Aortic valve replacement





Definition

Aortic valve replacement is the insertion of a mechanical or tissue valve in place of the diseased native aortic valve.


Purpose

Aortic valve replacement is necessary when the aortic valve has become diseased. The aortic valve can suffer from insufficiency (inability to perform adequately) or stenosis. An insufficient valve is leaky and allows blood flow retrograde from the aorta to the left ventricle during diastole. A stenotic valve prevents the flow of blood antegrade from the left ventricle to the aorta, during systole.

Either situation can result in heart failure and an enlarged left ventricle. With aortic stenosis (narrowing), angina pectoris, fainting, and congestive heart failure will develop with the severity of the narrowing. There is an increased rate of sudden death of patients with aortic stenosis. Dyspnea (labored breathing), fatigue, and palpitations are late symptoms of aortic insufficiency. Angina pectoris is associated with the latest stages of aortic insufficiency.


Demographics

Congenital birth defects involving a bicuspid aortic valve can develop stenosis. These patients may become symptomatic in mid-teen years through age 65. Patients with a history rheumatic fever have a disposition for aortic stenosis, but may live symptom free for more then four decades. Calcification of the aortic valve tends to effect an older population with 30% of patients over age 85 having stenosis at autopsy.

Patients with aortic stenosis who have angina, dyspnea, or fainting are candidates for aortic valve replacement. Asymptomatic patients undergoing coronary artery bypass grafting should be treated with aortic valve replacement, but otherwise are not candidates for preventive aortic valve replacement.

Patients with a history of rheumatic fever or syphilitic aortitis (inflammation of the aorta) face the possibility of developing aortic insufficiency. Successful treatment has decreased this causative relationship. Primary causes of aortic disease commonly include bacterial endocarditis, trauma, aortic dissection, and congenital diseases.

Patients showing acute symptoms, including pulmonary edema, heart rhythm problems, or circulatory collapse, are candidates for aortic valve replacement. Chronic pathologies are recommended for surgery when patients appear symptomatic, demonstrating angina and dyspnea. Asymptomatic patients must be monitored for heart dysfunction. Left ventricular dimensions greater then 2 in (50 mm) at diastole or 3 in (70 mm) at systole are indications for replacement when aortic insufficiency is diagnosed.



Description


While receiving general anesthesia in preparation for the surgery, the patient's cardiac function will be monitored. A sternotomy (incision in the sternum) or thoracotomy may be used to expose the heart, with the thoracotomy providing a smaller incision through the ribs. Anticoagulant is administered in preparation for cardiopulmonary bypass. Cardiopulmonary bypass is instituted by exposing and cannulating (putting tubes in) the great blood vessels of the heart, or by cannulating the

The heart is accessed through a chest incision (A). The patient's heart function is replaced by the heart-lung machine. The aorta is cut open to reveal a diseased aortic valve (B), which is then removed. A valve sizer is placed in the opening to determine the size of prosthesis needed (C). A prosthetic valve is sutured in place (D and E). (Illustration by Argosy.)
The heart is accessed through a chest incision (A). The patient's heart function is replaced by the heart-lung machine. The aorta is cut open to reveal a diseased aortic valve (B), which is then removed. A valve sizer is placed in the opening to determine the size of prosthesis needed (C). A prosthetic valve is sutured in place (D and E). (
Illustration by Argosy.
)


femoral artery and vein. A combination of cannulation sites may also be used. The heart is stopped after the aorta is clamped. The aortic root is opened and the diseased valve is removed. Sutures are placed in the aortic rim and into the replacement valve. The replacement valve can be either mechanical or biological tissue. The replacement valve will be sized prior to implant to ensure that it fits the patient based on the size of the aortic valve annulus. Once seated, the valve is secured by tying the individual sutures. The heart is then deaired. The cross clamp is removed and the heart is allowed to beat as deairing continues by manipulation of the left ventricle. Cardiopulmonary bypass is terminated, the tubes are removed and drugs to reverse anticoagulation are administered.

A heart valve is an orifice that blood passes through in systole, and it is also an occluding (blocking) mechanism necessary to prevent the flow of blood during diastole. Heart valves can be mechanical or biological tissue valves. For patients younger then 65 years of age, the mechanical valve offers superior longevity. Anticoagulation is required for the life of the patient implanted with a mechanical valve. The biological tissue valve does not require anticoagulation but suffers from deterioration, leading to reoperation particularly in those under age 50. Women considering bearing children should be treated with biological tissue valves as the anticoagulant of choice with mechanical valves, warfarin, is associated with teterogenic effects in the fetus. Aspirin can be substituted in certain circumstances.


