Aortic valve replacement

Aortic heart valve replacement is used to treat a diseased or damaged aortic valve. It may involve open-heart surgery.

The aortic valve

The heart has 4 chambers. There are two small chambers at the top of the heart called the atria, and 2 larger chambers at the bottom called the ventricles.

Each ventricle has 2 valves:

• one valve controls the blood flowing into the ventricle
• the other valve controls the blood flowing out of the ventricle

Each valve is made up of a thin ‘flap’ of strong tissue. These flaps open and close, acting as one-way gates for the blood to flow through.

The aortic valve controls the flow of blood out of the left ventricle of the heart to the body’s main artery (the aorta). From the aorta, the blood flows to the rest of the body.

The aortic valve opens to allow blood to flow from the heart out to the rest of your body. It then closes to stop any blood leaking back into the heart (valves can only open in one direction stopping backflow of blood).

Why is it necessary to replace the aortic valve?

The aortic valve may need to be replaced for 2 reasons:

• narrowing of the valve (aortic stenosis) – the aortic valve becomes narrowed and obstructs the blood flowing through it
• leaking of the valve (aortic regurgitation) – the aortic valve leaks and blood flows back through it into the left ventricle

If the aortic valve is no longer working properly, surgery may be required to replace it.

Read more about why you might need aortic valve replacement surgery.

How is aortic valve replacement carried out?

During surgery, an incision is made in the chest, and the chest bone (sternum) is broken to allow access the heart. The heart has to be stopped to allow surgery to proceed. A heart-lung bypass machine is used to take over the work of the heart during the operation. The damaged aortic valve is removed and a replacement valve inserted.

The heart is then started again, the sternum is wired back together, and the incision in the chest is closed.

Read more about what happens during aortic valve replacement surgery.

Risks

An aortic valve replacement carries a risk of complications, some of which can be life-threatening. Around 1 in 50 people who undergo this type of surgery die from complications during or shortly after surgery.

However, if aortic stenosis and aortic regurgitation are not treated, there is a much higher risk of dying from these conditions. Each case is carefully reviewed and the benefits of aortic valve replacement will usually far outweigh any associated risk of surgery.

Read more about the risks of aortic valve replacement.

Alternatives to aortic valve replacement

An aortic valve replacement is currently the most effective treatment for aortic stenosis and aortic regurgitation. Alternative treatment options are usually used only if a person is too frail for open-heart surgery.

Alternatives to aortic valve replacement include:

• transcatheter aortic valve implantation (TAVI) – the replacement valve is guided into place through the blood vessels rather than through an incision in the chest
• aortic valve balloon valvuloplasty – the valve is widened using a balloon  

Further information

Read the British Heart Foundation's Having Heart Surgery.

Chest Heart & Stroke Scotland (CHSS) provide free heart factsheets and booklets.

For further advice and support, contact CHSS Adviceline Nurses on free phone 0808 801 0899.

Aortic valve replacement is necessary if your aortic valve is:

• narrowed (aortic stenosis)
• leaking (aortic regurgitation)

Conditions that can affect the aortic valve are collectively known as aortic valve diseases.

Aortic valve diseases can be classified as:

• congenital – which means that you are born with it
• acquired – where the disease develops in later life, usually over many years

Some of the most common reasons why a person develops aortic valve disease are described below.

Common causes of aortic valve disease

Age-related aortic calcification

Age-related aortic calcification is the most common cause of aortic valve disease. It is a degenerative disease, which means that it occurs as a result of aging. Calcium deposits form on the valve, preventing it from opening and closing properly. In this case, you are most likely to be diagnosed with valve problems when you are in your 70s or 80s.

Bicuspid aortic valve

A bicuspid aortic valve is the most common type of congenital aortic valve disease. It affects around 1 in 50 people. It occurs when the aortic valve has only 2 flaps (which act as gates to allow blood through) instead of the usual 3. The valve may function normally for years without you being aware of the problem, often until you reach your 50s or 60s.

