Aortic Valve Surgery in the Young Adult Patient
Types of Aortic Valve Disease
Written with Gosta Pettersson, MD, Cardiovascular & Thoracic Surgery, Miller Family Heart & Vascular Institute.
Bicuspid aortic valve disease is the most common type of aortic valve abnormality.
Bicuspid aortic valve disease is a congenital condition(present at birth) and occurs in about two percent of the population. Instead of the normal three leaflets or cusps, the bicuspid aortic valve has only two. Without the third leaflet, the valve may be:
- Well-functioning: Two-thirds of people who have this defect have a bicuspid valve that functions well for life
- Stenotic: Stiff valves that can not open or close properly
- Leaky (also called regurgitation): Not able close tightly
Other Congenital and acquired aortic valve abnormalities (such as rheumatic disease, infection or radiation) may also be present in younger patients, but are less common.
Patients with congenital or bicuspid aortic valve disease often do not require aortic valve surgery until they are adults. Younger patients usually have features of a leaking valve rather than a stenotic valve.
Normal aortic valve
Bicuspid aortic valve
Concerns about aortic valve surgery
Most adolescent and young adult patients are concerned about aortic valve surgery because they want to:
- Maintain an active, normal lifestyle, including sports, travel, pregnancy, etc.
- Avoid the use of anticoagulant medications (blood thinners), which some patients are required to take after valve surgery
- Prevent the need for future surgery
What factors can help you and your surgeon determine the best option for aortic valve surgery?
There are several options for young adult patients with aortic valve disease. The type of aortic valve surgery that is recommended is based on several factors, including:
- Age of the patient
- Expected long-term survival
- Co-existing medical conditions including valve disease, other heart disease or other medical conditions
- Surgery risks
- Risk of thromboembolism (blood clots)
- Risk of endocarditis
- Valve durability
- Risk of bleeding complications with long-term anticoagulation therapy
- Patient’s lifestyle and personal preferences
What are the types of aortic valve surgery?
- Aortic valve repair
- Aortic valve replacement
- Mechanical valve
- Biological valve
- Homograft valve
- Ross procedure (also called the “Switch” operation
Below is a description of each surgical option for aortic valve surgery, and the advantages and drawbacks of each.
Aortic valve repair
Bicuspid aortic valve repair
Aortic valve repair may be an option for patients who have bicuspid aortic valve disease or other aortic valve conditions that are associated with valve regurgitation (leaking valve).
Aortic valve repair is performed less often and is more technically difficult than mitral valve repair. However, the majority (two-thirds), of leaky bicuspid aortic valves can be repaired with good results.
- Preserved heart muscle strength, and preserved natural heart anatomy
- Decreased risk of infection
- Decreased need for life-long anticoagulant medication
- This type of aortic valve surgery is technically difficult.
- Aortic valve repair is only an option for leaky aortic valves, not stenotic valves.
- Although a repaired valve can possibly last a lifetime, about 20 to 25 percent of patients will require a valve replacement within ten years. In the best case scenario, the repaired aortic valve will function like the original well-functioning bicuspid valve.
Cleveland Clinic Outcomes
In 2006, 89 percent of aortic valve surgeries performed at Cleveland Clinic were valve replacements, and 11 percent were repairs. There is a higher percentage of aortic valve replacements because aortic valve repair can only be performed on leaky aortic valves, not stenotic valves.
Despite the increasing complexity of procedures, hospital mortality for primary valve operations was only 1.7 percent in 2006.
The mortality for primary isolated aortic valve replacement at Cleveland Clinic in 2006 was 1.1 percent. This is below The Society of Thoracic Surgeons’ (STS) benchmark of 2.2 percent.
Aortic valve replacement
Mechanical Valve Replacement
Mechanical valves are made totally of mechanical parts that are tolerated well by the body. Mechanical valves are made of metal or carbon and are designed to perform the functions of the patient’s native valve. The bileaflet valve is the most common type of mechanical valve and consists of two carbon leaflets in a ring covered with polyester knit fabric.
