Advances in Heart Valve Surgery

Heart valve surgery has advanced on four fronts since the first valve replacement in 1960: better mechanical and tissue valve designs, a strong shift towards repairing the mitral valve rather than replacing it, minimally invasive operations that avoid splitting the whole breastbone, and new sutureless and polymer valves. The aim throughout has been to reduce the trade-off between blood thinners and valve wear.

That is the arc Dr. Z S Meharwal, Chairman & Head- Adult Cardiac Surgery, Fortis Escorts, New Delhi, India, traced in his masterclass on advances in cardiac surgeries for doctors across Africa in October 2025. He is a past president of the Indian Association of Cardiovascular-Thoracic Surgeons and has a particular interest in heart transplantation, ventricular assist devices (mechanical pumps that support a failing heart) and the wider mechanical circulatory support programme at his institute. Rather than skim every corner of the specialty, he chose to go deep on one: the surgical management of valvular heart disease. This guide sets out what he covered, from the history of the field to the practical questions referring doctors in Africa raised about timing, travel and cost.

Seven decades of open heart surgery

Open heart surgery became possible only once surgeons could stop the heart and keep the patient alive while they worked on it. The machine that made this possible, the heart-lung machine, was the product of many years of research by the American surgeon John Gibbon and his wife. On 6 May 1953 Gibbon used it to close an atrial septal defect, a hole between the upper chambers of the heart, in an 18-year-old girl. That operation is generally regarded as the beginning of open heart surgery.

Centres in the United States and elsewhere took up the technique quickly, and in the seven decades since, every area of the specialty has advanced. Dr. Meharwal listed the main ones:

• Coronary artery bypass grafting (CABG), which uses grafted vessels to carry blood around blocked coronary arteries, and is the commonest operation in any major cardiac centre.
• Valve repair and replacement, the subject of this series.
• Congenital heart surgery, the repair of defects present from birth in children.
• Aortic surgery, including complex operations for aortic aneurysms and dissections, an area of particular interest to him.
• Surgery for heart failure, including heart transplantation and ventricular assist devices.

Valve surgery itself began in the 1960s with the first mechanical valves. Tissue valves followed in the 1970s and 1980s, and the decades since have refined both. The story of how those two families of valve developed, and how surgeons and patients now choose between them, is told in detail in mechanical vs tissue heart valves: how to choose.

Mechanical or tissue valve: the central trade-off in valve replacement

Every heart valve replacement involves a choice between two imperfect options. A mechanical valve is built to last, but every patient who receives one needs lifelong anticoagulation with a vitamin K antagonist such as warfarin or acenocoumarol, with the attendant risks of bleeding, valve thrombosis and thromboembolism. A tissue (bioprosthetic) valve, made from animal tissue, avoids lifelong anticoagulation, but it undergoes structural valve degeneration: it wears out over a period of years and the patient eventually needs a further procedure.

"Unfortunately we don't have what we call an ideal valve today," Dr. Meharwal told the audience. Choosing a valve means weighing the risk of anticoagulation against the risk of degeneration and reoperation for each individual patient. Both American (ACC/AHA) and European (ESC/EACTS) guidelines now state that, provided there is no contraindication to anticoagulation and it can be managed properly, the choice should rest on the wishes of the informed patient. Age remains the most important practical criterion. Dr. Meharwal's practice is to favour a mechanical valve in younger patients and a tissue valve above roughly 60 to 65 years. Women who wish to become pregnant are the main exception: they are offered a tissue valve however young they are.

Developments have also eased the burden of anticoagulation itself. Patients can now test their INR (international normalised ratio, the blood test that measures warfarin's effect) at home with a portable device, and educated patients can adjust their own dose. That evidence, and the full guideline reasoning, are covered in the companion article on valve choice.

Mitral valve repair: when the patient's own valve can be saved

A leaking mitral valve can often be repaired rather than replaced, especially when the cause is degenerative disease. Valve repair is now used more and more often, mostly for the mitral valve. Repair preserves the patient's own valve and, unlike a mechanical replacement, does not commit the patient to lifelong anticoagulation. Which valves can be repaired depends on both the valve and the disease behind it:

• The aortic valve in adults is difficult to repair. Adults with aortic valve disease normally need replacement.
• Myxomatous mitral valves can be repaired quite easily. In myxomatous (degenerative) disease the valve tissue becomes thickened and floppy, so a leaflet prolapses, or bulges backwards, and the valve leaks (mitral regurgitation).
• Rheumatic valves are difficult to repair. Rheumatic heart disease, which follows untreated streptococcal infection and is more common in India, South-East Asia and Africa than in high-income countries, scars and stiffens the valve in ways that are much harder to correct.

