Surgical aortic valve replacement 

Overview

Surgical aortic valve replacement (SAVR) is a surgical procedure performed to replace a damaged aortic valve when it can no longer function properly. The aortic valve serves as the gateway between the heart and the main artery (aorta). Over time, the valve can deteriorate due to factors such as aging, causing it to become narrow or allowing it to leak. This condition is known as aortic valve disease. Initially, it may be asymptomatic, but as it worsens, it places additional strain on the heart, potentially leading to chest pain, breathing difficulties, and even life-threatening complications.

SAVR is a major open-heart surgery that involves making an incision in the chest to access the heart. It is a complex procedure with associated risks and benefits. While it carries some risks, including those typical of surgery, it can significantly improve a patient’s quality of life by alleviating symptoms, protecting the heart, and potentially extending their lifespan. Each individual’s case is unique, and healthcare providers carefully weigh the advantages and disadvantages of SAVR to make informed treatment decisions.

In an open, invasive aortic valve replacement, a surgeon replaces the malfunctioning aortic valve with an artificial one. The aortic valve is one of the heart’s four valves responsible for regulating blood flow. When the valve becomes dysfunctional, an artificial valve is used to restore normal blood flow from the heart to the body. This procedure is termed “open” because it involves a traditional chest incision, which is larger than the incisions used in minimally invasive aortic valve replacement surgeries. The choice of surgical approach depends on the patient’s specific condition and the recommendations of their healthcare team.

There are two main types of valves used in SAVR (surgical aortic valve replacement), and the choice between them depends on various factors. Healthcare providers decide whether to use a biological valve or a mechanical valve, each having its own advantages and disadvantages. Factors like age, personal preferences, and specific medical needs play a crucial role in determining the most suitable valve replacement.

• Biological valves: Also known as bioprosthetic valves, these are less likely to cause blood clots. They are typically made from heart tissue obtained from pigs, cows, or humans. Some biological valves may also incorporate synthetic components to enhance durability and facilitate the surgical implantation process. Bioprosthetic valves are often preferred for individuals aged 65 and older. However, they have a shorter lifespan compared to mechanical valves.
• Mechanical valves: Mechanical valves carry a higher risk of blood clot formation, necessitating lifelong use of blood-thinning medications for those who receive them. Additionally, the risk of infection is somewhat elevated with mechanical valves, as they are typically constructed from materials such as steel and carbon. These valves are commonly recommended for individuals under the age of 50.

Reasons for undergoing the procedure

When the aortic valve in the heart isn’t working properly, it can lead to conditions like aortic valve stenosis or aortic valve regurgitation. In some cases, surgery, known as SAVR (surgical aortic valve replacement), may be needed. Here’s what you should know:

• Aortic stenosis: This condition occurs when the aortic valve doesn’t open fully, which reduces the amount of blood leaving the heart.
• Aortic regurgitation: In this condition, the valve is faulty, allowing some blood to flow backward through the valve instead of moving forward to the rest of the body.

When the aortic valve isn’t working as it should, it can cause various symptoms, such as:

• Shortness of breath
• Fatigue
• Leg swelling
• Dizziness
• Chest pain
• Fainting
• Feeling your heart beating uncomfortably

It’s important to note that surgery isn’t always recommended for mild cases, and medications may be prescribed to improve heart function. However, in some situations, surgery might be recommended even if symptoms aren’t severe, as it tends to be most effective when done before problems become more advanced.

Risk

Surgery inherently carries specific risks, and the extent of these risks can vary among individuals due to their personal medical history, age, and other relevant risk factors. It’s imperative to have open discussions with your doctor to address any concerns you may have.

While open aortic valve replacement generally yields favorable outcomes for most individuals, it is essential to be aware of potential risks, which may include:

• Infection
• Excessive bleeding
• Irregular heart rhythms
• Blood clot formation leading to stroke or heart attack
• Complications related to anesthesia

Certain factors can elevate the likelihood of experiencing complications. Some of these factors include:

• Obesity
• Advanced age
• Smoking habit
• Respiratory issues
• Pre-existing chronic illnesses
• Concurrent heart conditions
• Susceptibility to infections

Before the procedure

Preparing for surgical aortic valve replacement (SAVR): Before undergoing surgical SAVR, you can expect a thorough pre-surgery assessment from your healthcare team. This comprehensive evaluation involves examining your heart and assessing your overall health to determine the most suitable surgical approach, whether it’s SAVR or the less invasive transcatheter aortic valve replacement (TAVR). The process includes:

• Diagnostic tests: You will undergo various diagnostic tests, including:
  • Chest X-ray
  • Cardiac catheterization
  • Computed tomography (CT) scan
  • Echocardiogram (Echo)
  • Electrocardiogram (EKG)
  • Blood and urine tests
• Individualized instructions: Your healthcare team will provide specific instructions tailored to your needs. This may include guidance on fasting before the surgery, adjustments to your medications, your precise hospital arrival time, and what items to bring or leave behind.
• Seek clarifications: If you have any questions or uncertainties about the instructions, don’t hesitate to seek clarification from your healthcare providers.
• Smoking cessation: If you are a smoker or use tobacco products, it’s highly advisable to quit as early as possible before your surgery. Quitting can significantly reduce the risk of complications during and after the procedure. Your healthcare provider can offer you resources and support to assist you in this important step towards a safer surgery and better recovery.