Diagnosis/Preparation

Initial diagnosis by auscultation (listening) is done with a stethoscope . Additional procedures associated with diagnosis to judge severity of the lesion include chest x ray , echocardiography , and angiography with cardiac catheterization . In the absence of angiography, magnetic resonance imaging (MRI) or computed tomographic (CT) imaging may be used.


Aftercare

The patient will have continuous cardiac monitoring performed in the intensive care unit (ICU) postoperatively. Medications or mechanical circulatory assist may be instituted during the surgery or postoperatively to help the heart provide the necessary cardiac output to sustain the pulmonary and systemic circulations. These will be discontinued as cardiac function improves. As the patient is able to breathe without assistance, ventilatory support will be discontinued. Drainage tubes allow blood to be collected from the chest cavity during healing and are removed as blood flow decreases. Prophylaxis antibiotics are given. Anticoagulation (warfarin, aspirin, or a combination) therapy is instituted and continued for patients who have received a mechanical valve. The ICU stay is approximately three days with a final hospital discharge occurring within a week after the procedure.

The patient receive wound care instructions prior to leaving the hospital. The instructions include how to recognize such adverse conditions as infection or valve malfunction, contact information for the surgeon, and guidelines on when to return to the emergency room.


Risks

There are unassociated risks with general anesthetic and cardiopulmonary bypass. Risks associated with aortic valve replacement include embolism, bleeding, and operative valvular endocarditis. Hemolysis is associated with certain types of mechanical valves, but is not a contraindication for implantation.


Normal results

Myocardial function typically improves rapidly, with decrease in left ventricle enlargement and dilation over several months, allowing the heart to return to normal dimensions. Anticoagulation therapy will be continued to elevate the INR to between 2.0 and 4.5, depending on the type of mechanical valve implanted. Implantation of biological tissue valves with maintenance of an INR of 2.0–3.0 for the initial three months post implant are associated with blood clot complications. If non-cardiac surgery or dental care is needed the antithrombotic therapy will be adjusted to prevent bleeding complications.


Morbidity and mortality rates

There is a 3–5% hospital mortality associated with aortic valve replacement. There is an average survival rate of five years in 85% of patients suffering from aortic stenosis that undergo aortic valve replacement. Structural valve deterioration can occur and is higher in mechanical valves during the first five years; however, biological tissue and mechanical valves have the same failure incidence at 10 years, with a 60% probability of death at 11 years as a result of a valve-related complications. Patients with a mechanical valve are more likely to experience bleeding complications. Reoperation is more likely for patients treated with a biological tissue valve, but not significantly different when compared to their mechanical valve counterparts. This combines to an average rate of significant complications of 2–3% per year, with death rate of approximately 1% per year associated directly with the prosthesis.


Alternatives

Balloon valvotomy may provide short term relief of aortic stenosis, but is considered palliative until valve replacement can be accomplished. Aortic valve repair by direct commisurotimy may also be successful for some cases of aortic stenosis. Medical treatment for inoperable patients with severe aortic stenosis is used to relive pulmonary congestion and prevent atrial fibrillation.

Severe aortic insufficiency can be treated with medical therapy. Pharmaceuticals to decrease blood pressure, with diuretics and vasodilators, are helpful in patients with aortic insufficiency.


Resources

BOOKS

Hensley, Frederick A., Donald E. Martin, and Glenn P. Gravlee, eds. A Practical Approach to Cardiac Anesthesia. 3rd Edition. Philadelphia: Lippincott Williams & Wilkins Philadelphia, 2003.


PERIODICALS

Bonow R, et al. "ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease." JACC 32 (November 1998): 1486–588.

Allison Joan Spiwak, MSBME

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?


Hospitals with cardiac surgery services provide aortic valve replacement. Specialization is required for young adults and pediatric patients. Cardiovascular and cardiac surgeons are trained to provide this treatment and the initial follow-up care. These surgeons are trained in their cardiac surgical residency to evaluate and perform these procedures and to care for the patient during the post-operative period.

QUESTIONS TO ASK THE DOCTOR


  • What type of valve is best suited for me?
  • What are the pros and cons associated with each type of valve for a person with my disease and/or associated diseases?
  • Why am I a candidate for valve replacement?
  • Are there any other more suitable alternative procedures?
  • If I am a female interested in having children, or currently pregnant are there additional options?
  • How often has the surgeon performed this procedure and what are the morbidity/mortality statistics for this surgeon and institution?
  • If I have an associated disease or complicated scenario does the surgeon have experience with follow-up care?


