Valve surgery, like most other heart surgery, is usually conducted through a straight incision of the skin on the front of the chest, from just below the adam’s apple to a little above the ubmilicus, and then  down through the breast bone. Because the valves are inside the chambers of the heart it is not possible to replace the valves without using a heart-lung bypass machine to temporarily take over the work of the heart and lungs. Blood is drained from the right side of the heart and the bypass machine removes carbon dioxide from the blood, replaces the oxygen and then pumps the blood back into the aorta. This allows the aorta to be clamped, isolating the heart.

Aortic valve replacement - the aorta is opened below the clamp. The abnormal valve is removed all the way back to the wall of the aorta. Stitches are placed at regular intervals around the wall of the aorta, and then through a sewing cuff around the outside of the artificial valve. The valve then slides down the stitches and is tied in place. The aorta is closed and the heart is restarted to take over the work of the circulation from the heart-lung bypass machine.

Mitral valve replacement - once the aorta is clamped isolating the heart from the rest of the circulation, the left atrium is opened allowing the mitral valve to be visualised. A certain amount of the mitral valve is then removed to allow sufficient space to place an artificial valve. Stitches are placed at regular intervals around the hole and then through a sewing cuff around the outside of the artificial valve. The valve then slides down and the stitches are tied in place. The left atrium is closed, the heart is restarted and takes over the work of the circulation from the heart lung bypass machine

Mitral valve repair - once the aorta is clamped isolating the heart from the rest of the circulation, the left atrium is opened allowing the mitral valve to be visualised. There are then a number of different techniques for repairing the valve depending on the specific problem. The most common problem is when an area on the middle of the posterior leaflet of the mitral valve is leaking. In this case this area is removed, the cut edges are sewn back together and a ring is usually sewn in around the outside of the valve to help strengthen the repair. When we do mitral valve repairs we always use a special technique during the operation, which allows us to look at the function of the heart using ultrasound waves transmitted from a probe placed in the oesophagus (transoesophageal echocardiography). This probe is placed after the patient is anaesthetised. This enables us to check that repair has worked and the valve is not leaking, before we complete the operation and move the patient to the intensive care unit.

Once the valve is replaced or repaired, and the heart is working well, bleeding is stopped and special wires called pacing wires are placed on the outside of the heart. The other ends of these wires are brought out through the skin and can be attached to a pacemaker to allow small currents of electricity to stimulate the heart to make it contract at any given speed. These can be useful, as the heart occasionally develops an abnormal rhythm after valve replacement surgery. Several drains are used, to drain any excess blood away from around the heart, and the breast bone is closed with strong wire. Finally the fat and the skin overlying the breast bone are closed, and the patient is moved round to the intensive care unit. Initially the patient is attached to a life support machine, to make sure the heart continues to work well and  there is no excessive bleeding. After a few hours the medicines keeping the patient asleep are switched off, the patient wakes up, starts breathing on their own and is taken off the breathing machine.