Aortic regurgitation surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2], Varun Kumar, M.B.B.S., Lakshmi Gopalakrishnan, M.B.B.S. Related Key Words and Synonyms: Aortic valve replacement.

Overview

Surgical treatment is controversial in asymptomatic patients. Surgery may be recommended if the ejection fraction falls below 50% or in the face of progressive and severe left ventricular dilatation. For both groups of patients, surgery before the development of worse aortic insufficiency ejection fraction/LV systolic dilatation, is expected to reduce the risk of sudden death, and is associated with lower peri-operative mortality.

The majority of patients with severe aortic regurgitation requiring surgery undergo aortic valve replacement against aortic valve repair which are preformed at few surgical centers which have appropriate technical expertise and experience in selecting potential patients.

ACC/AHA Guidelines- Indications for Aortic Valve Replacement/Repair in Chronic Aortic Insufficiency (DO NOT EDIT) [1]

“

Class I

1. AVR is indicated for symptomatic patients with severe AR irrespective of LV systolic function. (Level of Evidence: B)

2. AVR is indicated for asymptomatic patients with chronic severe aortic insufficiency and left ventricular systolic dysfunction (ejection fraction 50% or less) at rest. (Level of Evidence: B)

3. AVR is indicated for patients with chronic severe aortic insufficiency while undergoing coronary artery bypass graft(CABG) or surgery on the aorta or other heart valves. (Level of Evidence: C)

Class IIa

1. AVR is reasonable for asymptomatic patients with severe aortic insufficiency with normal left ventricular systolic function (ejection fraction greater than 50%) but with severe left ventricular dilatation (end-diastolic dimension greater than 75 mm or end-systolic dimension greater than 55 mm). (Level of Evidence: B)

Class IIb

1. AVR may be considered in patients with moderate aortic insufficiency while undergoing surgery on the ascending aorta. (Level of Evidence: C)

2. AVR may be considered in patients with moderate aortic insufficiency while undergoing CABG. (Level of Evidence: C)

3. AVR may be considered for asymptomatic patients with severe aortic insufficiency and normal left ventricular systolic function at rest (ejection fraction greater than 50%) when the degree of left ventricular dilatation exceeds an end-diastolic dimension of 70 mm or end-systolic dimension of 50 mm, when there is evidence of progressive left ventricular dilatation, declining exercise tolerance, or abnormal hemodynamic responses to exercise. (Level of Evidence: C)

Class III

1. AVR is not indicated for asymptomatic patients with mild, moderate, or severe aortic insufficiency and normal left ventricular systolic function at rest (ejection fraction greater than 50%) when the degree of dilatation is not moderate or severe (end-diastolic dimension less than 70 mm, end-systolic dimension less than 50 mm). (Level of Evidence: B)

”

Surgical Management of Chronic Aortic Insufficiency

Indications for surgery for chronic severe aortic insufficiency

Indications for surgery for chronic severe aortic insufficiency[2]
Symptoms Ejection fraction Other information
NYHA class III - IV ≥ 50 %
NYHA class II ≥ 50 % Progression of symptoms or worsening parameters on echocardiography
CHA class ≥ II angina ≥ 50 %
Regardless of symptoms 25 - 49 %
Cardiac surgery for other cause (ie: CAD, other valvular disease, ascending aortic aneurysm)











Surgical corrections of regurgitant aortic valve have shown to improve symptoms in symptomatic patients with severe aortic insufficiency. In some studies, the left ventricular function (ejection fraction) also was seen to improve with AVR[3] [4]. In severe aortic insufficiency, new onset of mild symptoms are also candidates for AVR. It is recommended that surgery should not be delayed till development of advanced symptoms as this may result in development of some degree of irreversible left ventricular dysfunction [5] [6]. Patients who are symptomatic with NYHA Class IV, have poor outcome post AVR with less likelihood of improvement of left ventricular systolic function [7] [8] [9] [10]. But with AVR, ventricular loading conditions are improved and expedite subsequent management of left ventricular dysfunction[11].

