Aortic regurgitation surgery

Aortic Regurgitation Microchapters
Home
Patient Information
Overview
Historical Pesrpective
Pathophysiology
Causes
Stages
Differentiating Aortic Regurgitation from other Diseases
Epidemiology and Demographics
Risk Factors
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms
Physical Examination
Cardiac Stress Test
Electrocardiogram
Chest X Ray
Echocardiography
Cardiac MRI
Treatment
Acute Aortic regurgitation Medical Therapy Surgery
Chronic Aortic regurgitation Medical Therapy Surgery
Precautions and Prophylaxis
Special Scenarios Pregnancy Elderly Young Adults End-stage Renal Disease
Case Studies
Case #1
Aortic regurgitation surgery On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Aortic regurgitation surgery All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Aortic regurgitation surgery
CDC on Aortic regurgitation surgery
Aortic regurgitation surgery in the news
Blogs on Aortic regurgitation surgery
Directions to Hospitals Treating Aortic regurgitation
Risk calculators and risk factors for Aortic regurgitation surgery

For the WikiPatient page for this topic, click here; For the main page of aortic insufficiency, click here

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., Mohammed A. Sbeih, M.D.[3]

Related Key Words and Synonyms: Aortic valve replacement.

Preoperative Evaluation

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:

• Echocardiogram (Doppler echocardiogram).
• Cardiac catheterization.
• Chest X-ray.
• Computed tomography (CT) scan.
• Electrocardiogram (ECG).
• Electrophysiology tests.
• Exercise tests.
• Holter monitor.
• Magnetic resonance imaging (MRI).

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

Aortic Valve Replacement Procedure

If the procedure is indicated; it could be done by one of the following approaches:

The Traditional Open Heart Surgery:

• The surgeon will make a 10-inch-long cut in the middle of the chest (sternum).
• Next, the surgeon will separate the breastbone (sternum) to be able to see the heart.
• Most people are connected to a heart-lung bypass machine or bypass pump. The heart is stopped while the patient is connected to this machine. This machine does the work of the heart while the heart is stopped.
• A small cut is made in the left side of the heart so the surgeon can repair or replace the aortic valve.

In Minimally Invasive Aortic Valve Surgery; there are several different ways to perform the procedure:

• The heart surgeon may make a 2-inch to 3-inch-long cut in the right part of the patient's chest near the sternum. Muscles in the area will be divided so the surgeon can reach the heart. A small cut is made in the left side of the heart so the surgeon can replace the aortic valve.
• In Endoscopic surgery; the surgeon makes one to four small holes in the chest, then he or she uses special instruments and a camera to do the surgery.
• For Robotically-Assisted Valve Surgery, the surgeon makes two to four tiny cuts (about a ½ to a ¾ inch) in the chest. The surgeon uses a special computer to control robotic arms during the surgery. The surgeon sees a three-dimensional view of the heart and mitral valve on the computer. This method is very precise.

The patient may or may not need to be on a heart-lung machine for these types of surgery, but if not; the heart rate will be slowed by medicine or a mechanical device.

There are two types of valves that can be used :

1. Mechanical which is made of man-made (synthetic) materials, such as a metal like titanium. These valves last the longest , but the patient will need to take blood-thinning medicine, such as warfarin (Coumadin) or aspirin, for the rest of his or her life.

2. Biological which made of human or animal tissue. These valves last 10 to 12 years, but the patient may not need to take blood thinners for life.

The 2006 American College of Cardiology/American Heart Association (ACC/AHA) recommendations for the choice of aortic valve :

• If the patient is under 65 years of age and do not have a contraindication to anticoagulation then mechanical valve is preferred.
• If the patient is ≥65 years of age who do not have risk factors for thromboembolism; Bioprosthetic valve will be reasonable.
• If the patient has already a mechanical valve in the mitral or tricuspid position (need anticoagulation).
• If the patient has active prosthetic valve endocarditis; the valve should be replaced.
• If the patient has contraindications to anticoagulation therapy regardless his or her age; then a bioprosthetic valve is indicated.
• In case of small oartic root; mechanical valve is indicated as there is a risk of annular enlargement in such patient if bioprosthetic valve is used.

Once the new or repaired valve is working, the surgeon will:

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

The patient may have a temporary pacemaker connected to the heart until his or her natural heart rhythm returns.

The surgeon may also perform coronary artery bypass surgery at the same time, if needed.

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

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, the use of this technique has been limited by high rates of pulmonary autograft failure with deterioration of right heart homografts. 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.

Recovery

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 & Prognosis

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 , 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

Complications

Risks of any surgery

• 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.
• Nausea and vomiting.
• Abnormal or painful scar formation.
• Allergic skin reaction

Possible risks from having open-heart surgery

• Heart attack or stroke.
• Heart rhythm problems; such as atrial fibrillation.
• Infection in the cut, which is more likely to happen in people who are obese, have diabetes, or have already had this surgery.
• Memory loss and loss of mental clarity, or "fuzzy thinking."
• Post-pericardiotomy syndrome, which is a low-grade fever and chest pain. This could last for up to 6 months.

Prosthetic heart valves are associated with a variety of complications

• Structural deterioration, particularly with bioprosthetic valves.
• Valve obstruction due to thrombosis or pannus formation.
• Systemic embolization.
• Bleeding.
• Endocarditis and other infections.
• Left ventricular systolic dysfunction, which may be preexisting (Heart failure).
• Hemolytic anemia.

Videos

Severe aortic insufficiency in patient after aortic valve replacement 1

{{#ev:googlevideo|-3829359717394053857}}

Severe aortic insufficiency in patient after aortic valve replacement 2

{{#ev:googlevideo|-1139143783733805104}}

Severe aortic insufficiency in patient after aortic valve replacement 3

{{#ev:googlevideo|-7501177211861270942}}

Severe aortic insufficiency in patient after aortic valve replacement 4

{{#ev:googlevideo|-4027195456056520519}}

Severe aortic insufficiency in patient after aortic valve replacement 5

{{#ev:googlevideo|3983126063629833286}}

Severe aortic insufficiency in patient after aortic valve replacement 6

{{#ev:googlevideo|5313961274473108141}}

Severe aortic insufficiency in patient after aortic valve replacement 7

{{#ev:googlevideo|-1049019986268408841}}

Severe aortic insufficiency in patient after aortic valve replacement 8

{{#ev:googlevideo|1577454681656420080}}