Posterior leaflet prolapse: the standard repair

The commonest degenerative lesion that surgeons repair is prolapse of the P2 segment, the middle scallop of the posterior leaflet of the mitral valve. The standard repair has two steps. The surgeon first removes the prolapsing segment with either a quadrangular or a triangular resection and reconstructs the leaflet. The repair is then completed with an annuloplasty ring, a prosthetic ring sewn around the valve's base (the annulus) to stabilise it and reduce the chance of the regurgitation recurring. Dr. Meharwal described this as quite a standard repair.

Anterior leaflet prolapse: harder, but repairable

Prolapse of the anterior leaflet can also be repaired, but the repair is more complex. Dr. Meharwal was candid about the results: repair of anterior leaflet prolapse succeeds less often, and freedom from reoperation afterwards is lower than for posterior leaflet repair. Surgeons nevertheless have several techniques available:

• triangular resection of the prolapsing segment
• chordal shortening, which tightens the elongated tendinous cords (chordae tendineae) that tether the leaflet
• chordal transfer, which moves healthy cords from another part of the valve to support the prolapsing segment
• chordal replacement with artificial cords

Annuloplasty rings, for both the mitral and the tricuspid valve, are what made repair of these valves possible with good long-term results.

Minimally invasive heart valve surgery

Minimally invasive heart valve surgery repairs or replaces the mitral or aortic valve through a small incision, without dividing the whole breastbone. It is the second major development in mitral and aortic surgery. Its purpose, in Dr. Meharwal's words, is to minimise pain after surgery, give a better cosmetic result, shorten the hospital stay, speed recovery and reduce the use of blood products.

Speed of recovery matters because of who needs these operations. Most of the patients who come to Dr. Meharwal for mitral or aortic valve repair or replacement are of working age, and he pointed out that the same holds in African countries. Many cannot afford a long absence from work. A standard open heart operation is performed through a median sternotomy, a vertical incision that divides the whole breastbone. It leaves a midline scar that many patients find unattractive, and the breastbone takes some weeks to heal, which is a functional burden as well as a cosmetic one.

The minimally invasive approaches he described differ by valve:

1. Aortic valve replacement through a right anterior thoracotomy. A small incision is made between the ribs through the second intercostal space on the right. The breastbone is not divided at all, so both the cosmetic and the functional results are better.
2. Aortic valve replacement through an upper partial sternotomy ("mini AVR"). Only the upper part of the breastbone is divided. Because the sternum is not split completely it is more stable afterwards, and the scar is smaller than with a full sternotomy.
3. Mitral valve surgery through a right anterior thoracotomy. For the mitral valve, the incision is made through the fourth intercostal space on the right. Dr. Meharwal noted that this approach matters particularly for women, for whom a scar down the front of the chest can be a real concern.

The first two are the commonly used techniques for aortic valve replacement. Sutureless valves, described below, make the minimally invasive aortic approaches easier still.

New heart valve technology

The newest developments target the weaknesses of both families of valve. Third-generation tissue valves resist calcification (the build-up of calcium deposits that stiffens valve tissue) for longer and are designed so that a later replacement can be done through a catheter, without reopening the chest. Sutureless valves are implanted without stitches, shortening the operation. A polymer valve, introduced commercially in India shortly before the masterclass, is designed to need neither lifelong anticoagulation nor reoperation. Each is examined in new heart valves: third-generation, sutureless and polymer.

Taken together, Dr. Meharwal's own summary of the field runs as a sequence: mechanical valves in the 1960s; tissue valves from the 1970s to free patients from anticoagulation; annuloplasty rings that made durable mitral and tricuspid repair possible; anti-calcification tissue treatment from the 1980s to make tissue valves last longer; and, most recently, techniques that minimise trauma to the patient. All of it, he said, has improved patient outcomes.

When to refer a patient for heart valve surgery

A patient with valve disease should be referred for surgical evaluation once symptoms and echocardiogram findings meet guideline criteria: not too early, but certainly not too late. For doctors practising in resource-constrained settings, the most common dilemma is when to manage a case locally and when to refer it across the border. Dr. Meharwal's answer turns on timing: a patient referred late has accumulated comorbidities, and the outcome may not be as good.

