Cost Guide of Heart Valve Replacement in India

Cost Guide of Heart Valve Replacement in India

What is Valve Replacement?

The heart is made up of tissues and muscles that pump blood. It is divided into a right and left side and has four chambers: 2 lower chambers called ventricles and 2 upper chambers called atria. Valves are present between each chamber of the heart to keep the blood from flowing back into the previous chamber and keep the blood flowing forward throughout the heart.

  • Pulmonary valve: It is located between the pulmonary artery and the right ventricle.
  • Tricuspid valve: It is present between the right ventricle and atrium.
  • Aortic valve: It is located between the aorta and the left ventricle.
  • Mitral valve: It is located between the left ventricle and left atrium.

When these valves are diseased or damaged and do not function normally, they may need repair or replacement. These conditions can be caused due to conditions like valve regurgitation (leaky valve) and valve stenosis (stiffness). When one or more valves become stiff or narrow, the blood has to be pumped with extra force by the heart. When one or more valves become leaky, the blood leaks back to the previous chamber leading to an inefficient amount of blood in the right direction.

Earlier traditional open heart surgeries were performed to replace or repair the damaged valves. Now, minimally invasive procedures are done that use artificial valves (human valves donors or made from animal valves).

Cost of Heart Valve Replacement in India

City Name Cost in USD
Delhi $2,368 – $5,554
Bangalore $5,500 – $10,377
Chennai $2,320 – $7,325
Gurgaon $3,523 – $4,697
Mumbai $1,403 – $12,208
Noida $3,957 – $5,276
Hyderabad $976 – $9766
Faridabad $2,624 – $7,000
Kochi $3,523 – $4,697
Ahmedabad $2,197 – $3662
Ghaziabad $4,883 – $5,493
Kolkata $1,465 – $5,493
Mohali $3,957 – $5,276
Panjim Enquire Now
Pune $2,746 – $6,714
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Types of Heart Valve Replacement in India And Their Cost

Depending on the disease and condition, the type of heart valve replacement surgery is chosen.

Types Cost in USD
Surgical valve repair $3,061 – $6,123
Percutaneous or balloon valvuloplasty $3,600 – $4400
Percutaneous mitral valve repair $3,371 – $6,307
Mechanical valve replacement $4,950 – $6,050
Biological valve replacement Enquire Now
Transcatheter aortic valve implantation $25,000 – $42,000

>>Surgical valve repair: This kind of surgery is usually done for tricuspid or mitral valves. It costs

  • Commissurotomy: It is done for repairing tight valves. The valve leaflets or flaps are slightly cut open to loosen them slightly that allows the blood to pass easily.
  • Annuloplasty: It is done for leaky valves. A ring of fibrous tissue is present at the base, called the annulus, of the valve of the heart. The enlarged annulus is repaired by sewing sutures around the ring that makes the opening smaller. Or a ring-like device is attached to the outside of the opening of the valve to support it so that it can close more tightly.
  • Valvulotomy: It is a procedure to enlarge the narrowed valves of the heart. It can also be done through a balloon.

>>Non-surgical valve repair: Catheter or percutaneous-based procedures are performed without any cuts or incisions in the chest or stopping the heart. In this, a flexible thin tube called a catheter is inserted in the blood vessel of the patient’s arm or groin and then threaded through the blood vessel to reach the heart.

  • Percutaneous or balloon valvuloplasty: It is used for narrowed or stiffened (stenosed) aortic, pulmonary, or mitral valves. The valve is enlarged through the inflation of the balloon tip end of the catheter.
  • Percutaneous mitral valve repair: It can fix the mitral valve in high-risk patients. A clip that is held by a catheter is inserted into the patient’s groin and up into the heart’s left side. The open clip is positioned beyond the leaking valve and then it is pulled back so that it can catch the leaflets or flaps of the mitral valve. The clip holds these together once it is closed and stops the leaking valve.

>>Heart valve replacement: If the heart valve is too damaged to be repaired, surgery may be required to replace it with a new biological or mechanical valve. Age is usually the deciding factor in this. Biological valves are used for older patients.

