Minimally Invasive Valve Surgery

Free consultation

Ask which valve operation your anatomy allows

Which valve is involved decides most of this, and only somebody looking at your images can tell you what is possible. Send the echocardiogram with its moving images, any cardiac CT, a recent angiogram if you have had one, your blood results and your medication list. A cardiac surgeon reads the file and answers three things. Whether your valve can be repaired, whether it can be reached through a small incision, and what each of those choices commits you to afterwards. No fee, no obligation, and a coordinator replies in your own language.

What to measure

Most of what is written about small incisions measures the wrong thing. Scar length, days in hospital and units of blood are easy to count and they are all short-term, whereas the thing a valve patient actually lives with is how well the valve works in ten years and whether anybody has to open the chest again. Those are the outcomes worth arguing about. This page is organized around them. There is a second reason to think valve by valve instead of incision by incision. Evidence is not spread evenly. Minimally invasive mitral surgery has been studied in randomized trials, in pooled analyses of more than a hundred studies and in single centers reporting a decade of follow-up. Minimally invasive aortic surgery has a good body of comparative work with one genuinely surprising finding in it. Minimally invasive tricuspid surgery has almost nothing, and any page that tells you otherwise is filling a gap with confidence in place of data, and reading a general claim about small incisions and then applying it to your own valve is how patients end up misinformed by perfectly accurate information.

Read the section that applies to your valve. Treat the strength of the evidence behind it as part of the answer and not as a footnote to it.

The mitral valve

The mitral valve is where the case for a small incision is strongest, and the reason is anatomical rather than commercial. This valve sits behind the left atrium, which faces the right side of the chest, so a camera coming in between the ribs on the right looks straight at it, without having to work its way around a beating organ to get there. Surgeons who work this way describe the view as better than the one they get through an open breastbone, where the valve has to be reached past the heart rather than through the wall in front of it. A single European center published what happened to 1,604 consecutive patients operated on this way over a decade, and the figures are worth reading slowly. Repair was achieved in 95 percent of the patients whose leak came from degenerative disease, the group in whom repair should always be the goal, and in-hospital mortality across the whole cohort, including replacements, redo cases and endocarditis, was 1.1 percent. Thirty-four patients, about one in fifty, needed the operation converted to a sternotomy partway through. Survival at ten years was 88 percent.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

One more finding from this valve is worth carrying into your consultation. A separate long-term series of more than two thousand minimally invasive repairs compared two ways of fixing a prolapsing leaflet, one using artificial cords and one cutting the excess leaflet away. Freedom from a second mitral operation at ten years was 97 percent for the cord technique and 96 percent for resection. That difference means nothing. Survival differed slightly and the leak on the scan before discharge was worse after resection, but the lesson worth taking away is that the technique used inside the heart deserves far more of your attention than the size of the hole the surgeon worked through.

The aortic valve

Here the picture is more interesting, because two different small incisions compete and one of them wins. The aortic valve sits deep in the middle of the chest, and it can be reached either by dividing the upper part of the breastbone or by going in between the ribs high on the right. Patients tend to assume the second is the better one, since it leaves the bone untouched. The pooled evidence says the opposite. A network analysis of 42 studies covering 14,925 patients compared all three routes against one another, and found operative mortality lower with the partial breastbone incision than with a full sternotomy, and lower again than with the incision between the ribs. Bleeding serious enough to require going back to theater was 65 percent more likely with the rib incision than with the partial breastbone one. Hospital stay was shortest with the partial breastbone incision. Mortality in the first year came out the same across all three.

Separately, a meta-analysis pooling 75 comparative studies confirmed the general direction, finding lower thirty-day mortality and shorter stays in intensive care and on the ward for the minimally invasive routes taken together, with the honest caveat that clamp and bypass times ran longer.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

Read that table before asking for the smallest possible scar on this valve. The partial breastbone incision still divides bone, so the six weeks of arm restrictions still apply, and it is nonetheless the route the numbers support, which is an uncomfortable thing to hear and a useful thing to know. Choosing the rib incision for an aortic valve is a decision that should be made with a surgeon who does a great many of them, and made for a reason you can state out loud.

The tricuspid valve

Now the honest part. No randomized trial and no meta-analysis has compared a small incision with a sternotomy for tricuspid valve surgery, so anybody quoting you a percentage here is quoting a single center. Two things are nonetheless known, and a third is worth stating as an absence.

On this valve, timing outweighs access. A tricuspid leak left until the liver and kidneys are affected is a harder operation through any incision, and no approach recovers what was lost by waiting.

Repair or replacement

A worry surfaces in almost every consultation about this surgery, and it deserves a direct answer. Patients ask whether a surgeon working through a small hole will give up on repairing a valve and put a prosthesis in instead, because that is quicker and easier through a narrow opening. The concern is reasonable and the evidence does not support it. Three findings answer it between them.

