Aortic Valve ReplacementKnow your options. Ask the right questions.
Minimally Invasive AVR allows for a rapid recovery..
The parasternal approach is a superior technique that’s least painful, allows for rapid recovery and suitable in all age groups including in the very old.
Choose Wisely! Minimally Invasive AVR is the current standard of care across the world.
Minimal access techniques allow for a less painful and more rapid recovery after heart surgery. The overall outcomes are far superior to conventional open heart surgery
Understanding Aortic Valve Replacement (AVR)
How are aortic stenosis and regurgitation treated?
The severity of aortic insufficiency can sometimes be reduced with medications, but aortic stenosis has no effective medical therapy. For both conditions, the most definitive treatment involves replacing the diseased valve with an artificial or prosthetic valve. Simply put surgical AVR is the gold standard for the treatment of aortic valve disease. Timely surgery is advised since significant delay can lead to irreversible heart failure. Surgical AVR is recommended for virtually all adult patients who do not have other serious medical conditions.
The decision to replace your aortic valve is best taken by your heart care team which will always comprise of a heart surgeon and cardiologist. The decision is based on your symptoms, findings on the echocardiogram and less commonly on the angiogram.
How is the aortic valve replaced?
Aortic valve replacements require the use of cardiopulmonary bypass, otherwise known as the heart-lung machine. This permits the surgeon to safely open the aorta and access the aortic valve in a bloodless field. In most cases, the heart is also stopped for about 1 hour to facilitate the replacement.
The operation involves opening of the aorta and removal of the diseased aortic valve leaflets. Commonly, calcifications around the valve must also be removed carefully. The resulting valve ring or annulus is then measured to select the size of the valve prosthesis. A series of sutures are then placed around the valve annulus and subsequently through the prosthetic valve. The valve is then lowered into the annulus and secured. The aorta is closed and the heart restarted. The total duration of the operation ranges from 2 to 3 hours.
Conventional Aortic Valve Replacement
This is the age old standard technique of replacing the aortic valve. This approach involves cutting the breast bone or sternum in full, exposing the heart completely and then replacing the valve as described above. The advantages are that the operation is easy to reproduce, can be done by most beginner surgeons and is well established. The problem is that cutting the sternum in full results in significant morbidity and damage to the chest wall, affecting the mechanics of breathing in addition to the higher risk of infection. The operation unnecessarily exposes parts of the heart that do not need to be exposed. A full operation is absolutely necessary in certain situations though. When aortic valve disease coexists with other valvular heart disease or when blocks in the blood vessels supplying the heart also need to be taken care of, a full sternotomy is the only way to go. It may also be required in very obese patients or those with a very small root where more complex enlargement procedures may be required.
Minimally Invasive Aortic Valve Replacement (Mini AVR)
This is now the approach in most patients requiring an aortic valve replacement. The philosophy is simple, why expose the whole heart when all the surgeon needs to see is the area of the aortic valve. Mini AVR’s have enormous benefits both in terms of rapid recovery, less blood loss, near zero infection, minimal trauma to the chest wall and negligible pain. Not cutting the bone is in itself a great advantage to the patient. Mini AVR’s can be performed by two techniques
- The Upper Hemisternotomy approach where in the breast bone is partially cut in the upper part while leaving the two thirds of the sternum intact. This approach may be opted in patients who are very obese or have a very small annulus or when a more complex procedure is anticipated
- Parasternal Approach is where no part of the chest bone is cut leaving the whole chest wall intact. This is the most advanced and superior technique and should be the choice in most patients.
Minimal Invasive AVR is the standard approach to replacing the aortic valve in most advanced heart surgery centers in the world. However not all surgeons are trained in the technique, in which case the open approach is the safest
Aritficial valves: What are the options?
Roughly there are two kinds of artificial valves – Mechanical valves and Biological valves. The type of valve suitable for you should be discussed with the surgeon prior to the surgery. Each type may have several variants manufactured and the surgeon may choose one or the other based on his comfort if implanting it. This should have little relevance to the patient.
What are the differences between mechanical and biological valves?
The principal advantage of these valves is their durability. Practically they do no wear out. The principal disadvantage is the risk of blood clots forming over them which requires anticoagulation (warfarin) blood thinners to be taken daily. Monitoring is frequently required to maintain adequate anticoagulation. If doses exceed the risk of bleeding either spontaneously or due to injury can serious.
These are also called tissue valves. These valves are made from bovine or porcine tissue. The principal advantage of these valves is that no anticoagulation is required, however this is offset by reduced durability. Most tissue valves last for around 10 to 15 years after which a rereplacement may be required. Its best to discuss the benefits of each valve with your surgeon. Tissue valves in general are recommended for patients over the age of 55 years. This rule may not apply in special situations.
