Aortic root replacement

Overview

Aortic aneurysms in the section of the aorta that connects to the heart are treated with a procedure called as aortic root replacement surgery. An aneurysm is a weak area in the wall of a blood vessel. Aneurysms have the potential to dissect (tear) or rupture, resulting in fatal internal bleeding. Marfan syndrome, an inherited disorder, may be the cause of aortic aneurysms close to the aortic root. Additional causes may encompass congenital heart conditions like a bicuspid aortic valve. By preventing rupture or dissection, aneurysm surgery can save a life.

The surgical approach can vary depending on several factors, including the condition of the aortic valve. It may entail either replacing both the valve and the aortic root or replacing the aortic root while preserving your valve (known as valve-sparing root replacement).

Types

Aortic root replacement surgery is categorized into two main types: aortic root replacement (ARR) and valve-sparing root replacement (VSRR). Each of these approaches offers distinct advantages and carries its own set of associated risks.

• Aortic root replacement (ARR): The aortic root and aortic valve are both replaced during aortic root replacement (ARR). It is also known as the Bentall procedure. It is for patients who also have aortic valve issues in addition to an aortic root aneurysm. If a patient has calcification (hardening) or regurgitation (leaky valve), ARR may be beneficial.
  The primary benefit of ARR is that they most likely won’t require another operation in the future to repair their valve. It treats both the aneurysm and the valve simultaneously
  This surgery can include giving the patient a mechanical valve. Blood thinners (anticoagulants) are required for people who have mechanical valves. Among the risks are bleeding and blood clots.
• Valve-sparing root replacement (VSRR): If their aortic valve is functioning properly, valve-sparing root replacement (VSRR) is a reasonable decision. For instance, if they don’t have calcification or acute regurgitation. It’s frequently the best option for younger patients with aortic root aneurysms linked to hereditary disorders.
  The aortic root is replaced during VSRR, but not the aortic valve. The two forms of VSRR are named after the healthcare provider who created them.
  • Yacoub procedure: The procedure entails remodeling your aortic valve. It works better for elderly patients whose aneurysms are unrelated to a genetic syndrome.
  • David procedure: Reimplantation of the aortic valve is required. It is more prevalent than the Yacoub procedure but also involves greater technical intricacy. Younger individuals with genetic syndromes or bicuspid aortic valves should consider it.

  Both types demonstrate outstanding long-term outcomes and pose a minimal risk of complications related to the valve. Based on the patient’s medical history and age, the surgeon decides what kind of treatment to perform.
  The main advantage of VSRR is that patients are spared a lifetime of using blood thinners. They might have lower risk to experience a stroke or endocarditis. As long as the valve continues to function properly, the patient can maintain it for many years.

Reasons for the procedure

Aortic root replacement may be required in individuals with aneurysms that are susceptible to rupture or dissection. Age-related alterations to the aorta can occasionally lead to an aortic root aneurysm. Aortic aneurysms can also be brought on by genetic conditions like Marfan syndrome and Loeys-Dietz syndrome. In younger people, such diseases can cause deadly aneurysms

Aneurysm rupture or dissection is a possibility for those with Marfan syndrome who do not undergo treatment. In this group, the typical mortality age is 32; nevertheless, life expectancy is significantly increased after aneurysm repair surgery. 60% to 80% of these fatalities are due to aortic root problems. Even with smaller aneurysms, if other family members have Marfan syndrome, they may be at increased risk. The optimal time to start therapy and your own unique risk should be discussed with the healthcare provider.

The size of the aneurysm and other aortic dissection risk factors are used to develop aortic root replacement guidelines. When the patient’s aortic root aneurysm reaches one of the following diameters, surgery may be necessary:

• 5.5 centimeters if they don’t have any hereditary disorders or additional risk factors.
• 5.0 centimeters if they have Marfan syndrome.
• 4.5 centimeters if the they have Marfan syndrome, a family history of aortic dissection, aneurysm growth of more than 3 millimeters per year, severe aortic or mitral valve regurgitation, or if they intend to get pregnant.
• 5.0 centimeters if they have bicuspid aortic valve and other risk factors. These include high blood pressure, aortic valve regurgitation, or aneurysm that grows rapidly.

Each person has a different medical background and specific requirements. As a result, the timing can vary depending on the patient’s age, general health, and risk of surgical complications. Smoking and uncontrolled hypertension are two factors that can fasten the growth of an aneurysm. Discuss the personal risks with the healthcare provider to determine the best time for the operation.

Risk

Aortic root replacement is a major surgical procedure. Similar to any major surgery, it involves potential risks and complications. Among them are the following:

• Bleeding.
• Blood clots.
• Graft infection
• Infection in the lungs, urinary tract or belly.
• Problems with breathing
• Kidney failure.
• Nerve damage.
• Stroke or heart attack

People with additional major medical conditions, such as heart disease, kidney failure, lung illness, and a history of stroke, are more at risk for any open surgery.

The risk depends on the individual. With aging, risks also rise. Discuss the various dangers and how to manage them with the healthcare provider.

Before the procedure

A successful surgery depends on preparation. The healthcare provider will perform a physical examination, and the patient will also visit the dentist for a check-up. The following pre-operative exams could be performed by the healthcare provider:

• Imaging tests like a heart MRI or CT scan to examine the entire aorta. Aortic valve disease and other aorta-related issues can occasionally be treated during the same operation.
• Blood test to check the function of the kidney.
• Coronary angiography, a test to determine the condition of the coronary arteries. If the patient have atherosclerosis, the healthcare provider has to know so they can determine the best surgical strategy for the patient.
• Duplex ultrasonography to examine the carotid arteries’ condition. During surgery, untreated carotid artery issues can increase the risk of having a stroke. This test is crucial for a person if they are over 65 or have peripheral vascular disease.

