Aortic Valve Replacement: Surgery, Procedure, Success Rate

Aortic valve replacement, as the name suggests, refers to the replacement of a damaged aortic valve with a new prosthetic one. The aortic valve is one of the four valves that help regulate blood flow from the heart into the aorta. The aorta is the largest artery that supplies blood throughout the body. 

The primary role of the aortic valve is to allow blood to pass forward from the left ventricle (the left chamber of the heart that pushes blood away from the heart) to the aorta (the blood vessel that supplies blood from the heart to the entire body). 

When the aortic valve becomes narrowed (a condition known as aortic stenosis) or leaky (a condition known as aortic regurgitation), it can significantly impair the heart's ability to pump blood efficiently. Thus, one needs to undergo an aortic valve replacement procedure.

In Western countries, including the United States, up to 85, 000 aortic valve replacements are performed every year

Anatomy and Physiology of Heart

The heart consists of four main chambers: right atria, right ventricle, left atria, and left ventricle. The left ventricle is responsible for pumping oxygenated blood from the heart to the entire body.

And while doing so, the blood is pushed from the left ventricle to the aorta, which is the biggest artery in the body. It has thick walls and a large diameter that helps blood to get distributed to all the parts of the body.

There is a valve at the junction of the left ventricle and aorta whose primary role is to prevent the backflow of blood when the blood is pushed from the heart to the aorta. It does so by opening and closing regularly during every heartbeat to maintain the proper flow of blood from the heart to the rest of the body.

This valve is known as the aortic valve, which can get affected by several diseases. It is crucial to get this valve replaced/repaired so as to avoid any complications or even death.

Aortic valve replacement is typically recommended for individuals who have aortic valve disease that significantly impairs their heart function or quality of life. 

However, not everyone with an aortic valve disease is recommended to undergo this operation. Specific criteria must be met before a patient is considered for the surgery. 

Some common indications for aortic valve replacement include:

1. Aortic Stenosis: In this condition, the aortic valve narrows and prevents blood from the heart from flowing into the aorta. Aortic valve replacement may be required if aortic stenosis is severe and causes symptoms like chest pain, shortness of breath, or fainting.

2. Aortic Regurgitation: This disorder, also known as aortic insufficiency, occurs when the aortic valve malfunctions, allowing blood to seep back into the left ventricle.

   Aortic valve replacement may be required in severe cases of aortic regurgitation due to symptoms like exhaustion, shortness of breath, and heart palpitations.

3. Congenital Valve Abnormalities: Aortic valve anomalies, such as stenosis or regurgitation, can occur at birth in some people. Aortic valve replacement may be advised if these issues are severe and are impacting heart function or creating symptoms.

4. Valve Disease Progression: Some people may have aortic valve disease that is mild to severe and worsens over time. Aortic valve replacement may be an option if the valve disease worsens to the point where it begins to affect heart function or produce symptoms.

Besides the conditions mentioned above, elderly patients may also need heart valve replacement surgery due to the wear and tear of the heart valves due to ageing.

An aortic valve replacement is a major surgical procedure performed by a cardiothoracic surgeon under general anaesthesia. Anaesthesia is administered to keep the patient comfortable throughout the procedure.

When it comes to how long aortic valve surgery takes, the operation usually takes 2 to 3 hours. However, it may take longer if there are any complications or associated risks.

Aortic valve replacement surgery can be performed in two ways. It could either be an open heart surgery or transcatheter aortic valve replacement. 

1. OpenAortic Valve Replacement Surgery: This procedure involves a large incision on the chest and the underlying tissues to reach the heart. As this procedure is invasive, it has increased risks of complications.

2. Transcatheter Aortic Valve Replacement: TAVR is an advanced surgery that involves minimal incision. In this type of surgery, only one or a few minor cuts are made on the chest.

When it comes to aortic valve replacement, two types of aortic valves are primarily used in aortic valve replacement surgeries: 

1. Mechanical Valves: Mechanical valves are made of materials like carbon, plastic or metal. 

1. They have a longer life but can lead to the formation of blood clots in the vessels. 

2. This can be life-threatening, and the patient must take lifelong blood-thinning medications to avoid blood clot formation. 