When preparing for SAVR, you’ll need to choose between two main types of replacement valves:

• Biological (bioprosthetic) valves: These are made from animal tissues (usually from pigs, cows, or occasionally humans) with some artificial support. They do not require lifelong blood-thinning medication.
• Mechanical valves: These valves are constructed from carbon and steel. If you opt for a mechanical valve, you will need to take a lifelong blood-thinning medication called warfarin (Coumadin®) to prevent blood clots, as they have a higher clotting risk.

Your surgeon will discuss these options with you and recommend the most suitable type based on your age and other health factors. Generally, mechanical valves are preferred for individuals under 50, while bioprosthetic valves are recommended for those over 65. For individuals aged 50 to 65, the choice may depend on personal preferences and medical considerations.

During the procedure

During a surgical aortic valve replacement (SAVR), the procedure involves several key steps. First, the patient is put under deep anesthesia to ensure they feel no pain and have no awareness of the surgery. A heart-lung machine is then connected to the patient, diverting blood away from the heart and lungs. This machine also temporarily stops the heart’s beating using a special solution, allowing the surgeon to work on it safely. The surgeon typically makes a long, vertical incision (sternotomy) in the breastbone, removes the damaged aortic valve, and replaces it with a new one. Finally, the breastbone is reconnected with wires, which usually remain in place for life, and the incision is closed. The entire SAVR surgery typically takes about two to four hours.

In some cases, for specific patients, minimally invasive techniques can be used for aortic valve replacement. These methods, such as partial sternotomy or right anterior thoracotomy, may be considered based on the patient’s individual medical condition and anatomy. If these less invasive options are suitable, the surgeon will provide more information and guidance. These approaches can offer certain benefits, including shorter recovery times and reduced scarring.

After the procedure

Recovery after aortic valve replacement surgery

• Hospital stay: You can expect to spend approximately five days in the hospital as you begin your recovery journey.
• Initial recovery: Your recovery will commence in either the intensive care unit or a recovery room.
• Waking up: Upon waking up from the surgery, you might initially feel a bit disoriented. This can happen a few hours after the procedure or even a little later.
• Immediate relief: Many patients experience immediate relief from their symptoms following aortic valve replacement surgery.
• Monitoring vital signs: The medical team will closely monitor your vital signs, including heart rate, often using monitoring equipment for ease of observation.
• Breathing assistance: You may have a breathing tube in your throat to assist with respiration. While this may be uncomfortable, it’s a temporary measure, usually removed within 24 hours.
• Chest drainage: A chest tube may be in place to drain excess fluid from your chest.
• Temporary pacemaker: In some cases, small temporary pacemaker wires may exit from your chest to assist with heart rhythm management.
• Incision care: Bandages will cover your surgical incision. These can typically be removed within a couple of days.
• Pain management: You may experience some soreness, but severe pain should not be the norm. You can request pain medication if needed.
• Mobility: Within a day or two, you should be able to sit in a chair and walk with assistance.
• Breathing therapy: Breathing therapy may be part of your recovery plan to help remove fluids that can accumulate in your lungs after surgery.
• Diet: You will likely be able to start drinking liquids the day after surgery and progress to regular foods as your tolerance allows.
• Leg circulation: Elastic stockings may be provided to promote blood circulation in your leg veins.

Remember that the specifics of your recovery may vary, so it’s essential to follow your medical team’s guidance and instructions closely during this process.

Outcome

Recovery from heart valve surgery typically spans four to eight weeks for most individuals, although those who underwent minimally invasive procedures may require as little as two weeks. The precise duration of your recovery will be determined by your surgeon, who will provide specific guidelines on what to expect and what activities to engage in or avoid during this period. It’s essential to recognize that the recovery process is gradual, and fatigue may persist for several weeks, which is entirely normal as your body requires adequate rest. It’s crucial not to rush the return to your regular routine and instead adhere to your surgeon’s recommendations regarding the safe resumption of your usual activities.

Please contact your healthcare provider immediately if you observe any indications of complications during your post-surgery recovery. Be vigilant for the following warning signals:

• Developing a fever or experiencing chills.
• Experiencing chest pain or a sensation of pressure in your chest.
• Sensing irregular heartbeats, such as palpitations or a sensation of your heart skipping a beat.
• Noticing any discharge or pus around the surgical incision site.
• Experiencing pain in the vicinity of the surgical incision.
• Observing swelling or redness around the surgical incision.
• Noticing swelling (edema) in your legs or feet.
• Gaining weight within one week