Minimally Invasive (Endoscopic) Mitral Valve Surgery
More than 90 percent of the mitral valve surgeries performed at Lankenau
use an endoscopic approach that was developed and perfected by Dr.
Scott Goldman and the heart
valve surgical team to treat mitral valve stenosis and/or mitral
valve regurgitation . During this approach, heart surgeons combine
robotic technology with the latest endoscopic surgical instruments to
achieve superior results for both mitral valve repair and replacement.
Endoscopic mitral valve surgery at Lankenau requires only a two-inch
incision and two port sites of less than a ¼ inch and significantly
minimizes the post-operative pain that patients experience.
Minimally Invasive Aortic Valve Replacement (AVR)
Minimally invasive AVR surgery at Lankenau is performed through a
three-inch incision and greatly reduces the post-operative discomfort
and recovery time. During minimally invasive AVR, Lankenau Heart
Institute heart valve specialists remove the native aortic valve and
replace it with a bioprosthetic (tissue) or mechanical valve. In 94.5
percent of cases, Lankenau surgeons have been able to successfully
replace the aortic valve with a bioprosthetic option, thereby
eliminating the need for the patient to take lifelong blood thinners.
Transcatheter Aortic Valve Replacement (TAVR)
This groundbreaking procedure for the treatment of severe aortic
stenosis is now being offered at Lankenau. TAVR
is a procedure that allows the diseased aortic valve to be replaced
without open heart surgery. Lankenau Heart Institute physicians perform
TAVR using a transapical or a transfemoral approach. This approach is
similar to cardiac catheterization, where a long flexible tube
(catheter) is inserted in a blood vessel in the upper thigh. TAVR may be
an option for some patients who require aortic valve replacement but may
not be a candidate for surgery or are at high risk for surgery.
A thorough evaluation is needed to determine whether TAVR, or another
treatment, is best. A multidisciplinary team of heart care specialists
from the valve clinic participates in this important evaluation.
(Open Heart Surgery)
Heart valve repair or replacement surgery is a treatment option for
valvular heart disease. When heart valves become damaged or diseased,
they may not function properly. Conditions which may cause heart valve
dysfunction are valvular stenosis and valvular insufficiency
When one (or more) valve(s) becomes stenotic (stiff), the heart muscle
must work harder to pump the blood through the valve. Some reasons why
heart valves become stenotic include infection (such as rheumatic fever
or staphylococcus infections) and aging. If one or more valves become
insufficient (leaky), blood leaks backwards, which means that less blood
is pumped in the proper direction. Based on your symptoms and overall
condition of your heart, your doctor may decide that the diseased
valve(s) needs to be surgically repaired or replaced.
Traditionally, repair or replacement of heart valves has involved
open-heart surgery, which means that the chest is opened in the
operating room and the heart stopped for a time so that the surgeon may
repair or replace the valve(s). In order to open the chest, the
breastbone, or sternum, is cut in half and spread apart. Once the heart
is exposed, large tubes are inserted into the heart so that the blood
can be pumped through the body during the surgery by a cardiopulmonary
bypass machine (heart-lung machine). The bypass machine is necessary to
pump blood because the heart is stopped and kept still while the surgeon
performs the valve repair or replacement procedure.
Newer, less invasive techniques have been developed to replace or repair
heart valves. Minimally-invasive procedures in which the incision is
much smaller often mean less pain postoperatively and shorter hospital
stays. Valvuloplasty is another method that may be used to treat valve
stenosis in some cases.
The diseased valve may be repaired using a ring to support a person's
own valve, or the entire valve may be removed and replaced by an
artificial valve. Artificial valves may be mechanical (made of metal or
plastic) or tissue (made from animal valves or human valves taken from
Other related procedures that may be used to assess the heart include
resting and exercise electrocardiogram (ECG), Holter monitor,
signal-averaged ECG, cardiac catheterization, chest X-ray, computed
tomography (CT scan) of the chest, echocardiography,
electrophysiological studies, magnetic resonance imaging (MRI) of the
heart, myocardial perfusion scans, radionuclide angiography, and
ultrafast CT scan. Please see these procedures for additional
better understand how valvular heart disease affects the heart, a review
of basic heart anatomy and valve function follows.
The heart is a pump made of muscle tissue. The heart has four pumping
chambers: two upper chambers, called atria, and two lower chambers,
called ventricles. The right atrium pumps blood into the right
ventricle, which then pumps the blood into the lungs where wastes such
as carbon dioxide are given off and oxygen and other nutrients are taken
into the blood.
