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Valve replacement

Valve replacement is a cardiac procedure to replace a damaged or diseased heart valve—typically one of the four main valves (aortic, mitral, tricuspid, or pulmonary)—with a prosthetic valve to restore proper blood flow and heart function.^[1] It is primarily indicated for severe valvular heart disease, such as stenosis (narrowing obstructing flow) or regurgitation (leakage causing backward flow), which can progress to heart failure if untreated.^[2] Symptoms often include shortness of breath, fatigue, chest pain, and arrhythmias; for instance, untreated symptomatic severe aortic stenosis has a 50% mortality rate at 2 years.^[2] Approaches range from traditional open-heart surgery, involving sternotomy and cardiopulmonary bypass, to minimally invasive techniques and transcatheter aortic valve replacement (TAVR). Per the 2020 ACC/AHA guidelines, TAVR—a catheter-delivered procedure expanding a prosthetic valve within the native one—is a Class I recommendation for patients over 80 years or with life expectancy under 10 years with severe symptomatic aortic stenosis, with shared decision-making for ages 65-80 across surgical risk categories.^[3] Prosthetic valves are either mechanical (durable but requiring lifelong anticoagulation) or biological (tissue-based, lasting 10-20 years without routine anticoagulants).^[4] Valve replacement carries risks including bleeding, infection, stroke, and mortality, though rates have declined with advances (e.g., 1-2% 30-day stroke and ~2-3% mortality for contemporary TAVR).^[5] ^[6] Preparation involves multidisciplinary assessment, medication review, and fasting.^[1]

Background

Heart valves and their function

The human heart features four valves that regulate blood flow through its chambers, ensuring unidirectional circulation: the tricuspid and pulmonary valves on the right side, which handle deoxygenated blood, and the mitral and aortic valves on the left side, which manage oxygenated blood.^[7] The tricuspid valve is positioned between the right atrium and right ventricle, consisting of three thin leaflets that open during atrial contraction (diastole) to permit blood entry into the ventricle and close during ventricular systole to block reflux.^[7]^[8] Similarly, the pulmonary valve lies between the right ventricle and pulmonary artery, with three cusps that open under ventricular pressure to propel blood toward the lungs and close to maintain forward momentum.^[7]^[9] On the left, the mitral valve, or bicuspid valve, separates the left atrium from the left ventricle and comprises two leaflets that facilitate blood transfer during diastole while sealing shut in systole to prevent backward leakage.^[7]^[10] The aortic valve, located between the left ventricle and aorta, has three cusps that part during systole to release blood into systemic circulation and coapt during diastole to avert regurgitation.^[7]^[11] These valves operate passively via pressure differentials, opening when upstream pressure exceeds downstream and closing otherwise, thus enforcing one-way flow across the cardiac cycle.^[12]^[13] The valves divide into two categories: atrioventricular (AV) valves (tricuspid and mitral), which guard atrial-ventricular junctions, and semilunar (SL) valves (pulmonary and aortic), which protect ventricular-arterial outlets.^[8] AV valves feature leaflets tethered by chordae tendineae to papillary muscles, which contract to stabilize the leaflets and inhibit prolapse during ventricular ejection.^[12]^[8] SL valves, in contrast, have unsupported cusps embedded in elastic arterial walls, relying on eddy currents in the sinuses of Valsalva for smooth closure.^[11] In healthy states, these mechanisms yield negligible transvalvular resistance, with mean pressure gradients typically below 5 mmHg across the aortic and mitral valves, signifying optimal hemodynamics.^[14] Basic hemodynamic assessment involves evaluating pressure gradients and effective orifice area to quantify flow efficiency. The Gorlin formula provides a standard method for estimating valve area from cardiac catheterization data, derived from hydraulic orifice principles:

A = \frac{CO / (SEP \times HR)}{44.3 \sqrt{\Delta P}}

where A is the valve area (cm²), CO is cardiac output (mL/min), SEP is the systolic ejection period (s/beat), HR is heart rate (beats/min), and \Delta P is the mean transvalvular pressure gradient (mmHg); the constant 44.3 incorporates gravity and unit conversions. Normal valves exhibit areas sufficient for peak flows (e.g., 3.0–4.0 cm² for aortic), minimizing energy loss.^[15] Structurally, all valves share a tri-layered extracellular matrix in their leaflets or cusps: the fibrosa (collagen-dense for tensile strength), spongiosa (glycosaminoglycan-rich for shock absorption), and atrialis/ventricularis (elastin-abundant for coaptation).^[8] Leaflets attach to fibrous annuli—D-shaped rings for AV valves and crown-like for SL valves—that integrate with the heart's fibrous skeleton for stability.^[8] In AV valves, the annulus contracts rhythmically to optimize geometry, while supporting chordae tendineae (string-like collagen extensions) and papillary muscles (ventricular projections) dynamically tension leaflets during systole.^[10]^[8] SL valve annuli, less rigid, interface with compliant arterial roots to buffer recoil.^[11] This architecture enables durable, low-friction operation over a lifetime.^[8]

