Aortic Valve Disease

Heart valve disease can vary from aortic stenosis, the narrowing of the valve that limits blood flow, to incompetence or improper closure of the valve, which causes blood to leak back into the heart. This condition may also be described as a valve leak or mitral leak. A range of treatment options is available at Saint Luke's Mid America Heart Institute, including medical therapy and surgical repair or replacement.

What is aortic valve regurgitation?

Aortic valve regurgitation describes the condition in which your aortic valve leaks. It's also called aortic insufficiency. The aortic valve is one of the heart’s 4 valves. These valves help the blood flow through the heart and out to the body. Normally, the aortic valve stops blood from flowing back into the left ventricle. With aortic valve regurgitation, some blood leaks back through the valve as the heart relaxes. Aortic valve regurgitation happens more often with age. It is a fairly common problem that affects both men and women.

Aortic valve regurgitation can be acute or chronic. With acute aortic valve regurgitation, the valve suddenly becomes leaky. The heart doesn’t have time to get used to the leak in the valve. With chronic aortic valve regurgitation, the valve slowly becomes leakier. This gives the heart time to get used to the leak.

What causes aortic valve regurgitation?

Aortic valve regurgitation can be caused by any condition in which the leaflets or the ring structure of the valve is damaged. This can occur with the following conditions:

  • Weakening and calcification of the valve from aging
  • High blood pressure
  • Defects of the aortic valve present at birth (congenital). This might be a bicuspid valve, instead of the normal tricuspid.
  • Rheumatic heart disease, an inflammatory disease caused by Strep bacteria
  • Widening of the aorta for unknown reasons
  • Marfan syndrome, a connective tissue disorder
  • Certain types of arthritis. These include ankylosing spondylitis, rheumatoid arthritis, and Reiter syndrome.
  • Syphilis, a sexually transmitted disease
  • Ehlers-Danlos syndrome, a connective tissue disorder
  • Use of certain appetite-suppressing medicines
  • Bacterial infection of the heart valve (endocarditis)
  • Tearing of the aorta
  • Injury

Who is at risk for aortic valve regurgitation?

Advancing age is a common risk factor for aortic regurgitation. You can reduce some risk factors for aortic valve regurgitation such as:

  • Manage high blood pressure with lifestyle and medicines
  • Use antibiotics to treat rheumatic fever and prevent rheumatic heart disease
  • Avoid IV drugs, lowering the risk for heart valve infection
  • Promptly treat medical conditions that can lead to the disorder

There are other risk factors, such as age, that you can’t change. You also can’t change certain genetic conditions, such as Marfan syndrome.

What are the symptoms of aortic valve regurgitation?

You may not have any symptoms from mild aortic regurgitation. If the condition becomes more severe, you may develop symptoms that worsen over time. These may include:

  • Shortness of breath with exertion
  • Shortness of breath when lying flat
  • Fatigue
  • Unpleasant awareness of your heartbeat
  • Swelling in your legs, abdomen, and the veins in your neck
  • Chest pain or tightness with exertion

Sudden severe aortic valve regurgitation is a medical emergency, and includes symptoms such as:

  • Symptoms of shock (such as pale skin, unconsciousness, or rapid breathing)
  • Severe shortness of breath
  • Abnormal heart rhythms that make the heart unable to pump effectively

How is aortic valve regurgitation diagnosed?

Your healthcare provider will take your health history and give you a physical exam. Using a stethoscope, he or she will check for heart murmurs or congestion in your lungs. You may also have tests such as:

  • Echocardiogram (ultrasound of the heart), to make the diagnosis, assess severity and evaluate for a possible cause
  • Transesophageal echocardiogram (ultrasound of the heart taken from the esophagus), to further assess severity and evaluate for tearing of the aorta if needed
  • Stress testing may be advised to assess functional capacity
  • CT or MRI can also be used to assess for tearing of the aorta
  • MRI may be advised to assess severity and heart function if echocardiogram images are not ideal
  • Cardiac catheterization, aortography, or coronary angiography may be advised before aortic valve surgery or when initial testing provides unreliable data.
  • Electrocardiogram (ECG), to assess heart rhythm
  • Chest X-ray, can identify enlargement of the heart and aorta

How is aortic valve regurgitation treated?

Treatment varies according to how severe your condition is. If you have a mild form of the condition, you may need only regular check-ups with your healthcare provider. You may not have symptoms for many years. Symptoms may get worse slowly over time and not affect daily life.

In severe aortic regurgitation, surgery is commonly recommended. The timing of surgery is important to discuss with your healthcare provider and surgeon. In some cases, severe aortic regurgitation may be treated with medicine. Medicine may also be used in the short-term before valve replacement surgery. Or it may be used ongoing if you are not able to have valve replacement surgery.

It is also important to manage your blood pressure.

