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There are four types of valves in the human heart – the mitral, aortic, tricuspid, and pulmonary valve. The mitral and the tricuspid valve are present between the upper and the lower chambers of the heart. On the other hand, the aortic and the pulmonary valve are present in the two arteries that leave the heart.

Most often, it is the mitral and the aortic valve that undergoes certain pathologic changes due to degenerative valve diseases, rheumatic heart diseases, or infective endocarditis. This may result in problems associated with the valve opening and closure.

These dysfunctions can be treated with either valve repair or valve replacement surgery. Aortic valve replacement or mitral valve replacement is carried out when just one of the valve is diseased or damaged. However, when both the valves are diseased or damaged, a double valve replacement surgery is conducted.

About the ailment

The heart valves present in the heart are responsible for permitting the flow of nutrient-laden blood through the heart chambers. After allowing the ushering of blood, each valve is expected to close completely. The diseased or damaged valves are not able to open and close properly, thus allowing the mixing and backflow of blood (regurgitation).

 A double valve replacement surgery mainly aims at correcting the problem of valvular heart disease and involves both aortic valve replacement and mitral valve replacement. The mitral valve is situated between the left atrium and the left ventricle while the aortic valve is located in between the aorta and the left ventricle.

Causes of Heart Valve Disease

Some of the causes of heart valve disease include the following:

  • Cardiac stenosis or narrowing
  • High blood pressure and heart failure, which enlarges the heart and arteries and contribute to valvular diseases
  • Atherosclerosis
  • Scar tissue formation and damage due to heart attack or any injury to the heart
  • Strep throat or rheumatic fever can give rises to valve problems
  • Infection due to germs entering bloodstream can affect heart valves and one such infection is infective endocarditis
  • Lupus-like autoimmune diseases can affect the aorta and mitral valve
  • Carcinoid syndrome
  • Diet medicines such as fenfluramine and phentermine can at times give rise to valve diseases
  • Marfan syndrome
  • Metabolic disorders such as Fabry disease or high blood cholesterol
  • Radiation therapy to the chest can give rise to heart valve diseases.

Symptoms of Double Valve Replacement

Some of the symptoms of valvular heart disease include the following:

  • Fluid retention in the lower limbs
  • Chest pain
  • Fatigue and light-headedness
  • Dizziness and shortness in breath
  • Cyanosis

About heart valve replacement

Double valve replacement surgery is a complicated procedure as compared to single valve replacement surgery. Aortic valve replacement and mitral valve replacement involves the replacement of just one valve but during double valve replacement surgery, both the diseased valves are removed at the same time and replaced with a synthetic (mechanical) or a biological valve.

In the case of mechanical valves, the components used are not of organic or natural origin. They are created from a combination of polyester and carbon material that the human body can tolerate and accept. Blood-thinning medications are given to patients who get mechanical valves to prevent blood clot formation.

Bioprosthetic valves or the biologic valves are either created from animal or human tissues and can be of the following types:

  • A bovine valve is usually derived from the tissues of a cow and is connected to the heart with the help of silicone rubber
  • A porcine valve has its origin rooted from a pig tissue and is implanted in the heart with or without the frame like a stent
  • A homograft or an allograft is usually collected from the human donor’s heart

The choice of a particular type of valve depends on the age, overall fitness, and the ability to metabolize anticoagulant medications. The only problem associated with a bioprosthetic valve is that it may not last a lifetime and one may have to undergo a replacement again later.

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Before the Treatment

Specific routine tests are conducted before heart valve replacement surgery to check for the overall health of the patient and confirm any underlying conditions. A routine chest X-ray is conducted and along with a transthoracic echocardiography.

Associated aortic aneurysm, aortic arch aneurysm, low chest profile, chest surgery or trauma, highly calcified mitral valve annulus or aortic valve, the requirement for aortic root reconstruction, coronary artery bypass grafting, peripheral atherosclerosis and stentless aortic bioprosthesis implantation is assessed for double valve replacement as contraindications.

You are advised to quit smoking and taking heavy and spicy foods that are difficult to digest weeks before the surgery. You should concentrate on leading a simpler lifestyle as it will speed up the recovery rate later.

How it is Performed

For the purpose of hemodynamic monitoring, the peripheral arterial and venous access are installed. The patient is anaesthetized in a supine position with a single lumen endotracheal tube.

