For the treatment of Aortic Valve Disease: Stenosis and Regurgitation
Written with Cleveland Clinic cardiovascular surgeons Tomislav Mihaljevic, M.D., and A. Marc Gillinov, M.D.
Aortic valve surgery is performed by heart surgeons to treat 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 chamber) and the aorta, which is the largest artery in the body. Valves maintain one-way blood flow through the heart. Click here to learn more about the heart valves.
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: Stiff, fused, inflexible valve leaflets that lead to the narrowing of the aortic valve, which limits or blocks the blood flow. Aortic valve stenosis occurs when calcium is deposited on the valve leaflets, limiting their mobility. Stenosis can occur in patients with a normal (3 leaflets) or a bicuspid (2 leaflets) aortic valve.
- Aortic valve regurgitation (also called valvular insufficiency, incompetence or "leaky valve"): Valve leaflets that do not close completely. Regurgitation causes the valve to leak, which limits the forward flow of blood through the aortic valve. Regurgitation may occur because of floppy leaflets (prolapse), infection of the valve (endocarditis), dilatation of the aorta (aneurysm), and rheumatic valve disease.
What causes aortic valve disease?
The aortic valve may be abnormal at birth (congenital aortic valve disease) or become diseased over time (acquired valve disease).
Congenital aortic valve disease
Bicuspid aortic valve disease is a congenital valve condition that affects about 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 open or close completely, or the opening may 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 valve disease may have some enlargement of the aorta above the valve.
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. Even minor infection, such as a tooth abscess can cause severe bacterial endocarditis of the aortic valve.
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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.
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Aortic valve degeneration 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.
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Other causes of aortic valve disease include: heart attacks, syphilis, hypertension, aortic aneurysms, connective tissue diseases, and less commonly, tumors, some types of drugs and radiation.
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:
- Fatigue
- Loss of energy
- Swelling of the ankles
- Palpitations (extra or skipped heart beats)
More advanced symptoms may include:
- Shortness of breath
- Chest pain
- Loss of consciousness
How is aortic valve disease diagnosed?
The diagnosis of aortic valve disease is made after your physician performs a physical exam, reviews your symptoms and evaluates the results of your diagnostic tests.
During the physical exam, your doctor will first listen to your heart with a stethoscope. 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. Echocardiogram allows the doctor to visualize the heart valves and determine the severity and cause of the aortic valve disease.
In most patients, a standard transthoracic echocardiogram (in which a a probe is placed on the skin of the chest to transmit the images) is adequate to visualize the valve. 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?
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 to having surgery to treat your condition.
Aortic valve surgery
There are two types of aortic valve surgery: aortic valve repair and aortic valve replacement.
During aortic valve 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. Minimally invasive surgery reduces blood loss, trauma, and length of hospital stay.
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 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 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.
In 2006, 82% of aortic valves were 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 easy to insert, durable (lasting from 15 to 20 years), and allow patients to avoid lifetime use of anticoagulants (blood thinning medications)
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 ideal valves for aortic valve replacement, especially when the aortic root is diseased or endocarditis (infection) is present. ( 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, such as warfarin (Coumadin), for the rest of their life to reduce the risk of blood clotting and stroke.
Ross Procedure (also called Switch Procedure)
The Ross operation is usually performed on patients under age 40 to 50 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.
Click here to learn about Aortic Valve Surgery in the Young Adult Patient: Repair, Replacement, and Ross Procedure.
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 1.8%, compared with The Society of Thoracic Surgeon's benchmark of 2.4%.
Mortality for minimally invasive isolated aortic valve replacement is 0% and mortality for minimally invasive isolated aortic valve repair is 0%.
Past history of heart surgery, your age, or other conditions that require surgical treatment will affect your individual risk. Ask your doctor about your surgical risk.
Our Experience
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 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 as well- in 2006, 27% of all valve procedures at Cleveland Clinic were reoperations.
We would be happy to evaluate you to help you determine the best surgical option.
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If you have questions or need more information:
To obtain a surgical consultation, or if you have additional questions or need more information, you may contact us by e-mail, using the Contact Us Form. Please state "Miller Family Heart & Vascular Institute at Cleveland Clinic" in the Question or Comment Section.
You may also call the Miller Family Heart & Vascular Institute Resource Nurse at 216.445.9288 or toll-free 866.289.6911. Webmail and phone calls are answered between 8:30 am to 4:00 PM on regular business days.
