Surgical Aortic Valve Replacement

What is surgical aortic valve replacement?

Surgical aortic valve replacement (SAVR) is surgery to give you a new aortic valve when your current valve is too damaged to work properly.

Your aortic valve is the “door” that connects your heart to your main artery (aorta). Due to aging or other factors, your valve might have trouble opening widely enough. That means less blood can flow from your heart into your aorta each time your heart beats. Or, your valve might not close properly, like a warped wooden door in the summer. In that case, some blood leaks backward.

When your aortic valve doesn’t work quite right, you have what healthcare providers call aortic valve disease. Your condition may be mild and not cause any symptoms. But as the condition gets worse, your heart may have to work harder to send out enough blood to your body. This extra workload can damage your heart. Problems with your aortic valve can also lead to symptoms like chest pain or feeling like you need to work harder to breathe. Over time and without treatment, aortic valve disease can be life-threatening.

Receiving a new aortic valve can help you feel better, protect your heart and allow you to live longer. SAVR is an open surgery, meaning a surgeon makes a cut (incision) in your chest to access your heart. It’s a major surgery that has some risks. Your healthcare provider will explain both the benefits and risks of SAVR in your unique situation.

What does SAVR treat?

Surgical aortic valve replacement treats the following conditions:

• Narrowing of your aortic valve (aortic stenosis).
• Leaky aortic valve (aortic regurgitation).

Mild cases of aortic stenosis or regurgitation typically don’t need surgery. Your healthcare provider may keep an eye on the situation and prescribe medications to help your heart work better. But if valve disease is severe and/or causing symptoms, your provider may recommend surgery.

How common is SAVR?

Surgeons have used SAVR for over 50 years as a reliable treatment option for aortic valve disease. Tens of thousands of people have SAVR each year.

What happens before this surgery?

Before SAVR, you can expect to have a physical exam and testing. Your healthcare team takes a close look at your heart and checks all aspects of your health to see what type of surgery is best for you. For example, they’ll decide whether you should have SAVR or the less invasive TAVR.

Possible tests you may need include:

• Cardiac catheterization.
• Chest X-ray.
• Computed tomography (CT) scan.
• Echocardiogram (echo).
• Electrocardiogram (EKG).
• Blood tests and urine tests.

Your healthcare team will give you instructions for how you should prepare for your surgery day. The instructions will be specific to your needs and tell you:

• When you should begin fasting (no foods or drinks) prior to your surgery.
• If you should temporarily stop taking any of your medications.
• When you should arrive at the hospital.
• What you should bring with you and what you should leave behind.

Be sure to ask if anything’s unclear or if you have further questions.

If you smoke or use tobacco products, you should quit as early as possible before your surgery. This can lower your risk for complications. Your provider can give you resources and support to help.

Choosing your replacement valve

A major part of preparation for SAVR is choosing the type of replacement valve you’ll receive. There are two main types of valves:

• Biological (bioprosthetic) valves. These valves are made of tissues from pigs, cows or (rarely) humans. They may also contain some artificial parts to give additional support and help your surgeon sew the valve in place.
• Mechanical valves. These valves are made of carbon and steel. If you receive a mechanical valve, you’ll need to take a blood-thinning medication (anticoagulant) called warfarin (also called Coumadin®) for the rest of your life to lower the risk of blood clots. Clots are more likely to form on mechanical valves than bioprosthetic valves.

Each type of valve has pros and cons. Your surgeon will talk to you about these options and recommend the type that’s better for you based on your age and other factors. In general, surgeons often recommend mechanical valves for people under age 50 and bioprosthetic valves for people over age 65. Either option may be suitable for people between ages 50 and 65 based on their preferences and medical needs.

What happens during surgical aortic valve replacement?

SAVR generally follows these steps:

1. Your care team gives you medication (anesthesia) that puts you into a deep sleep. You won’t feel any pain during the surgery or be aware of what’s going on, and you won’t remember it.
2. Your care team connects you to a heart-lung machine. This device offers a detour for your blood, allowing it to avoid your heart and lungs during the surgery. Providers also use this machine to give you solution (cardioplegia) that temporarily stops your heart. This allows your surgeon to safely operate on your heart when it’s not beating.
3. Your surgeon makes one long, vertical cut (about 6 inches) through your breastbone to access your heart (sternotomy).
4. Your surgeon removes your damaged aortic valve and sews a new valve in its place.
5. Your surgeon reconnects the two sides of your breastbone with wires. These wires typically stay in for life.
6. Your surgeon closes your incision.

