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  4. Adult Heart Disease‐Valvular

Adult Heart Disease‐Valvular

Cardiac Structure and Blood Flow

The heart is comprised of four chambers, which my be divided into the left and right atria, which take in blood, and the left and right ventricles, which pump it back out. The aorta comes out from the left ventricle, and the pulmonary artery from the right.
Deoxygenated blood returning from the rest of the body first enters the right atrium, then passes through the tricuspid valve to the right ventricle. From here, it is pumped through the pulmonary valve, and towards the lungs, exchanging carbon dioxide waste for fresh oxygen from the air, and returning to the heart at the left atrium. From here is passes through the mitral valve to the left ventricle, where the oxygenated blood is pumped through the aortic valve, to the rest of the body.

These four valves are responsible for preventing backflow, which is very important for keeping blood flowing smoothly throughout the body.

Videos of the normal aortic and mitral valves

The Normal Aortic

The Normal mitral valves

Provided by Edwards Lifesciences Corporation

Valvular Heart Disease

When an abnormality occurs in the function of these valves, a restriction of flow (stenosis) or regurgitation (incompetence) can result. This results in poor blood flow, also known as valvular heart disease, which may lead to heart failure. The high life-expectancy in Japan has led to an increasing trend of valvular heart disease, and it is now not considered an uncommon condition. Whether cardiac murmur is audible or not, most cases are detected and diagnosed by ultrasound examination (echocardiography).
Although we deal with various valvular diseases in our department, This section discusses various types of operations for conditions such as aortic valve stenosis, aortic regurgitation, mitral valve stenosis, and mitral regurgitation.

For other valvular diseases, please consult our department or the appropriate physician.

A selection of diseases handled by our department:

  • aortic valve stenosis and/or regurgitation, narrow or dilated aortic annulus
  • mitral valve stenosis and/or regurgitation, mitral valve prolapse, papillary muscle dysfunction or rupture, chordae tendinae rupture, ischaemic mitral valve regurgitation
  • surgery for atrial fibrillation (maze procedure) may be performed concurrently
  • tricuspid valve stenosis or regurgitation
  • pulmonary valve stenosis or regurgitation
  • multiple and mixed valvular disease
  • infectveendocarditis

Aortic Valve Stenosis

The most common cause of this disease is the progression of arteriosclerosis in the aortic valve. Especially in the elderly, arteriosclerosis causes the aortic valve to become hard with lime deposits, and so weakens the opening action. On the other hand, relatively young patients may also develop aortic valve stenosis due to a congentital abnormality in the valve called "aortic bicuspid valve".
In either case, when the condition is severe the aortic valve will barely open, sending insufficient blood to the body, which may cause chest pain, fainting, or shortness of breath.
In general, aortic valve replacement surgery is now the standard treatment. This is an open heart surgical procedure using a heart-lung machine, involving removal of the damaged aortic valve, and insertion of a prosthetic (mechanical/biological).
In October 2009, we began performing transcatheter aortic valve implantation surgery (TAVI), which achieves valve replacement without use of a heart-lung machine. The number of patients having undergone TAVI at our facility reached 400 in October 2016, the largest number of any Japanese facility .

Video of Aortic Valve Stenosis

Video of lesion

Video of mechanical valve replacement

Video of biological valve replacement

Provided by Edwards Lifesciences Corporation

Aortic Regurgitation

Due to aging and high blood pressure, the aortic valve may become damaged, leading to aortic regurgitation. Since the aortic valve is the boundary between the left ventricle and aorta, an englarged aorta also affects the valve, and may lead to insufficiency. In general this condition is asymptomatic at first, but as it progresses it will demonstrate the symptoms of heart failure, such as shortness of breath and fatigue.
Generally, aortic valve replacement surgery is required for cases of advanced aortic regurgitation. At our hospital, we prefer to employ MICS (Minimally Invasive Cardiac Surgery) for this procedure. This is performed via a small intercostal (between the ribs) opening in the right side of the chest, to reduce the physiological burden on the patient, and minimize surgical scarring to the greatest extent possible.
However, not all patients may undergo MICS, and we only perform MICS in cases assessed to be safe. Depending on the condition of the aortic valve, valvuloplasty may be performed to repair the aortic valve as much as possible without using a prosthetic valve.