Valve diseases

Heart valve diseases encompass a range of pathological conditions that impair the normal function of the heart's four valves—the mitral, tricuspid, aortic, and pulmonary—which regulate unidirectional blood flow between the heart's chambers and major vessels. These disorders arise when valves fail to open fully (stenosis) or close properly (regurgitation), leading to inefficient circulation, increased cardiac workload, and potential heart failure. Unlike healthy valves, which open and close seamlessly to maintain efficient blood flow, diseased valves disrupt this process, often progressively worsening over time.^[16] Common valvular diseases include aortic stenosis, characterized by calcification and narrowing of the aortic valve, which obstructs blood flow from the left ventricle to the aorta.^[17] Mitral regurgitation involves leakage of blood backward through the mitral valve due to prolapse, annular dilation, or chordal rupture, allowing blood to flow from the left ventricle back into the left atrium during systole.^[18] Rheumatic heart disease results from post-inflammatory scarring following acute rheumatic fever, primarily affecting the mitral and aortic valves with fibrosis and fusion of valve leaflets.^[19] Endocarditis causes infectious damage to valve surfaces, leading to vegetation formation, ulceration, and potential perforation or regurgitation.^[20] Causes and risk factors for these diseases vary by type but commonly include congenital defects present at birth, such as bicuspid aortic valve; age-related degeneration involving calcification and tissue stiffening; infections like bacterial endocarditis; and autoimmune conditions such as systemic lupus erythematosus, which can trigger valve inflammation.^[21] Additional risks encompass hypertension, hyperlipidemia, diabetes, and chronic kidney disease, which accelerate degenerative changes, particularly in the aortic valve.^[17] Rheumatic heart disease is predominantly linked to untreated streptococcal infections in childhood, with higher incidence in low-resource settings.^[19] Symptoms of valve diseases often manifest as exertional dyspnea, fatigue, and signs of heart failure, including orthopnea, peripheral edema, and palpitations, due to reduced cardiac output and pulmonary congestion.^[22] In advanced cases, patients may experience chest pain, syncope, or hemoptysis, particularly with aortic stenosis or mitral regurgitation.^[23] Diagnosis relies on clinical evaluation supplemented by imaging; echocardiography is the primary modality, assessing valve morphology, function, and severity—for instance, severe aortic stenosis is indicated by a valve area less than 1 cm² or mean gradient greater than 40 mmHg.^[24] Cardiac catheterization may be used for hemodynamic confirmation in equivocal cases, measuring pressures and gradients across the valve.^[25] Prevalence statistics highlight the global burden: as of recent estimates (2025), severe aortic stenosis affects approximately 3.4% of individuals aged 75 years and older, with prevalence increasing to around 8% by age 85, and projected to rise further due to aging populations (e.g., 1.4 million symptomatic severe cases in North America by 2050).^[26]^[27] Rheumatic heart disease, conversely, is more prevalent in developing countries, with an estimated 55 million cases worldwide and around 360,000 annual deaths as of 2025, disproportionately impacting children and young adults in regions like sub-Saharan Africa and South Asia.^[28] Overall, valvular heart disease contributes significantly to cardiovascular morbidity, with mitral regurgitation and aortic regurgitation also common in aging populations.^[29]