Minimally invasive options

Surgeons sometimes use minimally invasive methods to perform SAVR. These include a partial sternotomy or right anterior thoracotomy. Your surgeon will tell you more about these methods if they’re appropriate for you.

How long does aortic valve replacement surgery take?

SAVR surgery generally takes about two to four hours.

What happens after this surgery?

You’ll spend about five days in the hospital to begin your recovery. Your care team will watch your vital signs and check on you regularly to make sure you’re doing OK. They’ll also help you move around a little more each day.

Once you’re fully recovered from surgery (typically six to eight weeks later), you’ll likely begin cardiac rehab. This is a supervised program (typically lasting 12 weeks) that helps you return to exercise slowly and safely. You also receive education, counseling and support that you can use to make lasting lifestyle changes. For example, you may learn how to follow a heart-healthy diet or quit tobacco use.

What are the benefits of this procedure?

Replacing a valve that isn’t working right can be lifesaving. Without treatment, aortic valve disease may be fatal.

What is the success rate of aortic valve replacement surgery?

For most people, the likelihood of serious complications, including death and stroke, is 1% to 2%.

You’re more likely to live longer if you have a lower risk of surgical complications going into SAVR. Surgeons use formulas to calculate a person’s risk of complications or death. These scores help them decide whether surgery is safe for you. You may be low-risk, intermediate-risk or high-risk based on your age, overall health and other factors.

Your surgeon can tell you more about your individual level of risk and what that means for you.

What are the risks or complications of this procedure?

Possible complications of SAVR include:

• Arrhythmia (especially atrial fibrillation).
• Need for permanent pacemaker.
• Bleeding.
• Infection.
• Stroke.
• Death.

Not everyone faces the same level of risk. Factors that affect your risk of complications include your age and medical conditions.

Your surgeon can tell you more about your unique level of risk and what they can do to improve your chances of a successful surgery.

What is the recovery time?

Most people need about four to eight weeks to recover from heart valve surgery. You may need less time if you had minimally invasive surgery (as little as two weeks). Your surgeon can tell you how long your recovery may take and what you should do (and avoid) during this time.

It helps to remember that recovery is a process. You may feel tired for several weeks. This is normal, and your body needs time to rest. Don’t push yourself to get back to normal right away. Follow your surgeon’s guidance on when it’s safe for you to return to your usual activities.

When should I call my healthcare provider?

Call your healthcare provider right away if you notice any signs of complications as you recover from your surgery. Warning signs include:

• Chest pain or pressure.
• Drainage or pus around your incision.
• Fever or chills.
• Pain near your incision.
• Swelling or redness around your incision.
• Swelling (edema) in your legs or feet.
• The feeling that your heart is flip-flopping in your chest or skipping a beat (heart palpitations).
• Weight gain of more than three pounds in one week.

Is there an alternative to surgical aortic valve replacement?

For some people, transcatheter aortic valve replacement (TAVR) is a better option. It’s less invasive and has an easier recovery than SAVR. With TAVR, your surgeon uses small entry points and catheters (thin, flexible tubes) to insert a new valve inside your old one.

Your surgeon will talk to you about SAVR and TAVR. They’ll recommend the method that’s better for you based on your needs. They’ll take into account many factors, including your age, risk of surgical complications and medical conditions.

For some people, including those born with abnormal aortic valves (for example, bicuspid aortic valves) or those who need additional cardiac procedures (such as coronary artery bypass grafting or other valve repair/replacement), open heart surgery may have better short- and long-term outcomes.

A note from Cleveland Clinic

Learning you need a new heart valve can make you feel more aware of your heartbeat than ever before. Until you learn something is wrong, it can be easy to forget the constant effort your heart makes every second of every day to keep you going strong. Like any hard worker, your heart sometimes needs a little help to keep doing its job.

An aortic valve replacement can make a huge difference in how your heart works and how you feel as a result. Just like you’d remodel your house when something breaks down, surgeons can fix or replace things that aren’t working right in your heart (including its “doors”) so you can go on living. Talk to your healthcare team to learn more about SAVR and whether it’s the best option for you.