3. Mechanical valves also increase the risk of developing infections.

2. Biological Valves: These are made from animal tissues like a cow or a pig.

1. Biological valves can also be derived from human tissues, and these are called homograft valves. 

2. Biological valves have a shorter life than mechanical valves, so one must replace them in 10 to 20 years. 

3. However, patients who have undergone heart valve replacement surgery with biological valves do not need to take blood thinners since they have less risk of developing blood clots. 

Once the patient is prepared for the surgery in the operation theatre, the doctor carries out the following steps to undertake the open aortic valve replacement procedure: 

1. The patient is made to lie in a prone position, and an IV line is administered.

2. General anaesthesia is given to the patient, after which the patient will sleep and feel no pain during the procedure.

3. The vitals of the patient are monitored closely throughout the procedure.

4. The surgical site is cleaned and draped well.

5. A large incision is made on the chest wall (about 25 cm long). 

6. The doctor separates the breastbone and dissects the tissues of the chest in order to reach the heart.

7. The heart is temporarily stopped, and a bypass machine (known as the heart-lung machine) is connected instead, which functions as a heart.

8. The diseased heart valve is then removed and replaced by a new one.

9. The surgical team then detaches the heart-lung machine.

10. The breastbone is repaired using wires, and the skin's wound is repaired using stitches or staples.    

Transcatheter Aortic Valve Replacement 

Transcatheter aortic valve replacement is gaining popularity among patients who cannot undergo open heart surgery due to certain risks. For example, elderly patients are recommended transcatheter aortic valve replacement over open heart surgery due to increased morbidity and mortality. 

In transcatheter aortic valve replacement, the doctor may access blood veins from one of the following regions:

1. Groin or thigh

2. Stomach region

3. Chest

4. Neck or collarbone 

The doctor then inserts a small, flexible tube called a catheter into the vessel and routes it to the heart. A folded replacement valve inside the catheter is firmly inserted inside the old valve.

Once the new valve has been properly positioned, the doctor examines for leaks and any issues, such as a problem with the heart's electrical signalling.

Note: Please note that the treatment approach and selection of procedures depend on the patient’s health condition and the opinion of the treating surgeon.

Preceding the aortic valve replacement procedure, the doctor may run several tests and evaluate the patient's fitness to be eligible for surgery. These tests and checkups help the doctor plan the operation appropriately on an operative day so everything is carried out smoothly.

Before Aortic Valve Replacement

There are several points one must keep in mind before undergoing any procedure, but a heart procedure demands extra preoperative care and preparation. Hence, ensure the following points before going for an aortic valve replacement: 

1. Fasting and Lifestyle Changes:

1. One must completely avoid eating or drinking anything from midnight before the surgery.

2. It is advisable to stop smoking before the operation.

3. The doctor may tell the patient to avoid certain medications.

2. Personal Items: Avoid wearing contact lenses, eyeglasses, jewellery, or dentures during the procedure. Ensure to take them off before entering the operation theatre and hand them to loved ones. 

3. Counselling: The doctor informs the patient about the duration of the hospital stay, the estimated cost of the procedure, and the insurance formalities if needed.

   The doctor also explains the types of valves that can be used for the surgery and suggests the right one based on the individual's condition.

4. Examination: The doctor assesses the patient's condition by noticing the signs and symptoms the patient presents with and by performing clinical examinations. 

1. After meticulously taking the history and conducting clinical investigations, the doctor may suggest the patient get admitted. 

2. The doctor runs several diagnostic tests to rule out other comorbidities, such as:

1. Chest x-ray

2. Electrocardiogram (ECG)

3. Blood tests include CBC (complete blood picture), liver function, kidney function tests, etc.

4. Echocardiogram to see how the valves function 

5. Coronary angiography to assess the patency of coronary blood flow

5. Anaesthesia Check-Ups: Before any operation, getting a PAC (pre-anaesthetic check-up) clearance is a must. The anaesthetist examines the patient extensively before deeming them fit for surgery. The anaesthetist also decides the type of anaesthesia to be given. 

6. Common questions: One can ask whatever questions they might have in mind before the procedure. Some of the most commonly asked questions by patients who are about to undergo aortic valve replacement are as follows:

1. What happens if the aortic valve is not replaced?

2. What is the success rate of aortic valve replacement surgery?

3. How long does aortic valve replacement surgery take?

4. Can the aortic valve be replaced without open heart surgery?

5. How long after aortic valve replacement can a patient drink alcohol?

On the Day of Aortic Valve Replacement

On the day of the procedure, the patient may expect the following.

