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Valvular heart disease is a form of heart disease that occurs when one or more of the heart’s four valves don’t function properly. Valve replacement surgery may be an option if the valves of your heart are too fragile, scarred, or otherwise damaged to repair.
Aortic valve repair and aortic valve replacement are procedures that treat diseases affecting the aortic valve, one of four valves that control blood flow through the heart.
The aortic valve helps keep blood flowing in the correct direction through the heart. It 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 and force the heart to work harder to send blood to the rest of your body.
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.
Reasons for Replacement
The valves of the heart are responsible for allowing nutrient-rich blood to flow through the chambers of your heart. Each valve is supposed to close completely after ushering in blood flow. Diseased heart valves aren’t always able to perform the job as well as they should.
Stenosis, or a narrowing of the blood vessels, causes a less-than-normal amount of blood to flow to the heart. This causes the muscle to work harder. Leaky valves can also pose a problem. Instead of closing tightly, a valve may remain slightly open, letting blood flow backwards. This is called regurgitation. The signs of valvular heart disease can include:
- fatigue
- dizziness
- lightheadedness
- shortness of breath
- cyanosis
- chest pain
- fluid retention, especially in the lower limbs
Heart valve repair is also a solution for valvular heart disease. In some people, the damage is too far advanced and a total replacement of the affected valve is the only option.
Types
Mechanical and biologic valves are used to replace faulty valves. Mechanical valves are artificial components that have the same purpose as a natural heart valve. They’re created from carbon and polyester materials that the human body tolerates well. They can last between 10 and 20 years. However, one of the risks associated with mechanical valves is blood clots. If you receive a mechanical heart valve, you’ll need to take blood thinners for the rest of your life to reduce your risk of stroke.
Biologic valves, also called bioprosthetic valves, are created from human or animal tissue. There are three types of biologic heart valves:
- An Allograft or homograft is made of tissue taken from a human donor’s heart.
- A porcine valve is made from pig tissue. This valve can be implanted with or without a frame called a stent.
- A bovine valve is made from cow tissue. It connects to your heart with silicone rubber.
Biologic valves don’t increase your risk of developing blood clots. This means you most likely won’t need to commit to a lifetime of anti-clotting medication. A bioprosthetic doesn’t last as long as a mechanical valve and may require replacement at a future date.
Your doctor will recommend which type of heart valve you get based on:
- your age
- your overall health
- your ability to take anticoagulant medications
- the extent of the disease
Types of Valve Replacement Surgery
Aortic Valve Replacement
The aortic valve is on the left side of the heart and serves as an outflow valve. Its job is to allow blood to leave the left ventricle, which is the heart’s main pumping chamber. Its job is also to close so that blood doesn’t leak back into the left ventricle. You may need surgery on your aortic valve if you have a congenital defect or disease that causes stenosis or regurgitation.
The most common type of congenital abnormality is a bicuspid valve. Normally, the aortic valve has three sections of tissue, known as leaflets. This is called a tricuspid valve. A defective valve has only two leaflets, so it’s called a bicuspid valve. A recent study found that aortic valve replacement surgery has a 94 percent five-year survival rate. Survival rates depend on:
- your age
- your overall health
- other medical conditions you have
- your heart function
Mitral Valve Replacement
The mitral valve is located on the left side of the heart. It serves as an inflow valve. Its job is to allow blood from the left atrium to flow into the left ventricle. Surgery may be required if the valve doesn’t fully open or completely close. When the valve is too narrow, it can make it difficult for blood to enter. This can cause it to back up, causing pressure in the lungs. When the valve doesn’t close properly, blood can leak back into the lungs. This can be due to a congenital defect, infection, or a degenerative disease.
The defective valve will be replaced with either a metal artificial valve or a biological valve. The metal valve will last a lifetime but requires you to take blood thinners. The biological valve lasts between 15 to 20 years, and you won’t be required to take medication that thins your blood. The following also play a role in survival rate:
- your age
- your overall health
- other medical conditions you have
- your heart function
Ask your doctor to help assess your personal risks.
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Double Valve Replacement
A double valve replacement is a replacement of both the mitral and the aortic valve, or the entire left side of the heart. This type of surgery is not as common as the others and the mortality rate is slightly higher.
Pulmonary Valve Replacement
The pulmonary valve separates the pulmonary artery, which carries blood to the lungs for oxidation, and the right ventricle, which is one of the heart’s chambers. Its job is to allow blood to flow from the heart to the lungs through the pulmonary artery. The need for pulmonary valve replacement is usually due to stenosis, which restricts blood flow. Stenosis may be caused by a congenital defect, infection, or carcinoid syndrome.
Why it’s done
Aortic valve disease treatment depends on the severity of your condition, whether 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: This 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. The stenosis causes the aortic valve to become narrowed or obstructed, which makes it harder for the heart to pump blood into the aorta. This may be caused by congenital heart disease, thickening of the valve’s closure flaps (leaflets) or post-inflammatory changes, such as those associated with rheumatic heart disease.
- Congenital heart disease. Having this 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 get worse despite medical treatment. Most aortic valve conditions are mechanical problems that can’t be successfully treated with medication alone. Such conditions eventually require surgery to reduce symptoms and your risk of complications, such as heart failure, heart attack, stroke or death due to sudden cardiac arrest.
The Procedure
Heart valve replacement surgery is performed under general anesthesia with techniques that are either conventional or minimally invasive. Conventional surgery requires a large incision from your neck to your navel. If you have less invasive surgery, the length of your incision can be shorter and you can also reduce your risk of infection.
For a surgeon to successfully remove the diseased valve and replace it with a new one, your heart must be still. You’ll be placed on a bypass machine that keeps blood circulating through your body and your lungs functioning during surgery. Your surgeon will make incisions into your aorta, through which the valves will be removed and replaced.
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
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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
Before the procedure
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.
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 temporarily with a less invasive procedure called balloon valvuloplasty — which uses an approach called cardiac catheterization. You’re usually awake during cardiac catheterization.
During balloon valvuloplasty, your doctor inserts a thin, hollow tube (catheter) in a blood vessel, usually in your groin, and threads it to your heart. The catheter has a balloon at its tip that can be inflated to help stretch the narrowed aortic valve and then deflated for removal.
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.
Some replacement heart valves may begin to leak or not work as well over time. These issues can be fixed using surgery or 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 (valve). Another type of biological tissue valve replacement that uses your own pulmonary valve is sometimes possible.
Often, biological tissue valves eventually need to be replaced because 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. 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).
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.
After the procedure
If you had open-heart surgery, 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:
- 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 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.
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.
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