Open Aortic Valve Replacement Surgery

Blood flows out of your heart and into a large blood vessel called the aorta. The aortic valve separates the heart and aorta. The aortic valve opens so blood can flow out. It then closes to keep blood from returning to the heart. 

You may need aortic valve surgery to replace the aortic valve in your heart if:

  • Your aortic valve does not close all the way, so blood leaks back into the heart. This is called aortic regurgitation.
  • Your aortic valve does not open fully, so blood flow out of the heart is reduced. This is called aortic stenosis.
  • Open aortic valve surgery replaces the valve through a large cut in your chest.
  • The aortic valve can also be replaced using minimally invasive aortic valve surgery. This is done using several small cuts.

There are two main types of Aortic Valves used to replace damaged aortic valves

  1. Mechanical Valves are carbon, metal, or plastic and last for many years; however, mechanical valves also increase your chances of developing blood clots which means you will have to take drugs called blood thinners for the rest of your life.

Your Cardiologist will be monitoring your medication levels often to ensure your blood does not become too thin or is not thin enough to prevent blood clots.

  1. Biological Valves come from animal tissue. They typically last 10-20 years which is not as long as a mechanical valve, but they do not lead to clots and you will not need to be on blood thinners. You and your doctor should talk about the pros and cons of each type of valve and decide together what is best for you.

    Overview of Surgery
    Before your surgery, you will receive general anesthesia. You will be asleep and pain-free.Your surgeon will make a 10-inch-long (25 centimeters) cut in the middle of your chest.Next, your surgeon will divide your breastbone to be able to see your heart and aorta.You may need to be connected to a heart-lung bypass machine or bypass pump. Your heart is stopped while you are connected to this machine. This machine does the work of your heart while your heart is stopped.If your aortic valve is too damaged, you will need a new valve. This is called replacement surgery. Your surgeon will remove your aortic valve and sew a new one into place.Once the new valve is working, your surgeon will:

    • Close your heart and take you off the heart-lung machine.
    • Place catheters (tubes) around your heart to drain fluids that build up.
    • Close your breastbone with stainless steel wires. It will take about 6 to 12 weeks for the bone to heal. The wires will stay inside your body.
    • This surgery may take 3 to 5 hours.

    Sometimes other procedures are done during open aortic surgery. These include:

    Coronary artery bypass surgery (CABG), Aortic root replacement, Ross (or switch) procedure

    Why the Procedure is Performed

    You may need surgery if your aortic valve does not work properly. You may need open-heart valve surgery for these reasons:

    • Changes in your aortic valve are causing major heart symptoms, such as chest pain, shortness of breath, fainting spells, or heart failure.
    • Tests show that changes in your aortic valve are beginning to seriously harm how well your heart works.
    • Your heart valve has been damaged by infection of the heart valve (endocarditis).
    • You have received a new heart valve in the past and it is not working well.
    • You have other problems such as blood clots, infection, or bleeding.

Risks

Risks for any anesthesia are:

  • Blood clots in the legs that may travel to the lungs
  • Blood loss
  • Breathing problems
  • Infection, including in the lungs, kidneys, bladder, chest, or heart valves
  • Reactions to medicines
  • Possible risks from having open heart surgery are:
  • Heart attack or stroke
  • Heart rhythm problems
  • Incision infection, which is more likely to occur in people who are obese, have diabetes, or have already had this surgery
  • Infection of the new valve
  • Kidney failure
  • Memory loss and loss of mental clarity, or “fuzzy thinking”
  • Poor healing of the incision
  • Post-pericardiotomy syndrome (low-grade fever and chest pain) that could last up to 6 months
  • Death

Before Surgery

Tell your doctor about any medicines or supplements you take, including:

  • Vitamins
  • Herbal or natural medicines
  • Drugs you buy “over the counter” (meaning that they don’t need a prescription)
  • Prescription medicines

You may need to stop taking certain medications before surgery.

 

To make sure you’re healthy enough for surgery, you can expect the following:

  • Blood and urine tests
  • Chest X-ray
  • Electrocardiogram (EKG)
  • Physical exam

Also tell your doctor about any illnesses or known infections you have such as toothache, bleeding gums, or even a simple cold. It might seem minor, but it could seriously affect your recovery.

