Pulmonary valve repair and replacement
Medically reviewed on March 27, 2018
Pulmonary valve repair and pulmonary valve replacement are procedures that treat diseases affecting the pulmonary valve.
The pulmonary valve is one of four valves that regulate blood flow in the heart. The valve lies between one of the heart's upper chambers (atria) and lower chambers (ventricles).
With each contraction of the right ventricle, the pulmonary valve opens to allow oxygen-depleted blood to flow from the right ventricle into the pulmonary artery, which carries blood to the lungs for oxygen. When the ventricle relaxes, the pulmonary valve closes tightly to prevent blood from flowing back into the right ventricle.
When the pulmonary valve isn't working properly, it can interfere with blood flow from the heart to the lungs as well as force the heart to work harder to supply the necessary blood to the rest of your body.
Some children born with pulmonary valve disease may experience signs and symptoms shortly after birth and require immediate treatment. For others, pulmonary valve disease may not cause any noticeable symptoms for many years, if at all.
Pulmonary valve disease may occur on its own or as part of other congenital heart defects, such as tetralogy of Fallot. Often, the condition may only be detected by a physical evaluation or heart imaging for another reason.
Depending on the severity of the condition, signs and symptoms of pulmonary valve disease may include shortness of breath, fatigue, irregular heartbeat (arrhythmia) and heart failure.
Pulmonary valve repair or pulmonary valve replacement can treat pulmonary valve disease and help restore normal blood flow, reduce symptoms, prolong life and help preserve the function of your heart muscle.
A normal heart has two upper and two lower chambers. The upper chambers, the right and left atria, receive incoming blood. The lower chambers, the more muscular right and left ventricles, pump blood out of your heart. The heart valves, which keep blood flowing in the right direction, are gates at the chamber openings.
Why it's done
Pulmonary valve disease treatment depends on the severity of your condition, whether or not you're experiencing signs and symptoms, and if your condition is getting worse.
Many types of pulmonary valve disease are caused by heart conditions present at birth (congenital heart disease). Types of pulmonary valve disease that may require treatment with pulmonary valve repair or pulmonary valve replacement include:
Pulmonary valve regurgitation is a leaky pulmonary valve. The leaky valve allows blood to flow backward into the heart rather than directly to the lungs for oxygen.
The most common cause of pulmonary valve regurgitation is pulmonary hypertension. Other causes of pulmonary valve regurgitation are congenital heart disease (specifically, tetralogy of Fallot or congenital pulmonary valve stenosis), bacterial infection of the heart (infective endocarditis), complications after heart surgery, and rarely rheumatic fever.
Pulmonary valve stenosis occurs when the pulmonary valve becomes thickened or obstructed, which makes it harder for it to open properly and for the heart to pump blood into the pulmonary artery and to the lungs.
The cause of pulmonary valve stenosis is usually unknown. It often affects children and may be caused by congenital heart disease or an infection in the mother during pregnancy. It can also occur in adults as a result of a rare type of cancer that affects the heart (carcinoid heart disease).
Pulmonary atresia is a congenital heart defect in which a child is born without a well-defined pulmonary valve. In pulmonary atresia, blood can't flow from the right ventricle into the pulmonary artery. The only blood flow to the lungs is through an open passageway between the pulmonary artery and the main artery supplying blood to the body (aorta).
The cause is usually unknown. Children born with pulmonary atresia may also have other heart defects.
For some people with mild pulmonary valve disease without symptoms, careful monitoring under a doctor's supervision may be all that's needed.
But in many cases, pulmonary valve disease and dysfunction progress in adulthood and get worse without medical treatment. Most pulmonary valve conditions are mechanical problems that cannot be adequately treated with medications alone and will eventually require surgery to reduce symptoms and the risk of complications, such as heart failure, or death due to advanced heart failure or sudden cardiac arrest.