In the jugular vein, two percutaneous sheath introducers are placed for central venous pressure monitoring and drug administration. Another similar one is placed in the same right jugular vein for the purpose of introducing endocavitary pacemaker leads if required. External defibrillator pads are placed on the patient’s back and on the anterior left chest.

TEE or transesophageal echocardiography probe is used for an assessment of cardiac function, percutaneous venous cannulation guidance, and valve assessment. The skin is sterilized with iodine solution and an aseptic strip is applied on areas exposed. The double valve replacement procedure is very similar to isolated aortic valve replacement or mitral valve replacement, which is conducted via a single access right anterolateral minithoracotomy.

Before systemic heparinization, the venous introducer sheath is positioned in the femoral vein to prevent any unwanted bleeding. In the third intercostal space, an incision of 6 to 8 cms is made. Minithoractomy is made and in the 3rd and 5th intercostals spaces, two auxiliary working ports are placed. The first is for video assistance and the second is for gas insufflation, cardiotomy vent, and pericardial stay sutures. The pericardium is opened upwards and downwards after removal of the pericardial fat, which is 3 to 4 cm above the phrenic nerve. The pericardium is retracted using silk sutures.

In a standard way, two aortic purse strings are placed for direct arterial cannulation after the aorta has been exposed. The operation is continued with venous cannulation under the guidance of TEE. A guidewire in moved through the venous introducer and positioned in the superior vena cava.

With the central cannulation of the ascending aorta, arterial inflow is established. The cannula has an obturator and an advanced tip to aid aortic insertion within the thorax. With cannula rings, the tip is secured and with two tourniquets the cannula is secured. They allow maximum space to work during thoracotomy access.

Carbon dioxide flow keeps running and when the heart gets arrested, the aorta is opened in an oblique way with an incision like a hockey stick, k which is further extended to the non-coronary sinus Valsalva. After this, aortotomy is made far away from the cross-clamp and from the main pulmonary artery trunk; for the closure of aortotomy, enough aortic tissue must be kept. Now the problematic valve is excised. The annulus size is measured and calibrated with a sizer and then prosthesis is implanted. The aortic prosthesis is lowered and made to remain above the final plane of implantation.

Now focus shifts to the left atrium. It gets dissected in a Sondergaard’s plane, and with the help of one single silk suspension stitch and an atrial retractor, the mitral valve is exposed. If now required the left atriotomy can be further extended behind upwardly behind the superior vena cava or along the inferior vena cava downwardly.  In right minithoracotomy the visualization of the mitral valve is very good and allows valve and subvalvular repairs easily.

The procedure starts with synthetic braided sutures being placed in the mitral annulus whose diameters are measured using suitable valve sizes. For the mitral valve, reductive annuloplasty is performed. The sutures are passed and the retractor is removed and then attention is again diverted towards the aortic valve prosthesis. This is lowered into the annular plane and thereafter knotted.

For the assessment of the results of the repair, the atrial retractor is again positioned in the left atrium.  To estimate the competence of the valve, a water probe is applied with an implanted open mitral ring. After successful completion, the left atrium is closed leaving behind the ventricular vent via the mitral valve in the left ventricle. Aortic cross-clamp is removed and aortotomy suture is further knotted. The aortic vent is positioned in the ascending aorta. A polypropylene purse-string suture is hand-knotted after aortic vent is removed. After confirmation by the TEE, the procedure moves to the final stage where the aortic cannula is removed and a percutaneous cannula is also withdrawn with the femoral vein temporarily placed under compression, the skin incision is closed with a single silk stitch.


After the surgery, the patient is shifted to ICU for close monitoring for several days. Blood pressure, ECG tracing, breathing rate, and oxygen levels are closely studied. You may require staying in the hospital for several days after heart valve replacement surgery. With the help of the ventilator, breathing is assisted via a tube inserted in the throat. The breathing machine will be further adjusted as the patient keeps growing stable and once the patient is able to breathe and cough on their own, the tube is removed. Along with this, the stomach tube is also removed.