Types of replacement valves

Mechanical valves

Mechanical prosthetic valves are artificial devices designed to replace diseased heart valves, primarily constructed from synthetic materials to mimic the function of native valves. These valves are categorized into three main design types: ball-and-cage, tilting disc, and bileaflet. The ball-and-cage design, exemplified by the Starr-Edwards valve, features a Silastic ball housed within a titanium cage that moves to open and close the valve. Tilting disc valves, such as the Medtronic Hall, utilize a single disc that tilts to permit blood flow. Bileaflet valves, like the St. Jude Medical, incorporate two semicircular leaflets that rotate around struts for efficient opening and closing, representing the most commonly implanted type as of 2023 due to improved hemodynamics.^[30]^[31] The primary material used in modern mechanical valves is pyrolytic carbon, a durable, biocompatible coating applied over a metallic frame, often titanium alloy. This material provides exceptional resistance to wear and corrosion, ensuring structural integrity under high-pressure cardiac conditions. Pyrolytic carbon's low thrombogenicity reduces the risk of blood clot formation on the valve surface compared to earlier materials, though it does not eliminate the need for anticoagulation.^[32]^[33] A key advantage of mechanical valves is their longevity, lasting a lifetime without structural deterioration, making them suitable for younger patients with extended life expectancy. Unlike bioprosthetic valves, which may degenerate over time, mechanical options resist calcification and fatigue, minimizing the need for reoperation due to valve failure.^[34]^[35] However, mechanical valves carry significant disadvantages, including a high risk of thromboembolism due to their synthetic surfaces, necessitating lifelong anticoagulation therapy with warfarin to maintain an international normalized ratio (INR) of 2.0-3.0 for aortic positions or 2.5-3.5 for mitral positions. Modern bileaflet valves, such as the On-X, may allow reduced anticoagulation intensity (INR 1.5-2.0 with low-dose aspirin after the initial 3 months) in the aortic position for lower-risk patients per ACC/AHA guidelines.^[36]^[37]^[38]^[39]^[40] This regimen increases bleeding risks and requires regular monitoring. Additionally, the mechanical action produces an audible clicking sound from leaflet movement, which can disturb sleep or daily activities for some patients. Mechanical valves are generally contraindicated in young women planning pregnancy, as the hypercoagulable state of pregnancy heightens thromboembolic risks, and warfarin poses fetal teratogenic effects, complicating safe anticoagulation management.^[37]^[38]^[39]^[40] Implantation of mechanical valves requires precise sizing based on the patient's annular diameter, typically assessed preoperatively via transthoracic echocardiography to ensure optimal fit and hemodynamic performance. This measurement guides selection of the appropriate valve size, avoiding mismatches that could lead to paravalvular leaks or obstruction.^[41]^[42]

Bioprosthetic valves

Bioprosthetic valves, also known as tissue valves, are derived from biological materials and are widely used in heart valve replacement surgery to mimic the natural function of cardiac valves. These valves are primarily sourced from animal or human tissues and offer a viable alternative to synthetic options, particularly for patients who wish to avoid long-term anticoagulation therapy.^[43] The main types of bioprosthetic valves include xenografts, homografts, and autografts. Xenografts are the most common, fabricated from animal tissues such as porcine aortic valves or bovine pericardium, with the Carpentier-Edwards PERIMOUNT series serving as a prominent example of a stented pericardial bioprosthesis. Homografts, obtained from human cadavers, are less frequently used but provide a close match to native valve tissue, though they are susceptible to structural valve deterioration similar to xenografts. Autografts utilize the patient's own tissue, as in the Ross procedure, where the pulmonary valve is transplanted to replace the diseased aortic valve, followed by implantation of a homograft or another bioprosthesis in the pulmonary position.^[44]^[45]^[46]^[47] To prepare these valves for implantation, tissues undergo fixation with glutaraldehyde, a chemical process that cross-links proteins to enhance mechanical stability, reduce immunogenicity by masking antigens, and prevent tissue degradation. This treatment minimizes the risk of immune rejection while preserving the valve's flexibility and hemodynamic properties.^[48]^[49] A key advantage of bioprosthetic valves is the absence of need for lifelong anticoagulation; low-dose aspirin is often sufficient to manage thrombotic risks, making them suitable for older patients or those with contraindications to anticoagulants. They also provide quieter operation and more favorable hemodynamics compared to mechanical valves, which serve as longer-lasting alternatives for younger patients. However, their durability is limited, typically lasting 10-15 years in younger individuals due to accelerated calcification and structural degeneration, though this extends beyond 15 years in elderly patients with lower metabolic demands. Calcification, involving calcium phosphate deposition on valve leaflets, remains the primary mode of failure, driven by both immune responses and mechanical stress.^[43]^[50]^[51]^[52] Within xenograft designs, variations such as stented and stentless configurations address flow dynamics; stented valves, like the Carpentier-Edwards PERIMOUNT Magna, incorporate a supportive frame for easier surgical handling, while stentless options, such as certain porcine root bioprostheses, allow for larger effective orifice areas and reduced transvalvular gradients to optimize hemodynamics. Both designs demonstrate comparable early outcomes, but stentless valves may offer subtle long-term benefits in left ventricular mass regression.^[53]^[46]

