Aortic valve surgery

Overview

The aortic valve plays a crucial role in regulating blood flow within the heart. It’s one of the heart’s four valves and acts as a gate between the heart’s lower left chamber, known as the left ventricle, and the body’s principal artery, the aorta. As the heart contracts, the aortic valve swings open, allowing blood to flow from the left ventricle into the aorta. Then, as the heart relaxes, the valve closes, ensuring that blood doesn’t flow back into the heart.

If the aortic valve becomes damaged or diseased, it can disrupt this essential flow of blood. Such a malfunction may force the heart to exert more effort to distribute blood throughout the body. The valve could either become constricted, limiting the blood flow, or it may not close properly, causing blood to leak in the wrong direction. Some individuals might even have congenital heart issues from birth that impact the valve’s functioning.

To address these challenges, aortic valve repair or replacement procedures can be done. These interventions aim to enhance blood circulation, alleviate symptoms associated with heart valve issues, and ultimately extend one’s lifespan.

There are two primary surgical interventions to address pathological conditions of the aortic valve:

• Aortic valve repair: This procedure entails the restoration of the aortic valve by rectifying the compromised sections. The objective is to preserve as much of the native valvular tissue as medically and functionally appropriate.
• Surgical aortic valve replacement (SAVR): This involves the complete excision of the diseased aortic valve followed by the implantation of a prosthetic valve. SAVR is predominantly considered for patients who do not meet the criteria for a minimally invasive procedure, the Transcatheter Aortic Valve Replacement (TAVR or TAVI).

Several factors play a role in determining the type of surgery required, including:

• The results of diagnostic tests.
• Age.
•  The structure of the patient’s heart.
• The presence of other medical conditions.

Reasons for undergoing the procedure

Aortic valve disorders can lead to severe complications, such as heart failure, stroke, and sudden cardiac arrest. The two primary treatments for these conditions are aortic valve repair and replacement. While individuals with mild aortic valve disease may only need regular medical checkups, severe cases usually require surgical intervention.

The primary aortic valve conditions are:

• Aortic valve regurgitation: This happens when blood reverses into the left ventricle due to a faulty or leaky aortic valve. The root cause can be an innate valve defect from birth or any other condition harming the aortic valve.
• Aortic valve stenosis: In this condition, the aortic valve doesn’t open fully, causing the heart to exert more to push blood into the aorta. It can arise from a congenital heart defect or be the outcome of an infection like rheumatic fever, which inflames and damages the heart valve.
• Congenital heart defects: Some newborns might have aortic valves with inadequate cusps or no opening. Also, the valve can be incorrectly sized or shaped.

The decision between valve repair or replacement depends on:

• Disease severity
• Patient’s age and health status
• Any other concurrent heart conditions

Valve repair is generally preferred by surgeons since it preserves the natural heart valve, reduces infection risk, and can enhance heart performance. However, the suitable treatment varies based on the specific issue and the medical team’s proficiency.

Risk

Aortic valve surgery, as with other surgical procedures, comes with its own set of potential risks. These can include:

• Irregular heartbeats (arrhythmia).
• Anesthesia-related allergic reactions.
• Excessive bleeding.
• Myocardial infarction (heart attack).
• Heart failure.
• Post-operative infections.
• Stroke.

However, it’s worth noting that certain individuals may face a heightened risk of these complications based on various factors such as:

• Age.
• Existing health conditions.
• The surgical approach chosen (e.g., traditional open surgery vs. minimally invasive techniques).

Procedure

Before undergoing aortic valve repair or replacement surgery, your medical team will guide you through the entire process, detailing what will occur pre-operatively, intra-operatively, and post-operatively, while also highlighting the potential risks associated with the procedure. It’s essential to communicate with your caregivers prior to your hospital admission about the upcoming stay and to plan any assistance you might require upon returning home.

Before the procedure

Prior to your surgery, your healthcare provider might request certain preoperative tests. These tests could include:

• Cardiac catheterization (also known as heart catheterization).
• Chest radiography (commonly referred to as a chest X-ray).
• Computed tomography (known as a CT scan).
• Echocardiography (often called an echocardiogram or echo).
• Electrocardiography (referred to as an EKG or ECG).
• Laboratory tests, encompassing blood and urine assessments.

Your healthcare provider will provide detailed instructions which are crucial for you to adhere to. These guidelines will specify:

• The precise time you need to start fasting, which usually implies abstaining from food and beverages. In most cases, fasting starts after midnight on the eve of your surgery.
• Any necessary adjustments to your medication regimen.
• The designated time you need to report to the hospital.