From the lungs, the blood flows back into the left atrium, is pumped
into the left ventricle, and then is pumped through the aorta out to the
rest of the body and the coronary arteries. When the atria are pumping,
the ventricles are relaxed in order to receive the blood from the atria.
Once the atria have pumped their entire blood load into the ventricles,
they relax while the ventricles pump the blood out to the lungs and to
the rest of the body.
In order to keep the blood flowing forward during its journey through
the heart, there are valves between each of the heart's pumping
Tricuspid valve. Located between the right atrium and the right
Pulmonary (or pulmonic) valve. Located between the right
ventricle and the pulmonary artery
Mitral valve. Located between the left atrium and the left
Aortic valve. Located between the left ventricle and the aorta
If the heart valve(s) becomes damaged or diseased, a person may
experience the following symptoms:
Edema (swelling) of the feet, ankles, or abdomen
Rapid weight gain due to fluid retention
Valve repair or replacement surgery is performed to correct the problems
caused by one or more diseased heart valves.
There may be other reasons for your doctor to recommend heart valve
repair or replacement surgery.
Possible risks associated with heart valve repair or replacement surgery
include, but are not limited to, the following:
Bleeding during or after the surgery
Blood clots that can cause heart attack, stroke, or lung
Infection at the incision site
Dysrhythmias/arrhythmias (abnormal heart rhythms)
If you are pregnant or suspect that you may be pregnant, you should
notify your health care provider. If you are lactating, or
breastfeeding, you should notify your health care provider.
Patients who are allergic to or sensitive to medications, contrast dyes,
iodine, or latex should notify their doctor.
There may be other risks depending on your specific medical condition.
Be sure to discuss any concerns with your doctor prior to the procedure.
Your doctor will explain the procedure to you and offer you the
opportunity to ask any questions that you might have about the
You will be asked to sign a consent form that gives your
permission to do the test. Read the form carefully and ask
questions if something is not clear.
In addition to a complete medical history, your doctor may
perform a complete physical examination to ensure you are in
good health before undergoing the procedure. You may undergo
blood tests or other diagnostic tests.
You will be asked to fast for eight hours before the procedure,
generally after midnight.
If you are pregnant or suspect that you are pregnant, you should
notify your doctor.
Notify your doctor if you are sensitive to or are allergic to
any medications, iodine, latex, tape, or anesthetic agents
(local and general).
Notify your doctor of all medications (prescription and
over-the-counter) and herbal supplements that you are taking.
Notify your doctor if you have a history of bleeding disorders
or if you are taking any anticoagulant (blood-thinning)
medications, aspirin, or other medications that affect blood
clotting. It may be necessary for you to stop some of these
medications prior to the procedure.
Your doctor may request a blood test prior to the procedure to
determine how long it takes your blood to clot.
Notify your doctor if you have a pacemaker.
If you smoke, you should stop smoking as soon as possible prior
to the procedure. This may improve your chances for a successful
recovery from surgery and benefit your overall health status.
Based on your medical condition, your doctor may request other
Heart valve repair or replacement surgery requires a stay in a hospital.
Procedure may vary depending on your condition and your doctor’s
Generally, heart valve repair or replacement follows this process:
You will be asked to remove any jewelry or other objects that
may interfere with the procedure.
You will be asked to remove your clothing and will be given a
gown to wear.
You will be asked to empty your bladder prior to the procedure.
An intravenous (IV) line will be started in your arm or hand.
Additional catheters will be inserted in your neck and wrist to
monitor the status of your heart and blood pressure, as well as
for obtaining blood samples. Alternate sites for the additional
catheters include the subclavian (under the collarbone) area and
You will be positioned on the operating table, lying on your
The anesthesiologist will continuously monitor your heart rate,
blood pressure, breathing, and blood oxygen level during the
surgery. Once you are sedated, a breathing tube will be inserted
through your throat into your lungs and you will be connected to
a ventilator, which will breathe for you during the surgery.
A catheter will be inserted into your bladder to drain urine.
The skin over the surgical site will be cleansed with an
The doctor will make an incision (cut) down the center of the
chest from just below the Adam's apple to just above the navel.
The sternum (breastbone) will be divided in half with a special
operating instrument. The doctor will separates the two halves
of the breastbone and spread them apart to expose the heart.
