Aortic regurgitation surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief:Mohammed A. Sbeih, M.D.[2]; Usama Talib, BSc, MD [3] Related Key Words and Synonyms: Aortic valve replacement.

Aortic valve replacement is indicated in patients with severe aortic insufficiency who are either symptomatic or those who have a left ventricular end-diastolic diameter >55 mm or 25 mm/m2 or an left ventricular ejection fraction <55%.

The majority of patients with severe aortic regurgitation requiring surgery undergo aortic valve replacement instead of aortic valve repair which is sometimes preformed at highly specialized surgical centers which have appropriate technical expertise and experience in selecting potential patients.^[1]

Mechanical valves are made of man-made (synthetic) materials, such as a metal like titanium. Mechanical heart valves do not fail often. They last from 12 to 20 years. ^[2][3] However, blood clots develop on them. If a blood clot forms, the patient may have a stroke. Anticoagulation with warfarin will be required which can be associated with bleeding.

Bioprosthetic valves are made of human or animal tissue. Biological valves do not require anticoagulation, but they tend to fail over time.^[3][4]Patients with a biological valve may need to have the valve replaced in 10 to 15 years.

The 2006 American College of Cardiology/American Heart Association (ACC/AHA) recommendations for the choice of aortic valve ^[5][6]:

• If the patient is under 65 years of age and does not have a contraindication to anticoagulation then a mechanical valve is preferred.
• If the patient is ≥65 years of age and does not have risk factors for thromboembolism, then a bioprosthetic valve is reasonable
• If the patient already has a mechanical valve in the mitral or tricuspid position and already requires anticoagulation, then a mechical valve is preferred
• If the patient has active prosthetic valve endocarditis, then the valve should be replaced
• If the patient has contraindications to anticoagulation therapy regardless his or her age, then a bioprosthetic valve is indicated

The risk of death or serious complications from isolated aortic valve replacement is typically between 1-3%, 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.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Sara Zand, M.D.[2] Mohammed A. Sbeih, M.D.[3]; Rim Halaby, M.D. [4]; Usama Talib, BSc, MD [5]; Sabawoon Mirwais, M.B.B.S, M.D.[6] Synonyms and keywords: AR; Aortic Regurgitation; AVR; Aortic Valve Replacement;LVESD; Left Ventricular End Systolic Diameter;LV; Left Ventricle;LVEF;Left Ventricular Ejection Fraction;CABG;Coronart Artery Bypass Grafting;LVEDD; Left Vntricular End Diastolic Diameter;TAVI; Transcatheter Aortic Valve Replacement

Severe acute AR requires emergency surgery. The surgery should be performed as early as possible without a delay, particularly if hypotension, decreased perfusion, or pulmonary edema are present. In patients with chronic severe AR, mechanical or bioprosthetic valve may be used for valve surgery. In patients undergoing surgical replacement of the aortic sinuses and/or ascending aorta, maintaining of the native aortic valve (valve-sparing) may be possible in selected patients with favorable valve anatomy. Primary aortic valve repair is not yet generalizable, and durability is not known. AVR is recommended when there is LV dilation based on the measurement of LV in short-axis diameters. There are insufficient data on the relationship between LV volumes and outcomes of patients with AR.

Acute severe AR may cause death due to pulmonary edema, ventricular arrhythmias, electromechanical dissociation, or circulatory collapse. Individuals with bacteremia with aortic valve endocarditis should not wait for treatment with antibiotics to take effect, especially if there is hypotension, pulmonary edema, or low cardiac output given the high mortality associated with the acute AR.

Shown below is an algorithm for the treatment of acute AR.^[1]

Abbreviations: AVR: Aortic valve replacement; ACE: Angiotensin converting enzyme; ARB: Angiotensin receptor blocker; CCB: Calcium channel blocker; LVEF: Left ventricle ejection fraction; TTE: Transthoracic echocardiography

Replacement with an aortic valve homograft should be performed if feasible. The surgical approach depends upon the cause of AR. Aortic valve replacement or repair may be needed in cases of valvular structural abnormalities and aortic root repair/replacement may be needed in cases of aortic dissection.

Patients may be temporarily managed before surgery with vasodilators such as nitroprusside and possibly inotropic agents such as dopamine or dobutamine to improve stroke volume and reduce left ventricular end-diastolic pressure.^[4] Intra-aortic balloon pump is contraindicated as this would worsen aortic regurgitation by increasing afterload due to the inflation of the balloon during diastole.^[5]

In mild AR secondary to aortic dissection, the aortic valve can be repaired/replaced at the time of surgery for aortic dissection.

Medical treatment to lower LV afterload may temporarily stabilize patients with acute severe AR brought on by IE or aortic dissection, but surgery should not be postponed, especially if there is hypotension, pulmonary edema, or indications of low flow. 1-4 In individuals with acute severe AR, intra-aortic balloon counterpulsation is not recommended.

