Aortic stenosis surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]; Claudia P. Hochberg, M.D. [3]; Abdul-Rahman Arabi, M.D. [4]; Keri Shafer, M.D. [5]; Priyamvada Singh, MBBS [6]; Usama Talib, BSc, MD [7] Assistant Editor-In-Chief: Kristin Feeney, B.S. [8]

Surgical intervention may be a necessary component of treatment for symptomatic severe aortic stenosis. Aortic valve replacement is the mainstay of treatment of symptomatic aortic stenosis, as it improves both the symptoms and life expectancy in aortic stenosis patients, in contrast to medical therapy alone which may improve the symptoms without prolonging life expectancy. Intervention methods may include: a) Aortic valve replacement, mechanical and device based therapies such as bileaflet mechanical aortic valves; b) Aortic Balloon Valvotomy, aortic valvuloplasty (aortic valve repair).

Percutaneous aortic valve replacement is in its infancy and thus aortic valvuloplasty can offer palliation of symptoms and potentially prolong survival for these high risk patients in class III-IV heart failure. It can be performed emergently in patients with end-stage heart failure due to aortic stenosis, patients in cardiogenic shock, as a bridge to aortic valve replacement, patients with critical aortic stenosis needing emergent non-cardiac surgery, poor surgical candidates and nonagenerians, patients with congenital or rheumatic aortic stenosis. Valvuloplasty tends to alleviate heart failure symptoms and improve hemodynamics but rarely does it alleviate angina.

In open surgery, the surgeon makes a large cut in the sternum to reach the heart.

Minimally invasive aortic valve surgery is done through much smaller surgical cuts than the large cuts needed for open surgery.

The number of patients undergoing aortic valve replacement surgery to treat aortic stenosis has increased progressively over the past 10 years. The surgery is usually performed in elderly patients with preserved ejection fractions. Transcatheter aortic valve implantation (TAVI) represents a new option in patients with no surgical options.

Aortic stenosis requires aortic valve replacement if medical management does not successfully control symptoms. According to a prospective, single-center, nonrandomized study of 25 patients, percutaneous implantation of an aortic valve prosthesis in high risk patients with aortic stenosis results in marked hemodynamic and clinical improvement when successfully completed.^[1]

The procedure can be done either by the traditional open heart surgery or by the minimally invasive surgery. Before the surgery, the patient will receive general anesthesia. This will make the patient asleep and pain-free during the entire procedure. Other than the aortic valve replacement surgery; aortic stenosis could be treated by: percutaneous aortic balloon valvotomy or transcatheter aortic valve implantation.

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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]

The number of patients undergoing aortic valve replacement surgery to treat aortic stenosis has increased progressively over the past 10 years. The surgery is usually performed in elderly patients with preserved ejection fractions. Transcatheter aortic valve implantation (TAVI) represents a new option in patients with no surgical options.

Among the 512 aortic stenosis patients who underwent valve replacement, 54.3% were elderly (more than 70 years), 80% had a preserved left ventricular systolic function (left ventricular ejection fraction >60%) and 85% had symptoms of heart failure (NYHA class II-IV).^[1]

The number of the aortic valve replacement procedures performed over the last 10 years has increased. Mitral valve surgery was constant during the same period. ^[2]

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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]; Usama Talib, BSc, MD [4] Synonyms and keywords: As; Aortic stenosis; AVR; Aortic valve replacement; LVEF; Left ventricular ejection fraction; LV; Left ventricle

In symptomatic patients with severe high-gradient AS (Stage D1), AVR has beneficial effect on survival, symptoms, and LV systolic function. In asymptomatic patients with severe AS and normal LV systolic function, the risk of sudden death (<1% per year) is low. In patients with a low LVEF and severe AS, survival is better with AVR than medical therapy.

• In symptomatic patients with severe high-gradient AS (Stage D1), AVR has beneficial effects on survival, symptoms, and LV systolic function.
• The most common initial symptom of AS is exertional dyspnea or decreased exercise tolerance.
• More severe classical symptoms of AS, including HF, syncope, or angina, can be avoided by appropriate treatment at the onset of even mild symptoms.
• Outcomes after surgical or transcatheter AVR are excellent.
• Improvement in exercise tolerance has been shown by exercise test after AVR.
• In asymptomatic patients with severe AS and normal LV systolic function, the risk of sudden death is low (<1% per year). However, in patients with a low LVEF and severe AS, survival is better in those who undergo AVR than in those treated medically.^[1]
• Disease progression occurs in nearly all patients with severe asymptomatic AS. Initiation of symptoms within 2 to 5 years is likely when aortic velocity is ≥4.0 m/s or mean pressure gradient is ≥40 mm Hg.

