Surgical Aortic Valve Replacement (SAVR) is a treatment option for patients who are diagnosed with severe aortic stenosis, a narrowing of the aortic valve in the heart. It is a traditional, open-heart surgery that has been practised for more than 50 years to replace damaged or diseased aortic valves. Patients can now benefit from minimally invasive procedures such as mini aortic valve replacement (mini AVR) and, more recently, transcatheter aortic valve replacement (TAVR), which reduce recovery time and improve quality of life. A cardiothoracic surgeon inserts an incision in your chest to gain access to your heart during the surgery. Depending on the type of surgical technique chosen by your doctor, the length and placement of the incision may vary. Your aortic valve will be removed if it is damaged or diseased, and a replacement valve will be sewed in its place
What Is Involved in a SAVR Procedure?
General anaesthesia is required for a SAVR procedure. An incision is inserted in the chest to gain access to the heart during the procedure. Depending on the sort of surgical procedure chosen for the patient, the length and placement of the incision may vary. The heart is subsequently stopped, and the job of the heart is taken over by a heart-lung (bypass) machine. The deceased aortic valve is removed and replaced with a new one.
Complications in SAVR procedure
There is a possibility of problems with the SAVR operation, including:
- Clots in the blood
- Irregular Heartbeat
If you are not fit for open-heart surgery, then you may be asked to go for Transcatheter aortic valve replacement (TAVR), a minimally invasive procedure. For patients who are elderly, frail, deconditioned, or have other health concerns, TAVR may be a superior and safer therapeutic option.
Difference between SAVR and TAVR
|The average time for SAVR procedure takes up to 4 hours||The average TAVR procedure may take up to 1-2 hours and might take up to 8 hours, depending on the complexity|
|SAVR recovery time varies from 5 to 8 weeks, depending on the patient's health||The recovery Time of TAVR is Less than 2-3 days to 1 week|
|Might take a mental toll throughout the recovery process. (Only a few patients go through this)||Less anxiety and mental uneasiness|
What is the aortic valve?
Mitral, tricuspid, aortic, and pulmonic valves are among the four valves in the heart.
The aortic valve is situated between the left ventricle (the lower heart pumping chamber) and the aorta, the body's largest artery. Valves are like one way door that maintain one-way blood flow through the heart. They have leaflets which open and close with each beat.
What is aortic valve disease?
Aortic valve disease develops when the aortic valve fails to function properly. This might be due to:
Aortic valve stenosis:
It is a condition in which the aortic valve becomes obstructed. These stiff, fused, thickened, inflexible valve leaflets cause the aortic valve to constrict, limiting blood flow. Aortic valve stenosis progresses when calcium is deposited on the valve leaflets, further limiting their mobility. Stenosis can develop in people who have a tricuspid (3 leaflet) or bicuspid (2 leaflet) aortic valve.
Aortic valve regurgitation (also known as valvular insufficiency, incompetence, or "leaky valve") :
These valve leaflets do not entirely close. Regurgitation happens when the blood ejected by the heart returns to the heart as soon as it stops squeezing and relaxes. Regurgitation can be caused by floppy leaflets (prolapse), aberrant congenitally malformed valves (bicuspid or unicuspid), valve infection (endocarditis), the inability of the leaflets to shut securely owing to aortic dilatation (aneurysm), holes in the leaflets, or rheumatic valve disease.
What causes aortic valve disease?
The aortic valve can be defective from birth (often a bicuspid congenital aortic valve) or dysfunctional over time, which is more common in older individuals (acquired valve disease).
Congenital aortic valve disease
Patients with bicuspid aortic valves are born with them and make up around 1% to 2% of the population
Instead of the normal three leaflets or cusps, the bicuspid aortic valve has only two. The valve opening may not close entirely and leak (regurgitant) if the third leaflet is missing, or it may not open completely and become constricted (stenotic) or leak.
Bicuspid aortic valves can often operate properly for several years without requiring therapy.
