Aortic Valve Surgery

The aortic valve may need to be replaced for two reasons:

1. The valve has become narrowed (aortic stenosis) – the opening of the valve becomes smaller, obstructing the flow of blood out of the heart
2. The valve is leaky (aortic regurgitation) – the valve allows blood to flow back through into the heart

Problems with the aortic valve cause symptoms of:

• Breathing difficulty (Dyspnoea)
• Chest Pain (Angina)
• Dizziness or collapse
• Palpitations

The problems can get worse over time, and in severe cases, can lead to life-threatening problems such as heart failure, if left untreated. There are no medicines to treat aortic valve problems, so replacing the valve will be recommended if you have significant symptoms or you are at risk of your heart function deteriorating.

The diagnosis of aortic valve disease is usually made with an echocardiogram (doppler scan of your heart) and your cardiologist will also perform a coronary angiogram of your heart before referring you for surgery.

Almost all operations on the heart will be performed under general anaesthetic. Your anaesthetist will review you before the operation and discuss the anaesthesia and the risks involved. The anaesthetist will outline what lines will be used for the procedure but usually these involve:

• A drip in your arm to put you to sleep
• A radial artery pressure monitoring line in your wrist
• An endotracheal tube (breathing tube) to help your breathing under anaesthesia
• A line in your neck to administer drugs
• A Transoesophageal (TOE) probe to assess your heart during surgery
• A catheter in your bladder
• Pad protection for your eyes

An aortic valve replacement is carried out under general anaesthetic. This means you'll be asleep during the operation and won't feel any pain while it's carried out.

During the procedure a cut (incision) about 25cm long is made in your chest to access your heart – although sometimes a smaller cut (Keyhole incision- see below) may be made. The surgeon uses a heart-lung machine (cardiopulmonary bypass machine) to take over the work of the heart and lungs whilst the aortic valve surgery is being performed The damaged or faulty valve is removed and replaced with the new one and your heart is restarted and the opening in your chest is closed

The operation usually takes a few hours. You'll have a discussion with your surgeon before the procedure to decide whether a synthetic (mechanical) or animal (tissue) replacement valve is most suitable for you.

The breastbone is put back together with steel wire until the bone heals itself in 4-6 weeks.

In some operations, not all of the breastbone needs to be cut. This is called keyhole surgery or minimally invasive surgery. This can be performed in some centres where the procedure is performed regularly. This is called a Mini-AVR and can be performed with a cut either at the top of your breastbone or to the side of your breastbone between the ribs. The heart-lung machine (cardiopulmonary bypass machine) is still used to perform the procedure but you may need a separate cut in your groin to help with this.

Occasionally when the valve is leaking only (aortic regurgitation) and the leaflets of the valve are normal, the surgeon may wish to repair your aortic valve rather than replacing it. Often this is also combined with aortic root surgery.

After your operation you will be moved to intensive care for close monitoring until you wake up. The intensive care staff will only wake you once they are satisfied that you are stable. When you wake up you will notice that you still have the various lines inserted by the anaesthetist at the start of the operation but not the TOE probe.

Pain is usually controlled with strong painkillers in the first 24-48 hours after the operation but most patients find that the chest wound is comfortable after that with only paracetamol required to ease the discomfort.

You will also notice some drains at the bottom of your wound that help monitor any bleeding that invariably happens to a degree after heart surgery as the blood can be very thin and may not clot (stop bleeding) properly after surgery. Occasionally if there is excessive drainage from the tubes before you wake up, then the surgeon may decide to take you back to theatre to reopen the wound and wash out the area around your heart. Whilst the surgeon hopes not to have to do this, it is always safer to do this if needed. The drains are usually removed on the first or second day after the operation.

You may also notice thin wires near the drains called pacing wires. These are often placed onto the surface of your heart at the end of the operation to help regulate the heart rate. They are attached to a device called a pacing box which provides the electrical stimulus to regulate the heart rate during recovery. If they are no longer needed, then they are removed on the third or fourth day after surgery. Occasionally, if they are still needed after four or five days, a permanent pacemaker will be fitted before you leave for home. Your heart surgeon and cardiologist will discuss this with you if needed.

Once your condition is stable, you will be moved to the high dependency unit or the cardiac ward. You should be out of bed in a day or two and return home after a week, with full recovery after two or three months depending on your fitness, age and how complex the operation was.

Most people get excellent relief from breathlessness and other symptoms caused by your faulty valve, and improved quality of life. The operation will hopefully prevent your heart function from deteriorating in the near future and can often improve function if there has been a reduction in your heart pump function.

Because the aortic valve lies very near to the main electrical pathways in your heart, there is a higher chance that there could be permanent interference with the electrical conduction through your heart than with other types of heart operations. If this happens, a permanent pacemaker will be fitted before you leave the hospital. Overall, the risk of this is still low at 1-2%.

The risks of heart valve surgery are different from person to person, depending on the severity of heart disease, type of operation, age, and current state of health. You can visit our risk page on this website to help you understand these risks [link].

In many hospitals, after a heart operation, a member of the cardiac rehabilitation team will see you on the ward to give you information about your condition and the treatment you have had.

They will talk to you about making lifestyle changes and how to reduce your risk factors (the things that increase your risk of heart disease) to help protect your heart in the future. You can also ask the rehabilitation staff any questions about your recovery.

There are a number of options for treating narrowing of your aortic valve (aortic stenosis).

1. Follow up – If your aortic valve is only mildly or moderately diseased, your team may wish to follow you up with further tests (heart scans) over a period of time. Although narrowing of the valve tends to progress and not improve spontaneously over time, the rate at which the valve function deteriorates can vary widely between individuals and therefore follow-up and timing of surgery will be tailored to you.
2. Medication – If you are too frail or choose not to want any intervention on your heart, then medication can help control a number of the symptoms. It is important to realise that medication will only treat the symptoms for a period of time and does not treat the actual valve. Many patients will, however, benefit from continuing with medication alone.
3. TAVI – (Transcatheter Aortic Valve Implant) – This is a procedure performed to insert a stent and valve within your narrowed valve without opening the chest or using the heart-lung machine. For more information see Transcatheter Aortic Valve Implant (TAVI).