1. The patient needs to reach the hospital before the scheduled time.

2. The healthcare will ask the patient to sign the consent form.

3. A tetanus shot is usually given to patients who are not immunised, after which the patient is made to change into a gown/operation theatre clothes. 

4. The patient will be administered an IV line and urine line before shifting to the operation theatre.

5. After the preparation, the patient is shifted to the operation theatre and is made to remove any jewellery, dentures, or accessories. The vitals are monitored before the procedure. 

Resting and having a healthy meal are important to recover after any procedure. Full recovery also depends upon multiple factors like age and overall health. You may need to stay in the hospital for a few weeks after the procedure.

The Recovery Process in the Hospital

Soon after the procedure, once the patient is stabilised, 

1. The patient is shifted from the operation theatre to the recovery room for observation. 

2. Under observation, the vitals (heart rate, blood pressure, breathing rate) and effects of anaesthetic medications are strictly monitored. 

3. The doctor may prescribe antibiotics to prevent the risk of infections along with painkillers.

4. Depending upon the patient's condition, the patient may be required to stay for at least a week; however, it may take a few months to recover completely. 

5. Once the patient is stabilised, they are discharged after appropriate counselling and are asked to come for follow-ups.

Recovery Process/Expectation after Hospital Discharge

The patient is expected to strictly adhere to the doctor's instructions regarding the recovery process. Some of these crucial instructions the doctor might suggest to a patient who has undergone heart valve replacement surgery are covered below:

1. Lifestyle Changes: The patient is advised to take it easy during the initial stages of recovery and should avoid heavy activities, at least initially, as it may worsen their health. 

1. One can gradually resume their daily activities depending upon the speed of recovery. 

2. The doctor may suggest going on regular walks to increase the activity gradually. 

3. Breathing exercises are also recommended to help in the healing process.

2. Medications: The patient is usually prescribed painkillers for pain management and antibiotics to prevent infection. 

1. In some patients, especially those who have undergone an aortic valve repair procedure using a mechanical valve, lifelong oral anticoagulants may be prescribed. 

2. Most patients' medications are limited to a few weeks or months. 

3. Work and Activity Restrictions: One can resume working after at least six to twelve weeks of surgery. Also, it's best to avoid driving till at least six weeks after surgery. 

4. Psychological Support: Patients who have undergone a heart valve operation are prone to developing mental health issues like depression, anxiety, etc. Hence, counselling such patients becomes of utmost importance. 

First Follow-Up Appointment

After the patient is discharged, the patient is expected to come for follow-up to monitor recovery. The first follow-up is usually scheduled six to twelve weeks after the discharge.

 During the first follow-up appointment: 

1. The patient's wounds are examined.

2. The clinical status of the patient is assessed.

3. Any physical signs and symptoms, if present, are noted.

4. Routine blood investigations, serum electrolytes, liver function tests, kidney function tests, etc., are done.

5. ECG is done to notice any change in rate or rhythm.

6. A chest x-ray is ordered to ensure no abnormality related to the heart and lungs.

7. Echocardiography is ordered to assess the function and competence of the prosthetic valve, as well as any other abnormality that might be present.

After all these investigations and assessments of the patient's condition, the doctor suggests an appropriate follow-up routine depending on the individual patient's condition.

In case of an aortic valve replacement, patients are required to visit the doctor lifetime to ensure that the valves are functioning correctly.

Aortic Valve Replacement Success Rate in India

The success rate of aortic valve replacement is generally high, with a significant improvement in symptoms and quality of life for many patients. 

According to evidence, the overall success rate of aortic valve replacement is estimated to be around 94% or higher.  

The success rate of aortic valve replacement can be influenced by factors such as the patient's age, overall health, presence of other medical conditions, the specific type of valve used (mechanical or biological), and the skill and experience of the surgical team. 

Additionally, the success of the procedure also depends on proper preoperative evaluation, careful patient selection, and appropriate postoperative care and follow-up.

Aortic Valve Replacement Survival Rate

The survival rate following aortic valve replacement is an important indicator of the procedure's effectiveness and long-term success. 

According to reputable studies and clinical data, the survival rate after aortic valve replacement is generally high. The majority of patients experience improved survival rates and prolonged life expectancy following the procedure. 

