Aortic valve repair and aortic valve replacement

Overview

Aortic valve repair and aortic valve replacement are types of heart valve surgery. They are done to treat a damaged or diseased aortic valve.

The aortic valve is one of four valves that control blood flow in the heart. It is between the lower left heart chamber and the body's main artery, called the aorta.

Heart valves keep blood flowing in the correct direction through the heart. When the heart squeezes, the aortic valve opens. Blood flows from the lower left heart chamber into the aorta. When the heart relaxes, the aortic valve closes. This prevents blood from moving backward.

A diseased or damaged valve can change the flow of blood. The heart then has to work harder to send blood to the rest of the body.

Aortic valve repair and aortic valve replacement help improve blood flow and reduce symptoms of heart valve disease. The treatments also may prolong life. Aortic valve repair or replacement may be done as an open-heart surgery or as a minimally invasive procedure.

Why it's done

Aortic valve repair and aortic valve replacement are done to treat aortic valve disease. Types of aortic valve disease that may need valve repair or replacement include:

• Aortic valve regurgitation. The aortic valve doesn't close properly, causing blood to flow backward into the left lower heart chamber. Any condition that damages the aortic valve can cause regurgitation. Sometimes, a baby is born with an irregularly shaped aortic valve that leads to regurgitation.
• Aortic valve stenosis. The aortic valve flaps, called cusps, become thick and stiff, or they connect together. The valve becomes narrowed or doesn't open fully. This reduces or blocks blood flow. Aortic valve stenosis may be caused by a heart condition present at birth or by some infections that affect the heart valve.
• Other aortic valve problems present at birth, called congenital heart defects. Some babies may be born with an aortic valve that's missing a valve opening or that has two valve cusps instead of three. A congenital heart defect also can cause the valve to be the wrong size or shape.

You might need aortic valve surgery if your valve disease affects your heart's ability to pump blood. If you don't have symptoms or if your condition is mild, your healthcare team might suggest regular health checkups, lifestyle changes and medicines. But most aortic valve conditions eventually need surgery to reduce symptoms and lower the risk of complications such as heart failure.

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

• The severity of aortic valve disease, also called the stage of disease.
• Age and overall health.
• Whether surgery is needed to correct another valve or heart condition.

In general, surgeons recommend valve repair when possible. It lowers the risk of infection, saves the heart valve and may help the heart work better. The best option depends on the specific aortic valve disease, as well as the expertise and experience of the healthcare team.

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 healthcare team explains the benefits and risks of each option.

Risks

All surgeries have risks. Risks of aortic valve repair and replacement depend on many things, including:

• Your overall health.
• The specific type of valve surgery.
• The expertise of the surgeons and other healthcare professionals.

To reduce potential risks, aortic valve surgery should generally be done at a center with a multidisciplinary heart team that is experienced in such procedures and does many aortic valve surgeries.

Possible risks of aortic valve repair and aortic valve replacement surgery may include:

• Bleeding.
• Blood clots.
• Problem or failure of a replacement valve.
• Irregular heartbeats, called arrhythmias.
• Infection.
• Stroke.

How you prepare

Before surgery to have your aortic valve repaired or replaced, your healthcare team explains to you what to expect before, during and after the surgery and the potential risks of the surgery.

Before being admitted to the hospital for your heart valve surgery, talk to your caregivers about your upcoming hospital stay. Discuss any help you may need when you return home.

Don't hesitate to ask your care providers any questions you may have about the procedure.

Food and medications

Talk to your healthcare team about:

• When or if you can take your regular medicines before surgery.
• Allergies or reactions you or your child has to medicines.
• When or if you should stop eating or drinking the night before surgery.

Clothing and personal items

Your healthcare team may suggest that you bring several items to the hospital including:

• A list of your medicines.
• Eyeglasses, hearing aids or dentures.
• Personal care items such as a brush, a comb, a shaving kit and a toothbrush.
• Loose, comfortable clothing.
• A copy of your advance directive. This is a legal document. It includes instructions about the kinds of treatments you want — or don't want — in case you become unable to express your wishes.
• Items that help you relax such as portable music players or books.

During surgery, do not wear:

• Contact lenses.
• Dentures.
• Eyeglasses.
• Jewelry.
• Nail polish.

What you can expect

Before the procedure

You may need to have your body hair shaved where the surgical cuts, called incisions, are made. A special soap might be used to wash your skin to help prevent infection.

During the procedure

You receive medicine called an anesthetic to put you in a sleep-like state during the surgery. You are connected to a heart-lung bypass machine. The machine keeps blood moving through the body during the aortic valve surgery.