• Mean pressure gradient is a strong predictor of outcome after AVR, with better outcomes seen in patients with higher gradients.
• Outcomes are poor with severe low-gradient AS but are still better with AVR than with medical therapy in those with a low LVEF, especially in the presence of contractile reserve.
• Severe AS on dobutamine stress testing is defined when a maximum velocity >4.0 m/s with a valve area ≤1.0 cm2 at any point during the test protocol, with a maximum dobutamine dose of 20 mcg/kg per minute.
• Outcome in patients without contractil reserve is poor with either surgical or medical therapy.
• In patients undergone AVR, LVEF typically increases by 10 LVEF units and may return to normal if afterload mismatch was the cause of LV systolic dysfunction.
• Low-flow, low-gradient severe AS with preserved LVEF should be considered in patients with a severely calcified aortic valve, an aortic velocity <4.0 m/s (mean pressure gradient <40 mm Hg), and a valve area ≤1.0 cm2, stroke volume index <35 mL/m2, presence of small LV cavity with thick walls, diastolic dysfunction, and a normal LVEF (≥50%).^[2]
• If hypertension is present, blood pressure should is controlled before reevaluation of AS severity.
• Valve area is indexed to body size because an apparent small valve area may be only moderate AS in a small patient.
• An aortic valve area index ≤0.6 cm2/m2 suggests severe AS.
• Transaortic stroke volume is calculated by Doppler or 2D imaging.
• Exercise testing may be helpful in clarifying symptom status in patients with severe AS including a fall of ≥10 mm Hg in systolic blood pressure from baseline to peak exercise or a significant decrease in exercise tolerance as compared with age and sex normal standards.
• In patients with very severe AS and an aortic velocity ≥5.0 m/s or mean pressure gradient ≥60 mm Hg, the rate of symptom onset is approximately 50% at 2 years. ^[3] *Early surgery in patients with aortic velocity ≥4.5 m/s showed significant survival benefit.
• An elevated serum BNP level is a marker of subclinical HF and LV decompensation in severe AS.^[4]
• In asymptomatic patients with AS with the aortic velocity reaches ≥2 m/s, hemodynamic progression leading to symptom . ^[5]
• Hemodynamic progression occurs when aortic velocity increases about 0.3 m/s per year, an increase in the mean gradient of 7 to 8 mm Hg per year, and a decrease in valve area of 0.15 cm2 per year.
• Predictors of rapid disease progression include older age, more severe valve calcification, and a faster rate of hemodynamic progression in serial studies.
• Elective AVR may be considered In patients with an aortic velocity >4 m/s, and the presence of predictors of rapid disease progression.^[6]
• In adults with initially asymptomatic severe AS, the rate of sudden death is low (<1% per year). However, an aortic velocity ≥5 m/s or an LVEF <60% is associated with higher all-cause and cardiovascular mortality rates in the absence of AVR.
• A progressive decrease in LVEF is most likely in those with an LVEF <60% before AS becomes severe.^[7]
• Hemodynamic progression eventually leading to onset of symptom occurs in nearly all asymptomatic patients with AS.

. The rate of symptom onset is strongly dependent on the severity of AS.

• Patients with asymptomatic AS require periodic monitoring for the development of symptoms and progressive disease.

Abbreviations: BNP: B-type natriuretic peptide; CABG: Coronary artery bypass grafting; LV: Left ventricle; LVEF:Left ventricular ejection fraction ; CCT:Cardiac computed tomography; SAVR: Surgical aortic valve replacement; STS-PROM: Society of Thoracic Surgeons – predicted risk of mortality; SVi: Stroke volume index; TAVI:Transcatheter aortic valve implantation ; Vmax:Peak transvalvular velocity

Abbreviations: AS: Aortic stenosis; AV: Aortic valve; AVA: Aortic valve area; LVEF: Left ventricular ejection fraction ; CT: Computed tomography; △Pm: Mean pressure gradient; DSE: Dobutamine stress echocardiography; LV: Left ventricular; SVi: Stroke volume index; Vmax: Peak transvalvular velocity

• High flow is reversible in conditions such as anemia, hyperthyroidism orarterio-venous fistula and may also be present in patients with hypertrophic obstructive cardiomyopathy.
• Normal flow by pulsed Doppler echocardiography is defined as:

  Cardiac index 4.1 L/min/m2 in men and women

  SVi 54 mL/m2 in men, 51 mL/m2 in women

• DSE flow reserve is defined as > 20% increase in stroke volume in response to low-dose dobutamine.
• Pseudo-severe aortic stenosis is defined when AVA >1.0 cm2 with increased flow.^[10]
• CT measurement of aortic valve calcification (Agatston units) for definition of AS severity:

  High likely: men >3000, women>1600

  Likely: men >2000, women >1200

  Unlikely: men <1600, women <800

Abbreviations: AVR: Aortic valve replacement; VKA: Vitamin K antagonist

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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]

The preoperative assessment of patients undergoing surgery for aortic stenosis may include complete physical examination, echocardiogram (Doppler echocardiogram), cardiac catheterization, chest X-ray, computed tomography (CT) scan, electrocardiogram (ECG), electrophysiology tests , exercise tests, holter monitor, and magnetic resonance imaging.^[1][2]

The patient may need to have some tests before the procedure. The Cardiologist usually conducts a physical examination and diagnose the condition, he or she will assess the general health of the patient and will recommend the most appropriate treatment for the patient and if he or she needs surgery. Some of the tests that can be done before the procedure include:^[1][2]

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

Around 40% of patients with aortic stenosis that require surgery also have coronary artery disease.^[3] Usually coronary artery disease is treated at the same operation if CABG (Coronary artery bypass grafting) is indicated.