The survival rates can range from 85% to 95% or higher, depending on factors such as patient age, overall health, underlying conditions, and the specific type of valve used.

Aortic valve replacement is a highly effective procedure that offers several benefits to individuals with aortic valve disease. The following are some of the key benefits of aortic valve replacement:

1. Improved Heart Function: Aortic valve replacement can ease the cardiac strain and return blood flow to normal. 

1. The surgery increases the heart's capacity to pump blood effectively by substituting a prosthetic valve for an aortic valve that is broken or not functioning properly. 

2. This can enhance overall heart function and relieve symptoms, including weariness, breathlessness, and chest pain.

2. Enhanced Quality of Life: Due to symptoms like weariness and shortness of breath, daily activities might be severely restricted for people with severe aortic valve disease. 

1. These symptoms can be alleviated through aortic valve replacement, enabling patients to restore their energy, participate in physical activities, and live better.

3. Prevention of Complications: If neglected, aortic valve dysfunction can result in major problems such as heart failure, arrhythmias, and an elevated risk of infection. 

1. Aortic valve replacement helps prevent these consequences and lowers the chance of further heart damage by replacing the damaged valve.

4. Prolonged Lifespan: It has been demonstrated that aortic valve replacement increases long-term survival rates for people with severe aortic valve disease. 

1. Patients' lives can be greatly extended by the operation by restoring normal heart function and lowering the chance of problems.

5. Treatment for Structural Abnormalities: Aortic valve replacement can address structural problems of the valve, such as congenital malformations or acquired diseases, in addition to valve illness. 

1. Correcting these defects restores healthy valve function and enhances cardiac health in general.

Aortic valve replacement is associated with certain risks and complications like any other procedure. Some of the critical dangers after heart valve replacement surgery can be:

1. Bleeding postoperative

2. Formation of blood clots which may even result in stroke 

3. Abnormal heart rhythm (arrhythmias)

4. Infection at the wound site 

5. Heart valve infection 

6. Death

When to Consult a Doctor?

Some of the warning signs one must look out for in the postoperative period to avoid complications are:

1. Bleeding from the incision site

2. Signs of infection, such as oozing of pus, slow healing of wounds, etc., at the incision site

3. Experiencing symptoms like chest pain, shortness of breath, fatigue, etc. 

If these signs are not taken seriously, the patient might develop fatal complications such as shock, sepsis, and heart failure.

Hence, if you notice any such signs or symptoms mentioned above after the aortic valve replacement procedure, you must seek immediate medical attention!

Important Note: Older patients and those with pre-existing comorbidities are generally at an increased risk of developing complications. So it is even more crucial to watch out for signs in older people and patients with comorbidities. These comorbidities include certain chronic illnesses, heart conditions, lung problems, obesity, smoking, etc.

One may wonder about what happens if the aortic valve is not replaced. Well, a damaged aortic valve is not able to pump blood effectively, due to which the symptoms of aortic stenosis or regurgitation may worsen. A delay in replacing the diseased aortic valve can cause some severe complications, such as: 

1. Worsening of symptoms like chest pain, shortness of breath, fatigue, irregular heartbeat (murmurs), etc.

2. Increases the risk of complications such as heart failure, arrhythmias (irregular heart rhythms), stroke, blood clots, and infections.

3. Structural changes potentially lead to irreversible damage to the heart. 

4. Reduced treatment options.

5. Death.

Aortic valve replacement surgery is a life-saving procedure and shouldn't be delayed at any cost.

The cost of aortic valve replacement surgery in India range between ₹ 2,50,000 to ₹ 6,00,000. This cost depends upon several factors, primarily:

1. Patient's condition and comorbidities, if any

2. Patient’s age

3. The type of valve used to replace (biological or mechanical)

4. Hospital services and administration charges

5. Hospital type and location

6. Doctor’s expertise

7. Insurance coverage

Aortic valve replacement is a life-saving surgical procedure wherein a damaged aortic valve is replaced with a new one. It can be done by using either a mechanical or a biological valve.

The operation usually takes at least two hours to finish and a hospital day of around a week, depending upon the condition of the patient.

Aortic valve replacement is a major surgical procedure that requires careful planning and execution by a team of skilled healthcare professionals. If you are looking for a highly skilled surgeon, look no further.

We at HexaHealth have a fantastic team of highly qualified and experienced cardiothoracic surgeons. Avail a free consultation with our team right now!

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