Surgical techniques

Traditional open-heart surgery

Traditional open-heart surgery for valve replacement, pioneered by Albert Starr who performed the first successful mitral valve replacement in 1960, remains the standard approach for many patients requiring prosthetic valve implantation.^[54] This procedure involves a median sternotomy to access the heart and typically lasts 3 to 5 hours, conducted in a specialized operating room by a cardiac surgeon, perfusionist, and supporting medical team.^[55]^[56] The surgery begins with the administration of general anesthesia to render the patient unconscious and pain-free.^[57] A median sternotomy is then performed, creating an incision along the midline of the chest to expose the heart and great vessels.^[58] Cannulas are inserted into the major veins and aorta to initiate cardiopulmonary bypass (CPB), diverting blood flow to a heart-lung machine that oxygenates and circulates it throughout the body while the heart is isolated.^[57] Once on CPB, a cardioplegic solution is infused into the coronary arteries to induce controlled cardiac arrest, providing a still, bloodless field for precise surgical work.^[57] The surgeon excises the diseased native valve by incising the annulus and removing the leaflets or cusps.^[57] The prosthetic valve—either mechanical or bioprosthetic—is then seated in the annular position and secured using nonabsorbable sutures, often with pledgets for reinforcement to ensure a secure, leak-free attachment.^[57] If annular dilation is present, an annuloplasty ring may be incorporated to restore geometry, though the primary focus is on complete replacement rather than repair.^[57] After implantation, the heart is reperfused and de-aired, CPB is gradually discontinued as the heart resumes beating, and the sternum is closed with wires.^[57] This sternotomy-based method, while effective, contrasts with minimally invasive alternatives that aim to reduce trauma through smaller incisions.^[58]

Minimally invasive and transcatheter procedures

Minimally invasive surgical approaches to valve replacement utilize smaller incisions compared to traditional open-heart surgery, which typically involves a full sternotomy of 20-25 cm. These techniques, such as partial upper sternotomy or right anterior mini-thoracotomy, employ incisions of 5-8 cm while still requiring cardiopulmonary bypass (CPB) for circulatory support during the procedure. In partial sternotomy, the incision follows an inverted L or J shape through the upper sternum, providing access to the aortic valve for excision and implantation of a prosthetic valve using standard surgical instruments adapted for the limited exposure. Right mini-thoracotomy involves a lateral incision in the second or third intercostal space, often facilitated by videoscopic assistance to visualize the operative field and minimize trauma to surrounding tissues.^[59]^[60] Transcatheter aortic valve replacement (TAVR), also known as transcatheter aortic valve implantation (TAVI), represents a fully percutaneous alternative delivered via catheter, primarily through the femoral artery. The procedure begins with vascular access and placement of a guidewire across the stenotic native valve, followed by balloon aortic valvuloplasty to pre-dilate the annulus and create space. A compressed prosthetic valve is then advanced over the wire; for balloon-expandable valves like the Edwards SAPIEN series, rapid ventricular pacing is used during inflation to deploy the valve precisely within the annulus, while self-expanding valves such as the Medtronic Evolut (formerly CoreValve) gradually expand upon release from the sheath. Post-deployment, hemodynamic assessments confirm valve function, and balloon post-dilation may be performed if needed to optimize expansion and reduce paravalvular leak.^[61]^[62] Advancements in TAVR have broadened its applicability, with the U.S. Food and Drug Administration (FDA) expanding approval of devices like the Edwards SAPIEN 3 to low-surgical-risk patients in 2019 based on the PARTNER 3 trial, which demonstrated non-inferiority to surgical replacement in this group. Valve-in-valve TAVR has emerged as a key option for treating degenerated bioprosthetic valves, allowing transcatheter implantation within a failed surgical valve to avoid redo open surgery, with procedural success rates exceeding 95% in real-world registries as of 2025.^[63]^[64] These developments, including iterative valve designs with improved paravalvular sealing, have achieved procedural success rates of 96-97% in contemporary cohorts as of 2025, reflecting enhanced device iteration and operator experience.^[65] Transcatheter mitral valve replacement (TMVR) remains an emerging procedure as of 2025, primarily for high-surgical-risk patients with severe mitral regurgitation unsuitable for repair or edge-to-edge therapies. Devices such as the Abbott Tendyne (transapical delivery) and Medtronic Intrepid (transfemoral access) have shown procedural success rates of 93-97% in early trials, addressing challenges like left ventricular outflow tract obstruction through specialized anchoring mechanisms. Patient selection emphasizes complex anatomies with high screening failure rates, but ongoing trials like APOLLO and SUMMIT are evaluating broader efficacy.^[66]

