Why is Aortic Valve Surgery done?

• Aortic valve surgery is performed when an abnormality of the valve compromises the normal functioning of the valve.
• Other aortic valve abnormalities, congenital as well as aquired (for example rheumatic, infection radiation), occur but are less common. Many times, patients with congenital or bicuspid aortic valve disease do not require aortic valve surgery until they are adults

What factors help you determine the best option for aortic valve surgery?

There are several options for adult patients with aortic valve disease. The type of surgery used is individualized to each patient and based on several factors:

• Age of the patient
• Expected long-term survival

Normal aortic valve	Bicuspid aortic valve

• Co-existing cardiac and/or valve disease
• Co-existing other cardiac disease
• Co-existing non-cardiac disease
• Patient lifestyle
• Surgery risks
• Risk of thromboembolism (blood clots)
• Risk of endocarditis
• Valve durability
• Risk of bleeding complications with anticoagulation 
• Patient's wishes

What are the options for aortic valve surgery?

• Aortic valve repair 
• Aortic valve replacement
  • Mechanical valve
  • Bioprosthetic valve
  • Homograph valve
  • Ross procedure

Aortic valve repair

In the past few years, aortic valve repair has become an option for patients with aortic valve disease. Aortic valve repair is performed less often and is more technically difficult than mitral valve repair, however, the majority (2/3), of leaky bicuspid aortic valves can be repaired with good results.

Advantages: The heart's natural anatomy is preserved and patients do not need to take any blood thinner medications.
Drawbacks: The surgery is technically difficult. This procedure is not an option for stenotic valves - only leaky aortic 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 would behave like the original well-functioning bicuspid valve.

Aortic valve replacement

There are two types of artificial valves or prostheses: 

mechanical valves

• The principle advantage of mechanical valves is their excellent durability. From a practical standpoint, they do not wear out.
• The principle disadvantage is that there is a tendency for blood to clot on all mechanical valves. Therefore patients with artificial valves must take anticoagulants or "blood thinners" for the rest of their life. There is also a small but definite risk of blood clots causing stroke.

biological valves

• All share a reduced risk of blood clots forming, therefore no blood thinners are needed.
• All are less durable than mechanical valves. Given enough time, they will probably all wear out.
• The options in this category include :
  • "xenograft" valves made from animal tissues (most often pig aortic valves),
  • "homograft" or "allograft" valves retrieved from human cadavers, 
  • Ross Procedure or "pulmonary autograft" valves moved from the patient's pulmonary artery on the right side of the heart to the aortic position on the left.

What are the risks of surgery?

Individual risks of surgery can be best estimated by your cardiothoracic surgeon and cardiologist. Risks generally depend on age, general health, specific medical conditions, and heart function.

What can I expect after my aortic valve surgery?

After successful aortic valve replacement, patients can expect to return to their preoperative condition or better.
When you leave the hospital after heart surgery, you will be given instructions on how to care for yourself during the first phase of recovery which lasts about six to eight weeks. Those who have had minimally invasive surgery may have a shorter recovery time.

Typical instructions include:

Care of your incision

You will be told how to care for your incision(s) before you leave the hospital. It is important to:

• Keep your incision(s) clean and dry.
• Use only soap and water to cleanse the area. Place soapy water on your hand or washcloth and gently wash the incision up and down. Until the scabs are gone and the skin is completely healed, do not rub the incision with a washcloth. When showers and baths are permitted, they should be limited to 10 minutes. The water temperature should be warm - not too hot or cold. Extreme water temperatures can cause faintness
• Do not apply ointments, oils, salves or dressings to your incision unless specifically told to do so.
• Eat a healthy diet to help healing.
Call your doctor if signs of infection appear:
• Increased drainage or oozing from incision Increased opening of the incision line
• Redness or warmth around the incision
• Increased opening of the incision line
• Increased body temperature (greater than 101 degrees Fahrenheit or 38 degrees Celsius)

 Relief of pain
Some muscle or incision discomfort, itching, tightness and/or numbness along your incision are normal after surgery. You should not have pain in your chest similar to what you had before surgery. You will be given a prescription for a pain medication before you leave the hospital.
If you had bypass surgery, you may have more pain in your legs than around your chest incision if saphenous vein grafts were used. Walking, daily activities, and time will help to lessen leg discomfort and stiffness.