User Contributions:

Una
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Mar 29, 2006 @ 6:06 am
I had an aortic valve replaced Aug 04,aged 56 there was some chest pain afterwords but I got great pain relief, I was home after a week and made a good recovery, you need to give yourself 3 to 6 months to to fully get over the operation.
In my case I new that I might need the operation for many years,(I had heart surgery when I was 14 years old)so in many ways it was a relief to get it over with.
Una.
anil
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Oct 30, 2008 @ 2:02 am
this article is good for surgery coders

i would like to thank who ever created this website.
David Robbins
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Jul 15, 2009 @ 11:23 pm
I had 2 AVR's done in March, and July 2008. I had a pharmaceutical cardioversion to address the A fib. I am now told I have Aortic Stenosis, but a redo redo is out of the question, due to the lack of tissue to sew a new valve into. I have heard that the homografts may address this prior to a heart transplant. I have the symptoms of labored breathing, fainting occasionally and edema. I adress the excess fluid buildup through diuretics before CHF occurs, but I am feeling a sense of doom about my longevity. Any suggestions?
ANTHONY
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Oct 8, 2009 @ 2:14 pm
I am a 56 year old male -- i was born with a bicuspid aortic valve which is now suffering from stenosis and leaking --in addition the recent angiogram shows an aortic aneurism.I have been advised that i will require a valve replacement --i am curious as to usng a biological valve as opposed to a mechanical valve--i am a very active person--never sitting still and always finding something to work on. i do suppose that the mechanical would be better suited for my needs. I'm just wondering what sort of a time frame I might be able to expect as far as longevity. At my current level of health which is quite good, aside from the fact that i am also diabetic but under control-- I guess 10 or 11 years is about it ?
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May 17, 2010 @ 12:12 pm
I guess 10 or 11 years is about it ? I hope not. I'm 43 and had a mechanical valve put in 6 years ago. I was told the mechanical valves can last at least 50 years, but what they are seeing is more like 20 to 30 years, but even that was misleading because most people are over 50 when they get the valves. I'm fine other than getting agina when I excercise. It makes it difficult, because I'm a little over weight but when I try to excercise to help lose it I have to take it easier than the rest of my body wants. Over all though I'm good and I hope to be for many years to come. I hope this article is wrong in stating mechanical valves are also failing at 65% after 10 years. Its the first article I've seen that says that for mechanical valves.

Read more: Aortic Valve Replacement - procedure, blood, complications, adults, infection, heart, types, children, rate, Definition, Purpose, Demographics, Description, Diagnosis/Preparation, Aftercare, Risks, Normal results http://www.surgeryencyclopedia.com/A-Ce/Aortic-Valve-Replacement.html#ixzz0oCuQn2vN
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Jun 13, 2010 @ 9:09 am
I had my aortic valve replaced with a mechanical one almost 3 years ago at the age of 44. Before my surgery I was very active and was in good shape. Since my surgery my life has never been the same. I have had a lot of complications since getting the mechanical valve. I have periods of shortness of breath and chest pain. I have an echo's done every 6 months, but my doctors have been telling me everything is fine. However, 3 weeks ago I became very ill and I was vomiting what looked like coffee grounds. My doctor warned me about this because this is a sign of internal bleeding. Since I have a mechanical valve it requires me to be on coumadin and there is a big risk of bleeding. In addition, when I went to emergency for the vomiting they did another echo which now shows there is an increase in mean gradient pressure of my mechanical valve. The mean gradient pressure for my mechanical valve has been a mean of around 10 since surgery 3 years ago, but now it is at mean of 24. Does anyone know what would cause this increase and should I be worried? I'm seeing my cardiologist on June 22nd, but I worried that something is seriously wrong. I have a lot of shortness of breath, chest pain and dizzy spells.