Underlying health conditions

Several health conditions can damage the aortic valve, causing aortic valve diseases. These include:

• Marfan syndrome – a genetic condition that causes damage to the connective tissue (connective tissue provides support and structure to other tissue and organs)
• rheumatic fever – this condition can arise as a complication of a throat infection and causes widespread inflammation throughout the body (uncommon in the UK, it's still common in other parts of the world)
• lupus – a condition where the immune system goes wrong and starts attacking healthy tissue
• giant cell arteritis – a condition that causes inflammation of the lining of the body’s medium and large arteries
• endocarditis – a rare but serious condition where the inner lining of the heart becomes inflamed

Symptoms of aortic valve disease

Sometimes, if you have a problem with your aortic valve, you may not experience any symptoms until later on in the disease process. Any symptoms you feel occur because your heart cannot pump blood around your body efficiently. Symptoms you may have include:

• chest pain brought on by physical activity – this is caused by your heart having to work harder due to restricted blood flow through your aortic valve
• shortness of breath – at first you may notice this only when you exercise, but later you may experience this even when resting
• dizziness or light-headedness – this is caused by the obstruction of the flow of blood from your heart to the rest of your body
• loss of consciousness (fainting) – this is also a result of reduced blood flow caused by the obstruction in your heart

Testing

If your GP suspects you have aortic valve problems, they will refer you to a heart specialist (cardiologist) to do some tests:

• An echocardiogram is where an ultrasound scan is used to obtain a detailed image of your heart. An echocardiogram can often detect abnormalities with the shape and movement of the heart valves.
• An electrocardiogram  (ECG) is a quick and simple test to see how the electrics of your heart are working
• Coronary angiography is a type of X-ray that uses a special dye that helps the blood vessels of the heart show up clearly on an X-ray scan.

These tests will help to confirm a suspected diagnosis of aortic stenosis or regurgitation.

When surgery is required

If your symptoms are mild, you will be invited to come in for an echocardiogram every year or two to check whether the problem is getting worse.

If your symptoms are severe, it is highly likely that surgery to replace the valve will be recommended. Without treatment, stenosis or regurgitation of your aortic valve is likely to get worse and will eventually lead to heart failure, which is a long-term and sometimes debilitating condition.

There is also a small risk that the heart will suddenly stop beating (sudden cardiac death), which can also be fatal.

Research has found that people with severe aortic stenosis who are not treated with surgery have a 25% chance of dying in the first year after the symptoms start. The risk is 50% in the second year.

People with severe aortic regurgitation who are not treated with surgery have a 25% chance of dying after 5 years following the start of symptoms. The risk is 50% after 10 years.

Before having an aortic valve replacement, you will attend a pre-admission clinic. Here, you'll be seen by a member of the team who will look after you in hospital.

At the clinic, you will have a physical examination and will be asked for details of your medical history.

Any investigations and tests that you need will be arranged. For example, these will include a blood test or an X-ray. This is a good time to ask questions about the procedure, although you can discuss your concerns with your doctor at any time.

You will be asked if you are taking any tablets or other types of medication. These might be prescribed by your GP or bought over-the-counter (OTC) in a pharmacy. It helps if you bring details with you about any medication you are taking, for example by bringing the packaging with you.

You will be asked about any previous anaesthetics you have had, and whether you had any difficulties or side effects with these, such as nausea. You will also be asked whether you are allergic to anything. This is to prevent you having an allergic reaction to any medication you might need.

You will be asked about your teeth, including whether you have dentures, caps or a plate. This is because, during the operation, you will need to have a breathing tube inserted into your throat to help you breathe, and having loose teeth could be dangerous. It’s vitally important after having valve surgery that you maintain a high level of oral hygiene, as any formation of bacteria can lead to endocarditis (a rare, but serious condition where the inner lining of the heart becomes inflamed).

If you smoke, you will be advised to stop. Quitting smoking will lower the risks of complications occurring after surgery, such as chest infection or blood clots.

It is likely you will be in hospital for 5 to 7 days, so you will need to make some practical preparations. These include bringing clothes, toiletries and any equipment you use, such as a walking stick or hearing aid. 

An aortic valve replacement is carried out under general anaesthetic. This means you will be asleep during the operation and will feel no pain.

The surgeon will begin the operation by making a large incision down the centre of your breastbone (sternum). The incision will be around 25cm (10 inches) long.

This is known as a sternotomy and it allows the surgeon access to your heart.

Heart-lung machine

Tubes are inserted into your heart and major blood vessels, which are attached to a heart-lung (bypass) machine. When the heart-lung machine is turned on, your blood is diverted into the machine instead of into your heart. The machine pumps oxygen-rich blood around your body until the operation is complete, taking over the role of your heart and lungs. 

Your heart is stopped by filling the coronary arteries (the blood vessels that supply your heart with blood) with a chemical solution. The body’s main artery (aorta) is clamped shut, so that your surgeon can open your heart and operate on it without blood pumping through it.

Replacing the aortic valve

Your surgeon will open up your aorta so that they can see the aortic valve. The damaged valve is removed, and the new one put into place and attached with a fine thread (suture).