The patient should also engage in a discussion with their healthcare provider regarding:

• Current medicines intake: Prescription medications, over-the-counter remedies, and herbal remedies they are using must be disclosed to the healthcare provider. Prescription and over-the-counter medications fall under this category. As people are ready for surgery, the healthcare provider might advise them to stop using a certain medication.
• Medical conditions: Before the procedure, the patient will need to manage certain problems, such as high blood pressure. If a patient has chronic bronchitis, antibiotics may be necessary.
• Health status: Inform the healthcare provider if the patient has a cold, the flu, a herpes outbreak, or any other condition.
• Smoking or tobacco use: Prior to surgery, the patient must refrain from smoking and using other tobacco products for at least a month. Discuss the resources that are available to help them quit with the healthcare provider.

The healthcare provider will provide the patient with comprehensive pre-procedure instructions, which should be followed closely. Typical recommendations may involve:

• The night before their procedure, refrain from eating or drinking after midnight.
• Taking specific medications the morning of the procedure.
• Arranging for a driver to take the patient to the hospital and pick them up after they are discharged.

If the patient has any questions, be sure to ask the healthcare provider.

During the procedure

The patient will be made comfortable by the medical team, who will also provide anaesthetic to put them to sleep. They’ll be placed on a heart-lung machine (cardiopulmonary bypass). During surgery, this heart-lung machine performs the duties of the heart and lungs. The medical team may also stop the blood circulation via deep hypothermic circulatory arrest (DHCA). Throughout the procedure, these devices aid in controlling the blood flow.

Multiple steps are involved in aortic root replacement:

• Median sternotomy: The incision at the front of the chest to access the heart, will be made by the surgeon.
• Aneurysm removal: The aortic aneurysm will be removed out by the surgeon. This area of the aorta is bulged because the artery walls are weak. The aneurysm might exclusively impact your aortic root, or it could extend further into your ascending aorta.
• Graft insertion: The surgeon will insert a tube known as a graft to replace the aneurysm. This graft serves as a brand-new artery. It is composed of polyester coated with collagen.
• Aortic valve replacement or sparing: The procedure they use will determine this phase. The Bentall surgery, sometimes referred to as aortic root replacement (ARR), involves changing the valve. It will either be a biological valve or a mechanical valve. The aortic valve will be spared (preserved) if they undergo valve-sparing root replacement (VSRR). Before the procedure, the surgeon will let the patient know whether they will undergo the Yacoub method or the more popular David method.
• Coronary artery attachment: The coronary arteries will be joined to the new graft by the surgeon.
• Closure: Stitches will be used by the surgeon to close the wound.

For ARR, the procedure takes four to five hours. For VSRR, the procedure takes four to six hours.

After the procedure

The patient will stay in the intensive care unit (ICU) for a couple of days following surgery. After that, they will transfer to a standard hospital room. About a week will be spent in the hospital.

During their stay in the hospital, the patient will get:

• Urinary catheter to help them urinate.
• A fluid-draining tube that passes through the nose and stomach.
• Blood-thinning medications (anticoagulants) in some people.
• Blood clots in the legs can be avoided by wearing compression socks.
• Breathing assistance device for supporting the lungs.
• Medication for pain relief to facilitate your recovery.

Take things slowly and pay attention to the advice of the healthcare provider. The healing period is essential for helping them get back to normal.

Make sure to arrange for a ride from the hospital to their home. You should refrain from driving until your healthcare provider gives you the green light to do so.

Outcome

Recovery after an aortic root replacement procedure typically requires a minimum of six to twelve weeks, although some individuals may take two to three months to fully recuperate. This recovery period encompasses time spent in cardiac rehabilitation, at home, and in the hospital. It’s important to note that Medicare and most insurance providers offer coverage for up to 12 weeks of cardiac rehabilitation, making it a valuable investment in one’s recovery journey. Engaging in cardiac rehabilitation after heart surgery not only improves strength and quality of life but also provides an opportunity for patients to connect with others who have undergone similar experiences.

In order for the healthcare provider to assess the patient’s heart health after recovery, the patient will have routine follow-ups. Echocardiograms (echos) and CT scans will be part of their routine imaging. The aorta’s functionality is checked as a result of these tests.

The patient will be informed by the surgeon when it is okay to resume their regular activities. They should generally refrain from driving or lifting heavy goods for six weeks. After six to eight weeks, the patient might be able to go back to work, but only if their position doesn’t require much physical labor. They will have to wait longer for occupations that require physical exertion.

For the majority of patients, both surgical procedures—ARR and VSSR—are successful. According to research, 86% to 90% of patients do not require additional surgery 10 years after having their aortic roots surgery. Individuals with Marfan syndrome face an elevated likelihood of needing a subsequent surgical procedure.

In the majority of hospitals around the world, ARR is now a standard procedure. VSRR, notably the David method, is less common. This is due to the fact that VSRR is extremely complex and demands specific training and expertise. Excellent long-term outcomes and low rates of valve-related problems are associated with VSRR procedures.

As the patient recovers, pay attention to their body and how they are feeling. If any of the following issues arise, contact the healthcare provider immediately:

Incision (surgical wound) problems:

• The bandage soaking through with blood or clear liquid.
• Pain, swelling, warmth, or redness.
• Drainage that is green or yellow.
• The incision’s edges splitting apart.

Other problems:

• Shortness of breath or chest pain even while they are resting.
• Unable to move the legs or swollen legs.
• Lightheadedness, dizziness, or excessive fatigue.
• Coughing up blood, or green/yellow mucous when coughing.
• Fever or chills.
• Blood in the stool.

These issues could indicate a surgical complication. The healthcare provider will guarantee the patient receives the care and consideration they require.