For the treatment of Aortic Valve Disease: Stenosis and Regurgitation
Aortic valve surgery is performed by heart surgeons to treat most commonly bicuspid valves, other congenital aortic valve disease, aortic valve stenosis and aortic valve regurgitation.
This information will help you understand the conditions that may affect the aortic valve and why surgical treatment may be needed to treat your condition.
What is the aortic valve?
Your aortic valve
There are four valves in your heart including the mitral, tricuspid, aortic and pulmonic valves.
The aortic valve is located between the left ventricle (lower heart pumping chamber) and the aorta, which is the largest artery in the body. Valves maintain one-way blood flow through the heart.
What is aortic valve disease?
Aortic valve disease occurs when the aortic valve does not work correctly. This can be caused by:
- Aortic valve stenosis: These stiff, fused, thickened, inflexible valve leaflets lead to the narrowing of the aortic valve, that limits the blood flow. Aortic valve stenosis progresses when calcium is deposited on the valve leaflets, further limiting their mobility. Stenosis can occur in patients with either a tricuspid (3 leaflets) or a bicuspid (2 leaflets) aortic valve.
- Aortic valve regurgitation (also called valvular insufficiency, incompetence or "leaky valve"): These valve leaflets do not close completely. Regurgitation causes the blood that is ejected by the heart to immediately flow back into the heart once the heart stops squeezing and relaxes. Regurgitation may occur because of floppy leaflets (prolapse), abnormal congenitally deformed valves (bicuspid or unicuspid), infection of the valve (endocarditis), inability of the leaflets to close tightly due to dilatation of the aorta (aneurysm), holes in the leaflets, or rheumatic valve disease.
What causes aortic valve disease?
The aortic valve may be abnormal at birth (typically a bicuspid congenital aortic valve) or become diseased over time, usually seen in older patients (acquired valve disease).
Congenital aortic valve disease
Patients with bicuspid aortic valves are born with them and are present in about 1 - 2 percent of the population.
Normal aortic valve
Bicuspid aortic valve
Instead of the normal three leaflets or cusps, the bicuspid aortic valve has only two. Without the third leaflet, the valve opening may not close completely and leak (regurgitant) or not open completely and become narrowed (stenotic) or leak.
In many cases, bicuspid aortic valves may function normally for several years without requiring treatment.
About 25 percent of patients with bicuspid aortic valves may have some enlargement of the aorta above the valve. If it is greatly dilated, the aorta is known as being aneurismal.
Acquired aortic valve disease
With acquired aortic valve conditions, changes occur in the structure of the valve. Acquired aortic valve conditions include:
- Infective endocarditis is a bacterial infection of the valve, which is caused when bacteria enter your blood stream from the site of a remote infection and attach to the surface of your heart valves. Dental cleaning or even minor infection, such as a tooth abscess, can cause severe bacterial endocarditis of the aortic valve.
- Rheumatic fever is usually caused by a bacterial throat infection, such as strep throat. The valve itself is not infected in rheumatic fever, but antibodies developed by the body to fight infection react with the heart valves, causing stiffening and fusion of the leaflets of the aortic valve.
- Aortic valve degeneration from wear and tear is another cause of acquired aortic valve disease. In many patients, the aortic valve leaflets degenerate and become calcified with time. This most frequently causes aortic stenosis, but may also cause aortic regurgitation. This is the most common cause of aortic stenosis in people over the age of 65.
- Other causes of aortic valve disease include: rheumatoid arthritis, chronic inflammatory diseases, lupus, syphilis, hypertension, aortic aneurysms, connective tissue diseases, and less commonly, tumors, some types of drugs and radiation for cancers or lymphoma.
What are the symptoms of aortic valve disease?
Many patients with aortic valve disease are asymptomatic (have no symptoms), even when the stenosis (narrowing) or insufficiency (leak) are severe.
Initial symptoms of aortic valve disease usually include:
- Easy tiring
- Loss of energy
- Swelling of the ankles
- Palpitations (extra or skipped heart beats)
More advanced symptoms may include:
- Shortness of breath
- Chest pain
- Dizziness or loss of consciousness
How is aortic valve disease diagnosed?
The diagnosis of aortic valve disease is made after your physician reviews your symptoms, performs a physical exam and listens for a murmur, and evaluates the results of your diagnostic tests.
During the physical exam, using a stethoscope, the doctor may hear a murmur, which represents turbulent blood flow across an abnormal valve.
The diagnosis of aortic valve disease is confirmed by a specialized heart ultrasound called an echocardiogram. The echocardiogram allows the doctor to visualize the heart valves and determine the severity and possible cause of the aortic valve disease.
In most patients, a standard transthoracic echocardiogram (in which a probe with gel is placed on the skin of the chest to transmit the images) is adequate to visualize the valve. The test may be combined with exercising or IV infusion of drug allow the doctor to see the degree of stenosis more clearly.
Sometimes, a transesophageal echocardiogram (TEE - in which a probe is passed through the mouth into the esophagus) is necessary to more closely visualize the valve. A TEE is an outpatient procedure.
How is aortic valve disease treated?
If you do not have symptoms or heart damage, you will need to protect your valve from further damage by following precautions to reduce the risk of infective endocarditis, and you may need to take medications. In addition, surgery may be needed to treat your condition if you have symptoms, evidence of heart damage, or heart failure.
Aortic valve surgery
There are two types of aortic valve surgery: aortic valve repair and aortic valve replacement.
During aortic valve surgery, including aorta surgery, the aortic valve may be repaired or replaced. The results of your diagnostic tests, the structure of your heart, your age, the presence of other medical conditions and other factors will be considered to determine whether aortic valve repair or replacement is the best treatment approach for you.
Aortic valve surgery can be performed using traditional heart valve surgery or minimally invasive approaches.