Symptomatic patients even with mild to moderate left ventricular systolic dysfunction (ejection fraction 25%- 50%) should also undergo AVR. AHA/ACC guidelines recommends that patients with NYHA Class II and III symptoms should undergo valve replacement if [12]:

“
  1. symptoms and evidence of left ventricular dysfunction are of recent onset
  2. intensive short-term therapy with vasodilators and diuretics results in symptomatic improvement
  3. intravenous positive inotropic agents result in substantial improvement in hemodynamics or systolic function.
 ”

Aortic valve replacement/repair is not recommended in a truly asymptomatic patient with normal left ventricular function (left ventricular ejection fraction ≥50%) without severe left ventricular dilatation because this would expose the patient to perioperative mortality risk of 4% against less than 0.2% mortality risk without surgery and other long-term complications of a prosthetic heart valve[13]. In such patients 2006 AHA/ACC guidelines recommends [12]:

  1. Patients with end-systolic ventricular dimension <45 mm and end-diastolic ventricular dimension <60 mm should undergo clinical evaluation every 6-12months and echocardiography every 12months. However, if the patient is not stable or this is the initial study, he should be re-evaluated and echocardiography performed in 3months.
  2. Patients with end-systolic ventricular dimension 45-50 mm and end-diastolic ventricular dimension 60-70 mm should undergo clinical evaluation every 6months and echocardiography every 12months. However, if the patient is not stable or this is the initial study, he should be re-evaluated and echocardiography performed in 3months.
  3. Patients with end-systolic ventricular dimension 50-55 mm and end-diastolic ventricular dimension 70-75 mm with normal hemodynamic response to exercise should undergo clinical evaluation every 6months and echocardiography every 6months. However, if the patient is not stable or this is the initial study, he should be re-evaluated and echocardiography performed in 3 months.

While interpreting these breakpoints of left ventricular dimensions, body size of the patients should also be taken into consideration. Because women or patients with small body size may not be able to achieve ventricular dimensions mentioned above as they were established in men [14] [15]. Body surface area when considered for left ventricular dimension, tend to mask the diagnosis of left ventricular enlargement, especially in patients who are overweight[16]. Therefore patient's height and gender should be considered during interpretation of ventricular dimensions. [17]

Preoperative Evaluation

The patient may need to have some tests before the procedure. After the diagnosis of aortic insufficiency, the general health of the patient should be assessed and the most appropriate treatment should be recommended. Some of the tests that can be done before the procedure include:

Cardiac catheterization in patients with chronic aortic insufficiency is recommended if the noninvasive diagnostic tests are inconclusive, or if the patient is at risk of coronary heart disease and the coronary anatomy should be assessed.

Before the surgery:

  • The surgeon needs to know if the patient is taking any drugs, supplements, or herbs before the procedure.
  • The patient may be able to store blood in the blood bank for transfusions during and after the surgery. The family members can also donate blood (autologous donation).
  • For the 2-week period before surgery, the patient should be asked to stop taking drugs that make it harder for the blood to clot. These might cause increased bleeding during the surgery. Some of these drugs are aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn).
  • The day before the surgery, the patient should shower and shampoo well and wash the whole body below the neck with a special soap.
  • The patient may also be asked to take an antibiotic to guard against infection.
  • The patient should be informed which drugs he or she should still take on the day of the surgery.
  • The patient should stop smoking.

On the day of the surgery:

  • An intravenous (IV) line will be placed into a blood vessel in the patient's arm or chest to give fluids and medicines.
  • The patient should be asked not to drink or eat anything after midnight the night before surgery. This includes chewing gum and using breath mints. The patient can rinse mouth with water if it feels dry without swallowing.
  • Make sure that the patient is taking the drugs that he or she needs to take with a small sip of water.
  • Hair near the incision site may be shaved immediately before the surgery.
  • The patient should be informed when to arrive to hospital on the day of the surgery.