Medical treatment options may include:

  • Medicines to lower blood pressure and help the heart relax
  • Antiarrhythmic medicines to help maintain the heart’s rhythm
  • Water pills (diuretics) to reduce swelling

For people with severe aortic regurgitation, symptoms, enlargement of the left ventricle or abnormal pump function, the treatment is often somewhat different:

  • You may need surgery to replace the valve.
  • Your healthcare provider may recommend surgery even if you don’t yet have symptoms. People with advanced symptoms are less likely to recover well from the surgery. Because of this, it is important to closely follow up with your healthcare provider to make sure timing of surgery is appropriate for you.
  • You may need to take medicines until you have surgery.
  • Most people need an artificial aortic valve. In some cases, an aortic valve repair may be advised. The surgeon may do open surgery or may use a minimally invasive approach.
  • If you need heart surgery for another reason, your healthcare provider may advise aortic valve replacement at the same time.

Sometimes aortic valve regurgitation is acute:

  • Acute, severe aortic valve regurgitation needs surgery right away. You may need medicines for a short time to stimulate your heart or dilate your blood vessels.
  • In some cases, an infection of the heart valves can cause acute valve regurgitation. This may only need to be treated with antibiotics.

What are the complications of aortic valve regurgitation?

Complications are sometimes associated with aortic valve regurgitation such as:

  • Complications from valve replacement surgery
  • Blood clots that can cause heart attack or stroke
  • Bacterial infection of the heart valves
  • Heart failure
  • Sudden cardiac death

To reduce the risk of these complications, your healthcare provider may prescribe the following based upon your health history:

  • Medicines that prevent blood clots (blood thinners)
  • Medicines to help the pumping function of the heart

Living with aortic valve regurgitation

See your healthcare provider for regular checkups. Visit him or her right away if your symptoms change. Make note of your symptoms when you exercise. They may get worse during physical activity. It is common for symptoms to first be noticeable during exercise. Talk with your healthcare provider about your exercise habits. Tell all your healthcare providers and your dentist about your health history.

Your healthcare provider may prescribe treatments for heart problems related to aortic valve regurgitation such as:

  • A low-salt, heart-healthy diet to decrease blood pressure and the stress on your heart
  • Medicines to lower your blood pressure
  • Medicines to reduce the risk of arrhythmias
  • Reduction of caffeine and alcohol to reduce the risk of arrhythmias
  • Cholesterol-lowering medicines
  • Smoking cessation

When should I call my healthcare provider?

If you notice your symptoms gradually worsening, plan to see your healthcare provider soon. You may need surgery or a medicine change.

Seek medical help right away if:

  • You have symptoms of acute severe aortic valve regurgitation. These may include sudden shortness of breath, a rapid heartbeat, chest pain, severe lightheadedness, and loss of consciousness.
  • You notice sudden new symptoms.

Key points

  • In aortic valve regurgitation, the heart’s aortic valve does not work right. It becomes leaky allowing some blood flow back into the left ventricle.
  • You may not have symptoms for many years.
  • Chronic aortic valve regurgitation may get worse. It may require surgery.
  • Acute, severe aortic valve regurgitation is a medical emergency. You should get help right away.
  • See your healthcare provider regularly to monitor your aortic valve regurgitation. If your symptoms are severe or get worse, see your healthcare provider right away.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

  • Know the reason for your visit and what you want to happen.
  • Before your visit, write down questions you want answered.
  • Bring someone with you to help you ask questions and remember what your provider tells you.
  • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
  • Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
  • Ask if your condition can be treated in other ways.
  • Know why a test or procedure is recommended and what the results could mean.
  • Know what to expect if you do not take the medicine or have the test or procedure.
  • If you have a follow-up appointment, write down the date, time, and purpose for that visit.
  • Know how you can contact your provider if you have questions.

What is bicuspid aortic valve?

Bicuspid aortic valve is a type of abnormality in the aortic valve in the heart. In bicuspid aortic valve, the valve has only two small parts, called leaflets, instead of the normal three. This condition is present from birth. It can occur with other heart defects.

The heart’s ventricles are the two lower chambers of the heart. The left ventricle pumps oxygenated blood to the body. It connects to the aorta, the main blood vessel leading to the body. Between the left ventricle and the aorta is the aortic valve, one of the heart’s four valves. These valves help the blood flow through the heart’s four chambers and out to the body.

The aortic valve normally has three small parts, called leaflets. Sometimes, two leaflets develop instead of three. These leaflets may be thicker and stiffer than normal, too. That may cause aortic stenosis. In aortic stenosis, the valve won’t open as easily as it should when the heart squeezes. The left side of the heart has to work much harder than it normally would to get blood out to the body. Over time, this can damage the heart muscle.

Sometimes, the bicuspid aortic valve is leaky. That allows blood to flow back into the heart when the heart relaxes, instead of flowing forward into the body the way it should. This process is called aortic regurgitation. It can also make the heart work harder.

Only a small portion of people have a bicuspid aortic valve. But it is one of the most common heart defects present from birth. It is more common in boys than in girls.

What causes bicuspid aortic valve?

No one knows exactly what causes most cases of bicuspid aortic valve. Somehow, the valve does not develop normally before birth.

Bicuspid aortic valve tends to run in families. So it may result from gene defect. Researchers are still trying to learn more about the specific genes involved. It might also happen if a mother is exposed to certain infections or drugs while pregnant.

Certain factors can make the bicuspid aortic valve more likely to have problems. Some of these are:

  • High cholesterol levels
  • High blood pressure
  • Smoking
  • Chronic kidney disease

What are the symptoms of bicuspid aortic valve?