The surgeon will start your heart again, using controlled electric shocks, before taking you off the heart-lung machine. Your breastbone will be joined up with wires, and the wound on your chest closed using dissolvable stitches. Tubes are inserted into small holes in your chest (called chest drains) to drain away any blood and fluid that builds up.

The operation may be performed using smaller incisions and instruments, but you will still need to go on the heart-lung machine. In the future, it may be possible to perform this operation in a less invasive way, without the need for a heart-lung machine.

Choice of valve

There are 2 main types of replacement valve:

• mechanical valves are made out of man-made materials such as pyrolytic carbon (a material that is similar to graphite)
• biological valves are made out of animal tissue

Each type of valve has advantages and disadvantages.

Generally, if you are under 60 years of age, the surgeon will probably recommend a mechanical valve replacement. If you are over 65, a biological valve replacement will probably be recommended.

Mechanical valves

Mechanical valves are very hard-wearing and long-lasting.

However, there is a tendency for blood to clot on the surface of the valve. You will have to take anticoagulant (blood-thinning) medication for the rest of your life to prevent the clots forming.

There is a small risk of blood clots causing a stroke, when the blood supply to your brain is disturbed.

Mechanical valves can make a clicking noise, which can be disturbing at first, although most people soon get used to it.

Biological valves 

With biological valves, there is less risk of blood clotting. Therefore, anticoagulant medication is not usually needed, unless you are taking it for other problems.

However, biological valves may not last as long in younger, more active people, so further replacement valve surgery may be necessary.

After an aortic valve replacement, you will be taken to an intensive care unit (ICU). Here, the activity of your heart, lungs and other systems will be closely monitored for the first 24 to 48 hours.

You may be kept asleep for a few hours after your operation, or until the following morning, and you will remain on a ventilator during this time.

Ventilator

A ventilator is an artificial breathing machine that moves oxygen-rich air in and out of your lungs. This is done through a tube, called an endotracheal (or ET) tube, which is placed in your mouth and sometimes also in your nose.

When you wake up, the tube will still be in place and may be uncomfortable. You will not be able to talk or drink anything. Once the intensive care team are satisfied that you can breathe without aid, you will be taken off the ventilator, and the tube will be removed. A mask will be placed over your mouth and nose to supply oxygen for you to breathe.

Pain

As with any major operation, you can expect to have some discomfort after an aortic valve replacement.

While you are in hospital, you will be given painkillers to help ease the pain after your anaesthetic wears off.

If the painkillers do not control your pain, tell a nurse or the doctor in charge of your care. You may need a stronger painkiller.

You will also be given advice about painkillers to take at home. You can expect to have some discomfort around the site of the operation, but this will start to feel better as the wound heals.

Moving to a ward

You will be moved from the ICU to a surgical ward once the doctors treating you are satisfied that you're ready. This will probably be a high dependency unit (HDU) for people who need to be kept under observation after an operation.

You may have several tubes and monitors attached to you. These could include:

• chest drains – small tubes from your chest to drain away any build-up of blood or fluid (these will usually be removed the day after your operation)
• pacing wires – if necessary, these will be inserted near the chest drains to control your heart rate (they will usually be removed after 4 or 5 days)
• wires on sensor pads – these may be placed in various areas and can be used to measure your heart rate, blood pressure and blood flow, and the air flow to your lungs
• a catheter – a tube that is inserted into your bladder so that you can pass urine

On the ward, your care team will focus on increasing your appetite and getting you back on your feet.

Depending on how well you progress, you should be able to leave the hospital 5 to 7 days after your operation.

Someone from the cardiac rehabilitation team or physiotherapy department should visit you before you go home to discuss your rehabilitation with you.

They can give you advice on how to get back to normal, and where there is a cardiac rehabilitation programme or support group in your area. The aim is to help you recover as quickly as possible and get back to living as full and active a life as you can, while preventing further heart problems.

Recovery time

The recovery time after aortic valve replacement surgery varies from person to person and will depend on:

• your age
• your overall health and fitness
• how well you were before the operation

Your breastbone usually takes about 6 to 8 weeks to heal, but it may be 2 to 3 months before you feel completely back to normal.

Going home

You are likely to be pleased and relieved to get home, but you may also feel anxious about your recovery and how you will manage without full-time nursing care. Take things slowly and at your own pace. It is common to experience some or all of the following mild and short-lived symptoms.