Indications

Common conditions treated

Valve replacement is primarily indicated for severe aortic valve diseases, including symptomatic severe aortic stenosis with a valve area of less than 1 cm², mean gradient of at least 40 mm Hg, or peak velocity of at least 4 m/s, as per Class I recommendations in the ACC/AHA guidelines.^[67] Asymptomatic severe aortic stenosis with left ventricular ejection fraction (LVEF) less than 50% also warrants intervention to prevent progression to heart failure.^[67] For severe aortic regurgitation, replacement is recommended when symptomatic or when asymptomatic with LVEF between 25% and 50%, or left ventricular end-systolic dimension of at least 50 mm (or indexed end-systolic dimension of at least 25 mm/m²), indicating significant left ventricular dilation.^[67] Without intervention for symptomatic severe aortic stenosis, approximately 50% of patients die within 2 to 3 years.^[68] Mitral valve replacement addresses severe mitral regurgitation—often due to prolapse in primary disease or ischemia in secondary disease—when repair is not feasible, with Class I indications for symptomatic cases or asymptomatic primary severe regurgitation with LVEF of 30% to 60% or left ventricular end-systolic dimension of at least 40 mm (repair preferred if possible).^[67] For severe mitral stenosis, commonly resulting from rheumatic fever, valve replacement is indicated for symptomatic patients with a valve area of 1.5 cm² or less and mean gradient of at least 10 mm Hg when percutaneous mitral balloon commissurotomy or repair is unsuitable (e.g., due to unfavorable valve morphology).^[67] Tricuspid valve replacement is indicated for severe tricuspid regurgitation in the context of right heart failure—particularly when symptomatic and isolated or occurring during left-sided valve surgery—if repair is not feasible (repair is preferred when possible).^[67] Pulmonary valve replacement remains rare, typically reserved for congenital heart disease scenarios rather than acquired conditions.^[67] Note that valve repair is often prioritized over replacement for mitral and tricuspid diseases when anatomically suitable, to preserve native valve function and avoid prosthetic complications.^[67]

Patient eligibility criteria

Patient eligibility for valve replacement is determined through a comprehensive evaluation that assesses surgical risk, comorbidities, life expectancy, and patient preferences, primarily guided by multidisciplinary heart team (MDT) assessments as recommended in the 2020 ACC/AHA guidelines (with the 2025 ESC/EACTS guidelines offering updated international perspectives, such as a lower age threshold of 70 years for TAVR in suitable patients).^[3]^[69] The MDT, consisting of cardiologists, cardiac surgeons, imaging specialists, and other experts, reviews all patients with severe valvular heart disease (VHD) considering intervention to ensure shared decision-making and optimize outcomes (Class of Recommendation [COR] 1, Level of Evidence [LOE] C).^[3] Risk stratification is essential and typically involves validated tools such as the Society of Thoracic Surgeons (STS) score or EuroSCORE II to predict perioperative mortality and morbidity.^[3] The STS score, accessible via an online calculator, incorporates factors like age, renal function, prior cardiac surgery, and ejection fraction to estimate 30-day risk; scores greater than 8% classify patients as high-risk, often favoring transcatheter aortic valve replacement (TAVR) over surgical aortic valve replacement (SAVR) in symptomatic severe aortic stenosis (Section 3.2.3).^[3] Similarly, EuroSCORE II evaluates operative risk with thresholds like >10% indicating high risk, aiding in procedure selection (COR 1, LOE B-NR).^[3] These tools help identify low-, intermediate-, and high-risk categories to tailor interventions. Contraindications to valve replacement include conditions where the procedure's risks outweigh potential benefits, such as advanced dementia, severe frailty, active infection (e.g., endocarditis), or prohibitive surgical risk defined as >50% predicted 30-day mortality or irreversible morbidity.^[3] For instance, patients with active systemic infection or untreated comorbidities like severe pulmonary hypertension may be ineligible for immediate intervention, with treatment deferred until stabilization (Table 14).^[3] Frailty assessment, often using tools like the Fried Frailty Phenotype, further refines eligibility by evaluating physical resilience, as frail patients face higher complication rates.^[3] Overall, eligibility emphasizes a patient-centered approach, balancing disease severity from common conditions like aortic stenosis with individualized risk profiles.