• Repair rates hold up. Repair succeeded in about 96 percent of patients in the randomized mitral trial, whichever incision was used, and that figure did not move when the incision did. In the ten-year series, 95 percent of degenerative valves suitable for repair were repaired.
• Nothing about the repair is simplified. Annuloplasty rings, artificial cords, leaflet resection and sliding plasty are all done through the small opening with longer instruments, and the ten-year series used all of them.
• Checking happens before you wake. An ultrasound probe passed into the esophagus shows the working valve at the end of the operation, so an inadequate repair is redone during the same anesthetic instead of being found later.

What the incision does change is who ends up in the operating room to begin with. The kind of unit that performs valve surgery through small incisions is usually the kind that repairs instead of replacing, so the two things travel together without one causing the other. Ask for one number. The unit's repair rate in your specific valve disease will tell you far more about what you are walking into than any percentage they quote for minimally invasive access.

A second operation

Everything above concerns a first operation. That changes now. If you have already had heart surgery, the argument changes shape completely, and it changes in favor of the small incision more decisively than anywhere else on this page. Scar tissue is the reason. Months after a breastbone is wired back together, the heart and the great vessels stick to the underside of that bone, sometimes firmly enough that the saw cutting through it can tear something behind it. Surgeons manage this carefully, with a scan beforehand and often with the groin vessels exposed and ready before the bone is touched, whereas going in between the ribs avoids the plane altogether, which is why the numbers below look the way they do.

Pooled data from thirteen studies of second-time mitral surgery reported the following.

• Death in hospital, 3 percent against 9.2 percent. Roughly a third of the risk, and the largest single difference reported anywhere in this article.
• Going back to theater for bleeding, 3.8 percent against 5.9 percent. A smaller gap than the mortality one, pointing the same way, and consistent with a chest that was never reopened bleeding less than one that was.
• Acute kidney failure, 5 percent against 12 percent. Less than half, which matters for anybody whose kidneys are already borderline.
• Strokes and rhythm problems, lower but not conclusively. Neurological events ran at 3.4 percent against 5.5 percent and arrhythmias at 19.5 against 25.5 percent, with confidence intervals that crossed the line of no difference.

Two cautions belong beside those figures. All thirteen studies looked back at what had already happened rather than assigning patients at random, so some of the gap will be the same selection effect that inflates the benefit of small incisions in first-time surgery. The German tricuspid work mentioned earlier points the same way for that valve, from far weaker data. Even allowing for both cautions, if you have been through a sternotomy once already, this is the section of the page to take to your appointment.

What can go wrong

Valve surgery carries the risks of any operation on a stopped heart. These are the ones tied to reaching a valve through a small opening, in the order a surgeon would raise them.

1. Conversion to a sternotomy. Around one patient in fifty in the large mitral series. It happens for bleeding that cannot be reached, for adhesions nobody predicted, or because the valve turns out to need work the small opening cannot deliver. Consent to it in advance. It stops being frightening once it is expected, and the conversion itself changes nothing about the operation that follows except the size of the wound you wake up with.
2. The groin. Right-side operations run the heart-lung machine through the leg vessels, so the wound there can collect fluid or become infected, and the vessel itself can narrow or clot. Numbness along the thigh is common. It settles. Pain, coldness or a color change in that leg is not normal. See a doctor the same day.
3. Stroke. Two percent in the ten-year mitral series, which is what this operation carries through any incision. The screening that keeps it there is a scan of the aorta and the neck arteries before surgery, since blood is being pumped back up the aorta rather than down it.
4. Bleeding on the aortic route between the ribs. The specific finding from the network analysis, where that route carried a markedly higher chance of returning to theater than the partial breastbone incision did, and the clearest argument on this page for choosing your route by evidence instead of by scar size.
5. A lung that will not re-expand. One lung is kept out of the way for the whole operation and does not always re-expand willingly, so breathing exercises begun on the first day, physiotherapy on the ward and stopping smoking well beforehand are what keep it from turning into a chest infection.
6. Heart block. Stitches near the conduction tissue can interrupt it, and the chance depends on the valve rather than the incision, being highest for the tricuspid and aortic positions. Temporary wires cover the first days and a permanent pacemaker is fitted before discharge if the rhythm does not recover.
7. Nerve pain along the rib. A burning or aching band following the line of the incision, lasting weeks or occasionally months. It responds to the drugs used for nerve pain, and of everything listed here it is what patients most often say nobody warned them about.

The price of the opening

Every meta-analysis quoted on this page reports the same cost, always in the same sentence near the end, which is that working through a small opening takes longer, so the heart is stopped for longer and the bypass machine runs for longer. The aortic meta-analysis of 75 studies states it plainly. So does every mitral comparison.

