Mitral ‘Valve in Valve’ and ‘Valve in Ring’

What is ‘Valve in Valve’ and ‘Valve in Ring’?

Most patients who have had previous mitral valve surgery have usually had the valve replaced in full or repaired – usually with an annuloplasty ring. Tissue, or bioprosthetic, valves degenerate usually over many years and may become narrowed (stenosed) or leaky (regurgitant) and sometimes both. Likewise, a valve that has been repaired with an annuloplasty ring can degenerate over time so that the valve no longer functions properly. 

The standard treatment for both conditions is repeat open heart surgery, however, this may not be an option is some patients. Dr Smith has extensive experience of these procedures and is currently leading a trial supported by the British Cardiovascular Intervention Society (BCIS) to investigate the outcome of these specialist interventions in the UK.

Should I have a ‘Valve in Valve’ or ‘Valve in Ring’ Procedure?

Although we normally suggest repeat open heart surgery, this may not be appropriate for some patients, where the risk of surgery may be too high. We will usually first ask a surgeon to replace the valve, but if this is thought to be too risky, a valve in valve/ring procedure may be an alternative option. Whether or not the procedure can be undertaken will depend on a number of factors and you will need further assessment before we can be sure. We would normally ask for a dedicated CT scan of your heart and a transoesophageal echo scan (TOE) to be certain that the procedure can be undertaken safely.

How does it work?

A valve in valve or ring procedure is carried out under general anaesthetic and is guided by both XRAY and TOE scan throughout. It involves inserting a tube (sheath) into the vein in the groin and then making an opening in the wall between the right and left atrium (transeptal puncture – we often use a small balloon to enable the new valve to pass through). The new valve is mounted on a balloon and a stiff wire and is advanced from the right to the left atrium. Once in the left atrium, the new valve is steered down to the existing valve or ring and the balloon inflated once in place. The new valve is anchored in place within the old valve or ring and will function immediately.

What are the risks?

The risks of the procedure depends on a number factors, including your age and other medical problems. Generally, these procedures are performed at approximately a 2-3% risk of major complication. The risks tend to be higher in valve in ring procedures, where there is a slightly greater chance of leaving leak outside of the new valve (paravalvular leak) or of the new valve moving (embolisation). These risks are minimised by careful planning and selection of the ideal sized new valve. The risks of your procedure will be very carefully explained to you beforehand.

Our Team

Toufan Bahrami

Mr Toufan Bahrami is a senior consultant in cardiac surgery , working at both Royal Brompton and Harefield Hospital, where he treats both NHS and private patients.

He also works at The Harley street clinic in central London .With more than 4000 cardiac operations of which 1500 are minimally invasive procedures over past 21 years, He is the   only consultant in UK expert in all aspects of minimally invasive cardiac surgery including , Mitral , Aortic valve and root and CABG with a longstanding track record.

Saeed Mirsadraee

Dr Mirsadraee’s specialist interest is cardiovascular imaging and in particular imaging of the heart valves, surgical and transcatheter aortic and mitral valve procedure planning, and complex aortic conditions. He is the radiology lead for aortic and mitral imaging at the Royal Brompton and Harefield hospitals. Dr Mirsadraee uses CT images in planning Mitral valve procedures such as minimal access mitral valve surgery, transcatheter mitral valve implantation (eg. Tendyne, Sapien in ring/MAC), cord and left ventricular remodelling procedures (eg. Accucinch, Neocord).

Ali Vazir

Dr Ali Vazir is a consultant cardiologist based at the Royal Brompton and Harefield Hospitals, part of Guy’s and St Thomas’ NHS Foundation Trust. He is also an Honorary Clinical Senior Lecturer at National Heart and Lung Institute, Imperial College London. 

He is an expert in heart failure and echocardiography. He is the clinical lead for heart failure at the Royal Brompton Hospital. He trained in London and was a Post-doctoral research fellow at the Brigham and Women’s Hospital and Harvard Medical School, Boston, USA. He is a principal investigator for several multicenter trials. 

Lauren Connolly

Lauren has worked within the cardiology and cardiac surgery care setting for seven years. In recent years she has worked within the structural heart team as clinical nurse specialist and co-ordinator for the trans catheter team, specifically focusing in mitral and tricuspid valve disease.

Dr Robert Smith

Dr Smith’s specialist interest is Mitral valve disease and interventions. He leads one of the largest structural heart disease programmes in Europe at the world renowned Royal Brompton & Harefield Hospitals. It is also the first centre of excellence for MitraClip in the world.