Aortic valve repair and aortic valve replacement

Overview

Aortic valve repair and aortic valve replacement are procedures to treat a damaged or diseased aortic valve.

The aortic valve is one of four valves that control blood flow in the heart. It separates the lower left heart chamber (left ventricle) and the body's main artery (aorta).

When the heart squeezes (contracts), the aortic valve opens and lets blood flow from the left ventricle into the aorta. When the heart relaxes, the aortic valve closes to prevent blood from moving backward.

A diseased or damaged aortic valve can interfere with blood flow and force the heart to work harder to send blood to the rest of the body.

Aortic valve repair or aortic valve replacement can improve blood flow, reduce symptoms of heart valve disease and prolong life.

Aortic valve repair and aortic valve replacement are done to treat aortic valve disease. Mild aortic valve disease without symptoms may only require frequent health checkups. But most aortic valve conditions are mechanical problems that eventually require surgery to reduce symptoms and the risk of complications, such as heart failure, heart attack, stroke or death due to sudden cardiac arrest.

Types of aortic valve disease that may require treatment with aortic valve repair or replacement include:

• Aortic valve regurgitation. Blood flows backward through the aortic valve into the heart's main pumping chamber (left ventricle). Aortic valve regurgitation may result from a leaky or dysfunctional valve. Any condition that damages the aortic valve can cause regurgitation. Sometimes, a baby is born with an irregularly shaped aortic valve (congenital heart defect) that leads to regurgitation.
• Aortic valve stenosis. The aortic valve is narrowed or blocked. It's hard for the valve to open properly. The heart must work harder to pump blood into the aorta. Aortic valve stenosis may be caused by a heart condition present at birth (congenital heart defect). An infection called rheumatic fever may lead to inflammation that damages the heart valve (rheumatic heart disease).
• Other aortic valve problems present at birth (congenital heart defects). Some babies may be born with an aortic valve that's missing a valve opening or that doesn't have enough tissue flaps (cusps). A congenital heart defect can also cause the valve to be the wrong size or shape.

The decision to repair or replace a damaged aortic valve depends on many things, including:

• The severity (stage) of aortic valve disease
• Age and overall health
• Whether surgery is needed to correct another valve or heart condition

In general, surgeons recommend valve repair when possible, as it lowers the risk of infection, saves the heart valve and may improve heart function. The best option depends on the specific aortic valve problem, as well as the expertise and experience of the health care team.

Aortic valve repair and aortic valve replacement may be done through traditional open-heart surgery, which involves a cut (incision) in the chest, or by using minimally invasive methods, which involve smaller incisions in the chest or a catheter inserted in the leg or chest (transcatheter aortic valve replacement, or TAVR).

Minimally invasive heart surgery may involve a shorter hospital stay, quicker recovery and less pain than traditional open-heart surgery.

What type of valve surgery you have depends on your individual situation. For example, some people with aortic valve disease may not be candidates for traditional open-heart surgery due to other health problems, such as lung or kidney disease, that would make the procedure too risky. Your health care provider will explain the benefits and risks of each option.

Before the procedure

When you arrive for surgery, a care provider will insert an IV into your forearm or hand. Fluids and medicines can be given through the IV. A care provider may shave off any hair at the location where the procedure will take place.

For most valve repair and replacement procedures, you'll receive medications that put you in a sleep-like state (general anesthesia) so you won't feel any pain during the surgery.

You may be connected to a heart-lung bypass machine. The machine keeps blood moving through the body during the heart valve surgery.

During the procedure

Aortic valve repair

Aortic valve repair is usually done with open-heart surgery and by opening the chest bone (sternotomy). Surgeons wire the bone back together after the procedure to prevent movement and aid in healing.

Aortic valve repair procedures may involve several different types of repair, including:

• Inserting tissue to patch holes or tears in the flaps (perforated cusps)
• Adding support at the base or roots of the valve
• Separating valve cusps that have fused
• Reshaping or removing tissue to allow the valve to close more tightly
• Tightening or reinforcing the ring around the valve (annulus) by implanting an artificial ring (annuloplasty)

Minimally invasive aortic valve repair

If the aortic valve can't fully open due to aortic valve stenosis, a less invasive procedure called balloon valvuloplasty may be used to repair the valve. Minimally invasive heart valve surgery typically involves smaller incisions and a shorter hospital stay than traditional open-heart surgery.

During balloon valvuloplasty, a surgeon inserts a thin, hollow tube (catheter) into a blood vessel, usually in the groin, and threads it to the heart. A balloon on the tip of the catheter is inflated, which widens the narrowed valve.

Balloon valvuloplasty is often used to treat infants and children with aortic valve stenosis. However, the valve tends to narrow again in adults who have had the procedure, so it's usually only done in adults who are too ill for surgery or who are waiting for a valve replacement. You may need additional procedures to treat the narrowed valve over time.

Some replacement heart valves may begin to leak or not work as well over time. Surgery or a catheter procedure may be done to repair or plug a leaking replacement heart valve.

Aortic valve replacement

If the aortic valve can't be repaired, surgery may be needed to replace the valve. In this procedure, a surgeon removes the aortic valve and replaces it with a mechanical valve or a valve made from cow, pig or human heart tissue (biological tissue valve). Another type of biological tissue valve replacement that uses your own lung (pulmonary) valve is sometimes possible.

If you have a mechanical valve, you'll need to take blood-thinning medications for life to prevent blood clots. Biological valves often eventually need to be replaced, as they break down (degenerate) over time. Together, you and your health care providers should discuss the risks and benefits of each type of valve to choose the one that's best for you.

Aortic valve replacement may be done using open-heart surgery or minimally invasive methods, which involve smaller incisions than those used in open-heart surgery. Transcatheter aortic valve replacement (TAVR) is a type of minimally invasive aortic valve replacement. It is also sometimes called transcatheter aortic valve implantation (TAVI).

When minimally invasive aortic valve replacement is done by experienced surgeons and centers, the results are like those with traditional open-heart surgery.

After the procedure

After aortic valve repair or replacement, you'll may spend a day or more in the intensive care unit (ICU).

You'll be given fluids, nutrition and medications through intravenous (IV) lines. Other tubes will drain urine from your bladder and drain fluid and blood from your heart and chest. You may be given oxygen.

After your stay in the ICU, you'll be moved to a regular hospital room for several days. The time you spend in the ICU and hospital can vary, depending on your condition and procedure.

During your hospital stay, your care providers will:

• Watch for signs of infection in your incision sites
• Periodically check your blood pressure, breathing and heart rate
• Work with you to manage any pain you have after surgery
• Encourage you to walk regularly to gradually increase your activity and do breathing exercises as you recover

Recovery time depends on your procedure, overall health before the procedure and any complications.

Your health care provider may tell you to avoid driving a car or lifting anything heavier than 10 pounds for several weeks.