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Aortic valve repair and aortic valve replacement

Overview

Aortic valve repair and aortic valve replacement are procedures that treat diseases affecting the aortic valve.

The aortic valve is one of four valves that regulate blood flow through the heart. These valves keep blood flowing in the correct direction through the heart.

The aortic valve separates the heart's main pumping chamber (left ventricle) and the main artery that supplies oxygen-rich blood to your body (aorta).

With each contraction of the ventricle, the aortic valve opens and allows blood to flow from the left ventricle into the aorta. When the ventricle relaxes, the aortic valve closes to prevent blood from flowing backward into the ventricle.

When the aortic valve isn't working properly, it can interfere with blood flow as well as force the heart to work harder to supply the necessary blood to the rest of your body.

In some people, aortic valve disease may not cause any signs or symptoms for many years, if at all. Others may experience shortness of breath, fatigue, chest pain, loss of consciousness, irregular heartbeat (arrhythmia), heart failure and sudden cardiac death.

Aortic valve repair or aortic valve replacement can treat aortic valve disease and help restore normal blood flow, reduce symptoms, prolong life and help preserve the function of your heart muscle.

Chambers and valves of the heart

A normal heart has two upper (receiving) and two lower (pumping) chambers. The upper chambers, the right and left atria, receive incoming blood. The lower chambers, the more muscular right and left ventricles, pump blood out of your heart. The heart valves, which keep blood flowing in the correct direction, are gates at the chamber openings (for the tricuspid and mitral valves) and exits (for the pulmonary and aortic valves).

Why it's done

Aortic valve disease treatment depends on the severity of your condition, whether or not you're experiencing signs and symptoms, and if your condition is getting worse.

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

Aortic valve regurgitation occurs when blood flows backward through the aortic valve into the left ventricle each time the ventricle relaxes rather than in the normal, one-way direction from the ventricle to the aorta.

Back flow may be caused by a dysfunctional or leaky valve. This may be due to deterioration of the valve, an abnormal valve shape present at birth (congenital heart disease) or by a bacterial infection.

Aortic valve stenosis causes the aortic valve to become narrowed or obstructed, which makes it harder for the heart pump blood into the aorta. This may be caused by congenital heart disease, thickening of the valve's closure flaps (cusps) or post-inflammatory changes, such as those associated with rheumatic heart disease.

Congenital heart disease may contribute to aortic valve regurgitation or stenosis as well as result in other problems that prevent the aortic valve from working properly. For example, a person may be born with an aortic valve that doesn't have enough tissue flaps (cusps), the valve may be the wrong size or shape, or there may not be an opening to allow blood to flow normally (atresia).

For some people with mild aortic valve disease without symptoms, careful monitoring under a doctor's supervision may be all that's needed.

But in most cases, aortic valve disease and dysfunction progress and get worse despite medical treatment. Most aortic valve conditions are mechanical problems that cannot be adequately treated with medication alone and will 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.

Aortic valve repair or replacement?

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

  • The severity of your aortic valve disease
  • Your age and overall health
  • Whether you need heart surgery to correct another heart problem in addition to aortic valve disease, such as heart bypass surgery to treat coronary artery disease, so both conditions can be treated at once.

In general, heart valve repair is usually the first choice because it's associated with a lower risk of infection, preserves valve strength and function, and reduces the need to take blood-thinning medications for the rest of your life as necessary with certain types of valve replacement. For example, people with a hole in the valve's closure flaps (perforated valve leaflet) may be candidates for aortic valve repair rather than replacement, depending on the severity of their condition.

Not all valves can be repaired, however, and heart valve repair surgery is often harder to do than valve replacement. Your best option will depend on your individual situation as well as the expertise and experience of your multidisciplinary heart team.

Aortic valve repair and aortic valve replacement may be performed through traditional open-heart surgery, which involves a cut (incision) in the chest, or through minimally invasive methods that 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. Minimally invasive heart surgery should generally be performed by a multidisciplinary heart team experienced in these types of procedures.

What type of procedure you have depends on your individual situation, and your doctor will explain the benefits and risks of each option.

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.

Many people with aortic valve disease also have coronary artery disease and may need heart bypass surgery to improve blood flow. Heart bypass surgery is normally performed through traditional open-heart surgery, so your aortic valve procedure would be performed the same way.

Aortic valve regurgitation

In aortic valve regurgitation, the aortic valve doesn't close properly, causing blood to leak backward into the left ventricle.

Aortic valve stenosis

Aortic valve stenosis is a defect that narrows or obstructs the aortic valve opening, making it difficult for the heart to pump blood into the aorta. Mild cases may not have symptoms initially, but they can worsen over time. Typically the aortic valve has three cusps (tricuspid aortic valve), but some people are born with an aortic valve that has two cusps (bicuspid aortic valve).

Incisions in minimally invasive heart surgery and open-heart surgery

In minimally invasive heart surgery, surgeons access the heart through small cuts (incisions) in the chest, as shown in the top two images. In open-heart surgery, surgeons make a larger incision in the chest, as shown in the bottom image.

Risks

Aortic valve repair and aortic valve replacement surgery risks vary depending on your health, the type of procedure and the expertise of your health care team. To minimize potential risk, aortic valve surgery should generally be performed at a center with a multidisciplinary heart team experienced in these procedures and that performs high volumes of aortic valve surgeries.

Risks associated with aortic valve repair and aortic valve replacement surgery may include:

  • Bleeding
  • Blood clots
  • Valve dysfunction in replacement valves
  • Heart rhythm problems
  • Infection
  • Stroke
  • Death

How you prepare

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

Discuss with your doctor and treatment team any questions you may have about the procedure.

Before being admitted to the hospital for your surgery, talk to your caregivers about your hospital stay and discuss any help you may need when you return home.