If you smoke, you’ll need to stop 2 weeks before surgery to help prevent blood clots and problems breathing.

For the 1-week period before surgery, you may be asked to stop taking medicines that make it harder for your blood to clot. These might cause increased bleeding during the surgery.

  • Some of these drugs are aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn)
  • If you are taking warfarin (Coumadin) or clopidogrel (Plavix), talk with your surgeon before stopping or changing how you take these drugs.

During the days before your surgery:

Ask which medicines you should still take on the day of your surgery.

Remember – Always let your provider know if you have a cold, flu, fever, herpes breakout, or any other illness in the time leading up to your surgery.

Prepare your house for when you get home from the hospital.

Shower and wash your hair the day before your surgery. You may need to wash your whole body below your neck with a special soap. Scrub your chest 2 or 3 times with this soap.

On the day of your surgery:

You will be asked not to drink or eat anything after midnight the night before your surgery. This includes using chewing gum and breath mints. Rinse your mouth with water if it feels dry. Be careful not to swallow.

Take the medicines you have been told to take with a small sip of water.

You will be told when to arrive at the hospital.

After Your Surgery

Expect to spend 4 to 7 days in the hospital after surgery. You will spend the first night in the ICU and may stay there for 1 to 2 days. There will be 2 to 3 tubes will be in your chest to drain fluid from around your heart. These are usually removed 1 to 3 days after surgery.
You may have a catheter (flexible tube) in your bladder to drain urine. You may also have intravenous (IV) lines to deliver fluids. Nurses will closely watch monitors that display your vital signs (your pulse, temperature, and breathing).
You will be moved to a regular hospital room from the ICU. Your heart and vital signs will continue to be monitored until you go home. You will receive pain medicine to control pain around your surgical cut.

Your nurse will help you slowly resume some activity. You may begin a program to make your heart and body stronger.
You may have a pacemaker placed in your heart if your heart rate becomes too slow after surgery. It may be temporary or permanent.

Recovery

Your breastbone will take 6-8 weeks to heal, but it might be 3 months or so before you feel back to normal. Your doctor may suggest an exercise program or cardiac rehab to help.

As far as getting back to work, expect it to take 6-8 weeks for a desk job. If your work is more physical, it could take up to 3 months.

Alternative Names for Aortic Valve Surgeries

Aortic Valve Replacement (AVR); Aortic Valvuloplasty; Aortic Valve Repair

References

Aortic valve surgery – open: MedlinePlus Medical Encyclopedia. (2019, April 1). Retrieved from https://medlineplus.gov/ency/article/007408.htm

Otto CM, Bonow RO. Valvular heart disease. In: Mann DL, Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 10th ed. Philadelphia, PA: Elsevier Saunders; 2015:chap 63.

Rosengart TK, Anand J. Acquired heart disease: valvular. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 20th ed. Philadelphia, PA: Elsevier; 2017:chap 60.

Mitral Valve Repair

Mitral valve repair is an open heart procedure performed by cardiothoracic surgeons to treat stenosis (narrowing) or regurgitation (leakage) of the mitral valve. The mitral valve is the “inflow valve” for the left side of the heart. Blood flows from the lungs, where it picks up oxygen, and into the left atrium. When it opens, the mitral valve allows blood to flow from the left atrium to the heart’s main pumping chamber called the left ventricle. It then closes to keep blood from leaking back into the lungs when the ventricle contracts (squeezes) to push blood out to the body. It has two flaps, or leaflets.

The mitral valve is highlighted on this illustration of a heart. The mitral valve is the “inflow valve” for the left side of the heart. Blood flows from the lungs, where it picks up oxygen, and into the left atrium. When it opens, the mitral valve allows blood to flow from the atrium to the heart’s main pumping chamber called the left ventricle.

Occasionally, the mitral valve is abnormal from birth (congenital ). More often the mitral valve becomes abnormal with age (degenerative) or as a result of rheumatic fever. In rare instances the mitral valve can be destroyed by infection or a bacterial endocarditis. Mitral regurgitation may also occur as a result of ischemic heart disease.