For valve disease there are definite guidelines on when a patient with mitral or aortic valve disease should be referred for surgery. Two criteria matter most:

• Clinical symptoms, graded by functional class (the New York Heart Association classes I to IV that most physicians already use).
• Echocardiogram findings (an ultrasound scan of the heart): the severity of mitral or aortic stenosis (narrowing) or regurgitation (leakage), left ventricular function, pulmonary artery pressures, and the overall impact of the valve disease on the heart and the body.

Together these decide when a patient should go for surgery. A straightforward valve repair or replacement can be done locally; a case that looks challenging should be referred to a centre with more experience in cardiac care.

Heart valve surgery abroad: hospital stay, cost and remote follow-up

How long is the hospital stay after heart valve surgery?

For an adult having routine valve surgery, Dr. Meharwal put the typical hospital stay at about a week, seven to eight days. Patients are advised to stay in Delhi for at least a week after discharge. If they recover well they can fly home one to two weeks after discharge; most fly about two weeks after discharge, and some after one. Without complications, most patients are ready to fly within about three weeks of admission. Follow-up can then continue remotely through video or audio consultations with the surgical team.

What drives the cost of heart valve surgery

Dr. Meharwal identified two factors that determine the cost of mitral or aortic valve surgery. The first is the valve: mechanical valves are significantly less expensive than tissue valves, and among tissue valves the range is wide, with third-generation valves costing more than second-generation ones (first-generation valves are no longer used or even available). The second is the patient's course: a straightforward operation with a short stay and few comorbidities costs less, and any lengthening of the hospital stay raises the bill. The final cost is set once the patient has been assessed in person. Indicative figures for individual procedures, such as aortic valve replacement, are kept on Jivo Healthcare's treatment-cost pages.

When the patient cannot travel

Some patients clearly need specialist input but cannot travel or afford treatment abroad. Dr. Meharwal's advice in that case is to connect the patient's treating doctor directly with his team at Fortis Escorts to agree the best course of treatment. Consultation, advice and discussion can all be done remotely. He was clear about the limit, however: where a patient needs surgery, medical treatment helps only up to a point.

Beyond valves: congenital and coronary questions from the session

Doctors in the session also asked about conditions outside valve disease. Three of his answers are worth setting out; the full exchanges are on the Live Discussion page for this masterclass.

Tetralogy of Fallot. Repair of tetralogy of Fallot, a combination of four heart defects present from birth that causes cyanosis ("blue baby"), is one of the commonest operations in paediatric cardiac surgery, alongside closure of atrial and ventricular septal defects. Any paediatric cardiac centre does it routinely, and in Dr. Meharwal's account the outcomes are excellent. Complete repair is usually performed in the first year of life, but six years is not too late: many patients are operated on at that age or older, the outcome still depends mainly on the exact anatomy shown by a proper paediatric echocardiogram, and such a child certainly needs surgical correction. Indicative costs are on the tetralogy of Fallot repair page.

A heart mass in an infant. For a small, non-obstructing mass in a baby's heart thought to be a rhabdomyoma, Dr. Meharwal advised MRI and CT in addition to echocardiography to characterise the lesion, very close follow-up, and review by a dedicated paediatric cardiac surgical team. Cardiac rhabdomyomas often shrink on their own in early childhood, are strongly associated with tuberous sclerosis complex (a genetic condition that causes benign growths in several organs), and usually need surgery only if they obstruct blood flow or cause serious rhythm disturbance.

Myocardial bridging. Myocardial bridging, in which a segment of a coronary artery (normally the left anterior descending artery) runs through the heart muscle instead of over it, is not uncommon on angiography. If it causes no symptoms, nothing needs to be done. If it is symptomatic, Dr. Meharwal's approach is a stress thallium test, a nuclear scan of blood flow to the heart muscle: if the test is positive he recommends surgery, and if it is negative, which is what he sees most of the time, medical treatment alone is sufficient, provided the other coronary arteries are free of narrowing. Beta-blockers or non-dihydropyridine calcium-channel blockers are the usual first-line treatment, and surgery is generally reserved for patients with documented ischaemia whose symptoms persist despite medication.

What this means for patients and referring doctors

The practical lesson of the masterclass is that heart valve surgery now offers more than a binary choice between a mechanical valve and early reoperation. Many leaking mitral valves can be repaired. Many operations can be done without dividing the breastbone. Tissue valves last longer than they did, and can be replaced through a catheter when they fail. For referring doctors the key decision is timing: patients sent for evaluation while their heart function is still good, guided by symptoms and echocardiography, are the ones who gain most from these advances.