Video of Aortic Regurgitation

Video of lesion

Video of mechanical valve replacement

Video of biological valve replacement

Mitral Valve Stenosis

This condition is mostly attributable to chronic inflammatation caused by rheumatic fever, where the mitral valve becomes thickened, calcified, and adheres to the surrounding tissues, thus restricting its movement. Heart failure symptoms present as the condition progresses, such as shortness of breath.

Treatment of advanced mitral valve stenosis relies on transcatheter mitral valve replacement (TMVR), or normal mitral valve replacement (mechanical/biological). Although TMVR is less invasive than normal mitral valve replacement surgery, it may only be applied in certain cases. As it is necessary to assess each case individually, please feel free to contact us for consultation.
N.B. TMVR is performed in the Department of Cardiology

Video of Mitral Valve Stenosis

Video of lesion

Video of mechanical valve replacement

Video of biological valve replacement

Provided by Edwards Lifesciences Corporation

Mitral Valve Regurgitation

There are various causes of this disease, but in recent years the most common have been mitral valve prolapse and. Chordae tendinae are the "heartstrings" pulling the mitral valve from the left ventricle side. When there is a rupture, they weaken, and part of the valve flips over to the left atrium side, causing regurgitation to occur.
Continued regurgitation in moderate to severe cases may lead to heart failure, resulting in shortness of breath and/or accumulation of water in the lungs.
To treat mitral valve regurtation, we perform mitral valveoplasty to preserve the function of the original valve as much as possible. At our hospital, we prefer to employ MICS(Minimally Invasive Cardiac Surgery) for this procedure. This is performed via a small intercostal (between the ribs) opening in the right side of the chest, to reduce the physiological burden on the patient, and minimize surgical scarring to the greatest extent possible.
However, valvuloplasty is not possible for all patients. If valvuloplasty is judged to be unsuitable, we perform (mechanical/biological) valve replacement surgery.

Video of Mitral Valve Regurgitation

Video of lesion

Video of valvuloplasty

Video of mechanical valve replacement

Video of biological valve replacement

Provided by Edwards Lifesciences Corporation

Artificial Valves

There are two types of artificial valves, mechanical and biological.
Mechanical valves are made from a pyrite-carbon material, the majority being two-way valves. From a purely mechanical perspective, they have excellent durability, and can be expected to function for a lifetime. However, to prevent thrombus formation, after implanting a mechanical valve the patient must use the anticoagulant (blood-thinning) medicine warfarin for the rest of their life.
If the effect of warfarin is too large, blood will not solidify and bleeding may occur as a side effect. Conversely, if the effect is insufficient thrombosis will occur, so blood must collected about once a month to calibrate the dosage. Also, warfarin can cause complications during pregnancy, and is a known teratogen, i.e. it increases the chance of birth defects.
Biological valves are made from bovine pericardium (a thin membrane covering the cow heart surface) or a pig heart valve, processed for transplantation into the human heart. As the material is biological tissue, the chance of thrombosis is extremely low. If there are no other complications, it is not necessary to use warfarin for more than a few months after surgery. However, the durability of biological valves is significantly lower. After 15 year, most begin to harden, stenosis and regurgitation set in, and eventually surgery becomes necessary again.
Generally, the long-term durability of the mechanical valve leads to its selection for younger patients, whereas older patients usually receive biological valves. However, the selection also takes into consideration the condition of the patient, and the final decision is made after consultation with the patient.
As described above, surgery for valvular disease ranges from conventional valve replacement surgery or valvuloplasty, to minimally invasive surgery (TAVI, MICS), which is less burdensome for patients, with diagnosis, examination, and treatment requiring advanced judgement and specialist skills.

In addition to the above, we perform surgery for various other diseases such as pulmonary valve stenosis, pulmonary valve regurgitation, tricuspid stenosis, tricuspid regurgitation, and infective endocarditis.
If you are diagnosed with valvular disease and are interested in treatment at our hospital, you can arrange a medical consultation at any time, so please do not hesitate to contact us. The specialists of our department will decide, together with patients, on a treatment policy for our hard working surgeons to implement with the latest and best in medical care technology.

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