About 25% of individuals with bicuspid aortic valves may have some aortic expansion above the valve. The aorta is said to be aneurismal if it is significantly dilated.
Acquired aortic valve disease
Changes in the structure of the valve occur with acquired aortic valve problems. Acquired aortic valve conditions include:
Infective endocarditis is a bacterial infection of the valve that occurs when germs enter your bloodstream from a distant illness and adhere to the surface of your heart valves. Even small infections, such as a dental abscess, can result in serious bacterial endocarditis of the aortic valve.
Rheumatic fever is typically caused by a bacterial throat infection, such as strep throat. In rheumatic fever, the valve itself is not diseased, but antibodies produced by the body to combat infection react with the heart valves, causing stiffness and fusing of the aortic valve leaflets.
Aortic valve degeneration
Aortic valve degeneration from wear and tear is another cause of acquired aortic valve disease. The aortic valve leaflets deteriorate and become calcified in many individuals over time. This most commonly results in aortic stenosis, although it can also result in aortic regurgitation. In adults over the age of 65, this is the most prevalent cause of aortic stenosis.
Other causes of aortic valve
Other causes of aortic valve illness include rheumatoid arthritis, chronic inflammatory disorders, lupus, syphilis, hypertension, aortic aneurysms, connective tissue diseases, and, less frequently, tumours, certain types of medications, and radiation for malignancies or lymphoma.
What are the symptoms of aortic valve disease?
Many patients with aortic valve disease are asymptomatic (have no symptoms), even when the stenosis (narrowing) or insufficiency (leak) are severe.
Initial symptoms of aortic valve disease usually include:
- Easy tiring
- Loss of energy
- Swelling of the ankles
- Palpitations (extra or skipped heart beats)
More advanced symptoms may include:
- Shortness of breath
- Chest pain
- Dizziness or loss of consciousness
How is aortic valve disease diagnosed?
Your doctor will make the diagnosis of aortic valve disease after reviewing your symptoms, performing a physical exam, listening for a murmur, and analysing the findings of your diagnostic testing.
Using a stethoscope, the doctor may detect a murmur, which reflects turbulent blood flow over an irregular valve, during the physical exam.
An echocardiography, a type of specialist cardiac ultrasound, is used to confirm the diagnosis of aortic valve dysfunction. The echocardiography allows the clinician to see the heart valves and assess the severity and potential cause of aortic valve disease.
A conventional transthoracic echocardiography (in which a probe with gel is put on the skin of the chest to transmit pictures) is sufficient to see the valve in most individuals. The test may be combined with exercising or IV infusion of the drug to allow the doctor to see the degree of stenosis more clearly.
Sometimes, a transesophageal echocardiogram (TEE - in which a probe is passed through the mouth into the esophagus) is necessary to more closely visualize the valve. A TEE is performed as an outpatient treatment.
How is aortic valve disease treated?
If you have no symptoms or heart damage, you must preserve your valve from future damage by taking steps to decrease the chance of infective endocarditis, and you may need to take medicines. In addition, if you have symptoms, signs of heart damage, or heart failure, surgery may be required to address your disease.
Aortic valve surgery
Aortic valve surgery is classified into two types: aortic valve repair and aortic valve replacement.
The aortic valve may be repaired or replaced through aortic valve surgery, which also includes aorta surgery. The findings of your diagnostic tests, the anatomy of your heart, your age, the existence of other medical disorders, and other considerations will be taken into account to determine whether aortic valve repair or replacement is the best treatment option for you.
Traditional heart valve surgery or less invasive methods can be used to conduct aortic valve surgery.
Traditional Aortic Valve Surgery
A surgeon creates a 6- to 8-inch incision through the middle of your sternum during conventional aortic valve surgery, and part or all of the sternum (breastbone) is split to allow direct access to your heart. Your abnormal heart valve or valves are then repaired or replaced by the surgeon.