- Mechanical valves are very durable and are designed to last a lifetime.
- Re-operations for mechanical failures or tissue in-growth are uncommon.
- Due to the artificial material involved, patients who receive a mechanical valve replacement need to take an anticoagulant medication for the rest of their lives. Anticoagulant medications (blood thinners such as warfarin or Coumadin) delay the clotting action of the blood. Anticoagulants help prevent clots from forming on the replaced valve to reduce the risk of a heart attack or stroke.
- Some patients who have a mechanical valve replacement report a valve clicking noise at times. This is the sound of the valve leaflets opening and closing.
Bioprosthetic valve replacement and Homograft Biological Valves
Biological valves (also called tissue valves) are made of tissue, but they may also have some artificial parts to give the valve support and aid placement. Biological valves may be made from cow tissue (bovine), pig tissue (porcine) or pericardial tissue from other species.
Advantages: Most patients who receive a biological valve replacement do not need to take life-long anticoagulant therapy after surgery, unless they have other conditions (such as atrial fibrillation) that require these medications.
Drawbacks: Studies on the PERIMOUNT pericardial valve have shown that in a 40-year-old patient, these valves have a 50 percent chance of lasting 15 years or longer, without decline in function. In younger patients, these valves will not last as long, but will still last longer than previous generations of bioprostheses. In older patients they will last longer. The durability of present generation pericardial valves and homografts are very similar.
Homograft (also called allograft) valve replacement
A homograft is an aortic or pulmonic valve that has been removed from a donated human heart, preserved, antibiotic-treated, and frozen under sterile conditions. A homograft may be used to replace a diseased aortic valve, or it may be used to replace the pulmonic valve during the Ross procedure.
- Homografts are ideal valves for aortic valve replacement, especially when the aortic root is diseased or endocarditis (infection) is present.
- Homograft is the best and safest option for patients with severe infections causing aortic valve and root destruction, and abscesses. This is particularly true if the infected valve is a prosthetic valve.
- Homograft valves are well-tolerated by the body because they are most like native valves.
- Most patients who receive a homograft valve replacement do not need to take life-long anticoagulant therapy after surgery, unless they have other conditions (such as atrial fibrillation) that require these medications.
Drawbacks: The availability of homografts can be a drawback. In addition, this type of valve replacement surgery is technically difficult. Homograft valves are expected to last about 15 to 20 years. Like bioprosthetic valves, homografts are not as durable in younger patients.
Ross Procedure (also called Switch Procedure)
The Ross procedure is usually performed on patients younger than ages 40 to 50 who want to avoid taking long-term anticoagulant medications after surgery. During this procedure, the patient's own pulmonary valve is removed and used to replace the diseased aortic valve. The pulmonary valve is then replaced with a pulmonary homograft.
The Ross operation is not performed when operative findings contraindicate the procedure, or when the pulmonary valve does not appear normal on the echocardiogram, or on inspection during surgery.
Advantages: The pulmonic valve is anatomically very similar to the aortic valve and could be an ideal substitute for the aortic valve. The new aortic autograft is a living valve and it will grow as the young adult grows, making this a good option for young patients. The blood flows with less pressure through the pulmonary valve than the aortic valve, therefore a homograft valve could last longer in the right-sided pulmonary valve position. The risk of thromboembolic complications (blood clots, stroke) and the risk of valve infection are very low -- lower than for any alternative valve prosthesis. The hemodynamic performance makes the Ross operation an attractive alternative for athletes. The pulmonary autograft valve has a good chance* of being a life-lasting solution for the aortic valve.
*Our qualified guess is that the pulmonary autograft will last a lifetime in at least half of Ross procedure patients.
Drawbacks: The Ross procedure is a technically difficult and long surgery, as it requires two valve replacements. Therefore, this procedure is only recommended for young patients who would tolerate a long surgery time. The pulmonary autograft valve is transplanted from the low pressure pulmonary circulation over to the aortic high pressure system. The valve cusps are strong enough to withstand the systemic pressure, but the pulmonary artery wall does dilate when exposed to systemic pressure, occasionally enough to cause the autograft valve to leak.