  • Mechanical valve: These valves are made of plastic, carbon, and ceramic materials. They are durable. A fabric ring is a mechanical valve that is sewn into the heart valve. However, these valves can lead to the formation of blood clots. Patients with this have to anticoagulants or blood thinners every day for the rest of their lives. It also makes a soft clicking sound which can bother some people.
  • Biological (tissue or bioprosthetic) valve: These are specially prepared from natural valves that come from animal or human donors. Patients with this type of graft need to take blood thinners for a short duration. However, they are not as durable as mechanical valves but are effective in cases of older patients and aortic positions.
  • ->Cows and pigs are sources of animal valves (a xenograph) that are similar to human valves. They are well tolerated by the patient’s heart and there is decreased chance of blood clot formation.
  • ->Human heart valves come from a donated heart (homograft or allograft) and are well tolerated by the patient’s body and last longer than animal valves. It is uncommon to use these grafts.
  • ->Valves can be formulated from the patient’s own tissue (autograft). In a switch or Ross procedure, one’s functioning pulmonary valve is used to replace one’s damaged aortic valve.

>>Minimally invasive valve replacement and repair: It does not involve sawing through the breastbone and opening the chest. It does not require using a heart-lung machine or stopping the heart. The surgeon watches the heart on a video screen operates on the valve through small cuts through which long-handled surgical tools are inserted. Sometimes robotic or endoscopic surgeries are used.

  • Transcatheter aortic valve implantation (TAVI): It is also called transcatheter aortic valve replacement (TAVR). It is minimally invasive and used treat conditions like symptomatic aortic valve stenosis. It does not require open heart surgery and a new aortic valve is placed directly on top of the damaged valve rather than replacing, repairing, or removing it. Small incisions are done in the chest or the groin.
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Factors Affecting the Cost of Heart Valve Replacement in India
  • Esteemed hospitals: Hospitals in India are equipped with modern and novel infrastructure along with the latest technology for major and minor surgeries. Specialized intensive care units are also available to give premium care to the patient.
  • Exceptional medical professionals: The doctors and surgeons are highly skilled and have an immense level of expertise. The doctors discuss the procedure, risks, and aftercare of heart valve replacement with the patients.
  • Affordable cost: Medical procedure packages are available that include hotel charges, flight charges, etc. The cost of treatment, medication, post-operative care, transportation, etc. is affordable compared to other countries.
  • Type of heart valve disease: There can be three types of heart valve diseases, namely, Artesia, regurgitation, and stenosis. The type of heart disease depends on the valve that is affected like, mitral, tricuspid, aortic, and pulmonary.
  • The health and age of the patient: The overall age and health of the patient affect the treatment cost. Younger patients are overall healthier than the older patient and can tolerate higher doses of medications.
  • Pre and post-operative costs: Before any treatment plan is devised, physical examinations, blood tests, imaging tests, ECG, EKG, CT, MRI, etc. are required to identify the type of valve damage. After the surgery has been done, specific blood tests, scans, etc may be required, along with medications and aftercare steps.

Who Should Undergo a Heart Valve Replacement Procedure?

  • Congenital defects: It is a heart functional or structural defect that is present at birth or intrauterine life. These conditions develop prenatally and may be identified before, at birth, or later in life.
  • Aging and age-related valve disease: Heart valves can harden or weaken as people get older. The muscles and cells degenerate slightly. The heart valves, which control the flow of the blood, become stiff due to thickening. A heart murmur is fairly common in old people due to stiffness of the valve. Blood vessels also thicken that causes nutrients and wastes to be exchanged at a slower rate.
  • Illnesses and conditions: Certain heart conditions can affect the functioning of the heart. Diseases like rheumatic fever, poorly controlled high blood pressure, infective endocarditis, heart failure, and heart attack can damage a valve or can scar the tissues and muscles of the heart. Heart problems include stenosis, Artesia, and regurgitation.

Benefits of Valve Replacement Surgery 

  • Increased energy: Post-surgery some patients begin feeling better soon since the heart valve has started working properly now. Some patients may need a while longer to feel better.
  • Everyday activities: Patients with defective valves are often unable to do a lot of activities and everyday tasks. However, patients are able to do their activities after this procedure much more easily.
  • Breathing: Due to damaged valves there may be inefficient pumping of blood. Blood carries oxygen to tissues and muscles, and fluid builds up in the lungs and legs and causes shortness of breath. After this procedure, patients are able to breathe better.
  • Pain: Heart palpitations are feelings of pounding, fast-beating, or fluttering of the heart. Medications, stress, exercises, or rarely, medical conditions and diseases can trigger them. They are usually harmless but can be worrisome in some cases. After heart valve replacement surgery, patients do not feel any amount of pain after recovery.
  • Anxiety: This treatment further helps the patients to be relaxed and not stressed about their condition. Hence, it reduces the impact on their overall health.