• loss of appetite – it may take a while for your appetite to return and you may temporarily lose your sense of taste.
• Swelling and redness – the site of your incision may be swollen and red, but this will gradually fade over time. If your wound becomes more red, hot to touch, becomes increasingly painful, swollen or starts to ooze you should seek medical help as soon as possible.
• insomnia – some people have problems either falling asleep or sleeping through the night. This should improve with time. Taking a painkiller before bed may help.
• constipation – you may find it difficult to empty your bowels. Drinking plenty of fluid (1.2 litres or 6 to 8 glasses a day) and eating plenty of fruit and vegetables will help. Your doctor may also suggest taking a laxative (a medication to help you pass stools more easily)
• anxiety and depression – these are completely normal after heart surgery. Talking to your friends and family can help. If a cardiac or district nurse visits you, you may want to discuss it with them. You will start to feel emotionally stronger as you regain your health and strength.

Caring for your wound

You will have a scar where the surgeon cut down your breastbone. The scar will be red at first but will gradually fade over time.

Wash your wound using mild soap and water when you have a bath or a shower. In hospital, you should be able to have a shower after your pacing wires have been removed (after 4 or 5 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, because 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 3 weeks. Other types of stitches may need to be removed by a healthcare professional. You will be given advice about this, and 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 sex life. After your operation, you may feel like having a more active sex life. You can do so as soon as you feel able to, 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 cause them to lose interest in sex. In men, the emotional stress can also cause impotence, where it is difficult to get and maintain an erection. If you are worried about your sex life, talk to you partner, a support group or your GP.

Driving after surgery

After your operation, you can be a passenger in a car straightaway. However, you may not be able to drive again until around 6 weeks after you're discharged from hospital. Wait until you can comfortably do an emergency stop. If you are unsure, ask your surgeon for advice. If you drive a lorry or a passenger-carrying vehicle, you will need to tell the DVLA about your 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. You may be able to return to work 6 to 8 weeks after you have been discharged from hospital. However, if you do heavy manual work, it may up to 3 months before you can return to work. You may want to change your role to involve lighter duties, or speak to your occupational health department if your workplace has one.

After an aortic valve replacement, several complications could occur, although most of these are rare. Some possible complications are:

• infection – the new valve can become infected and inflamed (endocarditis), which can damage your heart. You will be given antibiotics to reduce the risk
• 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 – 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 1–2% 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)

In some cases, complications can be fatal. Recent data suggest that around 2% of people treated with aortic valve replacement will die in the first 30 days after surgery.

However, the risk of death from surgery is far lower than the risk of death associated with not treating severe aortic disease.

Aortic valve replacement is currently the most effective treatment for aortic valve diseases. But having open-heart surgery can place tremendous strain on the body.

Surgery may be too dangerous in people who are in very poor health. In this case, less invasive alternative methods may be required. Some alternative methods are described below.

Aortic valve balloon valvuloplasty

Aortic valve balloon valvuloplasty involves passing a catheter (a thin plastic tube) through a large blood vessel and into the heart. A balloon is then inflated to open up the narrowed aortic valve.

This can prevent the need for open-heart surgery, although, in adults, surgery is still the first treatment choice.

The National Institute for Health and Clinical Excellence (NICE) has recommended that aortic valve balloon valvuloplasty should only be used in people who are not suitable for traditional open surgery. It can also be used as a short-term treatment in babies and children until they are old enough for valve replacement.

The main drawback with this type of treatment is that the effects usually only last around 2 to 3 years. After this, further treatment is required.

Transcatheter aortic valve implantation (TAVI)

Transcatheter aortic valve implantation is a relatively new procedure. It involves accessing the aortic valve through the femoral artery or vein (one of your major blood vessels), or through a small surgical incision in your chest.

A balloon catheter (a thin plastic tube with an inflatable balloon on the tip) is guided into the left ventricle chamber in your heart, and it is used to position the prosthetic valve over the old one.

TAVI may be used if someone is too frail to cope with the stress of standard valve replacement surgery, for example due to their age or another illness.

While it is not as effective as traditional open surgery, a TAVI does offer a marked improvement in survival for people with severe aortic valve diseases. One study found that this type of treatment could half a person’s risk of death.

However, there is around a 1 in 16 chance of having a stroke in the first year after a TAVI.

Valve repair

Repairing the aortic valve is only possible in some situations, and will depend on the particular defect in your aortic valve. Valve repair may occasionally be an option for aortic regurgitation (leaking) but not for aortic stenosis (narrowing).

Possible types of repair include:

• aortic annuloplasty – using plastic to repair the valve
• supra-coronary graft – grafting healthy tissue on to the damaged valve