Aortic valve surgery - minimally invasive

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Definition

Blood flows out of your heart and into a large blood vessel called the aorta. The aortic valve connects the heart and aorta. The aortic valve opens so blood can flow out. It then closes to keep blood from returning to the heart.

You may need aortic valve surgery to replace the aortic valve in your heart if:

  • Your aortic valve does not close all the way so blood leaks back into the heart. This is called aortic regurgitation.
  • Your aortic valve does not open fully so blood flow through it is reduced. This is called aortic stenosis.

The aortic valve can be replaced using:

  • Minimally invasive aortic valve surgery -- done using  several small cuts
  •  Open aortic valve surgery -- done by making a large cut in your chest

Alternative Names

Balloon valvuloplasty; Mini-thoracotomy aortic valve replacement or repair; Cardiac valvular surgery; Mini-sternotomy; Robotically-assisted endoscopic aortic valve replacement

Description

Before your surgery you will receive general anesthesia.

You will be asleep and pain-free.

There are several ways to do minimally invasive aortic valve surgery. Techniques include thoracoscopy or endoscopy, robot-assisted surgery, and percutaneous surgery.

  • Your surgeon may make a 2-inch to 3-inch cut in the right part of your chest near the sternum (breastbone). The muscles in the area will be divided. This lets the surgeon reach the heart and aortic valve.
  • For the endoscopic or keyhole approach, your surgeon makes 1 to 4 small holes in your chest. Surgery is done through the cuts using a camera and special surgical tools.
  • For robotically-assisted valve surgery, the surgeon makes 2 to 4 tiny cuts in your chest. The cuts are about 1/2 to 3/4 inches each. The surgeon uses a special computer to control robotic arms during the surgery. A 3D view of the heart and aortic valve are displayed on a computer in the operating room. This method is very precise.

You may need to be on a heart-lung machine for all of these surgeries.

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 titanium or carbon. These valves last the longest. You will need to take blood-thinning medicine, such as warfarin (Coumadin) or aspirin, for the rest of your life if you have this type of valve.
  • Biological -- made of human or animal tissue. These valves last 10 to 20 years, but you may not need to take blood thinners for life.

In some cases, you will have coronary artery bypass surgery (CABG), or surgery to replace part of the aorta at the same time.

Once the new valve is working, your surgeon will:

  • Close the small cut to your heart or aorta
  • Place catheters (flexible tubes) around your heart to drain fluids that build up
  • Close the surgical cut in your muscles and skin

The surgery may take 3 - 6 hours.

Aortic valve surgery can also be done through a groin artery. No cuts are made on your chest. The doctor sends a catheter (tube) to the valve. The catheter has with a balloon on the end. The balloon is inflated to stretch the opening of the valve. This procedure is called percutaneous valvuloplasty. A catheter can be used to place a new valve in some cases.

Why the Procedure Is Performed

Aortic valve surgery is done when the valve does not work properly. Surgery may be done for these reasons:

  • Changes in your aortic valve are causing major heart symptoms, such as chest pain, shortness of breath, fainting spells, or heart failure.
  • Tests show that changes in your aortic valve are harming the working of your heart.
  • Damage to your heart valve from infection (endocarditis)

A minimally invasive procedure has many benefits. There is less pain, blood loss, and risk of infection. You will also recover faster than you would from open heart surgery.

Percutaneous valvuloplasty and catheter-based valve replacement are done only in patients who are too sick for major heart surgery. The results of percutaneous valvuloplasty are not long-lasting.

Risks

Risks for any anesthesia are:

Other risks vary by the patient's age. Some of these risks are:

  • Damage to other organs, nerves, or bones
  • Heart attack, stroke, or death
  • Infection of the new valve
  • Kidney failure
  • Irregular heartbeat that must be treated with medicines or a pacemaker
  • Poor healing of incision

Before the Procedure

Always tell your doctor or nurse:

  • If you are or could be pregnant
  • What medicines 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 medicines 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 medicines 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.

Shower and wash your hair the day before surgery. You may need to wash your 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.

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 may be asked not to drink or eat anything after midnight the night before your surgery. This includes using chewing gum and mints. Rinse your mouth with water if it feels dry. Be careful not to swallow.
  • Take the medicines 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

After your operation, you will spend 3 - 7 days in the hospital. You will spend the first night in an intensive care unit (ICU). Nurses will monitor your condition at all times.

Most of the time, you will be moved to a regular room or a transitional care unit in the hospital within 24 hours. You will start activity slowly. You may begin a program to make your heart and body stronger.

You may have two or three tubes in your chest to drain fluid from around your heart. Most of the time, these are taken out 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) lines for fluids. Nurses will closely watch monitors that display your vital signs (pulse, temperature, and breathing). You will have daily blood tests and EKGs to test your heart function until you are well enough to go home.

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

Once you are home, recovery takes time. Take it easy, and be patient with yourself.

Outlook (Prognosis)

Mechanical heart valves do not fail often. However, blood clots can develop on them. If a blood clot forms, you may have a stroke. Bleeding can occur, but this is rare.

Biological valves have a lower risk of blood clots, but tend to fail over time. Minimally invasive heart valve surgery has improved in recent years. These techniques are safe for most people and can reduce recovery time and pain. For best results, choose to have your aortic valve surgery at a center that does many of these procedures.

References

Fullerton DA, Harken AH. Acquired heart disease: valvular. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, Pa: Saunders Elsevier; 2012:chap 61.

Webb JG. Percutaneous therapies for structural heart disease in adults. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 59.

Bonow RO, Mann DL, Zipes DP et al. Valvular heart disease. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 66.

Coeytaux RR, Williams JW Jr., Gray RN, Wang A. Percutaneous heart valve replacement for aortic stenosis: state of the evidence. Ann Intern Med. 2010;153:314-324.

Schmitto JD, Mokashi SA, Cohn LH. Minimally-invasive valve surgery. J Am Coll Cardiol. 2010;56:455-462.

Version Info

  • Last reviewed on 2/6/2013
  • Matthew M. Cooper, MD, FACS, Medical Director, Cardiovascular Surgery, HealthEast Care System, St. Paul, MN. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Bethanne Black, and the A.D.A.M. Editorial team.

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This page was last updated: September 26, 2014

         
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