In order to perform the valve repair or replacement, the heart
must be stopped to allow the doctor to perform the very delicate
procedure. Tubes will be inserted into the heart so that the
blood can be pumped through your body by a cardiopulmonary
Once the blood has been completely diverted into the bypass
machine for pumping, the heart will be stopped by injecting it
with a cold solution.
When the heart has stopped, the doctor will perform the
procedure by removing the diseased valve and putting in the
artificial valve, in the case of a valve replacement. For a
valve repair, the procedure performed will depend on the type of
valve problem that exists, for example, separation of fused
valve leaflets, repair of torn leaflets, and/or the reshaping of
valve parts to ensure better function.
Once the procedure has been completed, the blood circulating
through the bypass machine will be allowed to reenter your heart
and the tubes to the machine removed. Your heart will be shocked
with small paddles to restart its electrical activity.
Once your heart is beating again, the doctor will observe the
heart to assess the function of the heart and the valves.
Temporary wires for pacing may be inserted into the heart. These
wires can be attached to a pacemaker and your heart can be
paced, if needed, during the initial recovery period.
The sternum will be rejoined and sewn together with small wires.
The skin over the sternum will be sewn back together. The
incision will be closed with sutures or surgical staples.
Tubes will be inserted into your chest to drain blood and other
fluids from around the heart. These tubes will be connected to a
suction device to drain fluids away from the heart.
A tube will be inserted through your mouth or nose into your
stomach to drain stomach fluids.
A sterile bandage or dressing will be applied.
In the hospital
After the surgery you may be taken to the recovery room before being
taken to the intensive care unit (ICU) to be closely monitored for
several days. Alternatively, you may be taken directly to the ICU from
the operating room. You will be connected to monitors that will
constantly display your electrocardiogram (ECG or EKG) tracing, blood
pressure, other pressure readings, breathing rate, and your oxygen
level. Heart valve repair or replacement surgery generally requires an
in-hospital stay of several days or longer.
You will most likely have a tube in your throat so that your breathing
can be assisted with a ventilator (breathing machine) until you are
stable enough to breathe on your own. As you wake up from the anesthesia
more and start to breathe by yourself, the breathing machine will be
adjusted to allow you to take over more of the breathing. When you are
awake enough to breathe completely by yourself and to be able to cough,
the breathing tube will be removed. The stomach tube will also likely be
removed at this time.
After the breathing tube is out, your nurse will assist you to cough and
take deep breaths every two hours. This will be uncomfortable due to
soreness, but it is extremely important that you do this in order to
keep mucus from collecting in your lungs and possibly causing pneumonia.
You will be given pain medication if you are hurting, and you should ask
for the medication before you become extremely uncomfortable. Your nurse
will show you how to hug a pillow tightly against your chest while
coughing to help ease the discomfort.
You may be on special IV drips to help your blood pressure and your
heart and to control any problems with bleeding. As your condition
stabilizes, these drips will be gradually decreased and turned off as
your condition allows.
Once the breathing and stomach tubes have been removed and your
condition has stabilized, you may start liquids to drink. Your diet may
be gradually advanced to more solid foods as you tolerate them.
When your doctor determines that you are ready, you will be moved from
the ICU to a postsurgical unit or acute care unit. Your recovery will
continue to progress. Your activity will be gradually increased as you
get out of bed and walk around for longer periods of time. Your diet
will be advanced to solid foods as you tolerate them.
Arrangements will be made for a follow-up visit with your doctor.
Once you are home, it will be important to keep the surgical area clean
and dry. Your doctor will give you specific bathing instructions. The
sutures or surgical staples will be removed during a follow-up office
visit, if they were not removed before leaving the hospital.
You should not drive until your doctor tells you to. Other activity
restrictions may apply.
Notify your physician to report any of the following:
Fever and/or chills
Redness, swelling, or bleeding or other drainage from the incision site
Increase in pain around the incision site
Your doctor may give you additional or alternate instructions after the
procedure, depending on your particular situation.
The content provided here is for informational purposes only, and was
not designed to diagnose or treat a health problem or disease, or
replace the professional medical advice you receive from your physician.
Please consult your physician with any questions or concerns you may
have regarding your condition.
This page contains links to other Web sites with information about this
procedure and related health conditions. We hope you find these sites
helpful, but please remember we do not control or endorse the
information presented on these Web sites, nor do these sites endorse the
information contained here.
For more information, call 1.866.CALL.MLH.