Risks of Heart Valve Replacement Surgery 

  • Bleeding after or during treatment
  • Damage to the blood vessels
  • Blood clots that can lead to stroke, heart attack, or lung issues
  • Infection at the cut or incision area
  • Pneumonia
  • Problems in breathing
  • Endocarditis or infection at the new valve (common in valve replacement)
  • Arrhythmias or abnormal heart rhythms or placement of a permanent pacemaker
  • Adverse reactions to anesthetics
  • Failure of the valve

Symptoms of Heart Valve Disease

  • Increase in shortness of breath (especially lying down or with physical activity)
  • Palpitations (rapid or slow heart rate)
  • Dizziness or weakness
  • Discomfort in the chest (especially during activity)
  • Edema (swelling abdomen, ankles, or feet)
  • Fatigue
  • If the valve failure or damage is caused by infection, one may notice body aches, chills, or fevers.

Diagnostics Test Required and Their Cost

Country Name Cost in USD
Blood Tests $5 – $75
Chest X-Ray $3 – $85
Electrocardiogram $2 – $6
Pulmonary Function Test $12 – $36
CT Scan $30 – $250
MRI $60 – $490
Carotid Doppler/ Ultrasound $12 – $48
Ankle-Brachial Index $158 – $325
Surface Echocardiogram $18 – $55
Vein Mapping $155 – $1800
Trans-esphogeal echocardiogram $842 – $1326
ECG-gated SPECT myocardial perfusion imaging $801 – $2958
Heart Catheterization $3755 – $6186
  • Blood testing: The patient’s overall health is checked through a series of blood tests like CBC, diabetes testing, LFT, KFT, etc. These tests indicate if a person has any additional problems that can cause complications in the heart valve replacement surgery. Other conditions may need to be treated first before operating on the patient.
  • Chest X-ray: In this, the heart, ribs, lungs, chest, diaphragm, and large arteries. Images from two views: one from chest to back (posterior-anterior view) through X-rays, and one from one side to the other side of the chest (lateral view).
  • Electrocardiogram (EKG): This technique measures the heart’s electrical activity. Stickers or electrodes are attached to specific areas of the body (legs, chest, and arms). Tracing of a graphical representation is generated that indicates one or more conditions that are related to the heart (valve disease, conduction disorders, arrhythmias, etc). Preparation is not required for this test.
  • Pulmonary Function Test (PFT): These tests are done to measure how well the lungs release and take in air and how well the gases move. In this, the patient is asked to breathe into the mouthpiece which is connected to a device called a spirometer. It records the rate and amount of air that one breathes in and out over a duration of time. This gives the surgeon an idea of how well one’s lung works and the risk of being on the ventilator for a long period of time. There is no preparation for this test. It generally takes an hour.
  • Computed Tomography Scan (CT Scan): It checks the aorta (largest blood vessel) lungs and other organs. It identifies if an aneurysm is present or any other conditions that may need to be treated at the time before the surgery. If the procedure is a re-operation, it will allow the doctor to enter the chest cavity safely. One cannot drink 6 hours before the procedure. IV contrast dye is administered for this. It takes 1 hour to finish.
  • Cardiac Magnetic resonance imaging (MRI): This test provides detailed images of the heart, the functioning, and the shape and size of the left ventricle. Also, allows the visualization of abnormal heart tissue and muscle.
  • Carotid Doppler/ Ultrasound: The main aim of carotid ultrasound is to check the patient for narrowing or a blockage of their carotid arteries, if present may heighten the risk of stroke. In this, warm water-based gel is applied to the patient’s neck, and then an ultrasound probe or a transducer is pressed firmly on the skin, moving it back and forth over the area to be observed until the required images are obtained. It generally takes 30 minutes to complete. There is no preparation required.
  • Ankle-Brachial Index (ABIs): It is a noninvasive test to check if there are any blockages in the arteries in the arms or legs (peripheral artery disease). People with peripheral artery disease have a high risk of poor circulation, stroke, leg pain, and heart attack. It usually takes 1 hour f this test. There is no preparation required.
  • Surface Echocardiogram (echo): It is a non-invasive test that checks one’s heart valves, chambers, and how well one’s heart is functioning. In this, warm water-based gel is applied to the patient’s chest, and then an ultrasound probe or a transducer is pressed firmly on the skin, moving it back and forth over the area to be observed until the required images are obtained. There is no discomfort or preparation for this test. It generally takes 30 minutes.
  • Vein Mapping: It is a non-invasive procedure that checks the veins in one’s legs. It creates a map of the veins in the legs for the surgeon in preparation for bypass graft surgery. For this, warm water-based gel is applied to the patient’s legs, and then an ultrasound probe or a transducer is pressed firmly on the skin, moving it back and forth over the area to be observed until the required images are obtained. There is no preparation or discomfort for this test. It takes 30 minutes to complete.
  • Trans-esophageal echocardiogram (TEE): It is an invasive test that evaluates the valves and chambers of the heart and how well the heart is functioning. It looks at the size/diameter of the aorta (small part). In this, one is given sedation, and a small probe is placed in one’s mouth through the throat (esophagus) and a camera that captures images of the heart. One cannot drink or eat 6 hours before this procedure. One will have an IV placed before the procedure. It takes one hour to complete and 2-3 hours to recover from anesthesia.
  • ECG-gated SPECT myocardial perfusion imaging (Stress Test): It is a cardiac perfusion scan that measures the amount of blood in the muscles of the heart at rest and during exercise. It is able to identify the areas in the coronary artery blood vessels that may not be receiving enough blood flow or parts of the muscles of the heart that are damaged. A camera takes images of the heart after a radioactive tracer has been injected into one’s arm. This travels through the blood and reaches the muscles of the heart and images are taken. One cannot drink or eat 4 hours before the procedure. There should be no consumption of specific medications and tobacco 24 hours before the procedure. It takes 3-6 hours to complete.
  • Heart Catheterization (Cath): It is an invasive test that indicates any blockages of the coronary blood vessels (coronary artery disease). If the blockages are present, one may require the prior intervention of bypass or surgery. For this, the patient needs to lie flat while a catheter is placed in their groin blood vessel (or sometimes an arm blood vessel) while a camera clicks an image of the heart. One cannot drink 6 hours before the procedure. IV contrast dye is administered for this. It takes 1 hour to finish and 4-6 hours to recover.