The decision to repair or replace a damaged pulmonary valve depends on many factors, including:
- The severity of your pulmonary valve disease
- Your age and overall health
- Whether you need heart surgery to correct another heart problem in addition to pulmonary valve disease, such as another valve surgery, for example, tricuspid valve repair or replacement, so both conditions can be treated at once
In general and whenever possible, heart valve repair is the preferred option because it is associated with a lower risk of infection, preserves valve strength and function, and eliminates the need to take blood-thinning medications, which may be necessary with valve replacement.
But not all valves can be repaired, and heart valve repair surgery is often harder to do than valve replacement. Your best option will depend on your individual situation as well as the expertise and experience of your health care team.
Pulmonary valve repair and pulmonary valve replacement may be performed via traditional open-heart surgery, which involves a cut (incision) in the chest (sternotomy), or via minimally invasive methods that involve smaller incisions in the chest (hybrid approach) or a catheter-based approach.
What type of procedure you have depends on the severity of your pulmonary valve disease, overall health and whether you need additional heart surgery to treat other issues.
In pulmonary valve regurgitation, a leaky valve allows blood to flow backward into the heart rather than directly to the lungs for oxygen.
Pulmonary valve repair and pulmonary valve replacement surgery risks vary depending on your health, the type of procedure, and the expertise of the surgeon and health care team. To minimize potential risk, pulmonary valve surgery should generally be performed at a medical center with staff experienced in these procedures and that performs high volumes of pulmonary valve surgeries.
Risks associated with pulmonary valve repair and pulmonary valve replacement may include:
- Blood clots
- Valve dysfunction in replacement valves
- Heart rhythm problems
- Heart attack
How you prepare
Before surgery to have your pulmonary valve repaired or replaced, your doctor and treatment team will explain to you what to expect before, during and after the surgery and potential risks of the surgery.
Discuss with your doctor and treatment team any questions you may have about the procedure.
Before being admitted to the hospital for your surgery, talk to your caregivers about your hospital stay and discuss any help you may need when you return home.
Food and medications
Talk to your doctor about:
- When you can take your regular medications and whether you can take them before your surgery
- When you should stop eating or drinking the night before the surgery
Clothing and personal items
Your treatment team may recommend that you bring several items to the hospital including:
- A list of your medications
- Eyeglasses, hearing aids or dentures
- Personal care items, such as a brush, comb, shaving equipment and toothbrush
- Loosefitting, comfortable clothing
- A copy of your advance directive or living will
- Items that may help you relax, such as portable music players or books
During surgery, avoid wearing:
- Contact lenses
- Nail polish
Your body hair will be shaved off at the location where the procedure will take place.
What you can expect
During the procedure
For most pulmonary valve repair and replacement procedures, you'll receive anesthetics so you won't feel any pain, and you'll be unconscious during the surgery.
You'll also be connected to a heart-lung bypass machine, which keeps blood moving through your body during the procedure.
Pulmonary valve repair
Pulmonary valve repair is usually performed via open-heart surgery and opening of the chest bone (sternotomy). Doctors wire the bone back together after the procedure to prevent movement and aid in healing.
Pulmonary valve repair procedures may involve several different types of repair, including:
- Separating fused valve leaflets
- Reconstructing one or more new leaflet(s) from your own heart tissues such as from your own pericardium
- Removing previous patches that were placed at the time of the initial repair of congenital heart disease, such as tetralogy of Fallot, and bringing the pulmonary valve leaflets together to create a working valve
- Reshaping or removing tissue to allow the valve to close more tightly
- Tightening or reinforcing the ring around a valve (annulus) by implanting an artificial ring (annuloplasty)
Pulmonary valves that can't open fully due to pulmonary valve stenosis may be repaired with surgery or a less invasive procedure called balloon valvuloplasty, which uses an approach called cardiac catheterization. You're usually awake during cardiac catheterization, and it requires a much shorter hospital stay than traditional heart surgery.