Risks and complications

Perioperative risks

Perioperative risks in valve replacement procedures encompass a range of immediate and short-term complications occurring during surgery or within the first 30 days postoperatively, influenced by patient factors, procedural complexity, and technique employed. These risks are particularly elevated in patients with comorbidities such as advanced age, renal dysfunction, or prior cardiac events, and they contribute significantly to early morbidity and mortality. Surgical approaches, including traditional open-heart surgery and transcatheter aortic valve replacement (TAVR), carry distinct profiles of adverse events, with overall 30-day mortality rates ranging from 1-3% in low-risk patients undergoing open surgery to 2-5% in TAVR cohorts.^[70]^[71] Common surgical risks include bleeding, which occurs in 5-10% of cases due to anticoagulation needs, vascular access issues, or intraoperative hemostasis challenges, often requiring transfusion or reoperation. Stroke, a devastating neurologic event, affects 1-3% of patients, primarily from embolization of debris during valve manipulation or manipulation of atherosclerotic aorta, with higher incidence in multivalve procedures up to 9.7%. Infection, particularly prosthetic valve endocarditis, is less frequent at under 1% in the perioperative period but can arise from intraoperative contamination or bacteremia, leading to severe sepsis if untreated. Arrhythmias, especially new-onset atrial fibrillation, develop in 30-40% of patients post-valve surgery, driven by atrial manipulation, inflammation, or ischemia, and are associated with prolonged hospital stays and increased thromboembolic potential.^[72]^[73]^[74]^[75]^[76] Anesthesia and cardiopulmonary bypass-related complications further compound risks, including myocardial infarction from inadequate myocardial protection or embolic events during bypass, occurring in a subset of patients with preexisting coronary disease. Renal failure, often acute kidney injury from hypoperfusion, hemodilution, or contrast use in TAVR, affects 5-43% of cases depending on baseline function and bypass duration, significantly elevating mortality risk.^[77]^[78] Procedure-specific risks are prominent in TAVR, where paravalvular leak—resulting from incomplete sealing between the prosthesis and annulus—affects 5-10% of patients, potentially causing hemodynamic instability or hemolysis. Conduction abnormalities, such as complete heart block from interference with the aortic valve's conduction pathway, necessitate permanent pacemaker implantation in 10-20% of TAVR cases, with rates varying by device type and pre-existing bundle branch blocks.^[79]^[80]^[81]

Long-term complications

Long-term complications of valve replacement encompass a range of delayed issues that can emerge months to years after surgery, primarily related to the prosthetic valve's durability, the need for ongoing anticoagulation in mechanical valves, and systemic effects of therapy. These complications affect patient quality of life, necessitate reinterventions, and contribute to morbidity and mortality, with risks varying by valve type, patient age, and position (aortic versus mitral). Mechanical valves, while durable, carry ongoing thrombotic and bleeding risks due to lifelong anticoagulation, whereas bioprosthetic valves are prone to progressive structural changes over time.^[67] Valve-related complications include thrombosis in mechanical prostheses and structural degeneration in bioprosthetic ones. For mechanical valves, thrombosis occurs at an annual incidence of 0.3–1.3%, influenced by factors such as valve position (higher in mitral) and anticoagulation adequacy, potentially leading to obstruction or embolism if untreated.^[82] In contrast, bioprosthetic valves experience structural valve deterioration—manifesting as calcification, leaflet thickening, or tears—at a cumulative incidence of approximately 20% at 10 years, with rates accelerating beyond this period and higher in younger patients due to increased metabolic stress on the tissue.^[83] Anticoagulation therapy, essential for mechanical valves, introduces significant bleeding risks and other systemic effects. Major bleeding events occur at rates of 2–3% per year in patients on warfarin, exacerbated by factors like advanced age, concurrent antiplatelet use, or supratherapeutic international normalized ratios.^[84] Long-term warfarin use is also associated with reduced bone mineral density and an elevated risk of osteoporosis or osteoporotic fractures, particularly in men, due to its interference with vitamin K-dependent proteins involved in bone metabolism.^[85] Additional long-term issues include prosthetic valve endocarditis and hemolysis. Prosthetic valve endocarditis affects 0.3–0.5% of patients annually, representing 10–30% of all infective endocarditis cases, with high in-hospital mortality (15–20%) and often requiring surgical intervention.^[86] Hemolysis, typically mild but occasionally severe, arises from paravalvular leaks around the prosthesis, causing mechanical shear stress on red blood cells and leading to anemia in up to 1% of cases with significant leaks.^[87] Reintervention rates reflect the cumulative impact of these complications, ranging from 10–20% at 10 years post-replacement, driven largely by structural degeneration in bioprosthetic valves and thrombosis or endocarditis in mechanical ones, with notably higher rates (up to 50% at 15 years) in younger patients who face prolonged exposure to these risks.^[67]^[83]

