Aortic Valve Surgery: Repair and Replacement

Aortic Valve Repair and Replacement

When heart valves are severely malformed or damaged, there is no medicine to reverse or repair the damage. In most cases, surgery is the only effective option for repairing the valve and and alleviating symptoms.

Heart valve repair: Heart valve repair surgery attempts to preserve the patients native valve. It may include cutting scarred flaps so they open more easily; remodeling valve tissue that has enlarged; or inserting prosthetic rings to help narrow a dilated valve. Because a person's own tissues are used, heart valve repair is possible for aortic regurgitation.

Valve Sparing Root, also known as the David Procedure is a commonly used aortic valve repair technique. When the aorta is dilated, but the aortic valve is structurally otherwise normal, the aorta can be replaced ("root replacement") while preserving the aortic valve ("valve sparing"). This avoids the need for a valve replacement with an artificial valve. Thus offering the possibility for a more durable repair, as well as avoiding the potential need for blood thinning medication.

Heart valve replacement: In some cases, particularly for aortic stenosis, heart valve replacement is necessary. When heart valves are severely malformed or destroyed, they may need to be replaced with a new mechanism. Replacement valve mechanisms fall into two categories: tissue (biologic) valves, which include animal valves and donated human aortic valves, and mechanical valves:

Mechanical valves are made of metal, plastic, or another artificial material and thus have greater durability. The downside is that it requires the patient to remain on anticoagulation for the rest of their life. They are traditionally recommended for patients:

< 60 years old
patients who want to avoid reoperation
patients are already on long-term anticoagulation for another reason

Tissue valves do not require long-term anticoagulation, but they are less durable. They are traditionally recommended for patients:

> 60 years old
patients who prefer to avoid anticoagulation for lifestyles reasons (eg extremely active lifestyle, recent GI bleed, childbearing age)

However durability of a tissue valve is age dependent, due to greater hemodynamic demands in younger PATIENTS. Structural valve deterioration in patients at 10 years:

0-40yo: 40%
40-69yo: 30%
>70yo: 10%

What is transcatheter aortic valve replacement (TAVR)?

Percutaneous and catheter based procedure s are available for patients who are not candidates for surgical replacement or are extremely high risk for surgery.

Transcatheter aortic valve implantation (TAVI) is also know as Transcatheter aortic valve replacement (TAVR). Using an approach similar to the approach used for cardiac catheterization of the coronary arteries, TAVI involves a puncture though the skin into the blood vessels in the groin. A catheter, about as wide as a pencil, is then threaded up through vessels in the leg into the aorta then into the heart. A special valve is compressed and inserted into position though the tip of this thin catheter. This approach avoids the need for opening the chest or using a heart lung machine.

Candidates for this percutaneous procedure include patients with severe symptomatic aortic stenosis and are deemed extremely high risk for surgery or inoperable by a heart surgeon. Typically no single factor makes a patient too high risk for surgery. Candidates typically have one or more of the following characteristics: advanced age, previous heart surgery, severe COPD, severe diabetes, home oxygen dependence, pulmonary hypertension, previous radiation to the chest, a severely calcified aorta (aka a porcelain aorta), and/or extreme frailty.

The New England Journal of Medicine recently reported that, in patients with severe symptomatic aortic stenosis who are not candidates for surgery, TAVI (aka TAVR) is associated significantly improved survival, improved symptoms, and improved quality of life compared to standard treatment. In fact, patients undergoing TAVI were nearly twice as likely to be alive at 1 year compared with those who did not.