Aortic regurgitation surgery procedure
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2], Varun Kumar, M.B.B.S., Lakshmi Gopalakrishnan, M.B.B.S., Mohammed A. Sbeih, M.D.[3]
Related Key Words and Synonyms: Aortic valve replacement.
Aortic Valve Replacement Procedure
If the procedure is indicated; it could be done by one of the following approaches:
The Traditional Open Heart Surgery:
- The surgeon will make a 10-inch-long cut in the middle of the chest (sternum).
- Next, the surgeon will separate the breastbone (sternum) to be able to see the heart.
- Most people are connected to a heart-lung bypass machine or bypass pump. The heart is stopped while the patient is connected to this machine. This machine does the work of the heart while the heart is stopped.
- A small cut is made in the left side of the heart so the surgeon can repair or replace the aortic valve.
In Minimally Invasive Aortic Valve Surgery; there are several different ways to perform the procedure:
- The heart surgeon may make a 2-inch to 3-inch-long cut in the right part of the patient's chest near the sternum. Muscles in the area will be divided so the surgeon can reach the heart. A small cut is made in the left side of the heart so the surgeon can replace the aortic valve.
- In Endoscopic surgery; the surgeon makes one to four small holes in the chest, then he or she uses special instruments and a camera to do the surgery.
- For Robotically-Assisted Valve Surgery, the surgeon makes two to four tiny cuts (about a ½ to a ¾ inch) in the chest. The surgeon uses a special computer to control robotic arms during the surgery. The surgeon sees a three-dimensional view of the heart and mitral valve on the computer. This method is very precise.
The patient may or may not need to be on a heart-lung machine for these types of surgery, but if not; the heart rate will be slowed by medicine or a mechanical device.
There are two types of valves that can be used [1]:
1. Mechanical which is made of man-made (synthetic) materials, such as a metal like titanium. These valves last the longest [2][3], but the patient will need to take blood-thinning medicine, such as warfarin (Coumadin) or aspirin, for the rest of his or her life.
2. Biological which made of human or animal tissue. These valves last 10 to 12 years, but the patient may not need to take blood thinners for life.
The 2006 American College of Cardiology/American Heart Association (ACC/AHA) recommendations for the choice of aortic valve [1][4]:
- If the patient is under 65 years of age and do not have a contraindication to anticoagulation then mechanical valve is preferred.
- If the patient is ≥65 years of age who do not have risk factors for thromboembolism; Bioprosthetic valve will be reasonable.
- If the patient has already a mechanical valve in the mitral or tricuspid position (need anticoagulation).
- If the patient has active prosthetic valve endocarditis; the valve should be replaced.
- If the patient has contraindications to anticoagulation therapy regardless his or her age; then a bioprosthetic valve is indicated.
- In case of small oartic root; mechanical valve is indicated as there is a risk of annular enlargement in such patient if bioprosthetic valve is used.
Once the new or repaired valve is working, the surgeon will:
- Close the heart and take you off the heart-lung machine.
- Place catheters (tubes) around the heart to drain fluids that build up.
- Close the sternum with stainless steel wires. It will take about 6 weeks for the bone to heal. The wires will stay inside the body.
The patient may have a temporary pacemaker connected to the heart until his or her natural heart rhythm returns.
The surgeon may also perform coronary artery bypass surgery at the same time, if needed.
Other aortic root diseases like marfan syndrome, bicuspid aortic valve and aortic dissection which can cause chronic aortic regurgitation should be treated with AVR and aortic root reconstruction when degree of dilatation of aorta or aortic root ≥ 50mm in diameter [5]
Ross or Ross/Konno procedure is another alternative surgical procedure where the pulmonary valve is transplanted to the aortic position, and a homograft conduit is implanted from the right ventricle to the pulmonary artery. Though this procedure shows promising results for aortic valve abnormalities in some[6][7][8], the use of this technique has been limited by high rates of pulmonary autograft failure with deterioration of right heart homografts[9]. These rates are higher in children as compared to adults. Further studies aimed at clarifying longer-term outcomes as well as preventing pulmonary homograft deteroration are needed. {{#ev:youtube|r50kKpKefP8}}
To summarize, mechanical valve replacement is the preferred surgical option at present as opposed to valve repair or biological valve replacement in view of lack of evidence of long-term durability and outcomes. However, they may be appropriate for patients in whom anticoagulation are contraindicated. Patients' age, ability to tolerate warfarin and patients' preference are taken into account for in deciding the type of valve (mechanical or bioprosthetic valve) to be used in valve replacement. [1]
References
- ↑ 1.0 1.1 1.2 Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172.
- ↑ Bloomfield P, Wheatley DJ, Prescott RJ, Miller HC (1991). "Twelve-year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses". N Engl J Med. 324 (9): 573–9. doi:10.1056/NEJM199102283240901. PMID 1992318.
- ↑ Hammermeister K, Sethi GK, Henderson WG, Grover FL, Oprian C, Rahimtoola SH (2000). "Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial". J Am Coll Cardiol. 36 (4): 1152–8. PMID 11028464.
- ↑ Vahanian A, Baumgartner H, Bax J, Butchart E, Dion R, Filippatos G; et al. (2007). "Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology". Eur Heart J. 28 (2): 230–68. doi:10.1093/eurheartj/ehl428. PMID 17259184.
- ↑ Lindsay J (1997). "Diagnosis and treatment of diseases of the aorta". Current Problems in Cardiology. 22 (10): 485–542. PMID 9339352. Retrieved 2011-03-28. Unknown parameter
|month=ignored (help) - ↑ Ohye RG, Gomez CA, Ohye BJ, Goldberg CS, Bove EL (2001). "The Ross/Konno procedure in neonates and infants: intermediate-term survival and autograft function". The Annals of Thoracic Surgery. 72 (3): 823–30. PMID 11565665. Retrieved 2011-04-08. Unknown parameter
|month=ignored (help) - ↑ Laudito A, Brook MM, Suleman S, Bleiweis MS, Thompson LD, Hanley FL, Reddy VM (2001). "The Ross procedure in children and young adults: a word of caution". The Journal of Thoracic and Cardiovascular Surgery. 122 (1): 147–53. doi:10.1067/mtc.2001.113752. PMID 11436048. Retrieved 2011-04-08. Unknown parameter
|month=ignored (help) - ↑ Laforest I, Dumesnil JG, Briand M, Cartier PC, Pibarot P (2002). "Hemodynamic performance at rest and during exercise after aortic valve replacement: comparison of pulmonary autografts versus aortic homografts". Circulation. 106 (12 Suppl 1): I57–I62. PMID 12354710. Retrieved 2011-04-08. Unknown parameter
|month=ignored (help) - ↑ David TE (2009). "Ross procedure at the crossroads". Circulation. 119 (2): 207–9. doi:10.1161/CIRCULATIONAHA.108.827964. PMID 19153280. Retrieved 2011-04-08. Unknown parameter
|month=ignored (help)