Postoperative care and recovery

Immediate postoperative management

Following valve replacement surgery, patients are typically admitted to the intensive care unit (ICU) for close monitoring to ensure hemodynamic stability, which involves maintaining a cardiac index greater than 2.2 L/min/m², pulmonary capillary wedge pressure below 20 mmHg, and heart rate between 80 and 110 beats per minute.^[88] Inotropic agents such as epinephrine (at doses of 1-6 mcg/min), dobutamine, or milrinone may be administered if low cardiac output is detected, while vasopressors like vasopressin are used for hypotension.^[88] Mechanical ventilation is weaned and extubation aimed for within 24-48 hours, provided oxygenation saturation exceeds 95%, diaphragmatic function is adequate, and hemodynamics are stable.^[88] Pain control is achieved through multimodal analgesia, including opioids and non-opioids, to minimize respiratory depression while addressing postoperative discomfort from sternotomy or thoracotomy incisions.^[88] Diagnostic evaluations are performed promptly to assess surgical outcomes and detect complications. A transthoracic echocardiogram (TTE) is conducted during the hospital stay to evaluate valve function, including transvalvular velocities, pressure gradients, and any paravalvular leaks, with transesophageal echocardiography (TEE) used if TTE is inconclusive.^[67] Chest X-rays are obtained routinely to identify pleural effusions, pneumothorax, atelectasis, or mediastinal widening suggestive of tamponade.^[88] Early mobilization is initiated to reduce the risk of deep vein thrombosis and promote recovery, with patients encouraged to sit upright and ambulate within 1-2 days postoperatively under supervision, once hemodynamic stability is confirmed. In enhanced recovery after surgery (ERAS) protocols for minimally invasive valve procedures, mobilization may begin even earlier, such as sitting and initial steps within hours of surgery, progressing to walking sessions on postoperative day 1.^[89] Discharge from the hospital occurs once criteria are met, typically 5-7 days after surgery for traditional open-heart approaches. These include a stable sinus rhythm (70-110 beats per minute), initiation of oral anticoagulation tailored to valve type (e.g., warfarin with target INR of 2.0-3.0 for mechanical valves, initiated as soon as hemostasis is achieved, typically within 24-48 hours post-surgery), and evidence of wound healing without infection or dehiscence.^[88]^[67] For transcatheter procedures, stays are shorter, often 1-3 days, with similar stability assessments.^[90] This phase transitions to outpatient follow-up for ongoing monitoring.^[67]

Long-term follow-up and lifestyle adjustments

Following valve replacement, patients require ongoing surveillance to monitor prosthetic valve function and detect early signs of complications. Annual clinical evaluations, including physical examination and assessment of symptoms, are recommended for all patients, with transthoracic echocardiography (TTE) performed at baseline 1 to 3 months post-procedure to establish hemodynamic parameters. For mechanical valves, TTE is typically repeated every 3 to 5 years if the patient remains stable, while for bioprosthetic valves, annual TTE is advised after 10 years due to the increasing risk of structural degeneration.^[67] Serial imaging, such as TTE or computed tomography, is essential for identifying degeneration signs like leaflet thickening, calcification, or regurgitation, guiding decisions on potential reintervention. Referral to cardiac rehabilitation programs is recommended to support recovery, improve exercise capacity, and reduce long-term risks.^[67] Anticoagulation management is critical, particularly for mechanical valves, where lifelong therapy with vitamin K antagonists (VKAs) such as warfarin is standard to prevent thromboembolism. International normalized ratio (INR) monitoring is required, targeting 2.0 to 3.0 for aortic mechanical valves and 2.5 to 3.5 for mitral or older-generation mechanical valves, with frequent adjustments based on diet, medications, and comorbidities; bridging with unfractionated heparin or low-molecular-weight heparin is used during interruptions for procedures.^[67] For bioprosthetic valves, short-term VKA therapy (3 to 6 months) is recommended post-implantation, especially in patients with atrial fibrillation or other thrombotic risks, after which aspirin monotherapy may suffice.^[67] Emerging 2025 data from observational studies suggest direct oral anticoagulants (DOACs) may be considered in select cases with bioprosthetic valves or non-mechanical indications like atrial fibrillation, but they remain contraindicated for mechanical valves due to increased stroke risk demonstrated in randomized trials.^[91] Lifestyle adjustments focus on reducing infection and thrombotic risks while promoting cardiovascular health. Endocarditis prophylaxis with antibiotics is advised prior to high-risk dental procedures (e.g., those involving manipulation of gingival tissue) for all patients with prosthetic valves, using regimens such as amoxicillin 2 g orally 30 to 60 minutes before the procedure.^[92] Patients on warfarin should maintain a consistent diet low in vitamin K-rich foods (e.g., leafy greens) to stabilize INR levels, and regular aerobic exercise is encouraged to improve fitness, though heavy lifting or isometric activities should be avoided initially to prevent strain on the prosthesis.^[67] Smoking cessation and weight management are also emphasized to support long-term valve durability and overall prognosis.^[67]