Upon reaching the hospital for your surgery, a medical specialist will insert an intravenous (IV) line into your forearm or hand. This IV will be used to deliver fluids and medicines. If necessary, they might also shave or trim hair around the area where the surgery will be conducted. For valve repair and replacement surgeries, it’s standard to administer general anesthesia, which ensures you’re in a deep, painless slumber throughout the procedure. During this surgery, you might be connected to a heart-lung bypass machine, guaranteeing uninterrupted blood flow in your body.

During the procedure

Aortic valve repair

Aortic valve repair typically requires open-heart surgery, where the chest bone or sternotomy is opened. After the procedure, surgeons use wires to join the bone back to facilitate healing.

There are various methods of aortic valve repair, including:

• Patching holes or tears in the flaps with tissue (for perforated cusps).
• Strengthening the base or roots of the valve.
• Unfusing valve cusps that have adhered to each other.
• Adjusting or removing tissue to ensure the valve closes securely.
• Reinforcing or tightening the valve’s surrounding ring by installing an artificial ring, a process known as annuloplasty.

Minimally invasive aortic valve repair

Balloon valvuloplasty is a less invasive procedure intended to fix an aortic valve that doesn’t open completely due to stenosis. This procedure usually means smaller cuts and a quicker hospital recovery.

In this technique, a surgeon threads a catheter, a thin hollow tube, from a blood vessel in the groin up to the heart. A balloon attached to the catheter’s end is then inflated to expand the constricted valve.

This method is commonly used for children and infants with aortic valve stenosis. However, for adults, the valve may narrow again post-procedure, so it’s generally reserved for those too ill for surgery or those awaiting valve replacement. Follow-up procedures might be required.

Replacement heart valves can sometimes leak or deteriorate. In such cases, either a surgery or a catheter procedure might be performed to mend or seal a leaking replaced heart valve.

Aortic valve replacement

Should the aortic valve be beyond repair, a replacement becomes necessary. The faulty valve is removed and substituted with either a mechanical one or a biological tissue valve sourced from cows, pigs, or human donors. In some instances, a person’s pulmonary valve can be used as a replacement.

Mechanical valves necessitate lifelong blood-thinning medication to avert blood clots. On the other hand, biological valves may wear out and require future replacements.

Aortic valve replacements can be achieved through traditional open-heart surgery or through minimally invasive techniques. One such method is the Transcatheter aortic valve replacement (TAVR), also known as Transcatheter aortic valve implantation (TAVI).

The outcomes of minimally invasive aortic valve replacements, when conducted by seasoned surgeons in specialized centers, are comparable to those of conventional open-heart surgeries.

After the procedure

After undergoing an aortic valve repair or replacement, you’ll likely stay in the intensive care unit (ICU) for at least a day. In the ICU, you’ll be administered fluids, nutrition, and medications through intravenous (IV) lines. Additionally, tubes will be in place to drain urine from your bladder and excess fluid or blood from your heart and chest, with oxygen supplied if necessary. Once stabilized, you’ll be shifted to a standard hospital room for several days, though the exact duration of your hospital stay, encompassing both the ICU and regular room, will depend on your health and the specifics of your procedure.

Throughout your hospitalization, the medical team will:

• Monitor your incision sites for any signs of infection.
• Routinely check vital signs such as blood pressure, respiratory rate, and heart rhythm.
• Assist in pain management post-surgery.
• Motivate you to engage in gentle walks and breathing exercises to aid your recovery.

The length of recovery is determined by the type of procedure, your pre-surgical health, and any complications after the surgery. Once discharged, you might be recommended to refrain from driving and from lifting objects heavier than 10 pounds for several weeks.

Outcome

Following aortic valve repair or replacement surgery, your healthcare professional will provide guidance on when you can resume daily activities, including work, driving, and exercise.

Regular checkups will be necessary to monitor your heart’s condition and to detect any potential complications, such as valve malfunction. Imaging tests may be conducted to ensure the proper functioning of the aortic valve.

Maintaining a heart-healthy lifestyle is crucial after heart valve surgery, and your healthcare provider may advise the following lifestyle adjustments:

• Incorporating regular physical activity into your routine.
• Managing your weight effectively.
• Adhering to a nutritious diet.
• Implementing stress management techniques.
• Quitting smoking if you are a smoker.

Furthermore, your healthcare provider may recommend participation in a cardiac rehabilitation program. This program combines education and exercise to enhance your overall health and facilitate your recovery following aortic valve surgery.

If you experience any of the following symptoms, please get in touch with your healthcare provider:

• Chest pain or a feeling of pressure in your chest.
• Presence of discharge or pus around the area of your surgical incision.
• Fever or experiencing chills.
• Heart palpitations (irregular or rapid heartbeat).
• Discomfort or pain near the site of your surgical incision.
• Noticeable swelling or redness around the incision site.
• Swelling (edema) in your legs or feet.
• A sudden weight gain of more than 3 pounds within a week.