How is Heart Valve Replacement Performed?

>>Before

  • An IV is inserted into the hand or forearm of the patient before the surgery. Medicines and fluids are administered through the IV. The patient should wear comfortable and loose clothing. They should avoid wearing contact lenses, jewelry, nail polish, eyeglasses, etc.
  • If hair is present in the area to be operated on, it may be shaved off.
  • For most valve replacement and repair surgeries, the patient will receive medications that induce a sleep-like state or general anesthesia. One may be connected to a heart-lung bypass machine so that the keeps flowing through the body during the surgery.

>>During

  • Aortic valve repair: It is generally done through open heart surgery through sternotomy or opening the chest bone. The bone is wired back together after the surgery to aid in healing and prevent movement. It includes different types of procedures: Tissue patched tears or holes in the flaps (perforated cusps), adding support at the roots or the base of the valve, separating fused valve cusps, removing or reshaping the tissue for a tighter valve closer, reinforcing or tightening the ring by implanting an artificial ring (annuloplasty) around the valve (annulus).
  • Minimally invasive aortic valve repair: If the aortic valve cannot close because of stenosis, a lesser invasive procedure called balloon valvuloplasty may be used for treatment. Small Incisions are made through which a hollow and thin tube or catheter is inserted through the groin and into the blood vessels to the heart. The balloon tip of the catheter is inflated which widens the narrowed valve. It is mainly done in children, infants, or adults who are too sick to undergo surgery.
  • Aortic valve replacement: If the aortic valve cannot be repaired, surgery is needed to fix it. In this, the surgeon removes and replaces the aortic valve with a mechanical cow, pig, biological human valve, or lung (pulmonary) valve.

If one has a mechanical valve, one needs to take blood thinners for the rest of their life. Biological valves need to be replaced as they break down or degenerate over time. Aortic valve replacement may be performed by open heart surgery or minimally invasive procedures like transcatheter aortic valve replacement.