Some infants with very narrow aortic valves might have symptoms early on. Most of these valves work well for many years, though. There might not be any symptoms. Or symptoms may not appear until adulthood. Many times, people may not even realize they have a bicuspid aortic valve until they have it diagnosed as adults. Most commonly, people start to have symptoms some time in middle age.

Over time, the valve can become harder to open. Or it can become leakier. Symptoms can gradually develop. They may include:

  • Shortness of breath with exertion
  • Chest pain
  • Lightheadedness or fainting

These symptoms may look like other health problems. Always see your healthcare provider for a diagnosis.

How is bicuspid aortic valve diagnosed?

Your healthcare provider will ask about your symptoms and past health. You will also need a physical exam. Some tests can also help with the diagnosis. These include:

  • Echocardiography, the most important test, to show the movement of blood through the valve
  • Electrocardiogram, to check the heart’s electrical rhythm
  • Chest X-ray, to view the heart anatomy and lungs
  • Cardiac CT or MRI, if more detail is needed about the valve, heart, or aorta

Sometimes, bicuspid aortic valve first appears on an echocardiogram done for other reasons. A cardiologist might first diagnose it.

How is bicuspid aortic valve treated?

Your healthcare provider may choose to monitor you with periodic echocardiograms. If your stenosis or regurgitation is more severe, he or she might need to do this testing as often as once a year.

Currently, there are no treatments known to prevent bicuspid valve from developing stenosis or regurgitation. Medicines such as statins to lower cholesterol may help some people.

If you have symptoms, your healthcare provider may recommend repairing or replacing the valve. That is the only certain treatment. Some people have this done during childhood. But other people may not need it until adulthood.

Your healthcare provider might recommend repairing the valve with a procedure using a long, thin tube (catheter). This tube is threaded through a blood vessel all the way to the aortic valve. In other cases, your healthcare provider might recommend open heart surgery. The aortic valve can then be replaced or fixed.

Healthcare providers sometimes use donor valves from cadavers for valve replacement. Other times, they use artificial valves. Some artificial valves require you to take blood thinners lifelong. Sometimes surgeons replace the bicuspid aortic valve with the person’s own pulmonary valve and use a donor valve to replace the pulmonary valve. Each type of procedure and surgery has its own risks and benefits. Talk with your healthcare provider about what makes sense for you.

If you are pregnant or considering becoming pregnant, talk with your healthcare provider about treatment. You may need treatment even if you don’t usually have symptoms.

What are the complications of bicuspid aortic valve?

An untreated bicuspid aortic valve can eventually lead to symptoms of heart failure. These include shortness of breath, fatigue, and swelling. Also, an aortic aneurysm might develop downstream from the aortic valve and can lead to bleeding or rupture. Healthcare providers prefer to treat bicuspid aortic valve before heart failure develops.

Endocarditis is another possible complication. It’s an infection of the heart valves. Your healthcare provider may give you special instructions about how to help prevent it.

People with bicuspid aortic valve can also have abnormal heart rhythms like atrial fibrillation. In rare cases, such rhythms can cause sudden death. That may be more likely to happen after exercise.

How to manage bicuspid aortic valve

Your healthcare provider may give you other instructions for managing your bicuspid aortic valve and any other existing heart disease. These might include:

  • Eating a heart-healthy diet
  • Maintaining a healthy weight
  • Exercising regularly (ask if you have any restrictions)
  • Taking medicine for high cholesterol or high blood pressure if needed
  • Avoiding smoking
  • Practicing good dental hygiene

If you have had a valve replacement, you may also need to take antibiotics before certain medical and dental procedures. Ask your healthcare provider if this applies to you. Some people will also need to take lifelong medicine to prevent blood clots.

When should I call my healthcare provider?

If your symptoms are gradually getting worse, see your healthcare provider soon. See a healthcare provider right away if you have symptoms like severe chest pain or shortness of breath.

Key points about bicuspid aortic valve

  • Bicuspid aortic valve is a type of abnormality of the aortic valve. It makes the heart work harder than it should.
  • Some people with bicuspid aortic valve will have symptoms in early childhood. Others won’t have symptoms until adulthood, if ever.
  • The valve can gradually become harder to open or leakier over time.
  • Your healthcare provider may choose to monitor your aortic valve. Eventually, you may need treatment to repair or replace the bicuspid aortic valve.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

  • Know the reason for your visit and what you want to happen.
  • Before your visit, write down questions you want answered.
  • Bring someone with you to help you ask questions and remember what your provider tells you.
  • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
  • Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
  • Ask if your condition can be treated in other ways.
  • Know why a test or procedure is recommended and what the results could mean.
  • Know what to expect if you do not take the medicine or have the test or procedure.
  • If you have a follow-up appointment, write down the date, time, and purpose for that visit.
  • Know how you can contact your provider if you have questions.

What is an open aortic valve replacement?

An open, invasive aortic valve replacement is a surgery to replace a poorly working aortic valve with an artificial valve. The aortic valve is one of the heart’s 4 valves. These valves help blood flow through the heart and out to the body. Under certain circumstances, your valve can stop working well. Your surgeon will use an artificial valve to replace your poorly working valve. This will ensure that your blood can exit the heart and flow out to the body normally. The surgery is called "open" because it uses a traditional type of incision to expose your heart. This incision is larger than those in minimally invasive types of aortic valve replacement surgery.

