Valve-sparing aortic root replacement

Overview

Valve-sparing aortic root replacement is a surgical procedure designed to replace the segment of the aorta directly attached to the heart, known as the aortic root, while preserving the patient’s natural aortic valve. The aortic root, connecting to the left ventricle, houses the aortic valve responsible for regulating blood flow from the heart to the aorta. During each heartbeat, the aortic valve opens during systole, allowing blood to enter the aorta, and closes during diastole to prevent backward blood flow into the heart.

In cases where the aortic root is damaged but the aortic valve remains healthy or only mildly diseased, a new aortic valve may not be necessary. Instead, the focus is on replacing the aortic root while potentially preserving the existing valve. Unlike the traditional aortic root replacement surgery, known as the Bentall procedure or composite graft replacement, which involves replacing both the aortic root and the aortic valve, valve-sparing aortic root replacement aims to maintain the patient’s natural valve.

This alternative procedure offers several advantages. By retaining the native aortic valve, it eliminates many risks associated with valve replacement, leading to generally favorable outcomes. Particularly in high-volume surgical centers with experienced surgeons specializing in these operations, the procedure has demonstrated excellent results. Additionally, avoiding the need for a new valve eliminates the lifelong requirement for the blood thinner Coumadin, which is typically necessary with mechanical valve replacements.

Reasons for undergoing the procedure

Valve-sparing aortic root replacement is a surgical intervention designed to address conditions such as aortic root aneurysm and ascending aortic aneurysm with dilated aortic sinuses. These conditions involve abnormal dilatation of the aorta, posing risks such as valve dysfunction, aortic dissection, or rupture. Individuals with predisposing factors, such as certain connective tissue disorders like Marfan syndrome, are at a higher risk.

Surgeons carefully assess the balance between the risks of surgery and potential complications before determining the need for intervention. Valve-sparing aortic root replacement, as an alternative to the Bentall procedure, is considered for individuals with specific criteria. Ideal candidates typically exhibit minimal or no calcium build-up on the aortic valve, minimal or no damage to the valve, and proper functionality or repairability of the valve.

In appropriately selected candidates, valve-sparing aortic root replacement has demonstrated favorable short- and long-term outcomes. The procedure aims to mitigate the risks associated with aortic root aneurysms, providing a tailored approach to address the individual’s unique circumstances.

Surgeons employ two primary techniques for aortic root replacement while preserving the aortic valve:

• Reimplantation: This method, specifically the modified reimplantation operation, is favored for individuals under 75 years old, those with connective tissue disorders, and those with aortic root aneurysms associated with inherited disorders. The modified reimplantation technique is designed to enhance long-term durability, with specific modifications detailed later in the article.
• Remodeling: The second technique involves remodeling the aortic root.

Risks

Valve-sparing aortic root replacement is a significant surgical procedure that demands the expertise of a skilled and seasoned surgeon. Similar to other major surgeries, there is a potential for rare complications. These may involve:

• Bleeding.
• Kidney failure.
• Difficulty of breathing
• Formation of blood clots.
• Infection in the graft.
• Occurrence of a heart attack or stroke.
• Requirement for a pacemaker.
• Infections in the lungs, urinary tract, or abdominal area.

It is crucial to engage in a detailed discussion with your surgeon to assess your specific risk level, taking into account your overall health and underlying medical conditions. When performed by experienced surgical professionals, the associated risks are generally minimal.

Before the procedure

Preparation for your upcoming surgery requires careful adherence to your surgeon’s detailed instructions. Key steps include:

• Medication management: Follow your surgeon’s guidance on adjusting your usual medication schedule. Do not alter any medications without explicit instructions.
• Fasting guidelines: Abstain from all foods and liquids, including water, after midnight on the evening before your surgery.
• Medication administration: Take specified medications on the morning of your surgery as directed by your surgeon.
• Transportation arrangements: Ensure you have arranged for someone to drive you to the hospital on the day of your surgery and pick you up when you are discharged.