• Symptoms is an important indication for AVR in patients with chronic severe AR.
• Taking a careful, detailed history regarding symptoms or reduced exercise capacity is important.
• AVR results in an improved survival rate even among symptomatic patients with a severe reduction in LVEF (<35%). ^[7]
• LV systolic function is an important determinant of survival and functional status after AVR.
• Optimal outcome reaches when AVR is performed before LVEF decreases below 55% or before the onset of symptoms.^{[8] [9]}
• Other types of cardiac surgery, such as CABG, mitral valve surgery, or surgery for correction of dilation of the aortic root or ascending aorta can be performed at the time of AVR.
• LVESD in patients with chronic AR indicates both the severity of the LV volume overload and the degree of LV systolic shortening.^[10]
• An elevated LVESD shows LV systolic dysfunction with a depressed LVEF. If LVEF is normal, increased LVESD indicates a significant degree of LV remodeling resulting development of symptoms and/or LV systolic dysfunction and an increased mortality rate after AVR.^[11]
• Body size index is important, especially in women or small patients.
• LV volumes may be a more sensitive predictor of cardiac events than LVESD index in asymptomatic patients.
• In patients with moderate AR who are undergoing other forms of cardiac surgery, such as CABG, mitral valve surgery, or replacement of the ascending aorta, consideration of aortic valve anatomy, aortic root size and shape, regurgitant severity, other comorbidities, and patient‘s preferences and values is recommended.
• Valve-sparing procedure may be considered in patients undergoing surgical repair or replacement of the aortic root or ascending aorta.
• In asymptomatic patients with chronic AR, LVEDD is a marker of the severity of LV volume overload and associated with clinical outcomes , and progressive increases in LVEDD are associated with a further need for surgery.^[12]
• TAVI for isolated chronic AR is challenging because of dilation of the aortic annulus and aortic root and lack of sufficient leaflet calcification.^[13]
• Risks of TAVI for treatment of AR include transcatheter valve migration and significant paravalvular leak.
• TAVI is rarely feasible, and transcatheter approach may be performed in the selected patients with severe AR and HF, high surgical risk , with valvular calcification and appropriate annular size.

Abbreviations: BSA: Body surface area; CABG: Coronary artery bypass grafting; LV: Left ventricle; LVEF:Left ventricular ejection fraction ; LVESV:Left ventricular end-systolic diamete

Shown below is an algorithm depicting the indications for aortic valve replacement (AVR) in chronic aortic regurgitation.

Abbreviations: LVEF: left ventricular ejection fraction; LVEDD: left ventricular end diastolic diameter; LVESV: left ventricular end systolic diameter; VC: vena contracta; RVol: regurgitant volume; RF: regurgitant fraction; ERO: effective regurgitant orifice

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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]; Usama Talib, BSc, MD [4]

Related Key Words and Synonyms: Aortic valve replacement.

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: ^{[1][2][3][4][5][6][7]}

• 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.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

Prior to surgery, the surgeon and patient must make a choice as to whether a mechanical or bioprosthetic valve should be inserted.

Shown below is an algorithm depicting the factors that influence the choice of the type of the prosthetic valve and the discharge anticoagulation therapy.^[1]

Abbreviations: AVR: Aortic valve replacement; INR: International normalized ratio; TAVR Tansthoracic aortic valve replacement

Mechanical valves are made of man-made (synthetic) materials, such as a metal like titanium. Mechanical heart valves do not fail often. They last from 12 to 20 years^[2][3]. However, blood clots develop on them. If a blood clot forms, the patient may have a stroke. Anticoagulation with warfarin will be required which can be associated with bleeding.

Bioprosthetic valves are made of human or animal tissue.Biological valves do not require anticoagulation, but they tend to fail over time ^[4][3]. Patients with a biological valve may need to have the valve replaced in 10 to 15 years.

The 2006 American College of Cardiology/American Heart Association (ACC/AHA) recommendations for the choice of aortic valve ^[5][6]:

• If the patient is under 65 years of age and does not have a contraindication to anticoagulation then a mechanical valve is preferred.
• If the patient is ≥65 years of age and does not have risk factors for thromboembolism, then a bioprosthetic valve is reasonable
• If the patient already has a mechanical valve in the mitral or tricuspid position and already requires anticoagulation, then a mechical valve is preferred
• If the patient has active prosthetic valve endocarditis, then the valve should be replaced
• If the patient has contraindications to anticoagulation therapy regardless his or her age, then a bioprosthetic valve is indicated
• If the oartic root is small then a mechanical valve is indicated as there is a risk of aortic annular enlargement if a bioprosthetic valve is used

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]; Usama Talib, BSc, MD [4]

Related Key Words and Synonyms: Aortic valve replacement.

If the procedure is indicated; it could be done by one of the following approaches:^[1][2]

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.

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 ^[3]

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^[4][5][6], the use of this technique has been limited by high rates of pulmonary autograft failure with deterioration of right heart homografts^[7]. 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. ^[8]

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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: Mohammed A. Sbeih, M.D.[2]; Usama Talib, BSc, MD [3]

Related Key Words and Synonyms: Aortic valve replacement.

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.^[1][2]

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.

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 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.^[2] 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.

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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]; Usama Talib, BSc, MD [4]

Related Key Words and Synonyms: Aortic valve replacement.

Most valve surgery operations are successful, but in some rare cases, an aortic valve repair may fail and another operation may be needed.

The risk of death or serious complications from isolated aortic valve replacement is typically between 1-3%, 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. Complications like myocardial Injury and acute kidney injury may negatively effect the prognosis.^[1][2][3]

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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]; Usama Talib, BSc, MD [4]

Related Key Words and Synonyms: Aortic valve replacement.

Risks of any surgery Some Complications associated with any surgical procedure include:^{[1][2][3][4][5][6][7]}

• Pulmonary embolism where blood clots in the legs 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 There are many risks associated with open heart surgery.^[1][2]The postoperative risk factors can be related to various factors including albumin, TLC and BMI.^[8] Other possible complications after an heart surgery include:^{[9][10][11][12]}

• Heart attack or stroke
• Heart rhythm problems; such as atrial fibrillation
• Infection at the site of the incision cut, which is more likely to happen in people who are obese, have diabetes, women, or have already had this surgery
• Memory loss and loss of mental clarity, or “fuzzy thinking” or pump head
• Post-pericardiotomy syndrome, which presents as 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 The complications associated with prosthetic heart valves include:^{[12][13][14][15]}

• 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

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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.

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