Why might I need an open aortic valve replacement?

When your aortic valve is working poorly such as in aortic valve stenosis or aortic valve regurgitation, you may need this procedure.

  • In aortic stenosis, your valve is unable to open fully, and less blood is able to exit your heart.
  • In aortic regurgitation, your valve is leaky. Some blood leaks backward through the valve instead of moving out to the rest of your body.

In both of these cases, you may need to have your aortic valve replaced. A poorly working aortic valve may lead to symptoms, such as:

  • Shortness of breath
  • Fatigue
  • Swelling in your legs
  • Dizziness
  • Chest pain
  • Passing out
  • An unpleasant awareness of your heartbeat

If these symptoms get worse, surgery may be needed. Your doctor may recommend the surgery even if you don’t have significant symptoms, since surgery is most effective if symptoms are not too advanced.

Both aortic stenosis and aortic regurgitation can result from general aging of the valve. Other causes of aortic valve disease include:

  • Heart birth defects (like a bicuspid aortic valve)
  • Bacterial infection of the heart valve
  • A tear in the aorta
  • Aortic aneurysm (weakened, stretched aorta wall)
  • Certain genetic conditions (like Marfan syndrome)
     

What are the risks of an open aortic valve replacement?

There are certain risks with any type of surgery. Your particular risks will vary based on your particular medical condition, your age, and other factors. Be sure to talk with your doctor about any concerns that you have.

Most people who have open aortic valve replacement will have a successful outcome. However, there are some possible risks. These include:

  • Infection
  • Bleeding
  • Irregular heart rhythms
  • Blood clots leading to stroke or heart attack
  • Complications from anesthesia

Certain factors increase the risk of complications. Some of these are as follows:

  • Chronic illness
  • Other heart conditions
  • Lung problems
  • Increased age
  • Being overweight
  • Being a smoker
  • Infections

How do I get ready for an open aortic valve replacement?

As you plan for the surgery, you and your healthcare provider will decide what kind of valve will work best for you. Your surgeon will replace your valve with a biological valve or a mechanical valve.

  • Biological valves are made mainly from pig, cow, or human heart tissue. Biological valves don’t last as long as mechanical valves but have less risk for blood clots.
  • Mechanical valves are man-made. People with mechanical valves need to take blood-thinning medicines for the rest of their lives because of the risk for blood clots. Mechanical valves also have an increased risk for infection.

Talk with your healthcare provider about how to prepare for your upcoming surgery. Remember the following:

  • Avoid eating or drinking anything after midnight before your surgery.
  • Try to stop smoking before your operation. Ask your doctor for ways to help.
  • You may need to stop taking certain medicines before your surgery. Follow your healthcare provider’s instructions if you usually take blood-thinning medicine like warfarin or aspirin.

You may arrive at the hospital the afternoon before your operation. This is a good time to ask any questions you have about the procedure. You may need some routine tests before the procedure to assess your health before surgery. These may include:

  • Chest X-ray
  • Electrocardiogram (ECG)
  • Blood tests
  • Echocardiogram (to assess your current valve)
  • Coronary angiogram (to assess blood flow in your heart arteries)

About an hour before the operation, someone will give you medicines to help you relax. In most cases your surgery will proceed as planned, but sometimes another emergency might delay your operation.

What happens during an open aortic valve replacement?

Check with your doctor about the details of your procedure. In general, during your open aortic valve replacement:

  • You will be given anesthesia before the surgery starts. This will cause you to sleep deeply and painlessly during the operation. Afterwards you won’t remember it.
  • The operation will take several hours. Family and friends should stay in the waiting room, so the surgeon can update them.
  • Your doctor will make an incision down the middle of your chest. To access your heart, your doctor will separate your breastbone.
  • The surgery team will connect you to a heart-lung machine. This machine will act as your heart and lungs during the procedure.
  • Your surgeon will remove your current heart valve and replace it with a new valve.
  • The surgery team will remove the heart-lung machine.
  • The team will wire your breastbone back together.
  • The team will then sew or staple the incision in your skin back together.   

What happens after an open aortic valve replacement?

After your open aortic valve replacement:

  • You will start your recovery in the intensive care unit or a recovery room.
  • When you wake up, you might feel confused at first. You might wake up a couple of hours after the surgery, or a little later.
  • Most people who have aortic valve replacement notice immediate symptom relief after their surgery.
  • The team will monitor your vital signs, such as your heart rate. They may hook you up to several machines so the nurses can check these more easily.
  • You may have a tube in your throat to help you breathe. This may be uncomfortable, and you won’t be able to talk. Someone will usually remove the tube within 24 hours.
  • You may have a chest tube to drain excess fluid from your chest.
  • You may have small temporary pacemaker wires exiting from your chest
  • Bandages will cover your incision. These can usually come off within a couple of days.
  • You will feel some soreness, but you shouldn’t feel severe pain. If you need it, you can ask for pain medicine.
  • In a day or two, you should be able to sit in a chair and walk with help.
  • You may do breathing therapy to help remove fluids that collect in your lungs during surgery.
  • You will probably be able to drink liquids the day after surgery. You can have regular foods as soon as you can tolerate them.
  • You may receive elastic stockings to help blood circulate through your leg veins.
  • You will probably need to stay in the hospital around 5 days.