How will my recovery be after valve replacement?
After successful aortic valve replacement, patients can expect to return to their preoperative condition or better. Anticoagulation (“blood thinners”) with a drug like Warfarin may be prescribed for life for those with mechanical valves. Once the wounds have healed, most patients should experience few if any restrictions to activity. Prophylactic antibiotics will be required whenever having dental work, and patients should always tell a doctor about their valve surgery before any surgical procedure.
The recovery time after aortic valve replacement surgery varies and will depend on:
- your age
- your overall health and fitness
- how well you were before the operation
Your breastbone usually takes about six to eight weeks to heal, but it may be two to three months before you feel completely normal. If you did undergo a minimally invasive procedure where no bone was cut then this does not apply to you.
Its natural to feel anxious while going home after your heart surgery. Some common experiences that you may have after you leave hospital are
- loss of appetite – it may take a while for this to return and you may temporarily lose your sense of taste
- swelling and redness – your incision may be swollen and red, but this will gradually fade. Seek medical help if it becomes more painful
- difficulty sleeping – some people have problems sleeping. This should improve with time, and taking a painkiller before bed may help
- constipation – you may find it difficult to go to the toilet. Eating fruit and vegetables will help. Your doctor may also suggest taking a laxative (a medication to help you pass stools more easily).
- cough and breathlessness – its usual to have a mild irritating cough after surgery, you may also feel short of breath with exertion both will disappear spontaneously as you recover. If they persist or if you feel that its unusually severe, it is important to speak to your doctor.
- anxiety and depression – these are completely normal after heart surgery. Talking to your friends and family can help. You will start to feel emotionally stronger as you regain your health and strength
Caring for your wound
When having a bath or shower, wash your wound using mild soap and water. In hospital, you should be able to have a shower after four or five days. Avoid very hot water and soaking in a bath until your incision wound has healed.
Protect the wound from exposure to sunlight during the first year after surgery, as the scar will be darker if it is exposed to the sun.
Call your doctor if you notice:
- increased tenderness around the incision site
- increased redness or swelling
- pus or oozing
- a high temperature of 38C (100.4F) or above
If dissolvable stitches have been used to close the wound, they should disappear within around three weeks. Other types of stitches may need to be removed by a healthcare professional, and you will be given a follow-up appointment to have your stitches removed, if necessary.
Sex after heart surgery
Before your operation, symptoms of fatigue or shortness of breath may affect your sexual activity. After your operation, you may feel like having a more active sex life. You can do so as soon as you feel ready, although avoid strenuous positions and be careful not to put any pressure on your wound until it has fully healed.
Some people find that having a serious illness can make them lose interest in sex. In men, the emotional stress can also cause impotence. If you are worried about your sex life, talk to your partner or your GP.
Driving after surgery
After your operation, you can be a passenger in a car straight away. However, you may not be able to drive again until around six weeks after you’re discharged from hospital. This applies to motorcycles as well. If you’re unsure, ask your surgeon for advice. This advice does not apply to minimally invasive surgery.
Returning to work
When you can return to work will depend on the type of work you do, so ask your surgeon for advice. This could be as soon as six to eight weeks after you’ve been discharged from hospital. This could be as early as a week if you underwent minimally invasive surgery.
What are the risks of surgery?
After an aortic valve replacement, several complications could occur, although this is rare.
Possible complications include:
- Infection – the new valve can become infected and inflamed (endocarditis), which can damage your heart. You will be given antibiotics to reduce the risk.
- Embolism (clotting) – this is more likely if you have had mechanical valve replacement. You will be prescribed anticoagulant medication if this is a significant risk.
- Stroke or transient ischaemic attack (TIA) – the supply of blood to the brain becomes blocked.
- The valve may wear out or become damaged – this is more likely if you are under 60 years old and have had a biological valve replacement.
- Irregular heart beat (arrhythmia) – this affects 25% of people temporarily, and 1 to 2% of people need to have a pacemaker fitted (a small battery-operated device that is inserted under the skin in your chest to help your heart beat regularly).
- Kidney failure – the kidneys do not work as well as they should, which affects around 3 to 5% of people.
Complications can be fatal, although the chance of any of the above occurring is rare. However, the risk of death from surgery is far lower than that associated with not treating severe aortic disease.
In trained hands, minimally invasive AVR is a safe operation that gives outstanding results and satisfaction to both surgeon and patient alike.
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