Call your doctor if your sternum feels like it moves, or it pops or cracks with movement.

Swelling - for those with vein grafts taken from their legs

You may return home with some swelling in your legs and feet, especially if you had vein graphs taken from your legs. If you notice swelling:

• Place your feet up higher than your heart level when resting. One way to do this is to lie on your bed or couch and put several pillows under your legs. Or, you may lie on the floor and place your feet on the couch. Try this three times a day for one hour to relieve swelling. (Note- recliners do not adequately elevate your feet).
• Do not cross your legs
• Walk daily even if your legs are swollen
• Hospital support hose may be suggested

Call your doctor if swelling in your leg(s) become worse or painful and/or associated with increased fatigue and/or shortness of breath.

Driving
Your doctor will tell you when you may resume driving. This usually occurs about six to eight weeks after surgery, however, time may be shorter if you had minimally invasive surgery. During this time, you may be a passenger as often as you like.

Activity

For the first six to eight weeks:

• Gradually increase your activity. You may do light household chores, but do not stand in one place longer than 15 minutes.
• Do not lift objects greater than 20 pounds (your doctor may give you a different number if appropriate). Also, do not push or pull heavy objects.
• It is OK to perform activities above shoulder level, such as reaching for an object or brushing your hair. But, do not hold your arms above shoulder level for a longer period of time.
• You may climb steps unless they have been restricted by your doctor. You may need to rest part of the way if you become tired. Do not climb up and down stairs several times during the day, especially when you first arrive home. It is better to plan activities to go downstairs in the morning and back upstairs when it is time for bed.
• Pace yourself - spread your activities throughout the day. If you become tired, rest and schedule unfinished activities for another time.
• Walk daily. Your doctor or cardiac rehabilitation specialist will give you guidelines for walking when you return home.
• Check with your doctor to confirm activity guidelines.

Medications

You may need medications after surgery. Your doctor will tell you if you need these medications until you recover from heart surgery or lifelong. Make sure you understand the names of your medications, what they are for, and what times to take them. Only take the medications that are prescribed when you are discharged from the hospital. If you want to take medications you were previously on for other conditions, discuss this with your doctor first.

Anticoagulation ("blood thinners") with a drug like Coumadin may be prescribed for 6 weeks to 3 months after surgery for those with biological valves, and for life for those with mechanical valves. Once the wounds have healed, most patients should experience few if any restrictions to activity. A patient will require preventative or prophylactic antibiotics whenever having dental work, and should always tell a doctor about their valve surgery before any surgical procedure.

Diet
You should eat a healthy diet to help you heal. Your doctor will tell you if you should follow any special diet instructions. It is common after surgery to have a poor appetite at first. If this is the case, try to eat smaller, more frequent meals. Your appetite should return within the first few weeks. If it does not, contact your doctor.

Sleep
It is important to get enough rest or you may feel overtired and irritable. Unfortunately, many people complain of having trouble sleeping for some time after surgery. Normal sleep patterns should return within a few months. Call your doctor if lack of sleep begins causing changes in behavior or if normal sleep patterns do not return.

Work

You will need to take time to recover, usually about six to eight weeks (may be earlier with minimally invasive surgery). Your doctor will tell you when you can return to work. If you have the flexibility at your job, ease back to your work schedule. If possible, start back at half-time and gradually increase back to your normal routine.

Emotions

It is common after surgery to feel sad or blue. These feelings should go away after the first few weeks. If they do not, call your doctor.

Sex

Many patients and their partners feel nervous about resuming sexual activity after heart surgery. The amount of energy it requires to perform intercourse with a spouse or regular partner is similar to climbing about one or two flights of stairs or walking about one half mile (0.8 km) at a brisk pace. If you cannot perform these activities without becoming tired or short of breath, please allow additional recovery time before resuming sexual activity. For the first six to eight weeks, use positions which limit pressure or weight on the breastbone or tension on the arms and chest.