When it opens (left), the mitral valve allows blood to flow into the heart’s main pumping chamber called the left ventricle. It then closes (right) to keep blood from leaking back into the lungs when the ventricle contracts (squeezes) to push blood out to the body. It has two flaps, or leaflets.

Often the mitral valve is so damaged that it must be replaced (refer to Mitral Valve Replacement) Occasionally, however, the valve can be repaired rather than replaced. One type of repair is a procedure called mitral commisurotomy. Mitral commisurotomy can be performed for some valves that are narrow or “stenotic” either from birth or from damage by rheumatic fever. Most often today, rheumatic mitral stenosis is treated by balloon valvuloplasty, a procedure performed in the cardiac catheterization laboratory by interventional cardiologists. Using a catheter with a balloon on the end, the balloon is expanded inside the valve “stretching” it open.

More often mitralvalve repair is performed to correct a leaking or regurgitant valve. Congenital mitral regurgitation may be due to a cleft mitral valve (a valve with a separation or cleft down the middle) associated with an atrial septal defect, a type of hole in the heart between the low pressure chambers or atria. Such valves can sometimes be repaired simply by closing the cleft with sutures. Valves regurgitant due to bacterial endocarditis can occasionally be repaired, however the majority of mitral valve repairs are performed for degenerative disease. Degenerative mitral valve disease may be due to an elongation or rupture of the chordal apparatus, the “heart-strings” that support the valve normally, or due to a more generalized weakness of the valve itself such as the “floppy valve” syndrome in which all of the components of the valve are enlarged and elongated.

Not all mitral valves can be repaired. A preoperative echocardiogram may help your surgeon predict the likelihood of repair, but cannot guarantee it. Mitral valves that are regurgitant due to rheumatic fever are often both stenotic andregurgitant, and are often beyond repair.

Why Is Surgery Necessary?

The mitral valve is the inflow valve into the left side of the heart. It closes during systole (when the ventricle contracts or squeezes blood out into the aorta and the rest of the body). When the mitral valve leaks, blood flows backwards into the lungs. The ventricle must therefore pump more blood with each contraction to produce the same forward output of blood throughout the body. This resulting condition is called a volume overload. The heart can compensate for this volume overload for many months or years (provided the leakage came on slowly and progressively), but it eventually begins to fail producing symptoms of shortness of breath or fatigue.

When Is Surgery Necessary?

The indications for mitral valve repair are undergoing constant reevaluation. Recent evidence suggests that earlier surgical intervention, particularly if repair is possible, may prevent irreversible damage to the heart. The decision regarding when to proceed with surgery should be made with your doctor. This decision will require judgement regarding the risk of surgery and the benefits available from surgery. In some cases blood pressure medications, such as ACE-inhibitors can significantly relieve symptoms.

Severe mitral regurgitation in the presence of symptoms of congestive heart failure is usually an indication for surgery. Severe regurgitation diagnosed by echocardiography even without symptoms, may be sufficient to warrant repair. Enlargement of the left atrium, particularly in the setting of the recent onset of an irregular heartbeat (atrial fibrillation, premature atrial contractions etc.) is considered by many doctors also to be an indication for surgery.

What Are The Results Of Mitral Valve Repair?

The first thing to remember is that a surgeon can predict the likelihood of repair before surgery, but cannot guarantee it. If repair is possible, the likelihood of long-term success is good, particularly for degenerative valve disease. Depending upon the underlying abnormality there may be an 85 to 95% chance of needing nothing further done to the valve over the next 10 years. If a more complex repair was required for degenerative disease, the chances of long-term freedom from reintervention (further surgery) may be less. If a valve was damaged by rheumatic fever, the disease may progress even after the repair, making the chances of the repair holding up in the long run less. Some surgeons are, therefore, reluctant to repair rheumatic valves. The results of repair of mitral regurgitation associated with coronary artery disease are the most difficult of all to predict.

What Will My Condition Be Like After Mitral Valve Replacement?

After successful mitral valve replacement you can expect to return to your preoperative condition or better. Anticoagulation (blood thinners) with Coumadin is often prescribed for 6 weeks to 3 months postoperatively. Generally this prescription is not required in the long term unless other indications for anticoagulation such as atrial fibrillation are present. Once wounds have healed there should be few if any restrictions on a patient’s activity.