Procedure

Other aortic root diseases like marfan syndrome, bicuspid aortic valve and aortic dissection which can cause chronic aortic regurgitation should be treated with AVR and aortic root reconstruction when degree of dilatation of aorta or aortic root ≥ 50mm in diameter [18]

Ross or Ross/Konno procedure is another alternative surgical procedure where the pulmonary valve is transplanted to the aortic position, and a homograft conduit is implanted from the right ventricle to the pulmonary artery. Though this procedure shows promising results for aortic valve abnormalities in some[19][20][21], the use of this technique has been limited by high rates of pulmonary autograft failure with deterioration of right heart homografts[22]. These rates are higher in children as compared to adults. Further studies aimed at clarifying longer-term outcomes as well as preventing pulmonary homograft deteroration are needed. {{#ev:youtube|r50kKpKefP8}}

To summarize, mechanical valve replacement is the preferred surgical option at present as opposed to valve repair or biological valve replacement in view of lack of evidence of long-term durability and outcomes. However, they may be appropriate for patients in whom anticoagulation are contraindicated. Patients' age, ability to tolerate warfarin and patients' preference are taken into account for in deciding the type of valve (mechanical or bioprosthetic valve) to be used in valve replacement. [12]

Recovery

Recovery at Hospital

The patient may spend 4 to 7 days in the hospital after surgery (much less in Minimally invasive mitral valve surgery-3 to 5 days). Then patient will wake up in theintensive care unit (ICU) and recover there for 1 or 2 days. Two to three tubes will be in the patient's chest to drain fluid from around the heart. They are usually removed 1 to 3 days after surgery.

The patient may have a catheter in the bladder to drain urine, and may also have intravenous lines to get fluids. Nurses will closely watch monitors that show information about the vital signs (pulse, temperature, and breathing).

The patient will be moved to a regular hospital room from the ICU. The nurses and doctors will continue to monitor the heart and vital signs until the patient is stable enough to go home. The patient will receive pain medicine to control pain around the surgical incision site.

A nurse should help the patient to slowly resume some activity, and the patient should begin a physical therapy program to make the heart and body stronger. A temporary pacemaker may be placed in the patient's heart if the heart rate becomes too slow after surgery.

Recovery at Home

The patient should be informed about the following:

  • Taking care for his or her healing incisions.
  • Recognizing signs of infection or other complications.
  • Coping with after-effects of surgery.
  • Followup appointments, medicines, and situations when he or she should call the doctor right away.
  • When he or she can go back to daily routine, such as working, driving, and physical activity.

After-effects of heart surgery are normal. They may include muscle pain, chest pain, or swelling. Other after-effects may include loss of appetite, problems sleeping, constipation, and mood swings and depression. After-effects usually go away over time.

Less recovery time is needed for off-pump heart surgery and minimally invasive heart surgery.

Ongoing Care

Ongoing care after valve surgery may include periodic checkups with the doctor. During these visits, the patient may have blood tests, an EKG (electrocardiogram),echocardiography, or a stress test. These tests will show how the patient's heart is working after the surgery.

Routine tests should be done to make sure the patient is getting the right amount of the blood-thinning medicine in case of mechanical valve placement.

The patient may be advised to change his or her lifestyle, this includes: quitting smoking, making changes to diet, being physically active, and reducing and managing stress.

Outcomes and Prognosis

Most valve surgery operations are successful. In some rare cases, a valve repair may fail and another operation may be needed. The risk of death or serious complications from isolated aortic valve replacement is typically quoted as being between 1-3% of cases, depending on the health and age of the patient, as well as the skill of the surgeon and the health care institute. The patient's past history of heart surgery affects the mortality rate as well. Patient with mechanical valve may hear a quiet clicking sound in his chest. This is just the sound of the new valve opening and closing, and a sign that the new valve is working.

Mechanical Versus Biological Valves

Mechanical heart valves do not fail often. They last from 12 to 20 years. However, blood clots develop on them. If a blood clot forms, the patient may have a stroke. Bleeding can occur, but this is rare. Biological valves tend to fail over time [23][24], but they have a lower risk of blood clots. Patients with a biological valve may need to have the valve replaced in 10 to 15 years. Patients with a mechanical valve will need to take a blood-thinning medicine for the rest of their lives.

