Advances in Heart Valve Surgery

The patient should be referred for further evaluation at the appropriate time — not too early, but also not too late, because if it is too late the patient develops more comorbidities and the outcome may not be as good. For valve disease specifically, there are definite guidelines for mitral and aortic valve disease on when a patient should be referred for cardiac surgery; whether it can be done locally depends on whether it looks like a straightforward repair or replacement, or a more challenging one. The two important criteria are the patient's clinical symptoms — which functional class (1, 2, 3, or 4) — and the echo findings, which show the severity of stenosis or regurgitation, LV function, and pulmonary artery pressures. Together these decide whether the patient should be referred for surgical treatment, locally or elsewhere.

Cost primarily depends on two things: which valve is used — mechanical valves are significantly less expensive than tissue valves, and among tissue valves, third-generation valves cost more than second-generation ones — and the patient's clinical course, since a straightforward surgery without a long hospital stay or comorbidities costs less. The average cost generally starts from $9,000 and goes up to $15,000–$16,000.

Cardiac tumours in children are well known, though this exact pathology is not very common. The echo gives us an idea, but I would suggest also doing an MRI and a CT to further delineate it. I would like the details of this patient sent to our institute so we can forward it to our paediatric cardiac surgeon, since paediatric cardiac surgery is a separate subspecialty from the adult cardiac surgery I practise, and we do have a dedicated paediatric cardiac surgical team. This child needs very close follow-up and further investigation.

Tetralogy of Fallot is one of the commonest surgical procedures, and the outcome depends on the exact anatomy delineated by a proper paediatric echo, but six years is not a very late stage — in India a lot of patients are operated on at this age or even older. The outcome of tetralogy repair even at 6 years is excellent, so this patient certainly needs surgical correction.

Myocardial bridging is not uncommon and is often seen on angiography. If it is asymptomatic, nothing needs to be done. If it is symptomatic, we normally do a stress thallium test — if positive, we recommend surgery; if negative, which is most of the time, only medical treatment is needed. If it is only myocardial bridging with no stenosis involved in other arteries (the circumflex or right coronary artery are normal), nothing needs to be done, but if the stress test is positive, surgery is recommended.

Open heart surgery became possible after the invention of the heart-lung machine, developed by John Gibbon and his wife after years of research. Using the machine to take over the work of the heart and lungs, Gibbon performed the first open heart operation on 6 May 1953, repairing an atrial septal defect in an 18-year-old girl.

In the more than seven decades since the first open heart operation, cardiac surgery has advanced across coronary artery bypass grafting, valve repair and replacement, paediatric heart surgery, aortic aneurysm and dissection surgery, and heart failure treatment including transplant and ventricular assist devices.

Surgical treatment of valvular heart disease began in the 1960s with the mechanical ball and cage valve. Tissue valves followed in the 1970s to reduce the need for lifelong anticoagulation, and annuloplasty rings developed in the same decade made mitral and tricuspid valve repair possible with good long-term results. Anti-calcification treatments in the 1980s, minimally invasive techniques, sutureless valves and valve-in-valve technology have since reduced trauma and improved outcomes further.

Dr. Z. S. Meharwal, Chairman and Head of Adult Cardiac Surgery at Fortis Escorts Heart Institute, New Delhi, has a special interest in heart transplant and ventricular assist devices and leads one of the largest heart transplant and mechanical circulatory support programmes in North India.