Aortic Root Repair

For patients who have aneurysms (dilatation) of the aortic root (the place where the ascending aorta meets the heart muscle), there are two main indications for surgery. 1) If there is an aneurysm in the aortic root and the aortic valve is calcified or stenotic, replacement of the aortic root may be necessary. When operating because of bicuspid valve disease, an aortic root procedure is usually considered necessary if the root diameter is enlarged to 4 cm or greater. 2) If the valve is functioning well, surgical intervention is not considered until the diameter of the aorta exceeds 5cm.

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

During the procedure a cut (incision) about 25cm long is made in your chest to access your heart. The surgeon uses a heart-lung machine (cardiopulmonary bypass machine) to take over the work of the heart and lungs whilst the aortic root surgery is being performed.

There are two main ways to repair this area of the heart:

1. Aortic valve and root replacement. In aortic valve and root replacement (composite aortic root replacement), your surgeon removes a section of your aorta and your aortic valve. The section of your aorta is replaced with an artificial tube (graft), and your aortic valve is replaced with a mechanical or biological valve. If you have a mechanical valve, you'll need to take anticoagulant medications for life to prevent blood clots.
2. Valve-sparing aortic root repair. In this procedure, your surgeon replaces the enlarged section of your aorta with an artificial tube (graft). Your aortic valve remains in place. In one technique, your surgeon sutures the valve inside of the graft.

With both types of operations, the two main coronary arteries (left and right coronary) need to be reattached to the side of the tubing.

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

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.

The goals of treatment for aortic root repair include restoring:

1. Normal aortic valve function
2. Normal aortic tube diameter

This will ensure that your heart keeps functioning well and your risk of spontaneous tearing of the aorta, and therefore death, is reduced.

The risks of heart bypass 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 limited options for treatment of damage to this area of your heart and aorta other than surgery.

1. Medication – If you choose not to want any intervention on your heart then medication can help control a number of the symptoms. Medication may help reduce blood pressure and therefore the stress on the aorta and reduce the risk of further dilatation and rupture. Medication will not treat the aortic disease itself. Many patients, who are very frail, will however benefit from continuing with medication alone.
2. Stenting – Internal stenting of the aorta at this area of the heart is extremely limited and performed by very few centres around the world. There is no evidence that it is better than surgery in preventing future complications.