Extra minutes on the bypass machine are borrowed against your reserve. A fit patient has plenty to lend. A patient with a weak heart muscle, poor kidneys or damaged lungs has very little, and that is who the small incision serves worst.

Those minutes are also the part of the equation a surgeon can change, since the difference between a unit doing these weekly and one doing them occasionally shows up first in operating time. That is what makes volume a safety question here and not a marketing one, and it is why the single most useful thing you can ask is how many of your operation, through your route, the named surgeon did last year.

Recovery and flying home

The first week

Four to seven days in hospital. The breathing tube comes out in intensive care within a few hours, drains follow over the next day or two, and you will be walking the corridor before the wound has stopped being sore. Pain between the ribs is sharper on a deep breath than breastbone pain is, so the nerve block placed during surgery and a proper schedule of tablets afterwards matter here, and patients who take them on time move sooner.

The first month

Two to four weeks to feel like yourself after a rib incision. After a partial breastbone incision, count on the same six weeks of arm restrictions that follow a full sternotomy, because the bone still has to knit whether half of it was divided or all of it. That difference is the single most practical reason to know which route you are having, and it is why the aortic section above is worth rereading if that is your valve. Anticoagulation adds its own timetable if you received a mechanical prosthesis, with testing every few days at first, stretching out as the dose settles, and a card in your wallet naming the valve, its size and the target range you are being kept inside. Get that card before you leave the ward. Cardiac rehabilitation is the other thing to arrange while the hospital is still writing your paperwork, because supervised exercise after valve surgery does more for how you feel in six months than anything else available to you.

Getting on the plane

Ten to fourteen days after a rib incision, two to three weeks after a partial breastbone one. The conditions are the same either way, meaning dry wounds, a stable rhythm, no significant collection of fluid around the operated lung, and blood thinning in range where it applies. Somebody examines you and writes the date, and the chest scan taken beforehand is what usually decides it. Book an aisle seat. Walk every hour, and keep the compression stockings on.

When the answer is no

Some patients are turned down. That is the right decision, and the tests behind it deserve more respect than they usually get. The tests that produce that answer are worth having done properly, because being told no by a unit that looked is far better than being told yes by one that did not. Diseased or narrowed arteries in the abdomen and legs rule out the groin connection that right-side routes depend on, which is why those vessels are scanned before anything is promised, and heavy calcium in the aorta rules out clamping it through a small opening. Lungs that will not tolerate being deflated on one side rule the approach out on their own, and breathing tests come before the surgical decision for exactly that reason. Previous surgery, radiotherapy or infection in the right chest can leave the space unusable. And severe pulmonary hypertension, a weak right ventricle and any operation done at short notice all shrink the reserve that the extra bypass time has to draw on. There is also a category that has nothing to do with safety. If your coronary arteries need grafting at the same time, or the aorta needs replacing, or two valves plus a rhythm procedure are planned together, the operation is simply bigger than the opening. A complete operation through an open chest beats a partial one through a small hole. Every time.

Reading a quote

You will find no figure on this page. A figure offered before your images have been looked at is worth very little. Valve surgery is priced by what the operation involves and by how many nights of monitored care your own condition is expected to need, and neither of those is knowable from an email describing your symptoms. Six questions turn a headline number into something you can compare. Which valve and which route it assumes. Whether it assumes a repair or a replacement, and what changes if the surgeon can repair after all. Which prosthesis or ring is included, and whether the number moves with the type chosen. Then the one that separates a serious quote from a brochure, which is what happens financially if the operation has to convert to a sternotomy partway through. How many intensive care nights are budgeted and what one extra costs. And whether the work-up sits inside the number, meaning the coronary angiogram, the CT of the aorta and leg vessels, and the lung function testing that decides whether the small incision is available to you at all.

Your own file moves the total as much as the technique does. Previous cardiac surgery, reduced heart muscle function, kidney disease, lung disease and a second procedure planned on the same bypass run each add expected nights, and two or three together add a good many. Packages published by Turkish hospitals and medical travel agencies for valve surgery generally include the airport transfer, pre-operative testing, surgeon, anesthesia and perfusion fees, the theater, the planned intensive care and ward nights, the implant, an interpreter and the review before departure. They generally exclude flights, insurance, unplanned additional intensive care, treatment of a complication and hotel nights beyond an agreed number. Check what you receive against those two lists first.

Coming to Istanbul

Three weeks covers most valve operations. The sequence below is what a coordinator will walk you through, and knowing it in advance makes the first email a much shorter one.

Your coordinator stays reachable on the same WhatsApp number afterwards, so a photograph of a wound or a question about a test result goes to somebody holding your notes. Get in touch straight away about a wound that reddens or leaks, a fever with no explanation, breathlessness that is getting worse, a pulse that turns irregular, or any pain, numbness or coldness in the leg that carried the bypass machine.

Minimally invasive valve surgery FAQ