Aortic Valve Surgery

Aortic valve surgery is performed by cardiovascular surgeons to treat congenital aortic valve disease, aortic valve stenosis, and aortic valve regurgitation. Disease aortic valves are repaired or replaced. The decision for repair vs. replacement is based on:

• Diagnostic test results (echocardiogram and cardiac catheterization)
• Heart structure and anatomy
• The patient’s age
• The presence of other medical conditions

Indications for Aortic Valve Surgery
Early surgical intervention (for valve repair in particular) may prevent irreversible heart damage. The decision about timing for elective (non-emergency) valve surgery is made between a patient and his or her doctor and is based on comparing the risk of surgery with the benefits available from surgery. Indications for having surgery sooner than later include:
• Problems with angina and syncope.
• Severe aortic valve regurgitation as diagnosed by echocardiography.
• Severe aortic valve regurgitation in the presence of left ventricular dysfunction and/or heart failure symptoms.
• Left ventricular dysfunction and low cardiac output due to aortic valve stenosis.

Traditional vs. Minimally Invasive Surgical Approaches
Patients who need surgery on the aortic valve alone or who need multi-valve surgery may be candidates for the minimally invasive approach, but the surgeon makes the determination based on each individual case. The patient’s individual anatomy, diagnosis, and overall heart function are contributing factors. This approach may also include the use of a surgical robot.

  Traditional Minimally Invasive
Incision length 6- to 8-inches   2- to 4-inches
Incision location Sternum Sternum or between ribs
Length of hospital stay (avg)    5 days 3.5 days
Trauma  Higher Lower
Blood loss Higher  Lower

Aortic Valve Repair
Aortic valve repair is used when the valve has aortic regurgitation but no stenosis and consists of:
• Returning a dilated aortic annulus (diameter) back to the proper size.
• Repairing a bicuspid or tricuspid aortic valve by reshaping the leaflets to allow the valve to open and close more completely.
• Repairing valve tears or holes with tissue patches (some tears can be caused by endocarditis).
• Repairing the aortic valve while simultaneously replacing an enlarged ascending aorta caused by the aortic valve disease (David procedure).

Aortic Valve Replacement
If valve repair is not an option, it may need to be replaced. Aortic valve replacement is an open heart procedure performed by cardiothoracic surgeons to treat aortic valve stenosis and aortic valve regurgitation. The diseased valve is removed, and a new valve is sewn in its place. The new valve can be a biological, homograft, or mechanical valve.

Biological Valves
Biological valves are made from pig tissue (porcine), cow tissue (bovine), or pericardium from other species. The natural tissue is supported by an artificial framework, which gives it structure and allows it to be surgically implanted. Biological tissue valves are also called bioprosthetic valves. They last from 15 to 20 years after implantation, are readily accepted by the body, and usually do not cause blood clotting problems.

Homograft Valves
A homograft valve has been donated from another human who has died. After removal from a donated human heart, it is treated with antibiotics, placed in preservative, and frozen under sterile conditions. Homograft valves are ideal for aortic valve replacement when the entire aortic root is diseased or infected.

Mechanical Valves
Mechanical valves are usually bileaflet valves that are made with non-reactive, well tolerated materials like pyrolite (qualities similar to a diamond) carbon leaflets surrounded with a polyester knit fabric—covered ring. Surgeons choose the type of valve to implant based on how it is sewn into place, but few differences exist between them. The advantage of mechanical valves is their excellent durability—they do not wear out over time. A huge disadvantage is that blood clots form on mechanical valves. Because of this risk, patients with a mechanical heart valve must take anticoagulant medications or “blood thinners” and be routinely tested for its level in their blood for the rest of their lives. Blood clots also pose a serious risk for causing stroke.

The Ross Procedure
The Ross procedure can be performed on young patients (age 50 or below) who have irreparable aortic valve disease but who do not want to take anticoagulation (blood thinning) medications for the rest of their lives. During this procedure, the diseased aortic valve is removed along with the patient’s normal pulmonary valve. The patient’s normal pulmonary valve is placed into the aortic valve’s spot, and a homograft valve is placed into the pulmonary valve’s spot. It is a complex surgery that is done at only a few centers in the United States by specially trained surgeons.

Risk
Past history of heart surgery, patient age, general health, and other conditions that require surgical treatment affect individual risk. Each patient who undergoes elective heart valve surgery should discuss risk factors and potential outcomes with his or her surgeon prior to undergoing the operation.

Life after Aortic Valve Surgery
Patients who undergo successful aortic valve surgery can expect to return to their preoperative condition or better. After wounds have healed, few if any restrictions are placed on the patient’s activity.


Resources

Cleveland Clinic www.clevelandclinic.org/heartcenter/pub/guide/disease/valve/aorticvalvesurgery.htm
The Society of Thoracic Surgeons www.sts.org/sections/patientinformation/valvesurgery/aorticvalve/