Aortic insufficiency surgery procedure

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Related Key Words and Synonyms: Aortic valve replacement.

Aortic Insufficiency Surgery Procedure
If the procedure is indicated; it could be done by one of the following approaches:

The Traditional Open Heart Surgery:


 * The surgeon will make a 10-inch-long cut in the middle of the chest (sternum).
 * Next, the surgeon will separate the breastbone (sternum) to be able to see the heart.
 * Most people are connected to a heart-lung bypass machine or bypass pump. The heart is stopped while the patient is connected to this machine. This machine does the work of the heart while the heart is stopped.
 * A small cut is made in the left side of the heart so the surgeon can repair or replace the aortic valve.

In Minimally Invasive Aortic Valve Surgery; there are several different ways to perform the procedure:


 * The heart surgeon may make a 2-inch to 3-inch-long cut in the right part of the patient's chest near the sternum. Muscles in the area will be divided so the surgeon can reach the heart. A small cut is made in the left side of the heart so the surgeon can replace the aortic valve.
 * In Endoscopic surgery; the surgeon makes one to four small holes in the chest, then he or she uses special instruments and a camera to do the surgery.
 * For Robotically-Assisted Valve Surgery, the surgeon makes two to four tiny cuts (about a ½ to a ¾ inch) in the chest. The surgeon uses a special computer to control robotic arms during the surgery. The surgeon sees a three-dimensional view of the heart and mitral valve on the computer. This method is very precise.

The patient may or may not need to be on a heart-lung machine for these types of surgery, but if not; the heart rate will be slowed by medicine or a mechanical device.

There are two types of valves that can be used :

1. Mechanical which is made of man-made (synthetic) materials, such as a metal like titanium. These valves last the longest, but the patient will need to take blood-thinning medicine, such as warfarin (Coumadin) or aspirin, for the rest of his or her life.

2. Biological which made of human or animal tissue. These valves last 10 to 12 years, but the patient may not need to take blood thinners for life.

The 2006 American College of Cardiology/American Heart Association (ACC/AHA) recommendations for the choice of aortic valve :


 * If the patient is under 65 years of age and do not have a contraindication to anticoagulation then mechanical valve is preferred.
 * If the patient is ≥65 years of age who do not have risk factors for thromboembolism; Bioprosthetic valve will be reasonable.
 * If the patient has already a mechanical valve in the mitral or tricuspid position (need anticoagulation).
 * If the patient has active prosthetic valve endocarditis; the valve should be replaced.
 * If the patient has contraindications to anticoagulation therapy regardless his or her age; then a bioprosthetic valve is indicated.
 * In case of small oartic root; mechanical valve is indicated as there is a risk of annular enlargement in such patient if bioprosthetic valve is used.

Once the new or repaired valve is working, the surgeon will:
 * Close the heart and take you off the heart-lung machine.
 * Place catheters (tubes) around the heart to drain fluids that build up.
 * Close the sternum with stainless steel wires. It will take about 6 weeks for the bone to heal. The wires will stay inside the body.

The patient may have a temporary pacemaker connected to the heart until his or her natural heart rhythm returns.

The surgeon may also perform coronary artery bypass surgery at the same time, if needed.

Other aortic root diseases like marfan syndrome, bicuspid aortic valve and aortic dissection which can cause chronic aortic regurgitation should be treated with AVR and aortic root reconstruction when degree of dilatation of aorta or aortic root ≥ 50mm in diameter

Ross or Ross/Konno procedure is another alternative surgical procedure where the pulmonary valve is transplanted to the aortic position, and a homograft conduit is implanted from the right ventricle to the pulmonary artery. Though this procedure shows promising results for aortic valve abnormalities in some , the use of this technique has been limited by high rates of pulmonary autograft failure with deterioration of right heart homografts. These rates are higher in children as compared to adults. Further studies aimed at clarifying longer-term outcomes as well as preventing pulmonary homograft deteroration are needed.

To summarize, mechanical valve replacement is the preferred surgical option at present as opposed to valve repair or biological valve replacement in view of lack of evidence of long-term durability and outcomes. However, they may be appropriate for patients in whom anticoagulation are contraindicated. Patients' age, ability to tolerate warfarin and patients' preference are taken into account for in deciding the type of valve (mechanical or bioprosthetic valve) to be used in valve replacement.