Outcomes

Survival and success rates

Valve replacement procedures demonstrate high overall survival rates, typically ranging from 85% to 90% at 5 years post-replacement across various patient cohorts. In low-risk patients undergoing transcatheter aortic valve replacement (TAVR), 5-year survival reaches approximately 90%, with surgical aortic valve replacement (SAVR) showing comparable outcomes at 91.8%. The PARTNER trials have established TAVR's non-inferiority to SAVR; for instance, the PARTNER 3 trial indicates 5-year survival rates of approximately 90% for TAVR and 91.8% for SAVR in low-risk patients. In the 2025 Evolut Low Risk trial 5-year follow-up, all-cause mortality was 13.5% for TAVR and 14.9% for SAVR in low-risk patients.^[93]^[94] Procedural success rates exceed 95% for both TAVR and SAVR, defined by successful valve deployment without major complications per Valve Academic Research Consortium criteria.^[95] Durability metrics highlight freedom from reoperation at 80% to 90% at 10 years for bioprosthetic valves in elderly patients, attributed to lower structural deterioration rates in older age groups where life expectancy aligns with valve longevity.^[96] Comparative data on valve types reveal equivalence in long-term survival between mechanical and bioprosthetic options for patients aged 50 to 70 years, as demonstrated in a 2014 cohort study showing no significant adjusted mortality difference after 15 years of follow-up. Recent analyses show better long-term survival with mechanical valves in this age group, though there is no significant difference in freedom from reintervention.^[97]^[98] Survival and success are influenced by factors such as patient age and valve position; younger patients exhibit higher absolute survival but increased reoperation risk due to longer exposure, while aortic valve replacements yield better outcomes than mitral, with 10-year relative survival rates of 84% versus 68.5%. Perioperative risks, including stroke and bleeding, can modestly impact these rates by 5-10% in high-risk subgroups.^[99]

Quality of life improvements

Valve replacement surgery, whether surgical or transcatheter, generally leads to substantial enhancements in patients' quality of life (QoL) by alleviating symptoms of valvular heart disease such as dyspnea, fatigue, and chest pain, thereby improving physical functioning and daily activities.^[100] Studies utilizing standardized instruments like the Short Form-36 (SF-36) and New York Heart Association (NYHA) functional class demonstrate these gains, particularly in physical and mental health domains, with benefits often evident within 6-12 months post-procedure and sustained long-term.^[101] For instance, in patients undergoing aortic valve replacement (AVR), physical functioning scores on the SF-36 improved significantly one year postoperatively, approaching population norms, while vitality and general health perceptions also rose markedly.^[101] In transcatheter aortic valve replacement (TAVR), functional status improves notably, with NYHA class reductions averaging 1-2 classes at 12-24 months, correlating with better mobility, reduced hospitalizations, and enhanced independence in activities of daily living.^[100] The SF-36 physical component summary (PCS) scores increase by 6-19 points at 6-12 months, and mental component summary (MCS) scores by 2-13 points, reflecting decreased emotional burden from chronic symptoms.^[100] Similarly, for mitral valve surgery, physical QoL as measured by SF-12 PCS rises from a median of 56 preoperatively to 74 at one year (P<0.001), with parallel gains in mental QoL from 63 to 70 (P<0.001), driven by improvements in vitality, social functioning, and emotional role limitations.^[102] Minimally invasive approaches, such as minimally invasive AVR (MIAVR), further bolster QoL through faster recovery, with patients reporting acceptable physical function and general health on SF-36 and EQ-5D scales, with limited evidence on superiority over full sternotomy.^[103] Overall, these interventions enhance psychological well-being, with WHOQOL-BREF domain scores post-valve replacement averaging 61-80 across physical, social, environmental, and psychological aspects, though factors like comorbidities can modulate outcomes.^[104] Elderly patients (>70 years) experience comparable benefits, including symptom relief and sustained functional status, underscoring the procedure's value in improving life satisfaction without significant differences between mechanical and bioprosthetic valves.^[105]^[106]

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