During balloon valvuloplasty, your doctor inserts a thin, hollow tube (catheter) in a blood vessel, usually in your groin, and threads it to your heart. The catheter has a balloon at its tip that can be inflated to help widen the narrowed pulmonary valve and then deflated for removal.
Balloon valvuloplasty is often used to treat infants and children with pulmonary valve stenosis. However, the valve tends to narrow again in adults who have had the procedure. You may need additional procedures to treat the narrowed valve over time.
Pulmonary valve replacement
In this procedure, your doctor removes the pulmonary valve and replaces it with a mechanical valve made from artificial materials or a biological valve made from cow or pig valves.
Biological tissue valves often eventually need to be replaced, as they degenerate over time. If you have a mechanical valve, you'll need to take blood-thinning medications for the rest of your life to prevent blood clots. Doctors will discuss with you the risks and benefits of each type of valve and discuss which valve may be appropriate for you.
Pulmonary valve replacement surgery may be performed via traditional open-heart surgery or minimally invasive methods, which involve smaller incisions than those used in open-heart surgery.
Minimally invasive pulmonary valve replacement helps to minimize the number of open-heart surgeries over a person's lifetime.
Minimally invasive pulmonary valve replacement is also less common than traditional open-heart surgery because the success and safety of these methods depend largely on the skill and expertise of the doctor and medical center performing the procedure.
When performed by experienced doctors and centers, the results of minimally invasive pulmonary valve replacement can be similar to those with traditional open-heart surgery. But the long-term results of some of these procedures are not yet known.
Transcatheter pulmonary valve replacement
The most common type of minimally invasive pulmonary valve replacement is transcatheter pulmonary valve replacement (percutaneous pulmonary valve replacement).
In this procedure, your doctor inserts a catheter in a large blood vessel in the groin or chest and guides it to the heart. A new, balloon-expandable replacement pulmonary valve at the end of the catheter is then deployed into place.
A catheter may also be used to insert a new pulmonary valve within an existing replacement valve that is failing in a valve-in-valve procedure.
After the procedure
After open-heart pulmonary valve repair or pulmonary valve replacement, you'll generally spend a day or more in the intensive care unit (ICU).
You'll be given fluids, nutrition and medications through intravenous (IV) lines. Other tubes will drain urine from your bladder and drain fluid and blood from your heart and chest. You may be given oxygen.
After the ICU, you'll be moved to a regular hospital room for few days. The time you spend in the ICU and hospital can vary, depending on your condition and procedure.
During your hospital stay, your treatment team will likely:
- Watch for signs of infection in your incision sites
- Periodically check your blood pressure, breathing and heart rate
- Work with you to manage any pain you experience after surgery
- Instruct you to walk regularly to gradually increase your activity and do breathing exercises as you recover
Your doctor may give you instructions to follow during your recovery, such as watching for signs of infection in your incisions, properly caring for incisions, taking medications, and managing pain and other side effects after your surgery.
Recovery time depends on your procedure, overall health before the procedure and any complications.
In a biological pulmonary valve replacement, a biological (tissue) valve replaces the damaged valve.
In a transcatheter valve-in-valve procedure, your doctor inserts a thin tube (catheter) equipped with a balloon-expandable replacement pulmonary valve into your femoral vein. The catheter is then guided to the heart, and the replacement valve is placed within the existing pulmonary valve.
After pulmonary valve repair or pulmonary valve replacement surgery, you may eventually be able to return to daily activities, such as working, driving and exercise.
You'll still need to take certain medications and attend regular follow-up appointments with your doctor. You may have several tests to evaluate and monitor your condition.
Your doctor and health care team may instruct you to incorporate healthy lifestyle changes — such as physical activity, a healthy diet, stress management and avoiding tobacco use — into your life to reduce the risk of future complications and promote a healthy heart.
Your doctor may recommend that you participate in cardiac rehabilitation — a program of education and exercise designed to help you improve your health and help you recover after heart surgery.