After you leave the hospital:

  • Make sure you have someone to drive you home from the hospital. You will also need some help at home for a while.
  • You will probably have your stitches or staples removed in a follow-up appointment in 7 to 10 days. Be sure to keep all follow-up appointments.
  • You may tire easily after the surgery, but you will gradually start to recover your strength. It may be several weeks before you fully recover.
  • After you go home, take your temperature and your weight every day. Tell your doctor if your temperature is over 100.4°F (38°C), or if your weight changes.
  • Ask your healthcare provider when it is safe for you to drive.
  • Avoid lifting anything heavy for several weeks. Ask your healthcare provider about what is safe for you to lift.
  • Follow all the instructions your healthcare provider gives you for medicines, exercise, diet, and wound care.
  • Make sure all your dentists and other healthcare providers know about your medical history. You may need to take antibiotics before certain medical and dental procedures to prevent getting an infection on your replacement valve.
     

Next steps

Before you agree to the test or the procedure make sure you know:

  • The name of the test or procedure
  • The reason you are having the test or procedure
  • What results to expect and what they mean
  • The risks and benefits of the test or procedure
  • What the possible side effects or complications are
  • When and where you are to have the test or procedure
  • Who will do the test or procedure and what that person’s qualifications are
  • What would  happen if you did not have the test or procedure
  • Any alternative tests or procedures to think about
  • When and how will you get the results
  • Who to call after the test or procedure if you have questions or problems
  • How much will you have to pay for the test or procedure

What is minimally invasive aortic valve replacement?

A minimally invasive aortic valve replacement is a surgery to replace a poorly working aortic valve with an artificial valve. The aortic valve is one of the heart’s 4 valves. The valves help blood flow through the heart’s 4 chambers and out to your body normally. The surgery is called “minimally invasive” because it uses a smaller incision than a traditional open repair. This may lead to easier and faster recovery from surgery.

Why might I need a minimally invasive aortic valve replacement?

This procedure may be needed  if your aortic valve is working poorly. This may happen if you have aortic valve stenosis or aortic valve regurgitation.

  • In aortic stenosis, the valve is unable to open fully. This means less blood is able to exit the heart.
  • In aortic regurgitation, the valve is leaky. Some blood leaks back through the valve instead of moving out to the rest of the body.

In both of these cases, you may need to have your aortic valve replaced. A poorly working aortic valve may lead to symptoms such as:

  • Shortness of breath
  • Fatigue
  • Swelling in your legs
  • Dizziness
  • Chest pain
  • Passing out
  • An unpleasant awareness of your heartbeat

If these symptoms continue, surgery may be needed. Your healthcare provider may recommend the surgery even if you don’t have significant symptoms. Surgery is most effective before symptoms become severe.

Both aortic stenosis and aortic regurgitation can happen because of general aging of the valve. Other causes of aortic valve disease include:

  • Heart birth defects (like a bicuspid aortic valve)
  • Bacterial infection of the heart valve
  • Tear of the aorta
  • Aortic aneurysm (weakened stretched aorta wall)
  • Certain genetic conditions (like Marfan syndrome)

What are the risks of minimally invasive aortic valve replacement?

There are certain risks with any type of surgery. Your risks will vary based on your medical condition, your age, and other factors. Be sure to talk with your healthcare provider about any concerns that you have.

Most people who have minimally invasive aortic valve replacement will have a successful outcome. However, there are some possible risks. These include:

  • Infection
  • Bleeding
  • Irregular heart rhythms
  • Blood clots leading to stroke or heart attack
  • Complications from anesthesia

Certain factors increase the risk for complications. Some of these are:

  • Chronic illness
  • Other heart conditions
  • Lung problems
  • Increased age
  • Being overweight
  • Being a smoker
  • Infections

How do I prepare for a minimally invasive aortic valve replacement?

As you plan for the surgery, you and your doctor will decide what kind of valve will work best for you. Your surgeon will replace your valve with a biological valve or a mechanical valve.

  • Biological valves are made mainly from pig, cow, or human heart tissue. Biological valves may not last as long as mechanical valves, but have less risk for blood clots.
  • Mechanical valves are man-made. People with mechanical valves need to take blood-thinning medicine for the rest of their lives because these valves increase the risk for blood clots. Mechanical valves also increase the risk for infection.

Talk with your doctor about how to prepare for your upcoming surgery. Remember the following:

  • Avoid eating or drinking anything after midnight before your surgery.
  • Try to stop smoking before your operation. Ask your doctor for ways to help.
  • You may need to stop taking certain medicines before your surgery. Follow your doctor’s instructions if you usually take blood-thinning medicines like warfarin or aspirin.

You may need to arrive at the hospital the afternoon before your operation. This is a good time to ask any questions you have about the procedure. You may need some routine tests before the procedure to assess your health before surgery. These may include:

  • Chest X-ray
  • Electrocardiogram (ECG)
  • Blood tests
  • Echocardiogram (to assess your current valve)
  • Coronary angiogram (to assess blood flow in your heart arteries)

The skin over the area where the incision will be made may be shaved. About an hour before the operation, someone will give you medicines to help you relax. In most cases, your surgery will proceed as planned. However, sometimes another emergency might delay your operation.

