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.
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.
Aortic valve repair or replacement?
The decision to repair or replace a damaged aortic valve depends on many things, 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 is 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, which may be 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.
However, most valves cannot be repaired, 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 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 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 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:
- Blood clots
- Valve dysfunction in replacement valves
- Heart rhythm problems
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:
- Contact lenses
- 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.
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.