Complications

Videos

Severe aortic insufficiency in patient after aortic valve replacement 1

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Severe aortic insufficiency in patient after aortic valve replacement 2

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Severe aortic insufficiency in patient after aortic valve replacement 3

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Severe aortic insufficiency in patient after aortic valve replacement 4

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Severe aortic insufficiency in patient after aortic valve replacement 5

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Severe aortic insufficiency in patient after aortic valve replacement 6

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Severe aortic insufficiency in patient after aortic valve replacement 7

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Severe aortic insufficiency in patient after aortic valve replacement 8

{{#ev:googlevideo|1577454681656420080}}

References

  1. ↑ Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; et al. (2008). "2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (13): e1–142. doi:10.1016/j.jacc.2008.05.007. PMID 18848134.
  2. ↑ "ACC/AHA guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association. Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease)". J. Am. Coll. Cardiol. 32 (5): 1486–588. 1998. PMID 9809971.
  3. ↑ Daniel WG, Hood WP, Siart A, Hausmann D, Nellessen U, Oelert H, Lichtlen PR (1985). "Chronic aortic regurgitation: reassessment of the prognostic value of preoperative left ventricular end-systolic dimension and fractional shortening". Circulation. 71 (4): 669–80. PMID 3156010. Retrieved 2011-03-27. Unknown parameter |month= ignored (help)
  4. ↑ Carabello BA, Usher BW, Hendrix GH, Assey ME, Crawford FA, Leman RB (1987). "Predictors of outcome for aortic valve replacement in patients with aortic regurgitation and left ventricular dysfunction: a change in the measuring stick". Journal of the American College of Cardiology. 10 (5): 991–7. PMID 3668112. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  5. ↑ Klodas E, Enriquez-Sarano M, Tajik AJ, Mullany CJ, Bailey KR, Seward JB (1997). "Optimizing timing of surgical correction in patients with severe aortic regurgitation: role of symptoms". Journal of the American College of Cardiology. 30 (3): 746–52. PMID 9283535. Retrieved 2011-03-27. Unknown parameter |month= ignored (help)
  6. ↑ Carabello BA (2004). "Is it ever too late to operate on the patient with valvular heart disease?". Journal of the American College of Cardiology. 44 (2): 376–83. doi:10.1016/j.jacc.2004.03.061. PMID 15261934. Retrieved 2011-03-27. Unknown parameter |month= ignored (help)
  7. ↑ Bonow RO, Dodd JT, Maron BJ, O'Gara PT, White GG, McIntosh CL, Clark RE, Epstein SE (1988). "Long-term serial changes in left ventricular function and reversal of ventricular dilatation after valve replacement for chronic aortic regurgitation". Circulation. 78 (5 Pt 1): 1108–20. PMID 2972417. Retrieved 2011-03-27. Unknown parameter |month= ignored (help)
  8. ↑ Greves J, Rahimtoola SH, McAnulty JH, DeMots H, Clark DG, Greenberg B, Starr A (1981). "Preoperative criteria predictive of late survival following valve replacement for severe aortic regurgitation". American Heart Journal. 101 (3): 300–8. PMID 6451163. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  9. ↑ Bonow RO, Picone AL, McIntosh CL, Jones M, Rosing DR, Maron BJ, Lakatos E, Clark RE, Epstein SE (1985). "Survival and functional results after valve replacement for aortic regurgitation from 1976 to 1983: impact of preoperative left ventricular function". Circulation. 72 (6): 1244–56. PMID 4064269. Retrieved 2011-03-27. Unknown parameter |month= ignored (help)
