Description

Before your surgery you will receive general anesthesia. This will make you fall into a pain-free sleep.

There are several different ways to do minimally invasive aortic valve surgery. Techniques include laparoscopy 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). Muscles in the area will be divided. This allows the surgeon to reach your heart and aortic valve.
• For the endoscopic, or keyhole, approach, your surgeon makes one to four small holes in your chest. Then your surgeon uses special instruments and a camera to do the surgery.
• For robotically-assisted valve surgery, the surgeon makes two to four tiny cuts (about 1/2 to 3/4 inches) in your 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 aortic valve on the computer. This method is very precise.

You will 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 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 10 to 12 years, but you may not need to take blood thinners for life.

In some cases, you will have coronary artery bypass surgery, or surgery to replace the first part of the aorta (large blood vessel leaving the heart) 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 to 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) with a balloon attached on the end to the valve. The balloon stretches the opening of the valve. This procedure is called percutaneous valvuloplasty.

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 (angina), shortness of breath, fainting spells (syncope), 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).

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 is only done 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:

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

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 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

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

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

You may have two to three tubes 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 the vein) lines for fluids. Nurses will closely watch monitors that display information about 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 tend to fail over time. But they have a lower risk of blood clots.

Techniques for minimally invasive heart valve surgery have improved greatly over the past 10 years. These techniques are safe for most people, and they reduce recovery time and pain. For best results, have aortic valve surgery at a center that does many of these procedures.

Alternative Names

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

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.

Popma JJ, Baim DS, Resnic FS. Percutaneous coronary and valvular interfention. 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 55.

Otto 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.

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.

Update Date: 1/26/2012

Reviewed by: A.D.A.M. Editorial Team: David Zieve, MD, MHA, and David R. Eltz. Previously reviewed by Shabir Bhimji, MD, PhD, Specializing in General Surgery, Cardiothoracic and Vascular Surgery, Midland, TX. Review provided by VeriMed Healthcare Network (1/26/2011).