Studies showed that concurrent bypass surgery adds little morbidity to the valvular procedure and does not increase the mortality. The 2006 ACC/AHA guidelines on the treatment of valvular heart disease included recommendations for coronary angiography prior to valve surgery in those who are suspected to have coronary artery disease and in those at risk for coronary disease.^[2] A noninvasive angiography using computed tomography (CT) or magnetic resonance imaging may be an alternative.

• 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.

• 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.

Template:WH Template:WS CME Category::Cardiology

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2], Claudia P. Hochberg, M.D. [3], Abdul-Rahman Arabi, M.D. [4], Keri Shafer, M.D. [5], Priyamvada Singh, MBBS [6]; Usama Talib, BSc, MD [7] Assistant Editor-In-Chief: Kristin Feeney, B.S. [8]

The procedure can be done either by the traditional open heart surgery or by the minimally invasive surgery. Before the surgery, the patient will receive general anesthesia. This will make the patient asleep and pain-free during the entire procedure. Other than the aortic valve replacement surgery; aortic stenosis could be treated by percutaneous aortic balloon valvotomy or transcatheter aortic valve implantation.^[1][2][3]

If the procedure is indicated; it could be done by one of the following approaches:^[4][5][1]

• 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:^[1]

• 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.

Different types of valves can be used to repair a damaged aortic valve.^{[6][7][8][9][10]}

1. Mechanical valve, 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 is 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 ^[6][11]:

• 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.

Different techniques can be used for aortic valve surgery depending on various factors including age and other risk factors. The retrograde technique is the most commonly used technique.^[5] Elderly patients with high risk can benefit from RDAVR i.e rapid-deployment aortic valve replacement technique also known as sutures technique. A new generation Edwards INTUITY-Elite® valve which is a balloon-expandable stented trileaflet bovine pericardial bioprosthesis is being used recently.^[12]Some of the characteristics of retrograde technique include:

• 8 French femoral sheath can usually accommodate a 20 mm balloon and minimizes vascular complications
• Alternatively two 6 Fr sheath from bilateral femoral approach and two smaller balloons can be used
• The letter may be necessary in female elderly patients with concomitant peripheral vascular disease
• 0.035” straight wire is commonly used to cross the valve and advance via pig-tail or Amplatz catheter; Right heart catheterization is done and transaortic gradient is typically measured pre-procedure
• The 0.035” wire is then exchanged for a stiffer 0.038”Amplatz exchange length wire with the tip shaped into a pig-tail shape so as not to injure the LV
• The 20-23 mmX 6 cm balloon is advance over the wire and positioned to straddle the aortic valve
• The balloon is manually inflated with a 60 cc syringe containing diluted contrast (slowly)
• Meticulous control of balloon position must be maintained at all times by backward traction on the balloon to prevent jumping forward and injuring/perforating the LV apex

The most preferable surgical closure method for this tenuous patient population is a perclose or angioseal closure. This particular closure method calls for a mandatory attention to the meticulous access technique. An antegrade approach may be a viable method in some patient populations. An example of such would be the venuous access with transseptal approach. This particular procedure can be done in a select population of patients. Many patients experience an adverse response to the hemodynamic effect of mitral valve incompetence. In this situation, the rigidity of the wire traveling across the mitral valve can directly result in mitral valve injury. It is, therefore, not an advisable treatment method for most populations.

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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]

The recovery of patient is divided into recovery at the hospital and recovery at home. Patient may spend 4 to 7 days in the hospital after surgery. Patient stays in ICU for one or two days. Recovery at home includes 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. 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.^[1]

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 the intensive 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. Anticoagulation with aspirin is started to minimise risk of post operative clot formation, cerebral ischemic events, and it also improves survival.^[1] 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 post operative recovery depends on the pre operative LVEF, showing an inverse relation.^[2]

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.

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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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]

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.^[1]

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. Patients with decreased (less than 40%) preoperative LVEF undergoing transcatheter aortic valve replacement showed an early LVEF recovery after surgery.^[1]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 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, ^[2][3] 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.

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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]

Complications of aortic stenosis surgery may include 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 valve, reactions to medicines, nausea and vomiting, abnormal or painful scar formation , and allergic skin reactions.^[1][2]

Surgeries are usually associated with various complications ranging from mild to severe in nature. ^[1][2][3][4]

• 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

There are many possible complications after an Open Heart Surgery. The postoperative risk factors can be related to various factors including albumin, TLC and BMI.^[5] Some possible complications after a cardiac surgery are:^[6][7][8][9]

• 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.
• Acute Renal Failure
• Metabolic complications like hyperglycaemia, hypokalemia and increased free fatty acid concentration.

The complications associated with a Prosthetic heart valve placement include:^{[10][11][12][9]}

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

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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]; Varun Kumar, M.B.B.S. [3]

Dr. Lars Svensson, Cardiothoracic Surgeon and Director of the Aorta Center, at the Cleveland Clinic describes heart surgery for bicuspid aortic valve {{#ev:youtube|nfzrZJzDTjo}}

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