Thanks,
Lenny
Liz
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Jun 27, 2010 @ 9:21 pm
I was 19 when they discovered i have a leaky aortic valve. The Doc told me that they would be doing surgery within 10 years (6 years ago) and it will be a tissue replacement. I was born with a congenetal heart defect and had open heart surgery for VSD age 4. I´m now 25 and terrified about having to repeat this every 10 years or so and I really was hoping to start a family in the next 2-3 years but I´m worried about the complications. The worst thing is that I know after the surgery, it doesn´t end. I feel terrible for my family, after all these years of hospitals and tests and I wouldn´t want to put my partner through any of this.
Jo Landry
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Jun 29, 2010 @ 8:08 am
My mom had a pulmonary valve transplant.Does anyone know any information or know where to find it including pictures?
Gikmi
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Aug 12, 2010 @ 3:03 am
I have just undergone an open heart surgery for replacement of the aortic valve. I have too many people telling me what food I should avoid and the precautions to be taken. I would like to know what food should be avoided and the precautions to be taken post surgery. I would also like to know what symptoms should I be aware of.
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Sep 30, 2010 @ 8:20 pm
My mom had aortic valve replacement 2 weeks ago. She is suffering from extreme soreness in her chest which she thinks is from the incision. It hurts the most when the nurses put her in bed during the process of laying her down on her back. It also hurts some during physical and occupational therapy. Is this normal 2 weeks after surgery?
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Nov 21, 2010 @ 4:04 am
I have aortic stenosis. At this point I have decided to not have surgery due to not feeling I have anything worth having more years added to my life for. I am finding all kinds of info about having surgery, but nothing on just what to expect from leaving my heart to continually to fail. For instance: will the valve fail to the point my heart will explode? Or, will my lungs start filling with blood at some point & I will eventually drown in fluids in my lungs? How bad will the pain from this be? Naturally, I don't think of any of this when I see my doctor. I was doing really good one month, then in just a days drive, I went to needed oxygen almost continually and getting breathless in just a few steps. I would appreciate any thoughts and information you can come up with. Thanks, Louise
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Dec 11, 2010 @ 10:22 pm
my mom just had her heart valve replaced and now after surgery her lungs are colapsed and she is on a feeding tube they have to let here lungs heal before they can fill her lungs back up not sure if she is going to pull through this, i pray she will so if anyone has any info about this please let me know
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Feb 4, 2011 @ 10:10 am
Excellent information!! I have shortness of breath and have been to my cardioligist but no answer as to why! Do you have any suggestions?
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Feb 22, 2011 @ 12:00 am
My husband had an aortic vavlve replacement (cow valve) May of 2010. After we have intimate encounters as well as after he eats he grasps for air, can hardly stand (sometimes not) and sometimes becomes unaware of time until he can breath again. Doctors keep telling him to rush to ER but the problem is symtomatic. PS have gone to ER and they say he's normal (by the time he gets there the symptoms have subsided, go figure!) Have any info please share? Mrs. Parisi
Anjali
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Feb 23, 2011 @ 11:11 am
I am a second year medical student doing a project on aortic valve replacements. Would it be possible for us to use the image of the procedure on a wiki that we have to submit to the University of Edinburgh? Would be very much appreciated. Thank you!
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Mar 9, 2011 @ 3:03 am
question? invasive mitral valve replacement , It was during plantation of the bio-prosthetic mitral valve that the femoral arterial line somehow dislodged. The surgeon thought that the fixation of the arterial line was adequate with the line being sutured to the skin and the perfusionist did not report any particularly high line pressures but it may be that the line worked its way out of disease or dissection in the right sided iliac artery. Despite a couple of attempts was unable to replace patient unperfused for a period of time of approximately 15mins.
Could this been prevented ? especially when the cut down it was noted by the surgeon that there was some disease in the right femoral artery, shouldnt the surgeon used the left groin instead? Isnt it up to the perfusionist to watch that area ? did the surgeon take too long and why did he try to recannulate in the same vien when it was deflated? I hope you can help me understand why this happen ? thank you Julia
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Mar 21, 2011 @ 8:20 pm
is it common to use the wrong size aortic valve during replacement surgery?
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Apr 30, 2011 @ 4:04 am
I have had my aortic valve replaced twice, in 2003 and 2007. Yesterday I had an emergency whilst driving. My vision became blurred, severe chest pains, sweating profusely and my tongue became very thick. I managed to stop my car and call for help. The ambulance arrived, I was rushed to hospital. Tests were done and was told that all was clear and that is was an anxiety attack. has anyone had this kind of experience?
Donna Hegley
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Feb 3, 2012 @ 3:15 pm
I am a 73 yr. old woman with aortic stenosis, lots of calcium buildup on valve and at this time have only 15% lung function. My heart surgeon feels I should have the valve replacement but ultimately, it is up to me. I want to know what my odds are of surviving this procedure at all and if I do an idea of length of life. Thanks for any info, Donna
makeleta
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Feb 7, 2012 @ 4:16 pm
unrelated question please

What does it mean when the doctor said we need to clean the blood of a patient in ICU currently using an artificial heart?