  10. ↑ Cunha CL, Giuliani ER, Fuster V, Seward JB, Brandenburg RO, McGoon DC (1980). "Preoperative M-mode echocardiography as a predictor of surgical results in chronic aortic insufficiency". The Journal of Thoracic and Cardiovascular Surgery. 79 (2): 256–65. PMID 7351849. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  11. ↑ Clark DG, McAnulty JH, Rahimtoola SH (1980). "Valve replacement in aortic insufficiency with left ventricular dysfunction". Circulation. 61 (2): 411–21. PMID 7351067. Retrieved 2011-03-28. Unknown parameter |month= ignored (help)
  12. ↑ 12.0 12.1 12.2 Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Retrieved 2011-03-28. Unknown parameter |month= ignored (help)
  13. ↑ Bekeredjian R, Grayburn PA (2005). "Valvular heart disease: aortic regurgitation". Circulation. 112 (1): 125–34. doi:10.1161/CIRCULATIONAHA.104.488825. PMID 15998697. Retrieved 2011-03-28. Unknown parameter |month= ignored (help)
  14. ↑ Stone PH, Clark RD, Goldschlager N, Selzer A, Cohn K (1984). "Determinants of prognosis of patients with aortic regurgitation who undergo aortic valve replacement". Journal of the American College of Cardiology. 3 (5): 1118–26. PMID 6707364. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  15. ↑ Klodas E, Enriquez-Sarano M, Tajik AJ, Mullany CJ, Bailey KR, Seward JB (1996). "Surgery for aortic regurgitation in women. Contrasting indications and outcomes compared with men". Circulation. 94 (10): 2472–8. PMID 8921790. Retrieved 2011-03-28. Unknown parameter |month= ignored (help)
  16. ↑ Mathew RK, Gaasch WH, Guilmette NE, Schick EC, Labib SB (2003). "Anthropometric normalization of left ventricular size in chronic mitral regurgitation". The American Journal of Cardiology. 91 (6): 762–4. PMID 12633821. Retrieved 2011-03-28. Unknown parameter |month= ignored (help)
  17. ↑ Vasan RS, Larson MG, Levy D, Evans JC, Benjamin EJ (1997). "Distribution and categorization of echocardiographic measurements in relation to reference limits: the Framingham Heart Study: formulation of a height- and sex-specific classification and its prospective validation". Circulation. 96 (6): 1863–73. PMID 9323074. Retrieved 2011-03-28. Unknown parameter |month= ignored (help)
  18. ↑ Lindsay J (1997). "Diagnosis and treatment of diseases of the aorta". Current Problems in Cardiology. 22 (10): 485–542. PMID 9339352. Retrieved 2011-03-28. Unknown parameter |month= ignored (help)
  19. ↑ Ohye RG, Gomez CA, Ohye BJ, Goldberg CS, Bove EL (2001). "The Ross/Konno procedure in neonates and infants: intermediate-term survival and autograft function". The Annals of Thoracic Surgery. 72 (3): 823–30. PMID 11565665. Retrieved 2011-04-08. Unknown parameter |month= ignored (help)
  20. ↑ Laudito A, Brook MM, Suleman S, Bleiweis MS, Thompson LD, Hanley FL, Reddy VM (2001). "The Ross procedure in children and young adults: a word of caution". The Journal of Thoracic and Cardiovascular Surgery. 122 (1): 147–53. doi:10.1067/mtc.2001.113752. PMID 11436048. Retrieved 2011-04-08. Unknown parameter |month= ignored (help)
  21. ↑ Laforest I, Dumesnil JG, Briand M, Cartier PC, Pibarot P (2002). "Hemodynamic performance at rest and during exercise after aortic valve replacement: comparison of pulmonary autografts versus aortic homografts". Circulation. 106 (12 Suppl 1): I57–I62. PMID 12354710. Retrieved 2011-04-08. Unknown parameter |month= ignored (help)
  22. ↑ David TE (2009). "Ross procedure at the crossroads". Circulation. 119 (2): 207–9. doi:10.1161/CIRCULATIONAHA.108.827964. PMID 19153280. Retrieved 2011-04-08. Unknown parameter |month= ignored (help)
  23. ↑ Hammermeister KE, Sethi GK, Henderson WG, Oprian C, Kim T, Rahimtoola S (1993). "A comparison of outcomes in men 11 years after heart-valve replacement with a mechanical valve or bioprosthesis. Veterans Affairs Cooperative Study on Valvular Heart Disease". N Engl J Med. 328 (18): 1289–96. doi:10.1056/NEJM199305063281801. PMID 8469251.
  24. ↑ Hammermeister K, Sethi GK, Henderson WG, Grover FL, Oprian C, Rahimtoola SH (2000). "Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial". J Am Coll Cardiol. 36 (4): 1152–8. PMID 11028464.

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