Aortic valve repair and aortic valve replacement may be done as:

• Open-heart surgery. This involves making a surgical cut, called an incision, through the middle of the chest to reach the heart.
• Minimally invasive heart surgery. This involves much smaller incisions than those used in open-heart surgery. Minimally invasive surgery usually does not require cutting any significant muscle or breaking any bones. Transcatheter aortic valve replacement (TAVR) is a type of minimally invasive heart valve surgery.

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

Aortic valve repair

Aortic valve repair is usually done with open-heart surgery and by opening the chest bone, a procedure called a sternotomy. Surgeons wire the bone back together after the procedure.

During aortic valve repair surgery, the heart surgeon might:

• Patch holes or tears in the aortic valve cusps.
• Add support at the base or roots of the valve.
• Separate valve cusps that have connected together.
• Reshape or remove tissue to allow the valve to close more tightly.
• Tighten or reinforce the ring around the valve, called the annulus.

Minimally invasive aortic valve repair

In some people with a narrowed aortic valve, a minimally invasive treatment called balloon valvuloplasty may be done to repair the valve. It uses much smaller surgical cuts than open-heart surgery. It does not require opening the chest bone.

During balloon valvuloplasty, the heart doctor places a thin, flexible tube called a catheter into an artery in the arm or groin. The tube is guided to the diseased or damaged aortic valve. A balloon on the tip of the catheter is inflated, which makes the valve opening larger. The balloon is deflated. The catheter and balloon are removed.

Balloon valvuloplasty is often used to treat infants and children with aortic valve stenosis. The aortic valve tends to narrow again in adults who have had the treatment. So balloon valvuloplasty is usually only done in adults who are too ill for surgery or who are waiting for a valve replacement.

Aortic valve replacement

If the aortic valve can't be fixed and other treatments aren't an option, the valve might need to be replaced.

During aortic valve replacement, a surgeon removes the valve and replaces it with a mechanical valve or a valve made from cow, pig or human heart tissue. Valves made from living tissue are called biological tissue valves.

A type of biological tissue valve replacement that uses your own lung valve, called the pulmonary valve, is sometimes possible. This more complicated surgery is called the Ross procedure.

Aortic valve replacement may be done using open-heart surgery or minimally invasive methods. Transcatheter aortic valve replacement (TAVR) is a type of minimally invasive aortic valve replacement. It also is called transcatheter aortic valve implantation (TAVI). During TAVR, long flexible tubes called catheters are used to place a biological valve in the heart to replace an aortic valve that is no longer working properly.

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

Aortic valve replacement

If the aortic valve can't be fixed and other treatments aren't an option, the valve might need to be replaced.

During aortic valve replacement, a surgeon removes the valve and replaces it with a mechanical valve or a valve made from cow, pig or human heart tissue. Valves made from living tissue are called biological tissue valves.

A type of biological tissue valve replacement that uses your own lung valve, called the pulmonary valve, is sometimes possible. This more complicated surgery is called the Ross procedure.

Aortic valve replacement may be done using open-heart surgery or minimally invasive methods. Transcatheter aortic valve replacement (TAVR) is a type of minimally invasive aortic valve replacement. It also is called transcatheter aortic valve implantation (TAVI). During TAVR, long flexible tubes called catheters are used to place a biological valve in the heart to replace an aortic valve that is no longer working properly.

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

The amount of time spent in the hospital after aortic valve surgery depends on the specific heart condition and type of procedure.

While in the hospital, you get fluids and medicines through an IV. Other tubes drain urine from the bladder and fluid and blood from the chest. You might get oxygen through a mask or a small plastic tube next to your nose.

During your hospital stay, your healthcare team does the following:

• Tracks your condition and watches for signs of infection.
• Checks your blood pressure, breathing and heart rate.
• Works with you to manage any pain.

You may be asked to walk regularly. This helps you slowly become more active. You are usually asked to cough and to do breathing exercises as you recover too. Recovery time depends on the specific type of aortic valve repair or replacement.

Results

After aortic valve repair or replacement surgery, your healthcare team tells you when you can return to your usual activities. You may be told not to drive or lift anything heavier than 10 pounds for several weeks.

You need to go to regular follow-up appointments with your healthcare professional. Imaging tests may be done to make sure the aortic valve is working correctly.

If you have a mechanical valve, you need to take blood thinners for life to prevent blood clots. Biological valves often need to be replaced eventually, as they tend to wear out over time. Mechanical valves usually do not wear out 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.

To keep your heart working well, your healthcare team may recommend lifestyle changes. Examples are:

• Eating a healthy diet.
• Getting regular exercise.
• Managing stress.
• Not smoking or using tobacco.

Your care team also might suggest a personalized exercise and education program called cardiac rehabilitation. It teaches ways to improve heart health after heart surgery. It focuses on exercise, a heart-healthy diet, stress management and a gradual return to usual activities.