Aortic valve surgery - open

Definition

Blood flows out of your heart and into the aorta through a valve. This valve is called the aortic valve. It opens up so blood can flow out. It then closes, keeping blood from flowing backwards.

Aortic valve surgery is done to either repair or replace the aortic valve in your heart.

• An aortic valve that does not close all the way allows blood to leak back into your heart. This is called aortic regurgitation.
• An aortic valve that does not open fully will restrict blood flow. This is called aortic stenosis.

In open surgery, the surgeon makes a large incision (cut) in your breastbone to reach the heart and aorta.

See also: Aortic valve surgery - minimally invasive

Alternative Names

Aortic valve replacement; Aortic valvuloplasty; Aortic valve repair; Replacement - aortic valve; Repair - aortic valve; Ring annuloplasty - aortic valve

Description

Before your surgery you will receive general anesthesia. This will make you unconscious and unable to feel pain.

• Your surgeon will make a 10-inch-long cut in the middle of your chest.
• Next, your surgeon will separate your breastbone to be able to see your heart and aorta (the main blood vessel leading from your heart to the rest of your body).
• Most people are connected to a heart-lung bypass machine or bypass pump. Your heart is stopped while you are connected to this machine. This machine does the work of your heart while your heart is stopped.

If your surgeon can repair your aortic valve, you may have:

• Ring annuloplasty -- The surgeon repairs the ring-like part around the valve by sewing a ring of metal, cloth, or tissue around the valve.
• Valve repair -- The surgeon trims, shapes, or rebuilds 1 or more of the 3 leaflets of the valve. The leaflets are flaps that open and close the valve.

If your aortic valve is too damaged, you will need a new valve. This is called replacement surgery. Your surgeon will remove your aortic valve and sew a new one into place. There are two main types of new valves:

• Mechanical -- made of man-made materials, such as cloth, metal, or ceramic. These valves last the longest, but you will need to take blood-thinning medicine, such as warfarin (Coumadin) or aspirin, for the rest of your life.
• Biological -- made of human or animal tissue. These valves last 12 to 15 years, but you may not need to take blood thinners for life.

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

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

This surgery may take 3 to 6 hours.

Sometimes other procedures are done during open aortic about surgery. These include the Ross (or switch) procedure, the David procedure, and a graft of the ascending aorta.

Why the Procedure Is Performed

You may need surgery if your aortic valve does not work properly. You may need open-heart valve surgery for these reasons:

• Changes in your aortic valve are causing major heart symptoms, such as angina (chest pain), shortness of breath, syncope (fainting spells), or heart failure.
• Tests show that changes in your aortic valve are beginning to seriously harm how well your heart works.
• Your heart valve has been damaged by endocarditis (infection of the heart valve).
• You have received a new heart valve in the past and it is not working well, or you have other problems such as blood clots, infection, or bleeding.

Risks

Risks for any anesthesia are:

• Reactions to medicines
• Breathing problems
• Blood clots in the legs that may travel to the lungs
• Infection, including in the lungs, kidneys, bladder, chest, or heart valves
• Blood loss

Possible risks from having open heart surgery are:

• Heart attack or stroke
• Incision infection, which is more likely to occur in people who are obese, have diabetes, or have already had this surgery
• Post-pericardiotomy syndrome, which is a low-grade fever and chest pain. This could last up to 6 months.
• Memory loss and loss of mental clarity, or "fuzzy thinking."
• Heart rhythm problems

Before the Procedure

Always tell your doctor or nurse:

• If you are or could be pregnant
• What drugs you are taking, even drugs, supplements, or herbs you bought without a prescription

You may be able to store blood in the blood bank for transfusions during and after your surgery. Ask your surgeon about how you and your family members can donate blood.

For the 2-week period before surgery, you may be asked to stop taking drugs that make it harder for your blood to clot. These might cause increased bleeding during the surgery.

• Some of them are aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn).
• If you are taking warfarin (Coumadin) or clopidogrel (Plavix), talk with your surgeon before stopping or changing how you take these drugs.

During the days before your surgery:

• Ask your doctor which drugs you should still take on the day of your surgery.
• If you smoke, you must stop. Ask your doctor for help.
• Always let your doctor know if you have a cold, flu, fever, herpes breakout, or any other illness in the time leading up to your surgery.

Prepare your house for when you get home from the hospital.

The day before your surgery, shower and shampoo well. You may be asked to wash your whole body below your neck with a special soap. Scrub your chest 2 or 3 times with this soap. You also may be asked to take an antibiotic, to prevent infection.

On the day of your surgery:

• You will usually be asked not to drink or eat anything after midnight the night before your surgery. This includes chewing gum and using breath mints. Rinse your mouth with water if it feels dry, but be careful not to swallow.
• Take the drugs your doctor told you to take with a small sip of water.
• Your doctor or nurse will tell you when to arrive at the hospital.

After the Procedure

Expect to spend 5 to 7 days in the hospital after surgery. You will wake up in the intensive care unit (ICU) and stay there for 1 or 2 days. Two to 3 tubes will be in your chest to drain fluid from around your heart. These are usually removed 1 to 3 days after surgery.

You may have a catheter (flexible tube) in your bladder to drain urine. You may also have intravenous (IV, in a vein) lines to deliver fluids. Nurses will closely watch monitors that show information about your vital signs (your pulse, temperature, and breathing).

You will be moved to a regular hospital room from the ICU. Your nurses and doctors will continue to monitor your heart and vital signs until you are stable enough to go home. You will receive pain medicine to control pain around your incision.

Your nurse will help you slowly resume some activity. You may begin a program to make your heart and body stronger.

A temporary pacemaker may be placed in your heart if your heart rate becomes too slow after surgery.

Outlook (Prognosis)

Mechanical heart valves do not fail often. However, blood clots develop on them. If a blood clot forms, you 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.

References

Fullerton DA, Harken AH. Acquired heart disease: valvular. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2008:chap 62.

Chiam PTL, Ruiz CE. Percutaneous transcatheter aortic valve implantation: Evolution of the technology. American Heart Journal. Feb 2009;157(2).

Otoo CM, Bonow RO. Valvular heart disease. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 62.