What happens during a minimally invasive aortic valve replacement?

Check with your healthcare provider about the details of your procedure. In general, during your minimally invasive aortic valve replacement:

  • An anesthesiologist will give you anesthesia before the surgery starts. This will cause you to sleep deeply and painlessly during the operation. Afterwards you won’t remember it.
  • The operation will take several hours. Family and friends should stay in the waiting room, so the surgeon can update them.
  • There are several different approaches used in minimally invasive aortic valve replacement. These can include a small incision through your breastbone, to the right of your breastbone, or between the ribs on your side. Sometimes surgeons use special instruments and a camera to do the surgery. With this approach, your surgeon will make several small holes in your chest. Some surgeons use robot-controlled arms to perform the surgery. Your doctor will review all of your options with you along with their associated risks and benefits.    
  • The surgery team will connect you to a heart-lung machine. This machine will act as your heart and lungs during the procedure.
  • Your surgeon will remove your current aortic heart valve and replace it with a new one.
  • The surgery team will remove you from the heart-lung machine.
  • The team will wire your breastbone back together (if necessary, depending on your incision position).
  • The team will then sew or staple the incision in your skin in back together.

What happens after a minimally invasive aortic valve replacement?

After your minimally invasive aortic valve replacement:

  • You will start your recovery in the ICU (intensive care unit) or a recovery room.
  • When you wake up, you might feel confused at first. You might wake up a couple of hours after the surgery, or a little later.
  • Most people notice relief of their symptoms right after surgery.
  • The team will carefully monitor your vital signs, such as your heart rate. They may hook you up to several machines so the nurses can check these more easily.
  • You may have a tube in your throat to help you breathe. This may be uncomfortable, and you won’t be able to talk. Your doctor or nurse will usually remove the tube within 24 hours.
  • You may have a chest tube to drain excess fluid from your chest.
  • You may have small temporary pacemaker wires coming from your chest.
  • Bandages will cover your incision. These can usually come off within a couple of days.
  • You will feel some soreness, but you shouldn’t feel severe pain. If you need it, you can ask for pain medicine.
  • In a day or two, you should be able to sit in a chair and walk with help.
  • You may perform breathing therapy to help remove fluids that collect in your lungs during surgery.
  • You will probably be able to drink liquids the day after surgery. You can have regular foods as soon as you feel ready to eat.
  • You may receive elastic stockings to help blood circulate through your leg veins.
  • You will probably need to stay in the hospital for 3 to 5 days.

After you leave the hospital:

  • Make sure you have someone to drive you home from the hospital. You will also need some help at home for a while.
  • You probably will have your stitches or staples removed in a follow-up appointment in 7 to 10 days. Be sure to keep all follow-up appointments.
  • You may tire easily after the surgery, but you will gradually start to recover your strength. Recovery time after minimally invasive valve surgery tends to be less than for an open aortic valve replacement.
  • After you go home, take your temperature and your weight every day. Tell your healthcare provider if your temperature is over 100.4°F (38°C), or if your weight changes.
  • Ask your doctor when it is safe for you to drive.
  • Avoid lifting anything heavy for several weeks.
  • Follow all the instructions your healthcare provider gives you for medicine, exercise, diet, and wound care.
  • Make sure all your dentists and doctors know about your medical history. You may need to take antibiotics before certain medical and dental procedures to prevent getting an infection on your replacement valve.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

  • Know the reason for your visit and what you want to happen.
  • Before your visit, write down questions you want answered.
  • Bring someone with you to help you ask questions and remember what your provider tells you.
  • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
  • Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
  • Ask if your condition can be treated in other ways.
  • Know why a test or procedure is recommended and what the results could mean.
  • Know what to expect if you do not take the medicine or have the test or procedure.
  • If you have a follow-up appointment, write down the date, time, and purpose for that visit.
  • Know how you can contact your provider if you have questions.

What is heart valve repair or replacement surgery?

The heart is a pump made of muscle tissue. It has 4 pumping chambers: 2 upper chambers, called atria, and 2 lower chambers, called ventricles. Valves between each of the heart's pumping chambers keep blood flowing forward through the heart.

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  • Tricuspid valve. Located between the right atrium and the right ventricle
  • Pulmonary valve. Located between the right ventricle and the pulmonary artery
  • Mitral valve. Located between the left atrium and the left ventricle
  • Aortic valve. Located between the left ventricle and the aorta

When valves are damaged or diseased and do not work the way they should they may need to be repaired or replaced. Conditions that may cause heart valve dysfunction are valve stenosis (stiffness) and valve regurgitation (leaky valve).

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When one (or more) valve(s) becomes stenotic (stiff), the heart has to work harder to pump the blood through the valve. Valves can become narrow and stiff from infection (such as rheumatic fever or staph) and aging. If one or more valves become leaky, blood leaks backwards, which means less blood is pumped in the right direction. Based on your symptoms and the overall condition of your heart, your healthcare provider may decide that the diseased valve(s) needs to be surgically repaired or replaced.