In every two hours, a nurse would help the patient take deep breaths and cough. This feels sore but is vital to prevent accumulation of mucus in the lungs and prevent pneumonia. The patient is taught to hug a pillow tightly while coughing to ease out any discomfort. The patient must express discomfort felt at coughing and medications are suggested accordingly. Slowly fluid intake is initiated and you can gradually increase your daily activities such as walking around the room. After a few days, the patient is shifted to the recovery room where the rest of the recovery takes place before discharge.

Notify your doctor if you feel swelling and redness around incision area, fevers and chills, or pain in the area of the incision. You should rest and keep the surgical area as clean as possible at home.

Cost Comparison

Heart Valve Replacement Surgery Cost in India

The cost of heart valve replacement in India is much cheaper and affordable than a majority of other countries in the world. Heart shape hospitals in India are globally renowned for their quality of services and the great expertise of the cardiac surgeons associated with them.

Heart surgery cost in India depends on the type of surgery that the patients are undergoing. For example, the patients who is supposed to get an AVR heart replacement would have to pay differently than a patient who is supposed to have aortic or mitral valve repair and not a replacement.

The cost of mitral valve repair is different from heart hole surgery cost and same is the case with aortic valve replacement cost. The cost of mitral valve replacement and aortic valve replacement is more or less the same. But the total heart surgery price for double valve replacement is more as it involves replacement of two valves and not just one. Additionally, it is a more risky and complicated procedure that takes more effort, time, and dedication.

The cost of double valve replacement in India or single valve replacement cost in India depends on several factors, including the following:

  • The experience of the surgeon
  • Number of surgeons participating in the surgery
  • Total number of days spent at the hospitalization
  • Total days spent in the ICU
  • Complications involved
  • Additional tests performed
  • Type of hospital
  • Type of valve used
The following tables highlight the approximate AVR/MVR cost 
Cost of AVR/MVR surgery in India $5300
Cost of AVR/MVR surgery in Thailand $9000
Cost of AVR/MVR surgery in South Korea $14000
Cost of AVR/MVR surgery in Hungary $34500
Cost of AVR/MVR surgery in UAE $21251
Cost of AVR/MVR surgery in Poland $22100

The following tables highlight the approximate double valve replacement cost in India and abroad:

Treatment cost in India: 9500
Treatment cost in Turkey: 15000
Treatment cost in United Arab Emirates: 45000
Treatment cost in Spain: n/a
Treatment cost in Thailand: 50000
Treatment cost in Israel: 65000
Treatment cost in Singapore: 100000
Treatment cost in Tunisia: 17000
Treatment cost in Greece: 28000
Treatment cost in Saudi Arabia: 33000
Treatment cost in South Africa: n/a
Treatment cost in Lebanon: n/a
Treatment cost in Lithuania: n/a
Treatment cost in Switzerland: n/a
Treatment cost in Czechia: 45000
Treatment cost in Hungary: n/a
Treatment cost in Malaysia: n/a
Treatment cost in Morocco: n/a
Treatment cost in Poland: 15000
Treatment cost in South Korea: 70000

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Q. How long will the heart valve surgery last?

A. Mechanical valves last for 25 years in some patients without problems. It is possible that a new artificial valve could last for the rest of the life. But in some situations, mechanical valves require replacement within months or a few years.

Q. Does the valve replacement require special care to prevent infection?

A. The doctor may prescribe certain antibiotics to fight infections.

Q. Is it safe to have an X-ray after heart valve replacement?

A. All types of heart valve replacements are safe with X-ray examination.

Q. Is it safe to have magnetic resonance imaging after heart valve replacement?

A. Usually, the valves are found to be safe during magnetic resonance imaging. The physician must be contacted before performing the test.

Q. What is the advantage of tissue valve over mechanical valve?

A. The tissue valve does not require blood thinning medications whereas mechanical valves require the patients to take blood thinning medications for the rest of their lives.

Q. What are the risks associated with double valve replacement surgery?

A. Some of the risks associated with double valve replacement surgery include bleeding during and after surgery, pneumonia, and formation of blood clots that can cause heart attacks

Q. How much does a heart valve replacement cost?

A. The cost of heart valve replacement depends on several factors such as number of valves replaced, the extent of damage, the hospital charges, and the number of days of hospitalization. The total heart valve replacement surgery cost may vary from $4000 and $40000, depending on the country that you choose to get operated in.

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Heart Double Valve Replacement