Minimally Invasive Aortic Valve Surgery (Key Hole Surgery)
Minimally invasive aortic valve surgery is a type of aortic valve repair surgery performed through smaller, 2- to 4-inch incisions without opening your whole chest. This is generally accomplished through a "J" incision and leaves your chest stable. Minimally invasive surgery minimises blood loss, trauma, hospital stay time, and often may hasten healing.
Most patients who require isolated aortic valve surgery are candidates for minimally invasive aortic valve surgery, but your surgeon will review your diagnostic tests and determine if you are a candidate for this type of surgery.
Repair of an enlarged aorta
Aortic valve dysfunction is frequently linked with an expansion (aneurysm) of the ascending aorta, the aorta's first section (the main blood vessel in the body that originates from the aortic valve).
If the aorta expansion is significant (typically greater than 4.5 or 5 cm in diameter), this section of the aorta may need to be replaced. The replacement is performed at the same time as the aortic valve repair or replacement. A specific operation (David procedure) can be done on individuals who have a leaking aortic valve and an enlarged aorta. Using the David technique, surgeons can repair the aortic valve while also replacing the enlarged ascending aorta.
Aortic valve replacement
If valve repair is not a possibility, your surgeon may recommend valve replacement. The old (native) valve is removed, and a replacement valve is stitched to the annulus of your original valve. The new valve might be mechanical or biological in nature.
Biological valve replacement
The majority of aortic valves are replaced with a bioprosthesis at Our Hospital. Biological valves (also known as tissue or bioprosthetic valves) are composed of tissue, although they may contain some artificial components to give additional support and allow the valve to be stitched in place.
About 80% of aortic valves are replaced with bioprosthesis
Biological valves can be produced from porcine tissue, bovine pericardial tissue, or other species' pericardial tissue.
These valves are easy to install, long-lasting (lasting 15 to 20 years), and allow patients to avoid taking anticoagulants for the rest of their lives (blood-thinning medications). At Our Hospital, the risk of death following isolated aortic valve replacement is less than 1% and has continuously been lower than expected mortality based on Society of Thoracic Surgeons (STS) national data.
Mechanical valves replacement
Mechanical valves are entirely composed of mechanical elements that are non-reactive and easily tolerated by the body. The bileaflet valve is used most often.
It is made up of two pyrolite (diamond-like) carbon leaflets in a ring wrapped in polyester knit fabric.
All patients with mechanical valve prostheses need to take an anticoagulant medication (blood thinning medication), warfarin (Coumadin), for the rest of their life to ensure the valve works smoothly and reduces the risk of blood clotting and stroke. Blood thinning also reduces the risk.
Ross Procedure (also called Switch Procedure)
The Ross procedure is often performed on patients under the age of 30 who want to avoid the need for anticoagulants (blood-thinning medicines) for the rest of their lives.
During this procedure, the patient's normal pulmonary valve is removed and used to replace the diseased aortic valve. The pulmonary valve is then replaced with a pulmonary homograft. The Ross procedure leaves two valves at potential risk of later failure.
Risk and Benefits
What is the risk of aortic valve surgery?At Our Hospital, the overall risk of death associated with surgery for isolated aortic valve replacement is less, compared with The Society of Thoracic Surgeons benchmark of 2.4%. Mortality for minimally invasive "j" incision isolated aortic valve replacement is even lower and mortality for minimally invasive isolated aortic valve repair is also extremely low even for the David valve preserving procedure. Past history of heart surgery, your age, co-existing organ disease (such as emphysema), or other conditions that require surgical treatment will affect your individual risk. Ask your doctor about your surgical risk.
For the treatment of Aortic Valve Disease: Stenosis and Regurgitation
Aortic valve surgery is performed by heart surgeons to treat most commonly bicuspid valves, other congenital aortic valve diseases, aortic valve stenosis, and aortic valve regurgitation.
This material will assist you in comprehending the problems that may damage the aortic valve and why surgical surgery may be required to treat your condition.