The risk of requiring re-operation for a leaking autograft valve is about 10 percent within 10 years after the operation.
The Ross procedure is not recommended for patients with tissue defects (such as Marfan syndrome) or for patients who have an abnormal pulmonary valve. The pulmonary homograft in the pulmonary position could also fail; the most common reason for failure is that it becomes stenotic. The risk of requiring replacement of the pulmonary homograft is about 10 percent within 10 years after the procedure.
The Ross procedure should only be performed by very skilled and experienced surgeons.
Minimally Invasive Aortic Valve Surgery
Minimally invasive surgery allows surgeons to perform aortic valve surgery through smaller incisions than traditional heart valve surgery. Other minimally invasive valve surgery techniques include endoscopic or keyhole approaches (also called port access, thoracoscopic or video-assisted surgery) and robotic-assisted surgery.
The benefits of minimally invasive surgery include a smaller incision (3 to 4 inches instead of the 6- to 8-inch incision with traditional surgery) and smaller scars. Other possible benefits may include a reduced risk of infection, less bleeding, less pain and trauma, decreased length of stay in the hospital (3 to 5 days) and decreased recovery time.
Valve surgeries, including valve repairs and valve replacements, are the most common minimally invasive cardiac procedures. The surgical team will carefully compare the advantages and disadvantages of minimally invasive valve surgery versus traditional valve surgery.
Your surgeon will review the results of your diagnostic tests before your surgery to determine if you are a candidate for any of these minimally invasive techniques.
Cleveland Clinic Experience: The percentage of isolated aortic valve replacements performed via a minimally invasive approach at the Cleveland Clinic was 65 percent in 2006 .
Who makes the final decision about the type of surgery?
Choosing the best aortic valve surgery for you requires an open discussion with your physician regarding your personal risks and benefits for each surgical option. Then, you and your cardiologist should choose the best surgeon to perform the procedure.
The surgeon should have experience in performing the procedure. Be sure to review the surgery center’s surgical outcomes for the procedure you are considering. The final decision about the type of aortic valve surgery that is performed is made by the surgeon, and this may not occur until the surgery itself, when the surgeon is able to view the diseased valve
For more information:
To obtain a surgical consultation, or if you have additional questions or need more information, you may contact us by email, using the Contact Us Form.
- Nash PJ, Vitvitsky E, Li J, Cosgrove DM, III, Pettersson G, Grimm RA. Feasibility of valve repair for regurgitant bicuspid aortic valves--an echocardiographic study. Annals of Thoracic Surgery 2005 May;79(5):1473-1479.
- Elkins R. The Ross Procedure; Pulmonary autograft replacement of the aortic valve. http://www.ctsnet.org/doc/2380; 2004.
- Pettersson G, Grimm RA. Current status of the Ross operation: Does it still have a role in the young adult patient with aortic valve disease? Heart Views 2003;4:110-122.
- Pettersson G. Which is the optimal operation for the young adult patient with aortic valve disease? Scandinavian Cardiovascular Journal 2002 Nov;36(5):272-274.
- Koul, B, Lindholm C, Koul M, Roijer, A. Ross Operation for Bicuspid Aortic Valve Disease in Adults: is it a Valid Surgical Option. Scand Cardiovas J. 36; 48-52, 2002.
- Stahle, E. Ross Procedure in Adults - a Valid Option for Whom? Scand Cardiovas J. 36; 2-5, 2002.
- Gillinov AM, Lytle BW, Hoang V, Cosgrove DM, Banbury MK, McCarthy PM, Sabik JF, Pettersson GB, Smedira NG, Blackstone EH. The atherosclerotic aorta at aortic valve replacement: surgical strategies and results. Journal of Thoracic and Cardiovascular Surgery 2000 Nov;120(5): 957-963.
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