Food and medications

Talk to your doctor about:

  • When you can take your regular medications and whether you can take them before your surgery
  • When you should stop eating or drinking the night before the surgery

Clothing and personal items

Your treatment team may recommend that you bring several items to the hospital including:

  • A list of your medications
  • Eyeglasses, hearing aids or dentures
  • Personal care items, such as a brush, comb, shaving equipment and toothbrush
  • Loosefitting, comfortable clothing
  • A copy of your advance directive or living will
  • Items that may help you relax, such as portable music players or books
  • Any prescribed medical devices or equipment

During surgery, avoid wearing:

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

Your body hair will be shaved off at the location where the procedure will take place.

What you can expect

For most aortic valve repair and aortic valve replacement procedures, you'll receive anesthetics so you won't feel any pain, and you'll be unconscious during the surgery.

You'll also be connected to a heart-lung bypass machine, which keeps blood moving through your body during the procedure.

Aortic valve repair

Aortic valve repair is usually performed through traditional open-heart surgery and opening of the chest bone (sternotomy). Doctors 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) that close off the valve
  • Adding support at the base or roots of the valve
  • Separating fused valve cusps
  • Reshaping or removing tissue to allow the valve to close more tightly
  • Tightening or reinforcing the ring around a valve (annulus) by implanting an artificial ring (annuloplasty)

Aortic valves that can't open fully due to aortic valve stenosis may be repaired with surgery or with a less invasive procedure called balloon valvuloplasty — which uses an approach called cardiac catheterization. You're usually awake during cardiac catheterization, and it requires a much shorter hospital stay than traditional heart surgery.

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 performed 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.

Doctors may also use a catheter procedure to perform aortic valve repair by inserting a plug or device to fix a leaking replacement heart valve.

Aortic valve replacement

In this procedure, your doctor removes the aortic valve and replaces it with a mechanical valve or a valve made from cow, pig or human heart tissue. Another type of biological tissue valve replacement that uses your own pulmonary valve is sometimes possible.

Often biological tissue valves often eventually need to be replaced, as they degenerate over time. If you have a mechanical valve, you'll need to take blood-thinning medications for the rest of your life to prevent blood clots. Doctors will discuss with you the risks and benefits of each type of valve and discuss which valve may be appropriate for you.

Aortic valve replacement surgery may be performed through traditional open-heart surgery or minimally invasive methods, which involve smaller incisions than those used in open-heart surgery.

But minimally invasive aortic valve replacement is less common because not all situations are best addressed by this method of access to the damaged valve. When performed by experienced surgeons and centers, the results are similar to those with traditional open-heart surgery.

Transcatheter aortic valve replacement (TAVR)

Transcatheter aortic valve replacement (TAVR) is another type of minimally invasive aortic valve replacement that has a nonsurgical approach. It is also sometimes called transcatheter aortic valve implantation (TAVI).

During TAVR, your doctors may access your heart through a blood vessel in your leg or a small incision in the chest. A hollow tube (catheter) is guided through your veins to the aortic valve. Once it is positioned correctly, a balloon-expandable or self-expandable replacement aortic valve is inserted.

TAVR may be an option for people who are considered to be at intermediate or high risk of complications from surgical aortic valve replacement.

TAVR may also be an option if you have an existing biological tissue valve that was previously inserted to replace the aortic valve, but it isn't functioning well anymore.

After the procedure

You'll generally spend a day or more in the intensive care unit (ICU). You'll be given oxygen, fluids, nutrition and medications through intravenous (IV) lines. Other tubes will drain urine from your bladder and drain fluid and blood from your chest.

After 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 treatment team will likely:

  • 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 experience after surgery
  • Instruct you to walk regularly to gradually increase your activity and do breathing exercises as you recover

Your doctor may give you instructions to follow during your recovery, such as watching for signs of infection in your incisions, properly caring for incisions, taking medications, and managing pain and other side effects after your surgery.

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

Your doctor may advise you to avoid driving a car or lifting anything more than 10 pounds for several weeks. Your doctor will discuss with you when you can return to normal activities.

Mechanical valve replacement

In a mechanical valve replacement, a mechanical valve replaces the damaged valve.

Biological valve replacement

In a biological valve replacement, a biological or tissue valve replaces the damaged valve.

Transcatheter aortic valve replacement (TAVR)

Transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure to replace a narrowed aortic valve that fails to open properly (aortic valve stenosis). In this procedure, doctors insert a catheter in your leg or chest and guide it to your heart. A replacement valve is inserted through the catheter and guided to your heart. A balloon is expanded to press the valve into place. Some TAVR valves are self-expanding.

Results

After aortic valve repair or aortic valve replacement surgery, you may eventually be able to return to daily activities, such as working, driving and exercise.

You'll still need to take certain medications and attend regular follow-up appointments with your doctor. You may have several tests to evaluate and monitor your condition.

Your doctor and health care team may instruct you to incorporate healthy lifestyle changes — such as physical activity, a healthy diet, stress management and avoiding tobacco use — into your life to reduce the risk of future complications and promote a healthy heart.

Your doctor may recommend that you participate in cardiac rehabilitation — a program of education and exercise designed to help you improve your health and help you recover after heart surgery.

What you can expect

Mayo Clinic's doctors and researchers are established pioneers in the field of heart surgery and are involved in numerous international and national studies to improve the technology and techniques used in aortic valve repair and aortic valve replacement.

Researchers study many areas related to heart valve diseases, including research in new blood-thinning medications for people with a mechanical valve replacement and genetics research in people with aortic valve disease.

As a patient at Mayo Clinic, you may have access to more than 100 heart-related clinical trials as a part of your treatment.

Last updated: March 27th, 2018

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