Traditionally, open-heart surgery is used to repair or replace heart valves. This means that a large incision is made in the chest and the heart stopped for a time so that the surgeon can repair or replace the valve(s). Newer, less invasive techniques have been developed to replace or repair heart valves. Minimally invasive procedures make smaller incisions, and mean less pain afterward and shorter hospital stays.

The diseased valve may be repaired using a ring to support the damaged valve, or the entire valve may be removed and replaced by an artificial valve. Artificial valves may be made of carbon coated plastic or tissue (made from animal valves or human valves taken from donors). You and your healthcare provider will talk about the pros and cons of each type and what might be best for you.

Why might I need heart valve repair or replacement surgery?

Valve repair or replacement surgery is done to correct the problems caused by one or more diseased heart valves.

If your heart valve(s) becomes damaged or diseased, you may have the following symptoms:

  • Dizziness
  • Chest pain
  • Breathing difficulties
  • Palpitations
  • Edema (swelling) of the feet, ankles, or abdomen (belly)
  • Rapid weight gain due to fluid retention

There may be other reasons for your healthcare provider to recommend heart valve repair or replacement surgery.

What are the risks of heart valve repair or replacement surgery?

Possible risks of heart valve repair or replacement surgery include:

  • Bleeding during or after the surgery
  • Blood clots that can cause heart attack, stroke, or lung problems
  • Infection
  • Pneumonia
  • Pancreatitis
  • Breathing problems
  • Arrhythmias (abnormal heart rhythms)
  • The repaired or replaced valve doesn't work correctly
  • Death

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your healthcare provider before the procedure.

How do I get ready for heart valve repair or replacement surgery?

 

  • Your healthcare provider will explain the procedure and you can ask questions. 
  • You will be asked to sign a consent form that gives your permission to do the surgery. Read the form carefully and ask questions if anything is unclear.
  • Along with a complete medical history, your healthcare provider may do a complete physical exam to make sure that you are in otherwise good health before surgery. You may need blood tests or other diagnostic tests.
  • You will be asked to fast (not eat or drink) for 8 hours before the procedure, generally after midnight.
  • If you are pregnant or think you could be, tell your healthcare provider.
  • Tell your healthcare provider if you are sensitive to or are allergic to any medicines, iodine, latex, tape, or anesthetic agents (local and general).
  • Be sure your healthcare provider knows about all medicines (prescription and over-the-counter), vitamins, herbs, and supplements that you are taking.
  • Tell your healthcare provider if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medicine, aspirin, or other medicines that affect blood clotting. You may be told to stop some of these medicines before surgery.
  • Your healthcare provider may do a blood test before surgery to see how long it takes your blood to clot.
  • Tell your healthcare provider if you have a pacemaker or any other implanted cardiac devices.
  • If you smoke, stop smoking as soon as possible. This improves your chances for a successful recovery from surgery and benefits your overall health status.
  • Based on your medical condition, your healthcare provider may request other specific preparation.

 

What happens during heart valve repair or replacement surgery?

Heart valve repair or replacement surgery requires a stay in a hospital. Procedures may vary depending on your condition and your healthcare providers practice.

Generally, open-heart valve repair or replacement follows this process:

  1. You will be asked to remove any jewelry or other objects that may interfere with the procedure.
  2. You will change into a hospital gown and empty your bladder.
  3. The surgical team will position you on the operating table, lying on your back.
  4. A healthcare professional will start an intravenous (IV) line in your arm or hand for injection of medicine and to give IV fluids. More catheters will be put in blood vessels your neck and wrist to monitor the status of your heart and blood pressure, and to take blood samples. 
  5. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
  6. Your doctor will put a breathing tube through your mouth into your lungs and connect you to a ventilator, a machine that will breathe for you during the surgery.
  7. Your doctor will place a transesophageal echocardiogram (TEE) probe into your esophagus (swallowing tube) so he or she can monitor the function of the valves.
  8. A soft, flexible tube (called a Foley catheter) will be put into your bladder to drain urine.
  9. A tube will be put through your mouth or nose into your stomach to drain stomach fluids.
  10. Someone on the surgical team will clean the skin over your chest with an antiseptic solution. If there is a lot of hair at the surgical site, it may be shaved off.
  11. If you are having an open-heart surgery, your healthcare provider will make an incision (cut) down the center of the chest from just below the Adam's apple to just above the navel. If you are having a less invasive procedure it may require smaller incisions.
  12. The sternum (breastbone) will be cut in half lengthwise. The healthcare provider will separates the halves of the breastbone and spread them apart to expose your heart.
  13. To do the valve repair or replacement, your doctor must stop your heart. He or she will put tubes into the heart so that the blood can be pumped through your body by a heart-lung bypass machine while your heart is stopped.
  14. Once the blood has been completely diverted into the bypass machine for pumping, your doctor will stop your heart by injecting it with a cold solution.
  15. When the heart has stopped, your doctor will remove the diseased valve and put in the artificial valve, in the case of a valve replacement. For a valve repair, the procedure done will depend on the type of valve problem you have, for example, your doctor may separate fused valve leaflets, repair torn leaflets, or reshape valve parts to ensure better function.
  16. Once the surgery is done, your doctor will shock your heart with small paddles to restart your heartbeat. Next, he or she will allow blood circulating through the bypass machine to re-enter your heart and remove the tubes to the machine. 
  17. Once your heart is beating again, your doctor will watch it to see how well the heart and valves are working and be sure that there are no leaks from the surgery.
  18. Your doctor may put wires for pacing into your heart. He or she can attach these wires to a pacemaker outside your body for a short time and your heart can be paced, if needed, during the initial recovery period.
  19. Your doctor will rejoin the sternum sewing it together with small wires (like those sometimes used to repair a broken bone).
  20. Your doctor will put tubes into your chest to drain blood and other fluids from around the heart. 
  21. Your doctor will sew the skin over the sternum back together and close the incision with sutures or surgical staples.
  22. A member of the surgical team will apply a sterile bandage or dressing.
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What happens after heart valve repair or replacement surgery?

