valvular heart disease. The optimal diagnostic evaluation, surgical treatment, and postoperative care of these patients are only possible through a cooperative effort of the primary care physician, the cardiologist, and the cardiac surgeon.

Methods: The literature was selectively searched for information on surgical indications, operative techniques, and postoperative care in acquired valvular heart disease. Evidence-based guidelines and treatment recommendations were also taken into account.

Results: A wide variety of techniques and implants are now available for the surgical treatment of acquired valvular heart disease. If they are used in evidence-based fashion, the perioperative mortality is low and the long-term outcome is favorable.

Conclusions: The volume of surgery for acquired valvular heart disease in Germany has increased substantially in recent years, from 25,495 cases in 2002 (corresponding to 26.5% of all heart operations in that year) to 33,412 in 2007 (36.5% of all heart operations). The causes for this include both demographic changes and the availability of new, less invasive surgical techniques that yield better results in elderly and/or multimorbid patients. Because of these new techniques, the indications for surgery have widened, while the results have remained favorable.

Keywords: cardiac surgery; cardiac valve reconstruction; cardiac valve replacement; endocarditis; valvular heart disease.

Figure 1

Excised septal leaflet of the tricuspid valve in an intravenous drug abuser with florid hepatitis C and acute endocarditis. Medically intractable right-heart failure and grade III to IV tricuspid regurgitation constituted the indication for surgery. At operation, the septal leaflet was found to be overlaid with massive, florid endocarditic deposits and to be almost totally detached from the valvular annulus. The valve was replaced with a biological prosthesis. Most cases of tricuspid endocarditis in intravenous drug users can, however, be treated conservatively.

Figure 2

Catheter-assisted aortic valve replacement by a transapical approach. (a) The prosthesis is loaded in the catheter device and is ready for deployment. (b) Intraoperative radiographic check of the position of the valve in the aorta after implantation.

Figure 3

Intraoperative view of a reconstructed mitral valve (indication: mitral regurgitation). Preoperatively, the posterior leaflet was prolapsed because of a chordal tear. The corresponding segment of the posterior leaflet was removed by quadrantectomy (a), the leaflet was reconstructed, and a flexible annuloplasty ring was implanted (b).