This is some one I know but not close to only by marriage. But I just want to know what is it. I am an RN in geriatric medical ward.
kausar s khan
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May 11, 2012 @ 12:00 am
My mother who is 85 has been advised replacement of aorta. she has not co-morbidities (e.g blodd pressure, diabetes, asthma). Her angiogram showed a normal heart, and her coronories are open.
Some family members are against the surgery, and there concerns are:
1. Suffering during post operational period, and how long it will be
2. After surgery her quality of life will not change, and the risks she faces with aorta labled 'severe' will remain even after the surgery.
Are the concerns of those opposing surgery valid ?
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Oct 21, 2012 @ 6:18 pm
wife 74 just had AVR, replacing a Bicuspid with a tissue valve 2 weeks ago.
day after operation her heart stopped and was revived within minutes with CPR.
Two days later a standard (non-defib) Pace Maker was implanted.
Question: does anyone know where I can get info regarding frequency of such a scenario,
and statistical outlook.
thank you.
gail
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Nov 13, 2012 @ 7:19 pm
I had avr and septal myectomy done 7 weeks ago and am experiencing increasing dizziness. Does anyone know anything about this?
sheila
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Jul 29, 2013 @ 1:01 am
i had a heart valve replacement done july 16 2013 at st dominic hosp in jacksson miss dr van cleave is excellet he made me feel safe I,m home now less than a wk in hosp it must say it was painful but so far I,m home doin ok working my way back to health gbu all and dr vancleave gbu tysm .my aortic valve was gone had limit on time 2 make mind up on surgery
sheila
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Jul 29, 2013 @ 1:01 am
i had a heart valve replacement done july 16 2013 at st dominic hosp in jacksson miss dr van cleave is excellet he made me feel safe I,m home now less than a wk in hosp it must say it was painful but so far I,m home doin ok working my way back to health gbu all and dr vancleave gbu tysm .my aortic valve was gone had limit on time 2 make mind up on surgery
S Chowdhury
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Aug 1, 2013 @ 10:10 am
My mum is 67 she had AVR surgery 8 yrs ago! The GP has found her blood results to now show Heart Failure
She hasn't been seen by cardiologist yet! But can anyone tell me what this means for her.
Clyde Waltemyer
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Sep 30, 2013 @ 9:21 pm
where can I read the replies to these 26 statements/questions these person(s)have asked?
SARFARAZ KHAN
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Dec 7, 2013 @ 5:05 am
I am 37 years old from India, I gone through with open heart by replacing aortic valve with my pulmonary valve by ROSS procedure on 24th of Sept 2013 2 months ago. I feel very good now , I can walk a lot now. Dr Anil Bhan in Medi City did my surgery who has experience of more than 15000 valve replacement surgery. Any one who wants to know more about this can email me at faraz1stcall@gmail.com
khash yash
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Oct 13, 2014 @ 7:19 pm
i had complications of chest pain for several years(6-7 years), i visited a doctor today and i have been told am a candidate of aortic valve replacement, but i don't want to do the surgery for now, am now 22 years old, and i want to undergo the surgery after 3-4 years from now, any help in terms of the urgency needed and my intention to differ the surgery?
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Nov 3, 2014 @ 1:13 pm
My Mother underwent a on Aortic Heart Valve Replacement in July 2014 in Rogers Arkansas. The Doctor installed too large of a valve into her heart to begin with. So within hours they had to open her chest up fully and redo the surgery. The surgeon stated that the first replacement valve blocked blood flow to her heart. This eventually led to her death within three days because of issues stemming from the installation of the wrong valve.

Before the surgery we were told that there was a 98% chance of survival the extra 2% related to human error. My mother fell into the 2% category.

The hospital and their staff could not give us an explanation as to WHy this happened. It took three attempts and contacting getting an attorney involved before the hospital provided us with the Autopsy. Needless to say it was like pulling teeth to even get the actual medical reports. On three different attempts we have received three different sets of records even though we requested ALL documents for her. So choose your doctor carefully one 2mm mistake by them could cost you your life.

I was also told her condition could be inherited genetics. That knowledge concerns me because if I happened to inherit these genetics then I do not know if I will be able to move forward with this procedure if I need it because of this surgeons 2mm mistake with my mother.
Diane
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Nov 12, 2014 @ 3:03 am
My mother,73, had a valve replacement yesterday, she is in recovery, but has double vision, can anybody comment on this, as Dr. has no answer for us.

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