• Keep in mind that a sexual relationship has both physical and emotional aspects
• Talk openly with your partner
• Allow a gradual return of sexual activity
• Have sex when you are rested and physically comfortable
• Create realistic performance expectations - it may take time to return to an active sex life
• Be caring honest and loving with each other

Soon you and your partner will return to a satisfying emotional and physical relationship. Anxiety on the part of either partner, as well as some medications, may interfere with sexual arousal or performance. So, discuss any difficulties with your doctor.

Mental Functioning and Heart Surgery

Some people become frustrated during recovery from heart surgery because they feel they are not as sharp mentally as they were before surgery. These cognitive changes are normal after heart surgery. The entire body, including the brain, was seriously stressed during surgery, especially if the surgery involved stopping the heart and circulating the blood through a heart-lung machine. With time, in most cases, normal cognitive functioning returns. Patience is needed to avoid the frustration that can accompany this side effect of surgery. You should not force yourself to work or perform mentally stressful tasks, such as balancing a checkbook in the first couple of weeks after surgery

What is Mended Hearts? 

Mended Hearts is a national organization dedicated to providing support and inspiring hope in heart disease patients and their families for more than 60 years. Mended Hearts of Greater Cleveland is a chapter of this national, nonprofit organization.

Mended Hearts helps people understand that there can be a rich, rewarding life after a heart event. The organization brings patients, families and caregivers together to form a network of caring individuals. Members listen, share their experiences and learn from healthcare professionals.

For dates of upcoming support group meetings and more information, visit MendedHearts138.org or email info@mendedhearts138.org

For our national office, visit MendedHearts.org

What is cardiac rehabilitation ?

 For many people with coronary artery disease, a cardiac rehabilitation program provides an excellent opportunity to begin an exercise program, learn about your heart disease, and learn strategies to change your lifestyle to prevent further progression of your disease. Your family doctor can give you information about the MetroHealth Cardiac Rehabilitation Program or programs in your local area. Cardiac rehabilitation is covered by most insurance companies.

Ross Procedure (also called Switch Procedure)

The Ross operation is usually performed on patients younger than ages 40 to 50 who want to avoid taking the blood-thinning medication, Coumadin, 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 immediate success rate in the operating room is very good, which means that most of the patients intended to have a Ross operation do leave the operating room with a successfully completed Ross operation and well-functioning valves.

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. The procedure may also be abandoned when any other technical issues are present.

Step 1: Measurement of the aortic and pulmonic valves	Step 2: The aorta and pulmonary artery are opened and the aortic and pulmonary valves are carefully inspected to determine if the Ross is an appropriate procedure.
Step 3: The diseased aortic valve is removed. Then, the pulmonary valve (autograft) is removed and placed in the aortic position.	Step 4: The autograft in sutured in place and the coronary arteries are re-attached.
Step 5: A pulmonary homograft is attached to the right ventricle outflow tract.	Step 6: The aorta is attached to the autograft and the pulmonary artery is attached to the homograft - the procedure is complete.

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 child or adolescent 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 is 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 this is going to be the case in 50% 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's syndrome) or for patients who have an abnormal pulmonary valve. The pulmonary homograft in the pulmonary position could also fail; the most common mode of failure is that it becomes stenotic. The risk of requiring replacement of the pulmonary homograft is about 10 percent 10 years after the procedure.

The Ross procedure should only be performed by very skilled and experienced surgeons, particularly interested in the operation.

Who makes the final decision?

Choosing the best surgery for you requires a frank and open conversation with your physician regarding your own personal risks and benefits for each surgical option. Then, you and your cardiologist should choose the best surgeon to perform the operation. The surgeon should have experience in performing the procedure and good surgical outcomes. The final decision is made by the surgeon, and this may not occur until the surgery itself, when the surgeon is able to view the diseased valve.