In the hospital

After the surgery, a member of the surgical team will take you to a recovery room and later the intensive care unit (ICU) to be closely monitored for several days. A nurse will connect you to machines that will constantly display your electrocardiogram (ECG) tracing, blood pressure, other pressure readings, breathing rate, and your oxygen level. Open-heart valve repair or replacement surgery generally requires an in-hospital stay of several days or longer.

You will most likely have a tube in your throat that's connected to a ventilator to help you breath until you are stable enough to breathe on your own. As you wake up from the anesthesia more and start to breathe by yourself, your doctor can adjust the breathing machine to allow you to take over more of the breathing. When you are awake enough to breathe completely by yourself and are able to cough, your doctor will remove the breathing tube. He or she may also remove the stomach tube at this time.

After the breathing tube is out, a nurse will help you cough and take deep breaths every couple of hours. This will be uncomfortable due to soreness, but it is very important that you do this to keep mucus from collecting in your lungs and possibly causing pneumonia. Your nurse will show you how to hug a pillow tightly against your chest while coughing to help ease the discomfort.

You will get pain medicine if you are hurting. Ask for the medicine before you become extremely uncomfortable.

You may be on IV (intravenous) medicines to help your blood pressure and your heart and to control any problems with bleeding. As your condition stabilizes, your doctor will gradually decrease then stop these medicines. He or she will also remove any pacing wires in your heart you may have.

Once your doctor has removed the breathing and stomach tubes and you are stable, you may start to drink liquids. You can start eating more solid foods as soon as you can tolerate them.

When your healthcare provider decides that you are ready, you will be moved from the ICU to a surgical unit or acute care unit. Your recovery will continue there. Your activity will be gradually increased as you get out of bed and walk around for longer periods.

A member of your healthcare team will arrange for you to go home and schedule a follow-up visit with your healthcare provider.

At home

Once you are home, it will be important to keep the surgical area clean and dry. You will be given specific bathing instructions. Your doctor will remove the sutures or surgical staples during a follow-up office visit, if they were not removed before leaving the hospital.

Do not drive until your healthcare provider tells you it's OK. Other activity restrictions may apply.

Tell your healthcare provider right away if you have any of these:

  • Fever of 100.4°F (38°C) or higher, or chills (these may be a sign of infection)
  • Redness, swelling, bleeding, or drainage from the incision site or any of the catheter sites
  • Increase in pain around the incision site
  • Trouble breathing
  • Increased swelling in the legs or abdomen
  • Easy bruising
  • Persistent nausea or vomiting
  • Rapid or irregular pulse
  • Weakness in the arms and legs

Your healthcare provider may give you other instructions after the procedure, depending on your situation.

Next steps

Before you agree to the test or the procedure make sure you know:

  • The name of the test or procedure
  • The reason you are having the test or procedure
  • What results to expect and what they mean
  • The risks and benefits of the test or procedure
  • What the possible side effects or complications are
  • When and where you are to have the test or procedure
  • Who will do the test or procedure and what that person’s qualifications are
  • What would  happen if you did not have the test or procedure
  • Any alternative tests or procedures to think about
  • When and how will you get the results
  • Who to call after the test or procedure if you have questions or problems
  • How much will you have to pay for the test or procedure
Study shows promising results for minimally invasive heart valve replacement option

Patients who are considered non-operable for conventional open heart valve surgery may have promising options using a new treatment available in the region only through Saint Luke's Mid America Heart Institute.

Valve Center at Saint Luke’s streamlines diagnosis and treatment

Building on a tradition of excellence in the treatment of heart valve disease, Saint Luke’s Mid America Heart Institute has established a comprehensive multidisciplinary Valve Center dedicated to the use of new transcatheter valve replacement therapies for patients with complex valvular disease. The center unites a highly skilled team of cardiologists and cardiovascular surgeons offering diagnosis, evaluation, and treatment in one convenient location.

Heart Valve Replacement without Invasive Surgery
Rosemary stopped her regular walk to Loose Park to admire the roses. Taking more than 20 steps robbed her of breath and tightened her chest with pain.

Saint Luke's Cardiovascular Consultants

A leader in cardiac care, Saint Luke’s Cardiovascular Consultants treats patients throughout the Kansas City area and surrounding communities. Our medical team consists of both board-certified clinical cardiologists as well as physicians certified in specialty areas of cardiology including interventional cardiology, echocardiography, nuclear cardiology, preventive cardiology, and electrophysiology.