How is the recovery after Heart Valve Replacement Surgery in India?

>>After

The patient may need to spend up to a week in the hospital and a day or more in the intensive care unit (ICU). The patient will be given medications, fluids, and nutrition through IV. Other tubes are placed in to drain urine the bladder and the blood and fluid from the chest and heart. One may be given oxygen. The time spend in the ICU may very according to the procedure and condition. It takes 6 to 8 weeks for the breast bone to heal but it may take 2-3 months to feel normal again. Heavy lifting or driving a car should be avoided.

Success Rate Heart Valve Replacement Surgery in India

The 5-year success rate of heart valve replacement surgery is about 91% for mitral valve replacement, 94% for aortic valve replacement, 96% for pulmonary valve replacement, and 79% for tricuspid valve replacement. All of these depend upon the age, overall health, symptom severity, which valve requires replacement, and risks of the surgery.

Top Hospitals for Heart Valve Replacement in India

>>Sarvodaya Hospital and Research, Faridabad

Sarvodaya Hospital and Research, Faridabad

Sarvodaya Hospital and Research are accredited with NABL and NABH. It has a 500-bed capacity with 65 inclusive ICU beds. It offers advanced technologies like 500 MA X-rays, 1.5 Tesla MRI, 128 Slice CT scans, a Mammography facility, etc. It has special departments like cardiac sciences, bariatric surgery, ENT, gastroenterology, infertility, etc.

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>>Fortis Hospital, Bangalore

Fortis Hospital, Bangalore

Fortis Hospital is accredited with ISO and NABH. It has a 250-bed capacity with 5 centers of excellence at the hospital. There is a 24×7 emergency service available. It has special departments for cardiac sciences, general surgery, neurology, orthopedics, oncology, etc. It also offers services like health insurance coordination, translator, rehabilitation, etc.

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>>Yashoda Hospital, Malakpet, Hyderabad

Yashoda Hospital, Malakpet, Hyderabad

Yashoda Hospital is accredited by NABL and NABH. It has a 1710-bed capacity with 3 heart and cancer institutes. It offers premium technologies like modular steel operation theatres, PFT labs, bronchoscopy units, CT 64 Slices, ultrasonography, mammography, etc. It also offers services like foreign exchange service, translator, airport transfer services, etc.

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>>Max Super Speciality Hospital, Vaishali

Max Super Speciality Hospital, Vaishali

Max Super Speciality Hospital is accredited NABH and NABL. It has a 350+ bed capacity and 15+ specialties. It offers modern technologies like 3D (4D) imaging, pure wave x Matrix technology, robotic heart surgeries, 3.0 Tesla digital broadband MRI, 256 Slice CT Angio, Da Vinci Xi robotic system, C-arm detector, etc. It also houses 128 critical care beds, 16 HDU beds, and 14 high-end modular operation theatres.

ENQUIRE NOW

>>MGM Healthcare, Chennai

MGM Healthcare, Chennai

MGM Healthcare is accredited by NABH and JCI. It has a 400-bed capacity and 100 inclusive critical care unit beds. It has 24×7 emergency care facilities and 12 operation theatres. It has specialized units for cardiac sciences, gynecology, obstetrics, liver transplantations, oncology, orthopedics, neurosciences, SICU, anaesthesiology, etc.

ENQUIRE NOW

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Top Doctors for Heart Valve Replacement in India?

1. Dr. Sameer Mahrotra
Cardiologist, Pushpawati Singhania Research Institute, Delhi
Experience: 21 years

Dr. Sameer Mahrotra | Best Cardiologist in India

Qualification: MBBS, MD, DM

  • He is a member of CSI, ISE, ASPI, and IHRS
  • He has successfully performed procedures like EPS and RFA, angioplasty, pacemaker implantation surgery, and angiography (including non-ionic contrast.
  • He has treated conditions like angina, blocked arteries, angina, arrhythmias, coronary artery disease, high blood pressure, dizziness, chest pain, palpitations etc.