Traditional Aortic Valve Surgery
During traditional aortic valve surgery, a surgeon makes a 6- to 8-inch incision down the center of your sternum, and part or all of the sternum (breastbone) is divided to provide direct access to your heart. The surgeon then repairs or replaces your abnormal heart valve or valves.
Minimally Invasive Aortic Valve Surgery
Minimally invasive aortic valve surgery is a type of aortic valve repair surgery performed through smaller, 2- to 4-inch incisions without opening your whole chest. This is typically done with a “J” incision and leaves your chest stable. Minimally invasive surgery reduces blood loss, trauma, length of hospital stay and may accelerate recovery.
Most patients who require isolated aortic valve surgery are candidates for minimally invasive aortic valve surgery, but your surgeon will review your diagnostic tests and determine if you are a candidate for this type of surgery.
Aortic valve repair
While the aortic valve is usually replaced, aortic valve repair may be an option.
Bicuspid aortic valve repair
Bicuspid aortic valve repair
A bicuspid aortic valve may be repaired by reshaping the aortic valve leaflets allowing the valve to open and close more completely.
Bicuspid aortic valve repair may be an option to treat leaking valves, but it can not be used to treat a stenotic or narrowed bicuspid aortic valve.
Bicuspid aortic valve repair can be performed using a minimally invasive “J” incision surgical technique. The aortic valve surgery is technically difficult and should be performed by a surgeon with experience repairing aortic valves.
Repair of an enlarged aorta
Aortic valve disease is often associated with enlargement (aneurysm) of the ascending aorta, the initial portion of the aorta (the main blood vessel in the body that originates from the aortic valve).
If the enlargement of the aorta is substantial (usually above 4.5 or 5 cm in diameter), this part of the aorta may need to be replaced. The replacement is done at the time of aortic valve repair or replacement. In patients who have leaky aortic valve and an enlarged aorta, a special procedure (David procedure) can be performed. The David procedure allows surgeons to repair the aortic valve and simultaneously replace the enlarged ascending aorta.
Repair of valve tears or holes
In addition, if the valve leaflets have tears or holes, the surgeon can patch these with tissue patches.
Aortic valve replacement
If valve repair is not an option, your surgeon may replace the valve. The native (original) valve is removed and a new valve is sewn to the annulus of your native valve. The new valve can either be mechanical or biological.
Biological valve replacement
At Cleveland Clinic, the majority of aortic valves are replaced with a bioprosthesis. Biological valves (also called tissue or bioprosthetic valves) are made of tissue, but they may also have some artificial parts to provide additional support and allow the valve to be sewn in place.
About 80% of aortic valves are replaced with a bioprosthesis.
Biological valves can be made from pig tissue (porcine), cow tissue pericardial (bovine), or pericardial tissue from other species.
These valves are safe to insert, durable (lasting from 15 to 20 years), and allow patients to avoid lifetime use of anticoagulants (blood thinning medications). At the Cleveland Clinic the risk of death is less than one percent for isolated aortic valve replacement and has consistently been better than predicted mortality based on the Society of Thoracic Surgeons (STS) national data.
Human Homograft (also called allograft) aortic valve replacement
A homograft is an aortic or pulmonic valve that has been removed from a donated human heart, preserved, treated with antibiotics, and frozen under sterile conditions.
Homografts are used especially when the aortic root is destroyed by endocarditis (infection). See surgery for endocarditis.
Mechanical valves replacement
Mechanical valves are made completely of mechanical parts, which are non-reactive and tolerated well by the body. The bileaflet valve is used most often.
It consists of two pyrolite (qualities similar to a diamond) carbon leaflets in a ring covered with polyester knit fabric.
All patients with mechanical valve prostheses need to take an anticoagulant medication, warfarin (Coumadin), for the rest of their life to reduce the risk of blood clotting and stroke. This increases the risk of bleeding.
Ross Procedure (also called Switch Procedure)
The Ross operation is usually performed on patients under age 30 who want to avoid lifetime use of anticoagulants (blood thinning medications) after surgery.
During this procedure, the patient's normal pulmonary valve is removed and used to replace the diseased aortic valve. The pulmonary valve is then replaced with a pulmonary homograft. The Ross procedure leaves two valves at potential risk of later failure.
What is the risk of aortic valve surgery?
At Cleveland Clinic, the overall risk of death associated with surgery for isolated aortic valve replacement is less than 1%, compared with The Society of Thoracic Surgeon's benchmark of 2.4%.
Mortality for minimally invasive "j" incision isolated aortic valve replacement is even lower and mortality for minimally invasive isolated aortic valve repair is also extremely low even for the David valve preserving procedure.
Past history of heart surgery, your age, co-existing organ disease (such as emphysema), or other conditions that require surgical treatment will affect your individual risk. Ask your doctor about your surgical risk
The Miller Family Heart & Vascular Institute at Cleveland Clinic is one of the largest valve surgery centers in the world. We offer many choices for valve surgery such as aortic valve repair, aortic valve replacement using several types of replacement options, and minimally invasive "j" incision aortic valve surgery.
Cleveland Clinic also has broad surgical experience with combined, complex valve procedures. 60% of patients undergoing primary valve operation also had other, concomitant procedures. We have extensive experience with valve reoperations and over one-quarter of all valve procedures at Cleveland Clinic are reoperations.
You may also be a candidate for an experimental valve inserted through a small incision on your groin or left chest, called Transcatheter aortic valve replacement (TAVR) .
We would be happy to evaluate you to help you determine the best surgical option.
For More Information
Written with Cleveland Clinic cardiovascular surgeons Lars G. Svensson, MD, PhD, A. Marc Gillinov, MD, and Tomislav Mihaljevic, MD,