Additionally, your surgeon may order various tests to plan for your surgery, such as:

• Echocardiogram
• Blood tests
• Cardiac and chest electrocardiogram (EKG) gated computed tomography (CT) scan
• Heart magnetic resonance imaging (MRI)
• Coronary angiogram
• Genetic blood test for suspected connective tissue disorder

Engage in discussions with your surgeon covering:

• Your current medication list, including over-the-counter medications.
• Any existing medical conditions.
• Recent health status, including recent illnesses.
• Smoking or tobacco use; refrain from tobacco products for at least one month before surgery.

Your consultations with the surgeon should also cover:

• Detailed information and risks associated with the surgery.
• Long-term prognosis and durability of the valve.

Throughout these appointments, do not hesitate to ask questions to ensure a comprehensive understanding of your responsibilities and what to anticipate during and after the surgery.

During the procedure

Valve-sparing aortic root replacement typically takes four to six hours, with your heart stopped for about an hour by an experienced surgeon. The procedure involves several key steps:

• Anesthesia: You are given medication to put you to sleep and prevent pain during surgery.
• Chest incision: A median sternotomy is performed to access your heart by making an incision in your chest.
• Heart-lung bypass machine: You are connected to a heart-lung bypass machine, which temporarily takes over the functions of your heart and lungs during surgery.
• Valve mobilization: Your surgeon separates your aortic valve from the surrounding tissues.
• Valve flap repair: If necessary, damaged valve flaps are repaired, especially in cases of a bicuspid aortic valve or significant valve leakage.
• Aorta repair: Abnormally widened portions of the aortic root and ascending aorta are removed.
• Graft insertion: A collagen-coated polyester tube (graft) is inserted to replace the damaged part of the aorta. Stitches secure the graft in place.
• Valve reimplantation: Your surgeon implants your valve into the graft and ensures it is securely sewn in place.
• Valve testing: A solution is sent through the graft to confirm proper valve function. The valve flaps are checked for correct shape and movement.
• Finalizing the procedure: Necessary final steps, such as connecting coronary arteries to the graft, are completed. The distal end of the graft is connected to the remaining part of the ascending aorta or aortic arch.
• Heart-lung bypass removal: You are gradually taken off the bypass machine to restore normal blood flow through your heart and lungs. The chest incision is then closed.
• Echocardiogram: A transesophageal echocardiogram is performed to check the success of the surgery before leaving the operating room.

After the procedure

Following valve-sparing aortic root replacement, one can expect to stay in the intensive care unit (ICU) for a day or two before transitioning to a standard hospital room. Typically, patients are discharged within four days to one week. Before leaving, a repeat echocardiogram and chest computed tomography (CT) scan are conducted to ensure the success of the repair. Throughout your hospital stay, the medical team will closely monitor your recovery, utilizing tubes to drain fluids and administering medications for pain relief and blood clot prevention. Adhering to the care team’s guidance is crucial, and it’s important to take a gradual approach to avoid setbacks in your recovery. Driving is only permitted when approved by your healthcare provider, so arrangements for a ride home upon discharge are necessary.

Outcome

Recovery typically takes six weeks after cardiac surgery. Engaging in cardiac rehab aids in a quicker recovery and provides a supportive community. Follow-up appointments with the surgery team are crucial, and routine imaging tests will be conducted by your cardiologist for long-term monitoring. Adhering to all appointments is vital for ongoing care.

Return to normal activities, including driving, lifting, and work, is usually allowed after six weeks, but individual instructions may vary. Some individuals, like NBA players, have returned to professional sports after modified reimplantation.

Immediate contact with your healthcare provider is necessary if you notice signs of post-surgery complications such as incision issues, chest pain, shortness of breath, leg swelling, dizziness, coughing up blood or unusual mucus, fever, or blood in stool.