2. Dr. Bikram K Mohanty
Cardio Thoracic and Vascular Surgeon, Venkateshwar Hospital, Delhi
Experience: 27 years

Dr. Bikram K Mohanty | Best Cardio Thoracic & Vascular Surgeon in India

Qualification: MBBS, MS, DNB

  • He was the HOD and sr. Consultant at Head of Cardiac Surgery at Shalby Group of Hospitals and CTVS at Kamineni Medical College and Hospitals
  • He has successfully performed procedures like Bentall procedure, coronary artery bypass grafting (CABG), atrial septal defect (ASD), Fontan procedure, TOF repair, etc.
  • He is an expert in valvular, redo and combined procedure.

3. Dr. Nidhi Rawal
Pediatric Cardiologist, Artemis Health Institute, Gurgaon
Experience: 19 years

Dr. Nidhi Rawal | Best Pediatric Cardiologist in India

Qualification:MBBS, MD, FNB

  • She is a member of PCSI and IAP
  • She has treated symptoms like fatigue, pale skin, shortness of breath, difficulty in feeding (becoming especiality sweaty during feeds), cyanosis (blue skin), etc.
  • She has successfully performed procedures like balloon atrial septosomy, arrhythmia, intravascular ultrasound (IVUS), intracardiac electrophysiology (EPS), etc.

4. Dr. Manisha Chakrabarti
Pediatric Cardiologist, Indraprastha Apollo Hospital, Delhi
Experience: 27 years

Dr. Manisha Chakrabarti | Best Pediatric Cardiologist in India

Qualification: MBBS, MD

  • She is a member of IAP, CSI, and PCSI. She also has fellowship in pediatric cardiology.
  • She has treated symptoms like pale skin,  cyanosis (blue skin), difficulty in feeding (becoming especiality sweaty during feeds), fatigue, shortness of breath, etc.
  • She has successfully performed procedures for conditions like congenital heart disease, hinderance in development and growth, heart infections, pulmonary hypertension, etc.

5. Dr. Sanjay Gupta
Cardiac Surgeon, Fortis Flt. Lt. Rajan Dhall Hospital
Experience: 33 years

Dr. Sanjay Gupta | Best Cardiac Surgeon in India

Qualification:MBBS, MS, MCh

  • He is a member of MCI and DMC. He is also certified in Cardio Thoracic and Vascular Surgery from K.G’s Medical College
  • He has treated and relived symptoms like shortness of breath, discomfort in the back, jaw, and neck, light headedness, chest pain, discomfort or pain in arms and shoulders, etc.
  • He has successfully performed procedures like cardiac valve replacement, VSD repair/closure, coronary artery bypass grafting, and double heart valve replacement.

>>Frequently Asked Questions

India provides premium care and the greatest quality of heart valve treatment care to national and international patients through medical and non-medical staff. Also, the cost of heart valve replacement is less compared to other countries. Hospitals have advanced equipment and modern infrastructure that provides the best environment and comfort to patients.

 The cost Heart valve replacement surgery is USD 6,000-15,000 in India.

Heart valve replacement surgery usually lasts 4 to 6 hours.

It is safe for a patient to undergo MRI or X-ray after heart valve replacement procedure as the artificial implants are made of titanium or carbon or biological material (human, cow or pig). These implants generally consist of two leaflets and a metal ring that is surrounded by a knitted fabrin ring, that is sewn onto the place of the original valve.

The patient can get back to their daily activities after 4 to 6 weeks. The incisions in the chest may be swollen or sore but get better in a few weeks.

TAVR is an alternative procedure to an open-heart valve replacement surgery. Patients who receive this treatment have a shorter hospital stay than patients who receive a surgical valve replacement. It is done in cases of severe aortic stenosis, biological graft that isn’t working well, or there are other health condition like kidney or lung disease.

Heart valve replacement surgery is a major procedure and like any other kind of surgery carries complications and risks. Risks include damage to bladder or lungs, or infection in the heart valve infections.

Transcatheter aortic valve replacement (TAVR) is one of the best alternative to a standard open heart surgery and is minimally invasive.

The success rate of heart valve replacement surgery is about 91% for mitral valve replacement, 94% for aortic valve replacement, 96% for pulmonary valve replacement, and 79% for tricuspid valve replacement.

 

Last modified on blank at Feb 06, 2024

Reviewed By :- Urvi Agrawal
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Guneet Bhatia

Guneet Bhatia is an avid reader, healthcare writer, and is currently Director of Patient Care Department, MediGence. She has also been featured on many prominent Healthcare portals such as IBTimes, HCIT Expert, Clinician Today.

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