Understanding Heart Valve Disease
Heart valves can fail in two fundamental ways - stenosis (the valve doesn’t open enough, restricting forward flow) or regurgitation (the valve doesn’t close properly, allowing backward flow). Each valve problem and severity level has a defined treatment threshold guided by current ESC and ACC/AHA guidelines.
Aortic valve stenosis: The most common valve condition in adults over 65 - progressive calcification stiffens the aortic valve leaflets. Severe AS (aortic valve area <1.0 cm-, mean gradient >40 mmHg) is a Class I indication for valve replacement when symptomatic (angina, syncope, or heart failure).
Treatment options:
- TAVI (Transcatheter Aortic Valve Implantation): Via femoral artery catheter; new valve delivered within the diseased valve; no open surgery; preferred for older/higher-risk patients
- SAVR (Surgical Aortic Valve Replacement): Open heart surgery; preferred for younger patients (mechanical valve longevity) or when anatomy is not suitable for TAVI
Aortic valve regurgitation: Leaky aortic valve - causes volume overload of the left ventricle. Repair is occasionally possible; replacement (biological or mechanical) is the primary surgical option.
Mitral valve stenosis: Predominantly caused by rheumatic heart disease. Percutaneous mitral balloon valvuloplasty (PMBV) is the preferred approach for pliable, non-calcified valves; surgical commissurotomy or replacement for complex cases.
Mitral valve regurgitation:
- Degenerative (Barlow’s, Fibroelastic deficiency): Repair is the gold standard - repair rate >95% achievable at high-volume centres; avoids anticoagulation and provides superior long-term LV function preservation
- Functional: Annuloplasty ring; MitraClip (transcatheter) for high-surgical-risk patients
- Mitral repair vs. replacement is a key decision - our cardiac team has strong mitral repair expertise
Prosthesis choice (for replacement):
- Mechanical valve: Lifelong anticoagulation (warfarin) required; valve itself lasts a lifetime; preferred in younger patients (<60-65) where durability outweighs anticoagulation inconvenience
- Biological (tissue) valve: No long-term anticoagulation needed; starts to deteriorate at 10-20 years; preferred in older patients (>65) or those unable to tolerate anticoagulation
Surgical vs. Transcatheter Valve Procedures
The decision between surgical and transcatheter approaches is made by a Heart Team - cardiac surgeon, interventional cardiologist, cardiac anaesthetist, and imaging specialist - reviewing each case together.
SAVR (Surgical Aortic Valve Replacement):
- Median sternotomy; cardiopulmonary bypass; aortic valve excised and replaced
- Mechanical or biological prosthesis sewn into the native annulus
- Highly durable repair; ability to address concomitant coronary disease simultaneously (if CABG also needed)
- Hospital: 7-10 days; recovery 6-8 weeks
TAVI (Transcatheter Aortic Valve Implantation):
- Catheter-based; valve delivered via femoral artery (most common) or transapical (through the LV apex) route
- Self-expanding (Medtronic Evolut) or balloon-expandable (Edwards SAPIEN) systems
- No open-chest surgery; typically conscious sedation or light GA
- Hospital: 3-5 days; recovery 2-3 weeks
- Now approved for intermediate and low surgical risk in addition to high risk
- Available at BB Global Health partner hospitals with full cath lab infrastructure
Minimally Invasive Cardiac Surgery (MICS): For valve surgery, minimally invasive approaches are available at select centres:
- Right mini-thoracotomy (5 cm incision in the right chest): for mitral and aortic valve surgery without full sternotomy
- Robotically-assisted valve surgery (limited centres)
- Advantages: less pain, faster recovery, better cosmesis, equivalent outcomes in experienced hands
MitraClip: Transcatheter mitral valve repair using an edge-to-edge clip - for high-risk surgical patients with severe mitral regurgitation. Delivered via transseptal catheter approach. Available at partner interventional cardiology centres.
Recovery and Long-Term Care
Hospital course (SAVR):
- Day 0: Cardiac ICU; ventilator removed within 8-12 hours
- Day 2-4: Transfer to cardiac ward; physiotherapy programme starts
- Day 5-7: Sternal wound healing assessment; anticoagulation initiated (mechanical valve - INR target 2.5-3.5)
- Day 7-10: Discharge to hotel for final recovery before flight home
Anticoagulation (mechanical valve):
- Warfarin initiated after mechanical valve replacement with INR monitoring
- Target INR depends on valve position and patient risk factors: aortic mechanical valve INR 2.0-3.0; mitral mechanical valve 2.5-3.5
- INR monitoring arranged with local GP or anticoagulant clinic in home country
- BB Global Health provides full anticoagulation protocol and target INR documentation for seamless transition to home anticoagulation management
Biological valve patient:
- Aspirin only for 3-6 months post-op; no long-term anticoagulation needed
- Annual echocardiogram monitoring
Long-term outcomes:
- SAVR for severe AS: 10-year survival comparable to age-matched population when treated before significant LV dysfunction
- Mitral valve repair durability: 90% of repairs remain free of re-operation at 15 years at high-volume centres
- TAVI at 5 years: comparable to SAVR for all-cause mortality and stroke
Cost overview: SAVR all-inclusive Turkey: -15,000-25,000; TAVI Turkey: -20,000-30,000 (implant cost is significant). UK private: -35,000-65,000 (SAVR); -50,000-90,000 (TAVI).